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Agosti E, Alexander AY, Leonel LCPC, Gompel JJV, Link MJ, Choby G, Pinheiro-Neto CD, Peris-Celda M. Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Middle-Inferior Clivectomy, Odontoidectomy, and Far-Medial Approach. J Neurol Surg B Skull Base 2024; 85:526-539. [PMID: 39228882 PMCID: PMC11368465 DOI: 10.1055/a-2114-4660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/19/2023] [Indexed: 09/05/2024] Open
Abstract
Introduction The clival, paraclival, and craniocervical junction regions are challenging surgical targets. To approach these areas, endoscopic endonasal transclival approaches (EETCAs) and their extensions (far-medial approach and odontoidectomy) have gained popularity as they obviate manipulating and working between neurovascular structures. Although several cadaveric studies have further refined these contemporary approaches, few provide a detailed step-by-step description. Thus, we aim to didactically describe the steps of the EETCAs and their extensions for trainees. Methods Six formalin-fixed cadaveric head specimens were dissected. All specimens were latex-injected using a six-vessel technique. Endoscopic endonasal middle and inferior clivectomies, far-medial approaches, and odontoidectomy were performed. Results Using angled endoscopes and surgical instruments, an endoscopic endonasal midclivectomy and partial inferior clivectomy were performed without nasopharyngeal tissue disruption. To complete the inferior clivectomy, far-medial approach, and partially remove the anterior arch of C1 and odontoid process, anteroinferior transposition of the Eustachian-nasopharynx complex was required by transecting pterygosphenoidal fissure tissue, but incision in the nasopharynx was not necessary. Full exposure of the craniocervical junction necessitated bilateral sharp incision and additional inferior mobilization of the posterior nasopharynx. Unobstructed access to neurovascular anatomy of the ventral posterior fossa and craniocervical junction was provided. Conclusion EETCAs are a powerful tool for the skull-base surgeon as they offer a direct corridor to the ventral posterior fossa and craniocervical junction unobstructed by eloquent neurovasculature. To facilitate easier understanding of the EETCAs and their extensions for trainees, we described the anatomy and surgical nuances in a didactic and step-by-step fashion.
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Affiliation(s)
- Edoardo Agosti
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - A. Yohan Alexander
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Luciano C. P. C. Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Jamie J. Van Gompel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Garret Choby
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Carlos D. Pinheiro-Neto
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
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Li L, Wei KL, Liu MS, Wang QL, Zeng TF, Chen RZ, Xia XW, Zhang HT. Hematoporphyrin derivative-mediated photodynamic techniques for the diagnosis and treatment of chordoma. Photodiagnosis Photodyn Ther 2024; 48:104231. [PMID: 38821238 DOI: 10.1016/j.pdpdt.2024.104231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/10/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Chordoma is a rare congenital low-grade malignant tumor characterized by infiltrative growth. It often tends to compress important intracranial nerves and blood vessels, making its surgical treatment extremely difficult. Besides, the efficacy of radiotherapy and chemotherapy is limited. The photosensitizer hematoporphyrin derivative (HPD) can emit red fluorescence under 405 nm excitation and produce reactive oxygen species for tumor therapy under 630 nm excitation. Herein, we investigated the effects of the photosensitizer hematoporphyrin derivative (HPD) on different cell lines of chordoma and xenograft tumors under 405 nm and 630 nm excitation. METHODS The photosensitizer hematoporphyrin derivative (HPD) and Two different chordoma cell lines (U-CH1, JHC7) were used for the test. The in vitro experiments were as follows: (1) the fluorescence intensity emitted by chordoma cells excited by different 405 nm light intensities was observed under a confocal microscope; (2) the Cell Counting Kit-8 (CCK-8) assay was performed to detect the effects of different photosensitizer concentrations and 630 nm light energy densities on the activity of chordoma cells. In the in vivo experiments, (3) Fluorescence visualization of chordoma xenograft tumors injected with photosensitizer via tail vein under 405 nm excitation; (4) Impact of 630 nm excitation of photosensitizer on the growth of chordoma xenograft tumors. RESULTS (1) The photosensitizers in chordoma cells and chordoma xenografts of nude mice were excited by 405 nm to emit red fluorescence; (2) 630 nm excitation photosensitizer reduces chordoma cell activity and inhibits chordoma xenograft tumor growth in chordoma nude mice. CONCLUSION Photodynamic techniques mediated by the photosensitizer hematoporphyrin derivatives can be used for the diagnosis and treatment of chordoma.
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Affiliation(s)
- Lei Li
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, 541001 Guilin, China
| | - Kai-Lun Wei
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, 541001 Guilin, China
| | - Ming-Song Liu
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, 541001 Guilin, China
| | - Qi-Lin Wang
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, 541001 Guilin, China
| | - Tong-Fei Zeng
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, 541001 Guilin, China
| | - Rui-Zhe Chen
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, 541001 Guilin, China
| | - Xue-Wei Xia
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, 541001 Guilin, China
| | - Hong-Tian Zhang
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, 541001 Guilin, China.
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Brown NJ, Gendreau J, Kuo CC, Nguyen O, Yang C, Catapano JS, Lawton MT. Assessing survival outcomes and complication profiles following surgical excision and radiotherapy as interventions for skull base chordoma: a systematic review of operative margins and surgical approaches. J Neurooncol 2023; 165:41-51. [PMID: 37880419 DOI: 10.1007/s11060-023-04477-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/08/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Despite their precarious behavioral classification (benign and low grade on histopathology yet behaviorally malignant), great strides have been taken to improve prognostication and treatment paradigms for patients with skull base chordoma. With respect to surgical techniques, lateral transcranial (TC) approaches have traditionally been used, however endoscopic endonasal approaches (EEA) have been advocated for midline lesions. Nonetheless, due to the rarity of this pathology (0.2% of all intracranial neoplasms), investigations within the literature remain limited to small retrospective series. Furthermore, radiotherapeutic treatments investigated to date have proven largely ineffective. METHODS Accordingly, we performed a systematic review in order to profile surgical and survival outcomes for skull base chordoma. Fixed and random-effect meta-analyses were performed for categorical variables including GTR, STR, 5-year OS, 10-year OS, 5-year PFS, and 10-year PFS. Additionally, we pooled eligible studies for formal meta-analysis to compare outcomes by surgical approach (lateral versus midline). Statistical analyses were performed using R Studio 'metafor' package or Cochrane Review Manager. Furthermore, meta-analysis of pooled mortality rates and sub-analyses of operative margin and surgical complications were used to compare midline versus lateral approaches via the Mantel-Haenszel method. We considered all p-values < 0.05 to be statistically significant. RESULTS Following the systematic search and screen, 55 studies published between 1993 and 2022 reporting data for 2453 patients remained eligible for analysis. Sex distribution was comparable between males and females, with a slight predominance of male-identifying patients (0.5625 [95% CI: 0.5418; 0.3909]). Average age at diagnosis was 42.4 ± 12.5 years, while average age of treatment initiation was 43.0 ± 10.6 years. Overall, I2 value indicated notable heterogeneity across the 55 studies [I2 = 56.3% (95%CI: 44.0%; 65.9%)]. With respect to operative margins, the rate of GTR was 0.3323 [95% CI: 0.2824; 0.3909], I2 = 91.9% [95% CI: 90.2%; 93.4%], while the rate of STR was significantly higher at 0.5167 [95% CI: 0.4596; 0.5808], I2 = 93.1% [95% CI: 91.6%; 94.4%]. The most common complication was CSF leak (5.4%). In terms of survival outcomes, 5-year OS rate was 0.7113 [95% CI: 0.6685; 0.7568], I2 = 91.9% [95% CI: 90.0%; 93.5%]. 10-year OS rate was 0.4957 [95% CI: 0.4230; 0.5809], I2 = 92.3% [95% CI: 89.2%; 94.4%], which was comparable to the 5-year PFS rate of 0.5054 [95% CI: 0.4394; 0.5813], I2 = 84.2% [95% CI: 77.6%; 88.8%] and 10-yr PFS rate of 0.4949 [95% CI: 0.4075; 0.6010], I2 = 14.9% [95% CI: 0.0%; 87.0%]. There were 55 reported deaths for a perioperative mortality rate of 2.5%. The relative risk for mortality in the midline group versus the lateral approach group did not indicate any substantial difference in survival according to laterality of approach (-0.93 [95% CI: -1.03, -0.97], I2 = 95%, (p < 0.001). CONCLUSION Overall, these results indicate good 5-year survival outcomes for patients with skull base chordoma; however, 10-year prognosis for skull base chordoma remains poor due to its radiotherapeutic resistance and high recurrence rate. Furthermore, mortality rates among patients undergoing midline versus lateral skull base approaches appear to be equivocal.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Julian Gendreau
- Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| | - Cathleen C Kuo
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Oanh Nguyen
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Chenyi Yang
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ, 85013, USA.
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Gendreau JL, Hameed NUF, Jimenez A, Chakravarti S, Mehkri Y, Mukherjee D. Fractionated Radiotherapy After Gross Total Resection of Clival Chordoma: A Systematic Review of Survival Outcomes. Neurosurgery 2023; 93:257-266. [PMID: 36826997 DOI: 10.1227/neu.0000000000002418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/21/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Current treatment guidelines for clival chordomas recommend surgical resection followed by high-dose radiotherapy (RT). However, in patients in whom gross total resection (GTR) is achieved, the benefits of additional RT remain unclear. OBJECTIVE To investigate whether RT offers any benefit to progression-free survival (PFS) in patients undergoing GTR of clival chordoma by performing a systematic review of all currently published literature. METHODS A total of 5 databases were searched to include all studies providing data on GTR ± RT for clival chordomas (January 1990-June 2021). Qualitative assessment was performed with Newcastle-Ottawa Scale guidelines for assessing quality of nonrandomized studies. Statistical analysis using individualized patient data of PFS was performed. RESULTS The systematic search yielded 2979 studies, weaned to 22 full-text articles containing 108 patients. All patients underwent GTR of clival chordoma, with 46 (43%) patients receiving adjuvant RT. Mean PFS for RT patients was 31.09 months (IQR: 12.25-37.75) vs 54.92 months (IQR: 14.00-85.75) in non-RT patients. Overall, RT did not increase PFS (HR 0.320, P = .069) to a value that achieved statistical significance. Stratifying by photon therapy vs particle beam therapy yielded no statistically significant benefit for particle beam therapy for PFS ( P = .300). Of patients with age ≥65 years, RT did not improve outcomes to statistical significance for PFS (HR 0.450, P = .481). Patients age ≥65 years had lower PFS on both bivariate analysis (HR 3.708, P = .007) and multivariate analysis (HR 3.322, P = .018). CONCLUSION After achieving GTR of clival chordoma, fractionated RT offers unclear benefit upon survival outcomes.
