Endoscopic endonasal transclival resection of chordomas: operative technique, clinical outcome, and review of the literature

Abstract

The endonasal endoscopic transclival approach represents a less invasive and more direct approach than a transcranial approach to treat certain moderate-sized midline skull base chordomas. Longer follow-up is necessary to determine comparability to transcranial approaches for long-term control. Large tumors with significant extension lateral to the carotid artery may not be suitable for this approach.

Critical Appraisal of Extent of Resection of Clival Lesions Using the Expanded Endoscopic Endonasal Approach

“…We were able to achieve > 95% resection rate in 81% of the cases for which a GTR was attempted. This rate agrees well with that of Fraser et al, 16 who reported an 87% success rate in achieving > 95% resection of clival chordomas with an endoscopic endonasal transclival technique. They cited tumor extension beyond the ICAs as the most important limitation to obtaining a GTR.…”

“…12,[14][15][16]20,[25][26][27][28][29][30] Our experience with clival lesions accessed using the EEEA complements the experience of others in that this approach can be highly effective in removing these surgically challenging lesions. We were able to achieve > 95% resection rate in 81% of the cases for which a GTR was attempted.…”

“…Despite these advantages, however, previous reports have demonstrated varying success rates in achieving gross total tumor resection (GTR) when utilizing an expanded endoscopic endonasal approach (EEEA) to remove lesions of the clivus. 14,[16][17][18][19][20] The panoramic view of the clivus and ventral brainstem that can be achieved with the endoscope has been demonstrated with anatomic studies in cadaveric specimens. Critical neurovascular structures, primarily the paraclival internal carotid artery (ICA) segments and the lower cranial nerves, are generally considered to represent the lateral limits of safe exposure.…”

Transsphenoidal endoscopic skull base surgery: state of the art and future perspective

“…Recent endoscopic studies have shown favorable rates of gross total removal. For example, Fraser et al [ 44 ] achieved > 95% tumor resection in seven (87%) of eight patients in whom complete tumor resection was the goal. Stippler et al [ 117 ] and Dehdashti et al [ 27 ] reported GTR resection rates for clival chordomas of 67% and 58% with CSF leak rates of 25% and 33%, respectively.…”

Use of a side-cutting aspiration device for resection of tumors during endoscopic endonasal approaches

“…Likewise, the tip of the instrument, where the aspiration occurs, is not easily visualized with a colinear, parallel endoscope, which provides better visualization for the side of the instrument. 4,5 Craniopharyngiomas, adenomas, and chordomas have a recurrence rate directly correlated with the percent of resection. 11 An ideal instrument for achieving this goal using endoscopic visualization would be a long, narrow side-cutting instrument whose tip and noncutting side could be placed in proximity to critical neurovascular structures for resection of firm tumors in a narrow working space without heating the surrounding tissue.…”