The Endoscopic Transnasal Transsphenoidal Approach for the Treatment of Cranial Base Chordomas and Chondrosarcomas

Frank, Giorgio; Sciarretta, Vittorio; Calbucci, Fabio; Farneti, Giovanni; Mazzatenta, Diego; Pasquini, Ernesto

doi:10.1227/01.neu.0000219914.17221.55

Cited by 154 publications

(167 citation statements)

References 29 publications

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“…3,5,16 An EEA is generally associated with reduced morbidity because vascular and neural structures are displaced away from the surgical field.…”

Section: 4mentioning

confidence: 99%

Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

Filho

Prevedello

et al. 2014

FOC

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Object Skull base chondrosarcomas are slow-growing, locally invasive tumors that arise from the petroclival synchondrosis. These characteristics allow them to erode the clivus and petrous bone and slowly compress the contents of the posterior fossa progressively until the patient becomes symptomatic, typically from cranial neuropathies. Given the site of their genesis, surrounded by the petrous apex and the clival recess, these tumors can project to the middle fossa, cervical area, and posteriorly, toward the cerebellopontine angle (CPA). Expanded endoscopic endonasal approaches are versatile techniques that grant access to the petroclival synchondrosis, the core of these lesions. The ability to access multiple compartments, remove infiltrated bone, and achieve tumor resection without the need for neural retraction makes these techniques particularly appealing in the management of these complex lesions. Methods Analysis of the authors’ database yielded 19 cases of skull base chondrosarcomas; among these were 5 cases with predominant CPA involvement. The electronic medical records of the 5 patients were retrospectively reviewed for age, sex, presentation, pre- and postoperative imaging, surgical technique, pathology, and follow-up. These cases were used to illustrate the surgical nuances involved in the endonasal resection of CPA chondrosarcomas. Results The male/female ratio was 1:4, and the patients’ mean age was 55.2 ±11.2 years. All cases involved petrous bone and apex, with variable extensions to the posterior fossa and parapharyngeal space. The main clinical scenario was cranial nerve (CN) palsy, evidenced by diplopia (20%), ptosis (20%), CN VI palsy (20%), dysphagia (40%), impaired phonation (40%), hearing loss (20%), tinnitus (20%), and vertigo/dizziness (40%). Gross-total resection of the CPA component of the tumor was achieved in 4 cases (80%); near-total resection of the CPA component was performed in 1 case (20%). Two patients (40%) harbored high-grade chondrosarcomas. No patient experienced worsening neurological symptoms postoperatively. In 2 cases (40%), the symptoms were completely normalized after surgery. Conclusions Expanded endoscopic endonasal approaches appear to be safe and effective in the resection of select skull base chondrosarcomas; those with predominant CPA involvement seem particularly amenable to resection through this technique. Further studies with larger cohorts are necessary to test these preliminary impressions and to compare their effectiveness with the results obtained with open approaches.

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“…3,5,16 An EEA is generally associated with reduced morbidity because vascular and neural structures are displaced away from the surgical field.…”

Section: 4mentioning

confidence: 99%

Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

Filho

Prevedello

et al. 2014

FOC

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“…12 These results were comparable to the postoperative CSF leak incidence after standard transsphenoidal or open transcranial approaches, 2,27-29 and lower than various other endoscopic closure methods. [3][4][5]10 Other groups have demonstrated reproducible results with the gasket seal technique. 30,31 Despite its advantages, the gasket seal technique poses some technical difficulties for the surgeon.…”

Section: Discussionmentioning

confidence: 97%

“…As displayed in the literature, numerous options for skull base reconstruction after endoscopic endonasal surgery, including both autologous and synthetic materials, have been described to date. [1][2][3][4][5][6][7][8][9][10][11] The primary goal of skull base reconstruction, regardless of surgical technique, includes watertight separation of the intracranial and sinonasal cavities. Failure to achieve these reconstructive goals can result in life-threatening complications such as CSF leak, meningitis, or tension pneumocephalus.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8][9][10][11] Many of these methods evolved from lessons learned from microscopic transsphenoidal approaches and incorporate a wide a range of surgical materials, including autologous fascia, muscle, fat, and bone, as well as various synthetic materials and tissue sealants for multilayered closure. The goal of reconstruction is to reduce the incidence of postoperative complications, such as infection and cerebrospinal fluid (CSF) leak.…”