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Affiliation(s)
- Julian L Gendreau
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - N U Farrukh Hameed
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adrian Jimenez
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sachiv Chakravarti
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yusuf Mehkri
- Department of Neurosurgery, University of Florida School of Medicine, Jacksonville, Florida, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Gupta KK, Balai E, Darr A, Jolly K. Reconstruction and Cerebrospinal Fluid Leaks in Endoscopic Endonasal Approach for the Management of Clival Chordomas-A Systematic Review. Indian J Otolaryngol Head Neck Surg 2022; 74:4807-4815. [PMID: 36742692 PMCID: PMC9895481 DOI: 10.1007/s12070-022-03114-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/25/2022] [Indexed: 02/07/2023] Open
Abstract
The success of the endoscopic endonasal approach (EEA) to surgically manage clival chordomas (CC) relies on robust repair methods to reduce complications, such as cerebrospinal fluid (CSF) leaks. Our study aims to evaluate the existing literature to assess reconstructive techniques utilised and post-operative CSF leak rates in this cohort. A systematic review and analysis was performed of all published data related to CC patients managed with an EEA. A total of 24 articles were included, representing 363 patients and 396 procedures. A variety of reconstruction methods were used with 95.9% of studies using an intracranial repair graft, 70.8% using a nasoseptal flap (NSF), 62.5% using glue/haemostat, 58.3% using nasal packs and 75.0% employing multi-layered reconstruction. Post-operative CSF leak rate was 10.1%. The leak rate was less in subgroups where a NSF was used (9.4%) although this was not statistically significant (p = 0.273). There were no differences in leak rates when glue/haemostat (p = 0.139) or nasal packs (p = 0.550) were used. Our review is the most up-to-date synthesis of the existing literature surrounding the EEA to CCs assessing reconstruction and post-operative CSF leaks. It demonstrates most authors employ a multi-layered reconstruction method. The lack of statistical significance observed for CSF leaks in subgroups is likely due to a variety of cofounding surgeon and patient factors. Higher quality prospective randomised multi-centric studies, with reporting of specific repair techniques will enable future systematic reviews to provide a more accurate consensus regarding optimal methods of reconstruction in this field.
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Affiliation(s)
- Keshav Kumar Gupta
- Department of Surgery, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Hallam Street, West Bromwich, B71 4HJ UK
| | - Edward Balai
- Department of Surgery, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Hallam Street, West Bromwich, B71 4HJ UK
| | - Adnan Darr
- Department of Otorhinolaryngology, New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, WV10 0QP UK
| | - Karan Jolly
- Department of Otorhinolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH UK
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Expanded endoscopic endonasal transsphenoidal approach to determine morphological characteristics and clinical considerations of the cavernous sinus venous spaces. Sci Rep 2022; 12:16794. [PMID: 36202967 PMCID: PMC9537152 DOI: 10.1038/s41598-022-21254-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 09/26/2022] [Indexed: 11/08/2022] Open
Abstract
The study aimed at investigating the morphological characteristics and interconnected regularities of the cavernous sinus (CS) venous spaces using an expanded endoscopic endonasal transsphenoidal approach. Surgical dissections were performed for 15-colored silicon-injected human head specimens. The CS venous spaces were examined for their morphological and clinical characteristics using an expanded endoscopic endonasal transsphenoidal approach. The intracavernous course of the internal carotid artery (ICA) divided the CS venous spaces into four interconnected virtual compartments: medial, anteroinferior, posterosuperior, and lateral. The CS venous spaces had peculiar morphological characteristics; the medial compartment was C-shaped while the anteroinferior compartment resembled a boat's bow. The mean distances from the medial border of the inferior horizontal segment of cavernous ICA to the mid-line of the pituitary gland (PG) were 6.07 ± 1.61 mm (left) and 5.97 ± 1.89 mm (right); the mean distances from the medial border of the subarachnoid segment of cavernous ICA to the mid-line of the PG were 5.77 ± 1.16 mm (left) and 5.63 ± 1.17 mm (right); the mean distances from the medial border of the anterior vertical segment of cavernous ICA to the mid-line of the PG were 10.27 ± 1.74 mm (left) and 10.47 ± 1.90 mm (right). Morphological characteristics and the knowledge of the interconnected regularities of the CS venous spaces may help surgeons accurately locate the neurovascular structure, and thus may contribute to the effective prediction of tumor invasion and extension during endoscopic CS surgery.
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Tamura R, Oda H, Kosugi K, Toda M. Surgical Planning and Simulation of Endonasal Endoscopic Surgery for Pituitary Adenoma With Cavernous Sinus Invasion. Oper Neurosurg (Hagerstown) 2022; 23:e276-e282. [PMID: 36001763 DOI: 10.1227/ons.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Transsphenoidal endoscopic endonasal surgery (EES) provides effective treatment for patients with lesions of the sella turcica. The endoscopic technique requires different instrumentation, which depends on the gross anatomy of the nasal cavity. The treatment of lateral lesions is more challenging in EES. OBJECTIVE To evaluate the effect of preoperative simulation using multiple anatomic landmarks. METHODS Pre- and postoperative tumor volumes were analyzed in 33 patients with nonfunctioning pituitary adenomas who underwent EES (Knosp grades 3 and 4). The surgical working angle and space were three-dimensionally simulated at the plane of the anterior/posterior surgical field (tuberculum sellae/posterior clinoid process) using multiple anatomic landmarks of high-resolution computed tomography scans, such as nasal piriform aperture (proximal surgical corridor), and the width of bilateral vidian canals or lamina perpendicularis of palatine bone (distal surgical corridor). Receiver operating characteristic curves for the removed tumor volume were used to determine the cutoff value for the simulated working angle and space. RESULTS Simulated working space at the plane of tuberculum sellae using piriform aperture and lamina perpendicularis of palatine bone was associated with the removed tumor volume in the cavernous sinus. Patients with a larger working space (≥42.7 mm) significantly showed a higher removed tumor volume ( P = .023). There was no relationship between other parameters and the removed tumor volume. CONCLUSION A new method to predict the surgical field for cavernous sinus lesions around sella turcica was successfully established. Further studies are needed to define and expand applications of this simulation method.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
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8
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Wang B, Li Q, Sun Y, Tong X. Surgical Strategy for Skull Base Chordomas : Transnasal Midline Approach or Transcranial Lateral Approach. J Korean Neurosurg Soc 2022; 65:457-468. [PMID: 35286801 PMCID: PMC9082126 DOI: 10.3340/jkns.2021.0187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE The clinical management paradigm of skull base chordomas is still challenging. Surgical resection plays an important role of affecting the prognosis. Endonasal endoscopic approach (EEA) has gradually become the preferred surgical approach in most cases, but traditional transcranial surgery cannot be completely replaced. This study presents a comparison of the results of the two surgical strategies and a summary of the treatment algorithms for skull base chordomas. METHODS We retrospectively analyzed the surgical outcomes and follow-up data of 48 patients with skull base chordomas diagnosed pathologically who received transnasal midline approaches (TMA) and transcranial lateral approaches (TLA) from 2010 to 2020. RESULTS Among the 48 patients, 36 cases were adopted TMA and 12 cases were performed with TLA. In terms of gross total resection (GTR) rate, 27.8% in TMA and 16.7% in TLA and with EEA alone it was increased to 38.9%, while 29.7% in primary surgery. In TMA, the cerebrospinal fluid (CSF) leak remains the most common complication (13 cases, 36.1%), other main complications included death, cranial nerve palsy, hypopituitarism, all the comparisons were no statistical significance. The Karnofsky Performance Scale scores in TMA were all better than those in TLA at different time, and the overall survival (OS) and recurrence free survival/progression free survival was just the reverse. CONCLUSION The EEA for skull base chordomas resection has improved the GTR rate, but transcranial approach is still an alternative approach. It is necessary to select an appropriate surgical approach based on the location and the pattern of tumor growth in order to obtain the best surgical outcomes.
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Affiliation(s)
- Benlin Wang
- School of Medicine, Nankai University, Tianjin, China
| | - Qi Li
- School of Medicine, Nankai University, Tianjin, China
| | - Yang Sun
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Xiaoguang Tong
- School of Medicine, Nankai University, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
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Baldassarre BM, Di Perna G, Portonero I, Penner F, Cofano F, Marco RD, Marengo N, Garbossa D, Pecorari G, Zenga F. Craniovertebral junction chordomas: Case series and strategies to overcome the surgical challenge. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:420-431. [PMID: 35068826 PMCID: PMC8740819 DOI: 10.4103/jcvjs.jcvjs_87_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/28/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction: Chordomas are rare and malignant primary bone tumors. Different strategies have been proposed for chordomas involving the craniovertebral junction (CVJ) compared to other locations. The impossibility to achieve en bloc excision, the impact on stability and the need for proper reconstruction make their surgical management challenging. Objective: The objective is to discuss surgical strategies in CVJ chordomas operated in a single-center during a 7 years' experience (2013-2019). Methods: Adult patients with CVJ chordoma were retrospectively analyzed. The clinical, radiological, pathological, and surgical data were discussed. Results: A total number of 8 patients was included (among a total number of 32 patients suffering from skull base chordoma). Seven patients underwent endoscopic endonasal approach (EEA), and posterior instrumentation was needed in three cases. Three explicative cases were reported: EEA for midline tumor involving lower clivus and upper cervical spine (case 1), EEA and complemental posterior approach for occurred occipitocervical instability (case 2), C2 chordoma which required aggressive bone removal and consequent implant positioning, focusing on surgical planning (timing and type of surgical stages, materials and customization of fixation system) (case 3). Conclusion: EEA could represent a safe route to avoid injuries to neurovascular structure in clival locations, while a combined approach could be considered when tumor spreads laterally. Tumor involvement or surgical procedures could give raise to CVJ instability with the need of complementary posterior instrumentation. Thus, a tailored preoperative planning should play a key role, especially when aggressive bone removal and implant positioning are needed.
