The management of clival chordomas: an Italian multicentric study

Abstract

OBJECTIVEIn the last 2 decades, the endoscopic endonasal approach in the treatment of clival chordomas has evolved to be a viable strategy to achieve maximal safe resection of this tumor. Here, the authors present a multicentric national study, intending to analyze the evolution of this approach over a 20-year time frame and its contribution in the treatment of clival chordomas.METHODSClival chordoma cases surgically treated between 1999 and 2018 at 10 Italian neurosurgical departments were included in this retrospective study. Clinical, radiological, and surgical findings, adjuvant therapy, and outcomes were evaluated and compared according to classification in the treatment eras from 1999 to 2008 and from 2009 to 2018.RESULTSOne hundred eighty-two surgical procedures were reviewed, with an increase in case load since 2009. The endoscopic endonasal transclival approach (EETA) was performed in 151 of 182 cases (83.0%) and other approaches were performed in 31 cases (17%). There was an increment in the use of EETA, neuronavigation, and Doppler ultrasound after 2008. The overall postoperative complication rate was 14.3% (26 of 182 cases) consisting of 9 CSF leaks (4.9%), 7 intracranial hemorrhages (3.8%), 5 cases of meningitis (2.7%), and 5 cerebral ischemic injuries (2.7%). Gross-total resection (GTR) was achieved in 93 of 182 cases (51.1%). Extent of resection (EOR) improved in the second era of the study. Signs and/or symptoms at presentation worsened in 27 cases (14.8%), and the Katz Index worsened in 10 cases (5.5%). Previous treatment, dural involvement, EETA, and intraoperative Doppler ultrasound correlated with GTR. Patients received adjuvant proton beam radiation in 115 of 182 cases (63.2%), which was administered more in the latter era. Five-year progression-free survival (PFS) and overall survival (OS) were 62.3% and 73.5%, respectively. GTR, EETA, proton beam therapy, and the chondroid subtype correlated with a better survival rate. The mean follow-up was 62 months.CONCLUSIONSThrough multicentric data collection, this study encompasses the largest series in the literature of clival chordomas surgically treated through an EETA. An increase in the use of this approach was found among Italian neurosurgical departments together with an improved extent of resection over time. The satisfactory rate of GTR was marked by low surgical morbidity and the preservation of patient quality of life. Surgical outcome was reinforced, in terms of PFS and OS, by the use of proton beam therapy, which was increasingly performed along the period of study.

Long Follow-up Surgical Results in 284 Cases of Clival Chordomas: The Risk Factors for Outcome and Tumor Recurrence

“…We found no signi cant difference, which is consistent with several studies [32,2]. Several previous studies showed that dural penetration [37,7] and age [29,5] were associated with long-term outcomes, and we demonstrated that they were not independent risk factors after multivariate analysis [23,36].…”

“…Dedifferentiated subtype, history of RT, lack of postsurgical RT, and metastasis increased the risk of both shorter survival and recurrence, which has been shown by previous studies [9, 17, 10, 5, 34]. However, it is controversial whether different survival rates exist between conventional and chondroid types [29,7]. We found no signi cant difference, which is consistent with several studies [32,2].…”

“…Tumors in the lower clivus have the lowest GTR rate [14,17,6,4]. Not surprisingly, history of surgery, large tumor volume and tumor location are independent risk factors for GTR, as supported by previous studies [30,14,17,26,7].…”

“…Because EMA is the shortest route to the tumor and majority of SBCs located in the midline region [10,23,26]. we agree that EMA is appropriate for most SBCs [7]. To achieve maximal resection, MLOA was still required in selected cases.…”

Systematic Review Comparing Open versus Endoscopic Surgery in Clival Chordomas and a 10-Year Single-Center Experience

“…8,18 For open surgery, four out of seven articles provided GTR definitions, all of which used postoperative MRI. [34][35][36][37] Rate of GTR was a mean 10% higher in the endoscopic group compared to the open surgery group (51.9 vs. 41.7%). This was still apparent when only using articles that defined GTR (52.0 vs. 41.5%) and when excluding the papers that did not define postoperative MRI ( In terms of complications, most papers provided some information regarding rates of either cranial nerve injury CSF leak or meningitis.…”