Section: Introduction Backgroundmentioning

confidence: 99%

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One-Piece Modified Gasket Seal Technique

Wessell¹,

Singh²,

Litvack³

2013

J Neurol Surg B

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“…Traditionally, transcranialtransbasal, extended frontal, transmaxillary, and transoral approaches are performed for lower clival lesions (2), but recent advances in endoscopic endonasal surgery have contributed to the application of midline skull base surgery. Some clival chordoma series by extended endoscopic endonasal approaches have been reported (5,7,12,17), but have not sufficiently described the surgical procedure and management of the lower clival tumor. We report herein a case of lower clival chondroid chordoma, focusing on the surgical procedure and management by endoscopic endonasal surgery.…”

Section: Introductionmentioning

confidence: 99%

Endoscopic management of a lower clival chondroid chordoma: case report

Komatsu

Komatsu²,

Tsugu³

et al. 2010

Turkish Neurosurgery

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We report herein a case of lower clival chondroid chordoma, focusing on the surgical procedure of endoscopic endonasal surgery. A 36-yearold woman presented with progressive headache, right shoulder pain, and right hypoglossal nerve palsy. Computed tomography (CT) and magnetic resonance (MR) imaging revealed an extradural tumor located in the lower clivus, including the anterior aspect of the foramen magnum, deeply compressing the medulla and upper cervical spinal cord. Endoscopic endonasal surgery was performed via two nostrils. Since the basiocciput was destroyed by the tumor, removal of the tumor allowed identification of the middle clivus superiorly, the anterior arch of the atlas inferiorly, and anteromedial parts of occipital condyles bilaterally without drilling the basiocciput. The tumor was removed except for laterally and inferiorly extended lesions. Pathological diagnosis was chondroid chordoma. Postoperative course was uneventful, and the patient was discharged without further neurological deterioration. Endonasal endoscopic surgery provided safe and reliable tumor resection for a lower clival lesion. We believe that this minimally invasive procedure should be considered as an alternative to traditional surgical treatment. KeywOrds: Endoscopic endonasal surgery, Chondroid chordoma, Lower clivus, Foramen magnum, Upper cervical ÖZBir olguda, alt klivusa yerleşmiş kondroid kordomanın endoskopik endonasal yol ile cerrahi tedavisi ele alınmıştır. Otuz altı yaşında kadın hasta, giderek artan başağrısı, sağ omuz ağrısı ve sağ hipoglossal sinir felci semptom ve bulguları ile hastanemize kabul edildi. Bilgisayarlı tomografi ve manyetik resonans görüntüleme çalışmasında alt klivus ve foramen magnumun anterior kenarını ekstradural olarak doldurmuş medulla ve üst servikal spinal korda bası yapan kitle lkezyonu görülmüştür. Her iki nostril kullanılarak nasal endoskopik cerrahi yapıldı. Basioksiput tümör tarafından harap edildiği için, tümörün çıkarılması ile klivusun orta kesimine üstten, atlasın anterior arkına alttan ve oksipital kondillerin anteromedial kesimlerine iki taraflı olarak cerrahi diril kullanılmadan ulaşıldı. Alt dışa uzanım gösteren tümöral yapı dışındaki tümör dokuları çıkarıldı. Patolojik tanı kondroid kordoma olarak geldi. Ameliyat sonrası dönemde ek sorunu olmayan hasta ek nörolojik defisit oluşmadan taburcu edildi. Endoskopik nasal cerrahi yöntem ile alt klival lezyonlar güvenli bir şekilde çıkarılabilmektedir. Bizim düşüncemize göre; minimal invaziv girişimler geleneksel cerrahi yöntemlere bir seçenek olarak düşünülmelidir.

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The Endoscopic Transnasal Transsphenoidal Approach for the Treatment of Cranial Base Chordomas and Chondrosarcomas

Abstract: The flexibility of this new technique with respect to the classical microscopic transsphenoidal approach permits us to widen the horizon of surgical management of aggressive cranial base tumors such as clival chordomas and chondrosarcomas.

Cited by 154 publications

References 29 publications

Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

One-Piece Modified Gasket Seal Technique

Endoscopic management of a lower clival chondroid chordoma: case report

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