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Affiliation(s)
- Bianca Maria Baldassarre
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Irene Portonero
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Federica Penner
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy.,Spine Surgery Unit, Humanitas Cellini Hospital, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy.,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Raffaele De Marco
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Nicola Marengo
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giancarlo Pecorari
- Department of Surgical Sciences, ENT Surgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
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Mattavelli D, Fiorentino A, Tengattini F, Colpani A, Agnelli S, Buffoli B, Ravanelli M, Ferrari M, Schreiber A, Rampinelli V, Taboni S, Verzeletti V, Deganello A, Rodella LF, Maroldi R, Ceretti E, Sartore L, Piazza C, Fontanella MM, Nicolai P, Doglietto F. Additive Manufacturing for Personalized Skull Base Reconstruction in Endoscopic Transclival Surgery: A Proof-of-Concept Study. World Neurosurg 2021; 155:e439-e452. [PMID: 34450324 DOI: 10.1016/j.wneu.2021.08.080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic transnasal transclival intradural surgery is limited by a high postoperative cerebrospinal fluid leak rate. The aim of this study was to investigate the role of three-dimensional printing to create a personalized, rigid scaffold for clival reconstruction. METHODS Two different types of clivectomy were performed in 5 specimens with the aid of neuronavigation, and 11 clival reconstructions were simulated. They were repaired with polylactide, three-dimensional-printed scaffolds that were manually designed in a computer-aided environment based either on the real or on the predicted defect. Scaffolds were printed with a fused filament fabrication technique and different offsets. They were positioned and fixed either following the gasket seal technique or with screws. Postdissection radiological evaluation of scaffold position was performed in all cases. In 3 specimens, the cerebrospinal fluid leak pressure point was measured immediately after reconstruction. RESULTS The production process took approximately 30 hours. The designed scaffolds were satisfactory when no offset was added. Wings were added during the design to allow for screw positioning, but broke in 30% of cases. Radiological assessment documented maximal accuracy of scaffold positioning when the scaffold was created on the real defect; accuracy was satisfactory when the predicted clivectomy was performed under neuronavigation guidance. The cerebrospinal fluid leak pressure point was significantly higher when the scaffold was fixed with screws compared with the gasket technique. CONCLUSIONS In this preclinical setting, additive manufacturing allows the creation of customized scaffolds that are effective in reconstructing even large and geometrically complex clival defects.
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Affiliation(s)
- Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Fiorentino
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Francesco Tengattini
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessandro Colpani
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Silvia Agnelli
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Stefano Taboni
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Vincenzo Verzeletti
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alberto Deganello
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Fabrizio Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Elisabetta Ceretti
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Luciana Sartore
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Cesare Piazza
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
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11
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Abstract
ABSTRACT Surgical removal of pterygopalatine fossa (PPF) tumors with endoscopic endonasal approach is still challenging. The present study aimed to evaluate our endoscopic endonasal management of PPF tumors based on the tumor pathology and purpose of the surgery. This comprised both a single nostril approach for biopsy and a binostril approach for complete resection of benign and noninfiltrating tumors. Based on this strategy, 12 patients underwent endoscopic endonasal surgery for PPF tumors between 2013 and 2018. The patients' data were analyzed retrospectively to demonstrate the significance of our treatment scheme. The surgery was terminated only after taking a biopsy specimen in 6 patients. Other 6 patients underwent gross total resection or bulk tumor reduction. Final pathological diagnosis was malignant in 6 cases and benign in the remaining 6. Post-operative treatment was needed in 7 patients. Four operations for the 6 patients who underwent either debulking or radical surgery were performed by the binostril approach; while 5 surgeries for the 6 biopsy patients were performed by the single nostril approach. Postoperative complications were tolerable. Endoscopic resection should be adopted preferentially for benign tumors that can be removed in a piecemeal fashion. However, as most malignant tumors were impossible to resect with a negative margin, priority should be given to tumor biopsy using an endoscopic approach, which is less invasive than an open approach, and an appropriate treatment customized to the pathological diagnosis should be administered.
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12
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Hasegawa H, Shin M, Makita N, Shinya Y, Kondo K, Saito N. Delayed Postoperative Hyponatremia Following Endoscopic Transsphenoidal Surgery for Non-Adenomatous Parasellar Tumors. Cancers (Basel) 2020; 12:cancers12123849. [PMID: 33419307 PMCID: PMC7766216 DOI: 10.3390/cancers12123849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/08/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022] Open
Abstract
Little is known about delayed postoperative hyponatremia (DPH) accompanied with transsphenoidal surgery for non-adenomatous skull base tumors (NASBTs). Consecutive data on 30 patients with parasellar NASBT was retrospectively reviewed with detailed analyses on perioperative serial sodium levels. Serological DPH (sodium ≤ 135 mmol/L) was observed in eight (27%), with four (13%) of them being symptomatic. DPH developed on postoperative day 7-12 where the mean sodium levels were 134 mmol/L (a mean of 7 mmol/L drop from the baseline) in asymptomatic and 125 mmol/L (a mean of 17.5 mmol/L drop from the baseline) in symptomatic DPH. Serological DPH was accompanied with "weight loss and hemoconcentration (cerebral salt wasting type)" in four (50%), "weight gain and hemodilution (syndrome of inappropriate antidiuretic hormone secretion type)" in three (38%), and no significant weight change in one. Intraoperative extradural retraction of the pituitary gland was the only significant factor for serological DPH (p = 0.035; odds ratio, 12.25 (95% confidence interval, 1.27-118.36)). DPH should be recognized as one of the significant postsurgical complications associated with TSS for NASBTs. Although the underlying mechanism is still controversial, intraoperative extradural compression of the pituitary gland and subsequent dysregulation of the hypothalamo-hypophyseal axis may be responsible.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan; (H.H.); (Y.S.); (N.S.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan; (H.H.); (Y.S.); (N.S.)
- Correspondence: ; Tel.: +81-3-5800-8853
| | - Noriko Makita
- Department of Endocrinology and Nephrology, The University of Tokyo Hospital, Tokyo 113-8655, Japan;
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan; (H.H.); (Y.S.); (N.S.)
| | - Kenji Kondo
- Department of Otolaryngology, The University of Tokyo Hospital, Tokyo 113-8655, Japan;
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan; (H.H.); (Y.S.); (N.S.)
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13
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Zweckberger K, Giese H, Haenig B, Federspil PA, Baumann I, Albrecht T, Uhl M, Unterberg A. Clivus chordomas: Heterogeneous tumor extension requires adapted surgical approaches. Clin Neurol Neurosurg 2020; 199:106305. [PMID: 33091655 DOI: 10.1016/j.clineuro.2020.106305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/01/2020] [Accepted: 10/11/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Clivus chordomas are semi-malignant, but infiltratively growing tumors. Currently, a widely-accepted treatment concept encompasses maximal, but safe, surgical resection and radiotherapy. Caused by the size and the tumor extension, different surgical approaches, especially in recurrent cases, might be necessary. METHODS Retrospective review of 50 patients on whom 70 surgeries were performed: 29 in primary and 41 in recurrent cases. Based on MRI images, all cases were asserted according to the size and the extension of the tumor. Used surgical approaches were evaluated. Postoperative complications, neurological function prior to and after the surgery, the extent of tumor resection on postoperative MR images were assessed and progression-free survival was calculated. RESULTS Tumor size was estimated as small (< 5 cm3) in 8, as medium (5-20 cm3) in 21, as large (20-100 cm3) in 17, and as giant (> 100 cm3) in 4 patients. Most frequently used surgical approaches in primary cases were the transsphenoidal one and midfacial degloving (51.7 % and 17.2 %, respectively). In recurrent cases, dependent on the tumor extension, transsphenoidal (21.9 %), retrosigmoidal (29.3 %), and pterional (19.5 %) approaches, as well as midfacial degloving (17.1 %) were used. Due to the vast tumor extension and infiltration, gross total or near total resection could be achieved in 12 patients (24 %), only. There was no mortality and no major complications in primary cases. In recurrences, however, postoperative hemorrhages and strokes emerged in 4.9 % and 7.1 %. Minor complications occurred in 17.1 % and were dominated by CSF leaks (12.2 %), both in primary in recurrent cases. While most cranial nerve impairments were caused by tumor infiltration of the cavernous sinus, and hence have not improved by treatment, the sixth nerve palsy as a consequence of tumor mass compression, could significantly be improved by surgery. Following surgery, patients were subjected to radiotherapy (68.9 % for primary cases, and 36.6 % for recurrences) mainly with carbon ions. Overall, 5-year progression-free survival was 44.7 %. CONCLUSION Caused by the heterogenous pattern of growth of clivus chordomas, surgical approaches should be chosen individually. Vast and infiltrative tumor extension constitute major limitations of surgical resection, and hence result in poor progression-frees survival.
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Affiliation(s)
| | - Henrik Giese
- Department of Neurosurgery, University of Heidelberg, Germany
| | - Benjamin Haenig
- Department of Neurosurgery, University of Heidelberg, Germany
| | - Philippe A Federspil
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Heidelberg, Germany
| | - Ingo Baumann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Heidelberg, Germany
| | - Tobias Albrecht
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Heidelberg, Germany
| | - Matthias Uhl
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
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14
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Surgical Outcomes with Midline versus Lateral Approaches for Cranial Base Chordomas: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 140:378-388.e2. [DOI: 10.1016/j.wneu.2020.03.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 12/15/2022]
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15
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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16
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Beer-Furlan A, Vellutini EDAS, Balsalobre L, Stamm AC. Endoscope-Assisted Middle Fossa Approach: Optimizing the Surgical Corridor for the Resection of Multicompartmental Chordomas. J Neurol Surg B Skull Base 2020; 82:e172-e178. [PMID: 34306933 DOI: 10.1055/s-0040-1702218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/10/2020] [Indexed: 10/24/2022] Open
Abstract
Background Skull base chordomas are a major therapeutic challenge. The surgical management involves selecting an approach that will offer the patient the best chance of largest/complete removal while minimizing morbidity and mortality. Methods Medical records and imaging review of two skull base chordomas involving the middle fossa and posterior fossa that were successfully treated with an endoscope-assisted middle fossa approach. Results The use of angled endoscopes provided better identification of anatomical landmarks and improved tumor resection when compared with the microscopic surgical exposure. The approach selection, anatomical landmarks, and technical aspects of the intraoperative setting of the endoscope-assisted approach are discussed. Conclusion Endoscopic assistance in the middle fossa approach is a safe and valuable tool for maximizing the reach of the surgical corridor when treating skull base chordomas.
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Affiliation(s)
- André Beer-Furlan
- São Paulo Skull Base Center, São Paulo, Brazil.,DFVneuro Neurosurgical Group, São Paulo, Brazil.,Department of Neurological Surgery, Rush University, Chicago, United States
| | | | - Leonardo Balsalobre
- São Paulo Skull Base Center, São Paulo, Brazil.,Department of Otolaryngology, São Paulo ENT Center, Hospital Professor Edmundo Vasconcelos, São Paulo, Brazil
| | - Aldo Cassol Stamm
- São Paulo Skull Base Center, São Paulo, Brazil.,Department of Otolaryngology, São Paulo ENT Center, Hospital Professor Edmundo Vasconcelos, São Paulo, Brazil
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17
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Transclival approaches for intradural pathologies: historical overview and present scenario. Neurosurg Rev 2020; 44:279-287. [PMID: 32060761 DOI: 10.1007/s10143-020-01263-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/29/2019] [Accepted: 02/06/2020] [Indexed: 12/17/2022]
Abstract
Recently, endoscopic transsphenoidal transclival approaches have been developed and their role is widely accepted for extradural pathologies. Their application to intradural pathologies is still debated, but is undoubtedly increasing. In the past five decades, different authors have reported various extracranial, anterior transclival approaches for intradural pathologies. The aim of this review is to provide a historical overview of transclival approaches applied to intradural pathologies. PubMed was searched in October 2018 using the terms transcliv*, cliv* intradural, transsphenoidal transcliv*, transoral transcliv*, transcervical transcliv*, transsphenoidal brainstem, and transoral brainstem. Exclusion criteria included not reporting reconstruction technique, anatomical studies, reviews without new data, and transcranial approaches. Ninety-one studies were included in the systematic review. Since 1966, transcervical, transoral, transsphenoidal microsurgical, and, recently, endoscopic routes have been used as a corridor for transclival approaches to treat intradural pathologies. Each approach presents a curve that follows Scott's parabola, with evident phases of enthusiasm that quickly faded, possibly due to high post-operative CSF leak rates and other complications. It is evident that the introduction of the endoscope has led to a significant increase in reports of transclival approaches for intradural pathologies. Various reconstruction techniques and materials have been used, although rates of CSF leak remain relatively high. Transclival approaches for intradural pathologies have a long history. We are now in a new era of interest, but achieving effective dural and skull base reconstruction must still be definitively addressed, possibly with the use of newly available technologies.
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18
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Karadag A, Senoglu M, Middlebrooks EH, Kinali B, Guvencer M, Icke C, Sayhan S, Karabay N, Camlar M, Olomu OU, Tanriover N. Endoscopic endonasal transclival approach to the ventral brainstem: Radiologic, anatomic feasibility and nuances, surgical limitations and future directions. J Clin Neurosci 2020; 73:264-279. [PMID: 32005412 DOI: 10.1016/j.jocn.2020.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/04/2020] [Indexed: 12/25/2022]
Abstract
The endoscopic endonasal transclival approach (EETA) is less invasive than traditional open approaches; however, there is currently limited data on the pre-operative features that may predict success of the EETA. Surgical landmarks and exposure of the EETA and expanded EETA are assessed. We retrospectively measured multiple anatomic features in 154 adult dry skulls, 22 C1 and C2 dry bone vertebrae, and 500 paranasal sinus computed tomography (CT) scans. We also dissected 13 formalin-fixed, silicone-injected adult cadaveric heads. Relevant qualitative and quantitative data were obtained with CT (n = 10) and cadaveric dissection (n = 13). They are expressed as mean (SD), as appropriate and compared with unpaired t tests. Categorical variables were compared with χ2 tests. We determined the prevalence of clival and sphenoid sinus anatomic variations and assessed potential exposure of the craniovertebral region, based on the relative position of the nasal bone tip, posterior point of the hard palate, and their relation to the position of C1 and C2. Depending on anatomic features, EETA should allow visualization of the ventral brainstem. The mean (SD) dimensions of the surgical window for EETA were 43.2 (5.1) × 18.3 (1.1) mm, in the craniocaudad and horizontal dimensions, respectively. The craniocaudad dimension enlarged to 60.2 (4.7) mm with expanded EETA. The EETA allowed satisfactory exposure for odontoid and C1 anterior arch resection (expanded EETA) in all specimens, regardless of the orientation of the palate. The combination of preoperative radiographic assessment and intraoperative considerations allows safe and effective application and facilitate selection of the most appropriate approach.
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Affiliation(s)
- Ali Karadag
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mehmet Senoglu
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey.
| | - Erik H Middlebrooks
- Division of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Burak Kinali
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Mustafa Guvencer
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Cigdem Icke
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Salih Sayhan
- Department of Anatomy, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Nuri Karabay
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Mahmut Camlar
- Department of Neurosurgery, Health Science University, Tepecik Research and Training Hospital, Izmir, Turkey
| | - Osarenoma U Olomu
- Department of Otorhinolaryngology/Audiology, Mayo Clinic, Jacksonville, FL, USA
| | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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19
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Yumiko Oishi, Tamura R, Takahashi S, Morimoto Y, Sato M, Horikoshi T, Hassaan S, Yoshida K, Toda M. A Comparative Study Between Traditional Microscopic Surgeries and Endoscopic Endonasal Surgery for Skull Base Chordomas. World Neurosurg 2019; 134:e1099-e1107. [PMID: 31785435 DOI: 10.1016/j.wneu.2019.11.113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 11/16/2019] [Accepted: 11/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Skull base chordomas (SBCs) are rare clinically aggressive neoplasms, developing local recurrences after surgical resection. Although SBCs have traditionally been resected by craniotomy or microscopic transsphenoidal surgery (TSS), the recent development of the endoscopic endonasal approach (EEA) has revolutionized treatment strategies through minimally invasive techniques. This study aimed to evaluate clinical outcomes after traditional microsurgeries or EEAs for SBCs. METHODS The present retrospective study investigated 66 patients with primary SBCs who underwent surgery between 1977 and 2019. Resection was performed via EEA in 17 cases, craniotomy in 23, transoral approach in 8, TSS in 12, staged surgery in 4, and others in 2. The median follow-up period for progression-free survival (PFS) was 19.5 months. RESULTS There were no significant differences in preoperative tumor volume or resection rate among these approaches. The incidence of postoperative cranial nerve palsy was significantly lower in EEA than that in craniotomy (P < 0.05). Although total resection was observed in 4 cases of EEA expanding into the superior and inferior part of the clivus, no cases of transoral approach or TSS achieved total resection for both parts. No significant difference in PFS was found among these approaches. Multivariate analysis showed that being female and the absence of radiotherapy were significantly associated with shorter PFS (P < 0.05 and P < 0.001, respectively). The resection rate was not associated with PFS. CONCLUSIONS EEA is a less invasive surgical approach for SBCs. The development of surgical instruments and postoperative radiotherapy will further improve patients' outcomes.
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Affiliation(s)
- Yumiko Oishi
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Satoshi Takahashi
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yukina Morimoto
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Tochigi Medical Center, Utsunomiya-shi, Tochigi, Japan
| | - Tomo Horikoshi
- Department of Neurosurgery, Tochigi Medical Center, Utsunomiya-shi, Tochigi, Japan
| | - Shady Hassaan
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan; Department of Neurosurgery, Assiut University, Assiut Governorate, Egypt
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.
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20
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Kosugi K, Tamura R, Mase T, Tamura H, Jinzaki M, Yoshida K, Toda M. Relationship between pneumatization of lateral recess in the sphenoid sinus and removal of cavernous sinus invasion in pituitary adenomas by endoscopic endonasal surgery. Surg Neurol Int 2019; 10:222. [PMID: 31819816 PMCID: PMC6884956 DOI: 10.25259/sni_169_2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 10/31/2019] [Indexed: 01/30/2023] Open
Abstract
Background: Endoscopic endonasal transsphenoidal surgery (EES) is the gold standard for pituitary adenoma (PA) resection. The sphenoid sinus (SS), a highly variable anatomic structure, is located in the center of the cranial base. It has previously been reported that poor pneumatization of the lateral recess of the SS (LRSS) increases the difficulty level of the surgery and the risk of neural and vascular injury. However, to date no studies have evaluated the association between LRSS volume and PAs removal rate by EES. Methods: The present study analyzed 23 consecutive patients with new-onset PAs categorized as Knosp Grades 3 and 4 who underwent EES. A retrospective radiographic analysis was conducted on patients undergoing magnetic resonance imaging and high-resolution computed tomography scans. Results: Among PA cases categorized as Knosp 3 and 4, no significant association was found between the whole tumor’s resection rate and LRSS volume (R = 0.08, P = 0.70). However, a significant association was found between cavernous sinus (CS) tumors’ removal rate and LRSS volume (R = 0.52, P = 0.011). The same results were achieved in PAs with a Knosp Grade 4, with a stronger correlation (R = 0.60, P = 0.014). Conclusion: The development of LRSS pneumatization affects the removal rate of CS tumors in PAs. Preoperative analysis of LRSS development should be considered when planning EES against PA with CS invasion.
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Affiliation(s)
- Kenzo Kosugi
- Departments of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Ryota Tamura
- Departments of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Taro Mase
- Departments of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Haruka Tamura
- Departments of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Masahiro Jinzaki
- Departments of Radiology, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Kazunari Yoshida
- Departments of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Masahiro Toda
- Departments of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo, Japan
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Watanabe K, Zomorodi AR, Labidi M, Satoh S, Froelich S, Fukushima T. Visualization of Dark Side of Skull Base with Surgical Navigation and Endoscopic Assistance: Extended Petrous Rhomboid and Rhomboid with Maxillary Nerve–Mandibular Nerve Vidian Corridor. World Neurosurg 2019; 129:e134-e145. [DOI: 10.1016/j.wneu.2019.05.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/05/2019] [Accepted: 05/07/2019] [Indexed: 10/26/2022]
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Endoscopic Endonasal Approaches for Treatment of Craniovertebral Junction Tumours. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:209-224. [PMID: 30610324 DOI: 10.1007/978-3-319-62515-7_30] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tumours involving the craniovertebral junction (CVJ) are challenging because of their local invasiveness and high recurrence rates, as well as their proximity to critical neurovascular structures and the difficulty of reconstructing the resulting skull base defect at this site. Several surgical techniques are currently available to access these lesions, including the far lateral, extreme lateral, direct lateral, transcervical, transoral and transnasal approaches. In this paper, application of the endoscopic endonasal approach (EEA) in the treatment of CVJ tumours is analysed. The indications, contraindications, preoperative workup, step-by-step surgical technique, skull base reconstruction options and postoperative management are described. The advantages and limitations of the EEA are also discussed. Finally, a systematic review of the literature is provided to elucidate the levels of evidence supporting the use of the EEA in this field. Employment of this approach to the CVJ has contributed to high success rates in achieving gross total resection of tumours and improvement in neurological symptoms. Intraoperative and postoperative complication rates are acceptable, with cerebrospinal fluid leakage being the major concern (with a 17-25% incidence). Moreover, in comparison with traditional approaches to the CVJ, the EEA provides lower rates of postoperative dysphagia and respiratory complications. Use of the EEA for treatment of CVJ tumours appears to be a rational alternative to the conventional transoral, transcranial and transcervical approaches in selected cases. Multidisciplinary teamwork including different specialists-such as medical and radiation oncologists, radiologists, otorhinolaryngologists and neurosurgeons-is strongly recommended for the purpose of offering the best treatment strategy for the patient.
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Zou Y, Neale N, Sun J, Yang M, Bai HX, Tang L, Zhang Z, Landi A, Wang Y, Huang RY, Zhang PJ, Li X, Xiao B, Yang L. Prognostic Factors in Clival Chordomas: An Integrated Analysis of 347 Patients. World Neurosurg 2018; 118:e375-e387. [DOI: 10.1016/j.wneu.2018.06.194] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 06/21/2018] [Accepted: 06/22/2018] [Indexed: 12/11/2022]
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Bibliometric Analysis of Journals in the Field of Endoscopic Endonasal Surgery for Pituitary Adenomas. J Craniofac Surg 2018; 29:e83-e87. [PMID: 29194269 DOI: 10.1097/scs.0000000000004133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Endoscopic endonasal surgery for pituitary adenomas is being performed more frequently worldwide in the recent years. This first bibliometric analysis was conducted aiming to have a microscopic view of research activities about endoscopic endonasal surgery for pituitary adenomas. The original articles about endoscopic endonasal surgery for pituitary adenomas were extracted from the Web of Science (WoS) and analyzed concerning their distributions. We also explored the potential correlations between publications of different countries and their gross domestic product (GDP) via Pearson correlation test. The total number of original articles retrieved from WoS was 307 from 1997 to 2017. The number of original articles published in the last decade has increased by 530.95% compared with that published in the former decade. The United States has published 124 articles (40.391%), followed by Italy with 40 (13.029%) and Japan with 27 articles (8.795%). The journal that published the highest number of original articles was Journal of Neurosurgery with 31 (10.098%), followed by Neurosurgery (n = 23, 7.492%), World Neurosurgery (n = 23, 7.492%), and Neurosurgical Focus (n = 15, 4.886%). There was a strong correlation between publication numbers and GDP of different countries (r = 0.889, P < 0.001). There is a skyrocket trend of endoscopic endonasal surgery for pituitary adenomas during the last 2 decades, and countries with high GDP tend to make more contributions to this field.
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Freeman JL, DeMonte F, Al-Holou W, Gidley PW, Hanna EY, Kupferman ME, Su SY, Raza SM. Impact of early access to multidisciplinary care on treatment outcomes in patients with skull base chordoma. Acta Neurochir (Wien) 2018; 160:731-740. [PMID: 29270681 DOI: 10.1007/s00701-017-3409-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 11/14/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine if early access to multidisciplinary surgical care affects outcomes in patients with skull base chordoma. METHOD A retrospective chart review of prospectively collected data was performed on 51 patients treated from 1993 to 2014. The cohort was divided into those presenting (1) for initial management (ID, n = 21) or (2) with persistent/progressive disease after prior biopsy/surgery (PD, n = 30) outside of a multidisciplinary setting. The impact of initial surgical management in a multidisciplinary center on progression-free survival (PFS) was assessed with Kaplan-Meier and log-rank analyses. RESULTS Mean follow-up, median PFS, median overall survival (OS), and 10-year OS for the entire cohort was 70 months, 47 months, 159 months, and 19%, respectively. Initial management in a multidisciplinary center resulted in a significant improvement in PFS versus initial surgery with or without radiotherapy (XRT) outside of this setting (64 vs 25 months, p = 0.035). Initial surgical resection outside of a multidisciplinary setting increased the risk of recurrence/progression on univariate (HR, 2.276; p = 0.022) and multivariate analysis (HR, 2.831; p = 0.006), respectively. CONCLUSIONS The results from this study emphasize the impact that coordinated multidisciplinary surgical care has on patient outcomes for chordomas of the clivus. Biopsy followed by attempted radical resection at a dedicated center does not affect PFS and, therefore, represents a reasonable first step in management for patients presenting outside of multidisciplinary setting.
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Long-term follow-up after endoscopic trans-sphenoidal surgery or initial observation in clivus chordomas. Acta Neurochir (Wien) 2017. [PMID: 28623412 DOI: 10.1007/s00701-017-3236-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Resection of clivus chordomas through extensive skull base approaches is associated with high mortality and morbidity even in experienced hands. We report our experience with endoscopic trans-sphenoidal surgery, or a "wait-and-scan" strategy in selected patients. METHOD Ten patients were diagnosed with clivus chordomas during an 8-year period. Six patients underwent primary treatment with endoscopic trans-sphenoidal surgery, followed by adjuvant proton-beam therapy in three of these patients. Four patients with minor symptoms were followed-up untreated. Mean follow-up was 91 months. RESULTS Of the six patients operated on, total or gross total resection was achieved in four, partial resection in one and biopsy was taken in one. Preoperative cranial neuropathies resolved in three out of five patients, and no new cranial nerve palsies were encountered. Postoperative cerebrospinal fluid leak occurred in one patient. Four patients were initially followed-up without any treatment, and three of these have remained stable without tumour progression for a mean of 94 months. Due to a slow, though progressive growth of tumour, one patient was operated on after 80 months of initial observation. CONCLUSIONS The natural course of clivus chordomas has yet to be defined. The endoscopic trans-sphenoidal approach is a valid, minimally invasive alternative for the treatment of clival chordomas, and in selected patients a "wait and scan" strategy can be considered. Our long-term results show low mortality and good functional outcome. An endonasal endoscopic trans-sphenoidal approach should be a principal part of the armamentarium of surgeons treating clivus chordomas.
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Surgical resection of skull-base chordomas: experience in case selection for surgical approach according to anatomical compartments and review of the literature. Acta Neurochir (Wien) 2017; 159:1835-1845. [PMID: 27924417 DOI: 10.1007/s00701-016-3032-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Chordoma is a rare bony malignancy known to have a high rate of local recurrence after surgery. The best treatment paradigm is still being evaluated. We report our experience and review the literature. We emphasize on the difference between endoscopic and open craniotomy in regard to the anatomical compartment harboring the tumor, the limitations of the approaches and the rate of surgical resection. METHOD We retrospectively collected all patients with skull-base chordomas operated on between 2004 and 2014. Detailed radiological description of the compartments being occupied by the tumor and the degree of surgical resection is discussed. RESULTS Eighteen patients were operated on in our facility for skull-base chordoma. Seventeen endoscopic surgeries were done in 15 patients, and 7 craniotomies were done in 5 patients. The mean age was 48.9 years (±19.8 years). When reviewing the anatomical compartments, we found that the most common were the upper clivus (95.6%) and lower clivus (58.3%), left cavernous sinus (66.7%) and petrous apex (∼60%). Most of the patients had intradural tumor involvement (70.8%). In all craniotomy cases, there was residual tumor in multiple compartments. In the endoscopic cases, the most difficult compartments for total resection were the lower clivus, and lateral extensions to the petrous apex or cavernous sinus. CONCLUSIONS Our experience shows that the endoscopic approach is a good option for midline tumors without significant lateral extension. In cases with very lateral or lower extensions, additional approaches should be added trying to achieve complete resection.
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Abstract
Chordomas are rare primary bone tumors arising from embryonic remnants of the notochord. They are slow-growing, locally aggressive, and destructive and typically involve the axial skeleton. Genetic studies have identified several mutations implicated in the pathogenesis of these tumors. Treatment poses a challenge given their insidious progression, degree of local invasion at presentation, and high recurrence rate. They tend to respond poorly to conventional chemotherapy and radiation. This makes radical resection the mainstay of their treatment. Recent advances in targeted chemotherapy and focused particle beam radiation, however, have improved the management and prognosis of these tumors.
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Affiliation(s)
- Carl Youssef
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | - Salah G Aoun
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | - Jessica R Moreno
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
| | - Carlos A Bagley
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, USA
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Mangussi-Gomes J, Beer-Furlan A, Balsalobre L, Vellutini EAS, Stamm AC. Endoscopic Endonasal Management of Skull Base Chordomas: Surgical Technique, Nuances, and Pitfalls. Otolaryngol Clin North Am 2016; 49:167-82. [PMID: 26614836 DOI: 10.1016/j.otc.2015.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chordoma is a rare primary bone tumor derived from transformed notochord remnants. It has a local aggressive behavior and high recurrence rates. Treatment of skull base chordomas is complex and challenging. Control of the disease relies mainly on surgical excision of the tumor, sometimes followed by high-dose radiation therapy. The main surgical goal is to achieve maximal tumor removal with minimal morbidity. Development of the expanded endoscopic endonasal approach has improved surgical and prognostic results of skull base chordomas. This article highlights important aspects of approach selection, technique, and nuances of surgical management of this tumor.
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Affiliation(s)
- João Mangussi-Gomes
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; São Paulo ENT Center, Edmundo Vasconcelos Hospital, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil
| | - André Beer-Furlan
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; DFVneuro Neurosurgical Group, Rua Dona Adma Jafet, 74, cj.121, São Paulo 01308-050, Brazil
| | - Leonardo Balsalobre
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; São Paulo ENT Center, Edmundo Vasconcelos Hospital, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil
| | - Eduardo A S Vellutini
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; DFVneuro Neurosurgical Group, Rua Dona Adma Jafet, 74, cj.121, São Paulo 01308-050, Brazil
| | - Aldo C Stamm
- São Paulo Skull Base Center, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil; São Paulo ENT Center, Edmundo Vasconcelos Hospital, Rua Afonso Brás, 525, cj. 13, São Paulo 04511-011, Brazil.
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Kshettry VR, Thorp BD, Shriver MF, Zanation AM, Woodard TD, Sindwani R, Recinos PF. Endoscopic Approaches to the Craniovertebral Junction. Otolaryngol Clin North Am 2016; 49:213-26. [PMID: 26614839 DOI: 10.1016/j.otc.2015.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The endoscopic endonasal approach provides a direct surgical trajectory to anteriorly located lesions at the craniovertebral junction. The inferior limit of surgical exposure is predicted by the nasopalatine line, and the lateral limit is demarcated by the lower cranial nerves. Endoscopic endonasal odontoidectomy allows preservation of the soft palate, and patients can restart an oral diet on the first postoperative day. Treating the condition at the craniovertebral junction using this approach requires careful preoperative planning and endoscopic endonasal surgical experience with a 2-surgeon 4-handed approach combining expertise in otolaryngology and neurosurgery.
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Affiliation(s)
- Varun R Kshettry
- Rosa Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, 9500 Euclid Avenue, S73, Cleveland, OH 44195, USA
| | - Brian D Thorp
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive #7070, Chapel Hill, NC 27599-7070, USA
| | - Michael F Shriver
- Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Adam M Zanation
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive #7070, Chapel Hill, NC 27599-7070, USA; Department of Neurosurgery, University of North Carolina at Chapel Hill, 170 Manning Drive #7060, Chapel Hill, NC 27599-7060, USA
| | - Troy D Woodard
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Skull Base Surgery, Minimally Invasive Cranial Base and Pituitary Surgery Program, CCLCM, CWRU, 9500 Euclid Avenue, S-73, Cleveland, OH 44195, USA
| | - Raj Sindwani
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Skull Base Surgery, Minimally Invasive Cranial Base and Pituitary Surgery Program, CCLCM, CWRU, 9500 Euclid Avenue, S-73, Cleveland, OH 44195, USA
| | - Pablo F Recinos
- Section of Rhinology, Sinus and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, A71, Cleveland, OH 44195, USA; Skull Base Surgery, Minimally Invasive Cranial Base and Pituitary Surgery Program, CCLCM, CWRU, 9500 Euclid Avenue, S-73, Cleveland, OH 44195, USA.
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Liebelt BD, Boghani Z, Haider AS, Takashima M. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci 2016; 28:152-6. [DOI: 10.1016/j.jocn.2015.10.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
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Messerer M, Cossu G, Pasche P, Ikonomidis C, Simon C, Pralong E, George M, Levivier M, Daniel RT. Extended endoscopic endonasal approach to clival and paraclival tumors: Indications and limits. Neurochirurgie 2016; 62:136-45. [PMID: 27179389 DOI: 10.1016/j.neuchi.2015.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 12/11/2015] [Accepted: 12/25/2015] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To report our experience with the Extended endoscopic endonasal approach (EEEA) for clival and paraclival tumors. DESIGN Retrospective analysis of a consecutive series of patients. RESULTS Eleven patients were considered: 3 chordomas, 3 meningiomas, 3 metastatic lesions, one chondroma and one chondrosarcoma. Gross total resection (GTR) was achieved in all chordomas and in chondromas with patients free of disease at the last follow-up. The chondrosarcoma was first operated on using a transfacial approach and endoscopy was performed for local progression with subtotal resection. The meningiomas were treated by a combination of transcranial and endoscopic approach due to their extension. The resection was subtotal and the residue treated by radiosurgery. Two patients with rhinopharyngeal carcinoma underwent palliative debulking. One metastatic melanoma that underwent GTR experienced remission. Two patients had postoperative cranial nerve palsy. No other complications were observed. CONCLUSIONS EEEA allows a direct access to the skull base. Through a minimal access, it limits the incidence of neurological morbidities. For midline epidural clival tumors, EEEA allows a total excision. It also offers an excellent access to the clival component of intradural lesions. A combined approach permits good tumor control with minimal complications.
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Affiliation(s)
- M Messerer
- Département des neurosciences cliniques, service de neurochirurgie, centre hospitalier universitaire Vaudois, université de Lausanne, rue du Bugnon 44, 1011 Lausanne, Switzerland; Département de neurochirurgie, hôpital Kremlin-Bicêtre, université de Paris Sud, 94270 Paris, France.
| | - G Cossu
- Département des neurosciences cliniques, service de neurochirurgie, centre hospitalier universitaire Vaudois, université de Lausanne, rue du Bugnon 44, 1011 Lausanne, Switzerland
| | - P Pasche
- Service d'otorhinolaryngologie, centre hospitalier universitaire Vaudois, université de Lausanne, UNIL, 1011 Lausanne, Switzerland
| | - C Ikonomidis
- Service d'otorhinolaryngologie, centre hospitalier universitaire Vaudois, université de Lausanne, UNIL, 1011 Lausanne, Switzerland
| | - C Simon
- Service d'otorhinolaryngologie, centre hospitalier universitaire Vaudois, université de Lausanne, UNIL, 1011 Lausanne, Switzerland
| | - E Pralong
- Département des neurosciences cliniques, service de neurochirurgie, centre hospitalier universitaire Vaudois, université de Lausanne, rue du Bugnon 44, 1011 Lausanne, Switzerland
| | - M George
- Département de neurochirurgie, hôpital Kremlin-Bicêtre, université de Paris Sud, 94270 Paris, France
| | - M Levivier
- Département des neurosciences cliniques, service de neurochirurgie, centre hospitalier universitaire Vaudois, université de Lausanne, rue du Bugnon 44, 1011 Lausanne, Switzerland
| | - R T Daniel
- Département des neurosciences cliniques, service de neurochirurgie, centre hospitalier universitaire Vaudois, université de Lausanne, rue du Bugnon 44, 1011 Lausanne, Switzerland
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Shin M, Kondo K, Hanakita S, Hasegawa H, Yoshino M, Teranishi Y, Kin T, Saito N. Endoscopic transsphenoidal anterior petrosal approach for locally aggressive tumors involving the internal auditory canal, jugular fossa, and cavernous sinus. J Neurosurg 2016; 126:212-221. [PMID: 27035173 DOI: 10.3171/2016.1.jns151979] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Reports about endoscopic endonasal surgery for skull base tumors involving the lateral part of petrous apex remain scarce. The authors present their experience with the endoscopic transsphenoidal anterior petrosal (ETAP) approach through the retrocarotid space for tumors involving the internal auditory canal, jugular fossa, and cavernous sinus. METHODS The authors performed the ETAP approach in 10 patients with 11 tumors (bilateral in 1 patient) that extensively occupied the lateral part of petrous apex, e.g., the internal auditory canal and jugular fossa. Eight patients presented with diplopia (unilateral abducens nerve palsy), 3 with tinnitus, and 1 with unilateral hearing loss with facial palsy. After wide anterior sphenoidotomy, the sellar floor, clival recess, and carotid prominence were verified. Tumors were approached via an anteromedial petrosectomy through the retrocarotid triangular space, defined by the cavernous and vertical segments of the internal carotid artery (ICA), the clivus, and the petrooccipital fissure. The surgical window was easily enlarged by drilling the petrous bone along the petrooccipital fissure. After exposure of the tumor and ICA, dissection and resection of the tumor were mainly performed under direct visualization with 30° and 70° endoscopes. RESULTS Gross-total resection was achieved in 8 patients (9 tumors). In a patient with invasive meningioma, the tumor was strongly adherent to the ICA, necessitating partial resection. Postoperatively, all 8 patients who had presented with abducens nerve palsy preoperatively showed improvement within 6 months. In the patient presenting with hearing loss and facial palsy, the facial palsy completely resolved within 3 months, but hearing loss remained. Regarding complications, 3 patients showed mild and transient abducens nerve palsy resolving within 2 weeks, 3 months, and 6 months. Postoperative CSF rhinorrhea requiring surgical repair was observed in 1 patient. No patient exhibited hearing deterioration, facial palsy, or symptoms of lower cranial nerve palsy after surgery. CONCLUSIONS The ETAP approach can offer a simple, less invasive option for invasive skull base tumors involving petrous regions, including the internal auditory canal, jugular fossa, and cavernous sinus. The ETAP approach can reach more extensive areas in the extradural regions around the petrous bone. The authors' results indicate that the transsphenoidal retrocarotid route is sufficient to approach the petrosal areas in select cases. Further expansion of the surgical field is not always necessary. However, experience with intradural lesions remains limited, and the extent of tumor resection largely depends on tumor characteristics. Application of the ETAP approach should thus be carefully determined in each patient, taking into consideration the size of the retrocarotid window and tumor characteristics.
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Affiliation(s)
| | - Kenji Kondo
- Otolaryngology, the University of Tokyo Hospital, Tokyo, Japan
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Ozawa H, Tomita T, Watanabe Y, Sekimizu M, Ito F, Ikari Y, Saito S, Toda M, Ogawa K. Sigmoid incision rescue nasoseptal flap technique for endoscopic endonasal skull base surgery. Acta Otolaryngol 2016; 136:636-40. [PMID: 26901123 DOI: 10.3109/00016489.2016.1143122] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Conclusion The sigmoid-incision (S-I) rescue flap technique has the advantage of both reduced-invasiveness and providing a sufficient surgical corridor for endoscopic endonasal skull base surgery (EESBS). Objective Skull base reconstruction with nasoseptal flap (NSF) is critically important in managing post-operative cerebrospinal fluid (CSF) leakage after tumor removal by EESBS. The NSF needs to be elevated before sphenoidotomy and posterior septectomy to preserve the pedicle. However, most extradural surgery without CSF leakage does not require NSF and, therefore, NSF preparation is often futile. As a result, a rescue flap technique to overcome this problem has been developed, whereby a new S-I rescue flap method is used that enables wide exposure of the sphenoidal rostrum and smooth manipulation of surgical instruments to preserve the NSF pedicle. Materials and methods Starting in April 2014, 19 cases underwent EESBS with S-I rescue flap. Results All patients underwent tumor resection under an adequate operative field with smooth manipulation of surgical instruments. Two complications were experienced. One patient had CSF leak after removal of the nasal packing, but the leakage was successfully closed by conventional NSF. Another patient had epistaxis from the septal wall, but this was controlled by electrocautery.
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Affiliation(s)
- Hiroyuki Ozawa
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Toshiki Tomita
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshihiro Watanabe
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mariko Sekimizu
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Fumihiro Ito
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuichi Ikari
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shin Saito
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Toda
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Ogawa
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, Tokyo, Japan
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Gui S, Zong X, Wang X, Li C, Zhao P, Cao L, Zhang Y. Classification and surgical approaches for transnasal endoscopic skull base chordoma resection: a 6-year experience with 161 cases. Neurosurg Rev 2016; 39:321-32; discussion 332-3. [PMID: 26846667 DOI: 10.1007/s10143-015-0696-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 08/29/2015] [Accepted: 10/31/2015] [Indexed: 01/13/2023]
Abstract
The aim of this study is to retrospectively analyze 161 cases of surgically treated skull base chordoma, so as to summarize the clinical classification of this tumor and the surgical approaches for its treatment via transnasal endoscopic surgery. Between August 2007 and October 2013, a total of 161 patients (92 males and 69 females) undergoing surgical treatment of skull base chordoma were evaluated with regard to the clinical classification, surgical approach, and surgical efficacy. The tumor was located in the midline region of the skull base in 134 cases, and in the midline and paramedian regions in 27 cases (extensive type). Resection was performed via the transnasal endoscopic approach in 124 cases (77%), via the open cranial base approach in 11 cases (6.8%), and via staged resection combined with the transnasal endoscopic approach and open cranial base approach in 26 cases (16.2%). Total resection was achieved in 38 cases (23.6%); subtotal resection, 86 cases (53.4%); partial resection of 80-95%, 29 cases (18%); and partial resection <80%, 8 cases (5%). The clinical classification method used in this study seems suitable for selection of transnasal endoscopic surgical approach which may improve the resection degree and surgical efficacy of skull base chordoma. Gross total resection of skull base chordoma via endoscopic endonasal surgery (with addition of an open approach as needed) is a safe and viable alternative to the traditional open approach.
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Affiliation(s)
- Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuyi Zong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinsheng Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lei Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
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Tamura T, Sato T, Kishida Y, Ichikawa M, Oda K, Ito E, Watanabe T, Sakuma J, Saito K. OUTCOME OF CLIVAL CHORDOMAS AFTER SKULL BASE SURGERIES WITH MEAN FOLLOW-UP OF 10 YEARS. Fukushima J Med Sci 2015; 61:131-40. [PMID: 26370681 DOI: 10.5387/fms.2015-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Skull base chordomas are clinically malignant because of the difficulty of total removal, high recurrence rate, and occasional drop metastasis. Although aggressive surgical resection and postoperative radiation have been recommended, the long-term outcome remains unsatisfactory. METHODS From 1992 to 2011, we treated 24 patients with skull base chordoma using aggressive surgical removal as a principal strategy. Skull base approaches were selected according to tumor extension to remove the tumor and surrounding bone as completely as possible. After surgery, all patients were closely observed with MRI to find small and localized recurrent tumors, which were treated with gamma-knife radiosurgery or surgical resection. The mean postoperative follow-up duration was 10.2 years (range, 1-17.2 years). RESULTS The 5-, 10-, and 15-year overall survival rates were 86%, 72%, and 72%, respectively. The 5- and 10-year progression-free survival rates were 47% and 35%, respectively. Tumor extension to the brainstem and partial tumor removal were the factors related to poor survival. CONCLUSIONS Our results suggest that aggressive surgical removal improves the long-term outcome of patients with skull base chordoma. We would like to emphasize that skull base chordomas should be aggressively removed using various skull base approaches.
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Di Maio S, Yip S, Al Zhrani GA, Alotaibi FE, Al Turki A, Kong E, Rostomily RC. Novel targeted therapies in chordoma: an update. Ther Clin Risk Manag 2015; 11:873-83. [PMID: 26097380 PMCID: PMC4451853 DOI: 10.2147/tcrm.s50526] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Chordomas are rare, locally aggressive skull base neoplasms known for local recurrence and not-infrequent treatment failure. Current evidence supports the role of maximal safe surgical resection. In addition to open skull-base approaches, the endoscopic endonasal approach to clival chordomas has been reported with favorable albeit early results. Adjuvant radiation is prescribed following complete resection, alternatively for gross residual disease or at the time of recurrence. The modalities of adjuvant radiation therapy reported vary widely and include proton-beam, carbon-ion, fractionated photon radiotherapy, and photon and gamma-knife radiosurgery. As of now, no direct comparison is available, and high-level evidence demonstrating superiority of one modality over another is lacking. While systemic therapies have yet to form part of any first-line therapy for chordomas, a number of targeted agents have been evaluated to date that inhibit specific molecules and their respective pathways known to be implicated in chordomas. These include EGFR (erlotinib, gefitinib, lapatinib), PDGFR (imatinib), mTOR (rapamycin), and VEGF (bevacizumab). This article provides an update of the current multimodality treatment of cranial base chordomas, with an emphasis on how current understanding of molecular pathogenesis provides a framework for the development of novel targeted approaches.
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Affiliation(s)
- Salvatore Di Maio
- Division of Neurosurgery, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Stephen Yip
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gmaan A Al Zhrani
- National Neuroscience Institute, Department of Neurosurgery, King Fahad Medical City, Riyadh, Saudi Arabia ; Department of Neurology and Neurosurgery, The Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Fahad E Alotaibi
- National Neuroscience Institute, Department of Neurosurgery, King Fahad Medical City, Riyadh, Saudi Arabia ; Department of Neurology and Neurosurgery, The Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Abdulrahman Al Turki
- National Neuroscience Institute, Department of Neurosurgery, King Fahad Medical City, Riyadh, Saudi Arabia ; Department of Neurology and Neurosurgery, The Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Esther Kong
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Robert C Rostomily
- Department of Neurological Surgery, University of Washington, University of Washington Medical Center, Seattle, WA, USA
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Shin M, Kondo K, Kin T, Suzukawa K, Saito N. Endoscopic transnasal interseptal approach for invasive clival tumors: development of an approach method regarding maximal preservation of the nasal anatomy. Neurol Med Chir (Tokyo) 2015; 55:336-44. [PMID: 25797777 PMCID: PMC4628181 DOI: 10.2176/nmc.oa.2014-0280] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Asian people frequently show small noses, narrow nasal apertures, and congestive mucosa on the turbinates and septum. To reduce the risk of nasal morbidity with increased radicality for skull base tumors in these patients, we developed endoscopic transnasal interseptal approach (ETISA) in transsphenoidal surgery for invasive clival tumors (ICTs). Indication for ETISA is radical resection for tumors occupying deep ventral skull base regions, confined posterior to the level of the middle turbinates. After removing ethmoidal air cells, the middle turbinates are laterally deflected. A linear incision is made vertically on each side of the septal mucosa, which is separated from the bony septum as far as the sphenoid rostrum. The blades of an adjustable speculum are inserted submucosally, and the bony septum is temporarily displaced. The surgical pathway is widely maintained from the entrance to the deep surgical field without sacrificing the nasal mucosa and turbinates. Thirty-two consecutive patients with clival tumors (18 chordomas, 11 chondrosarcomas, 3 others) were treated. Bilateral middle turbinectomy was routinely performed in the initial 3 patients, but in only 4 of the remaining 29 (3 unilaterally, 1 bilaterally). Tumor was sufficiently resected in 29 patients (90.6%; gross total removal n = 25, subtotal resection n = 4). As complications, 6 patients showed mild and transient worsening of cranial nerve symptoms. Nasal complications arose in 3 patients, persisting > 3 months in 2 (5.7%). This approach allows fine bimanual handling and swift delivery of surgical equipment while reasonably preserving the nasal anatomy, which is useful in endoscopic transsphenoidal surgery for ICT.
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Affiliation(s)
- Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital
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Shidoh S, Toda M, Kawase T, Nakajima H, Tomita T, Ogawa K, Yoshida K. Transoral vs. endoscopic endonasal approach for clival/upper cervical chordoma. Neurol Med Chir (Tokyo) 2014. [PMID: 25446380 PMCID: PMC4533355 DOI: 10.2176/nmc.st.2014-0135] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The surgical results of 18 cases of clival/upper cervical chordoma treated in the last decade via the endoscopic endonasal approach (EEA, 9 cases) and the transoral-transpalatal approach (TO-TPA, 9 cases) were compared. Each group showed the same incidence of subdural invasion, with 5 cases each. The superior (frontal base) and lateral surgical fields were wider by EEA, but the inferior view lower than the cranio-vertebral junction (CVJ) was wider by TO-TPA. Gross total removal was achieved in 3 cases in the EEA group, but in only 1 case in the TO-TPA group. Differences in radicality might be due to the extent of the lateral and subdural overview. However for large tumors extending below the CVJ, TO-TPA was the only viable approach for surgical removal. Surgical complications were higher in the EEA (4 cases) than the TO-TPA group (1 case), and were mainly caused by aggressive management of subdural invasion in the EEA group. Post-operative oral intake was earlier and the operative time was shorter in the EEA group. The surgical results were more radical and less invasive in the EEA group than the TO-TPA group. However in tumors extending below the CVJ, the surgical field in EEA was limited, indicating the need to use the transoral route or a combination of routes. A higher complication rate following subdural management was a negative factor that requires improvement in the EEA group and two-staged EEA followed by a transcranial approach may be considered for the cases with subdural invasion.
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Affiliation(s)
- Satoka Shidoh
- Department of Neurosurgery, Keio University School of Medicine
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Koechlin NO, Simmen D, Briner HR, Reisch R. Combined transnasal and transcranial removal of a giant clival chordoma. J Neurol Surg Rep 2014; 75:e98-e102. [PMID: 25083400 PMCID: PMC4110148 DOI: 10.1055/s-0034-1373668] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/31/2014] [Indexed: 10/25/2022] Open
Abstract
Clival chordomas confront the surgeon with the task of resecting an aggressively invasive and destructive tumor in a critical surrounding. For many, mainly smaller, chordomas, the transnasal transclival approach is a feasible and safe surgical access. Larger tumors and especially those with extensive intradural, retrochiasmal, and/or deep cervical expansion are mostly approached by open craniotomy. Staged procedures are also commonly used in the case of expansive tumor growth. We present the first case of a single-session combined transnasal and transcranial approach to radically resect a large clival chordoma.
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Affiliation(s)
- Nicolas O Koechlin
- Centre for Endoscopic and Minimally Invasive Neurosurgery, Klinik Hirslanden, Zurich, Switzerland
| | - Daniel Simmen
- ORL-Zentrum, Center for Otology, Skull Base Surgery, Rhinology and Facial Plastic Surgery, Klinik Hirslanden, Zurich, Switzerland
| | - Hans Rudolf Briner
- ORL-Zentrum, Center for Otology, Skull Base Surgery, Rhinology and Facial Plastic Surgery, Klinik Hirslanden, Zurich, Switzerland
| | - Robert Reisch
- Centre for Endoscopic and Minimally Invasive Neurosurgery, Klinik Hirslanden, Zurich, Switzerland
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Little RE, Taylor RJ, Miller JD, Ambrose EC, Germanwala AV, Sasaki-Adams DM, Ewend MG, Zanation AM. Endoscopic endonasal transclival approaches: case series and outcomes for different clival regions. J Neurol Surg B Skull Base 2014; 75:247-54. [PMID: 25093148 DOI: 10.1055/s-0034-1371522] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 12/15/2013] [Indexed: 10/25/2022] Open
Abstract
Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution's experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.
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Affiliation(s)
- Ryan E Little
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Robert J Taylor
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Justin D Miller
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Emily C Ambrose
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Anand V Germanwala
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, United States
| | - Deanna M Sasaki-Adams
- Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Matthew G Ewend
- Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Adam M Zanation
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, United States
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Soudry E, Turner JH, Nayak JV, Hwang PH. Endoscopic Reconstruction of Surgically Created Skull Base Defects. Otolaryngol Head Neck Surg 2014; 150:730-8. [DOI: 10.1177/0194599814520685] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To systematically review the literature concerning techniques of closure of endoscopically created skull base defects based on site of skull base defect and flow rate of cerebrospinal fluid (CSF). Data Sources PubMed, SCOPUS, and Cochrane databases. Review Methods A comprehensive systematic literature review. Results The literature search produced a total of 1708 studies. Of these, 1585 studies were excluded based on title and/or abstract review. A total of 123 articles remained for full-text review, 101 of which were subsequently excluded primarily because of lack of detailed information as to the reconstructive techniques used or clinical outcomes. Of the 22 studies remaining for final analysis, all were case series. A total of 673 patients were included in the analysis, with an overall postoperative CSF leak rate of 8.5%. Subgroup analysis was performed based on location of the skull base defect and presence and quality of intraoperative CSF leak. Conclusions Based on level 4 evidence, in cases of low-flow intraoperative CSF leaks, skull base reconstruction with multilayered free grafts and synthetic materials offers similar outcomes to vascularized flaps. In cases of high-flow intraoperative CSF leaks, pedicled vascularized flaps appear to be superior. Location of the defect does not seem to be a significant factor in determining successful closure, with the exception of clival defects. In all other sites, good closure may be achieved by multiple reconstructive approaches. More consistency in data reporting and higher levels of evidence will ultimately be necessary to make definitive recommendations.
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Affiliation(s)
- Ethan Soudry
- Stanford University School of Medicine, Stanford, California, USA
| | - Justin H. Turner
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jayakar V. Nayak
- Stanford University School of Medicine, Stanford, California, USA
| | - Peter H. Hwang
- Stanford University School of Medicine, Stanford, California, USA
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43
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Vaz-Guimaraes Filho F, Wang EW, Snyderman CH, Gardner PA, Fernandez-Miranda JC. Endoscopic endonasal “far-medial” transclival approach: Surgical anatomy and technique. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.otot.2013.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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44
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Kasemsiri P, Prevedello DMS, Otto BA, Old M, Filho LD, Kassam AB, Carrau RL. Endoscopic endonasal technique: treatment of paranasal and anterior skull base malignancies. Braz J Otorhinolaryngol 2013; 79:760-79. [PMID: 24474490 PMCID: PMC9442400 DOI: 10.5935/1808-8694.20130138] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 09/22/2013] [Indexed: 11/20/2022] Open
Abstract
Objective Method Conclusion
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Affiliation(s)
- Pornthep Kasemsiri
- M.D. (Department of Otorhinolaryngology, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand)
| | | | - Bradley Alan Otto
- M.D. (Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA)
| | - Matthew Old
- M.D. (Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA)
| | - Leo Ditzel Filho
- M.D. (Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA)
| | - Amin Bardai Kassam
- M.D. (Department of Neurological Surgery, Ottawa University, Ottawa, Canada)
- Institute Wexner Medical Center, at The Ohio State University
| | - Ricardo Luis Carrau
- M.D. (Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA)
- Send correspondence to: Ricardo Luis Carrau. Starling Loving Hall-Room B221 320 West 10 Avenue, Columbus OH 43210. Tel: +1 614.293.8074
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Chambers KJ, Lin DT, Meier J, Remenschneider A, Herr M, Gray ST. Incidence and survival patterns of cranial chordoma in the United States. Laryngoscope 2013; 124:1097-102. [DOI: 10.1002/lary.24420] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 07/08/2013] [Accepted: 09/05/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Kyle J. Chambers
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Derrick T. Lin
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Josh Meier
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Aaron Remenschneider
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Marc Herr
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Stacey T. Gray
- Department of Otolaryngology-Head and Neck Surgery; Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
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46
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Han S, Ding X, Tie X, Liu Y, Xia J, Yan A, Wu A. Endoscopic endonasal trans-sphenoidal approach for pituitary adenomas: is one nostril enough? Acta Neurochir (Wien) 2013; 155:1601-9. [PMID: 23736939 DOI: 10.1007/s00701-013-1788-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/23/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Over the past decade, the endoscopic endonasal trans-sphenoidal approach has been used to resect pituitary adenomas. However, in the use of this procedure, some research teams prefer a two-nostril method, whereas other groups are in favor of the one-nostril method. Here, we present a series of pituitary adenomas and try to confirm whether or not one nostril is enough for endoscopic resection of most pituitary adenomas. METHODS A total of 250 consecutive patients who underwent an endoscopic endonasal trans-sphenoidal approach were reviewed retrospectively, of which 200 were via the unilateral nostril (group 1) and 50 were via bilateral nostrils (group 2). Surgical and clinical outcomes were analyzed. RESULTS For microadenomas, intrasellar macroadenomas and macroadenomas with moderate extrasellar extension, the prevalence of gross total resection (GTR), hormonal outcome and visual improvement were similar between the two groups. The one-nostril group had better results for duration of surgery and blood loss, with fewer rhinological complications. However, for macroadenomas with extensive extrasellar invasion, GTR was obtained in two of seven patients in group 2 but none in group 1. CONCLUSION The one-nostril method, which is relatively fast and minimally invasive, is adequate for endoscopic resection of most pituitary adenomas with moderate extension.
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Affiliation(s)
- Sheng Han
- Department of Neurosurgery, The First Hospital of China Medical University, Nanjing Street 155, Heping District, Shenyang, 110001, China
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