5-year-old boy with a clival mass

Enigmatic entity in childhood: clival chordoma from a tertiary center's perspective

PURPOSE

Chordoma is a rare neoplasm that arises from embryonic notochordal remnants along the axial skeleton (i.e., clivus, sacrum) and the vertebral bodies. They comprise less than 1 % of CNS tumors and 1-4 % of all bone malignancies. It rarely affects children and adolescents (<5 %). Chordomas are locally aggressive and highly recurrent. Their management is challenging for clinicians.

METHODS

This retrospective study includes six pediatric patients with pathological evidence of clival chordoma. These cases were identified over a period of 15 years in a tertiary care institute.

RESULTS

There were two boy and four girls with a mean age of 10.6 years (range, 4-16 years). The chief complaint was due to cranial nerve palsy (or dysfunction), mostly affecting lower cranial nerves (66.6 %), followed by diplopia and headache. One patient had obstructive sleep apnea. All patients were operated and a total of 15 surgeries were performed (mean, 2.5). Tumor recurrence was observed in four patients (67 %). Two-year and 5-year progression-free survivals (PFS) were 67 and 33 %, respectively. None of the patients were lost either during the surgery or the follow-up period (6.9 years: 1-14 years).

CONCLUSIONS

Clival chordomas are challenging tumors in neurosurgical practice. A multidisciplinary approach is warranted in each patient. Today, the best management strategy seems to be surgical resection followed by radiotherapy. Chemotherapy should be considered in selective and preference basis. Sharing institutional experiences will provide future insights in prognosis of these rare tumors. Implementing newer surgical instruments, endoscope in particular, is encouraged in management of the clival chordomas.

Endoscopic transsphenoidal approach versus microscopic approach in children

OBJECTIVES

To confirm the efficacy and safeness of the endoscopic endonasal transsphenoidal (ETS) approach in the treatment of sellar and parasellar lesions in children compared with the conventional microscopic transsphenoidal approach (CTS).

STUDY DESIGN

Case series with chart review.

SETTING

A. Gemelli - University Hospital - Catholic University of Sacred Heart - Rome.

SUBJECT AND METHODS

We retrospectively evaluate 21 children (mean age 8.3 years) affected by sellar/parasellar lesions: 11 were treated via microscopic sublabial approach between 1995 and 2005 and 10 were treated with ETS approach between 2006 and 2009.

RESULTS

The past series (group A) comprised all sellar/suprasellar lesions and we observed: gross total surgical excision in 81.2% of cases, permanent morbidity in 1/11 patients, CSF fistula in 1/11 patients, mean hospitalization time of 5.8 days and PICU was required. The present series (group B) included 8 sellar/suprasellar and 2 clival lesions and we observed: GTS excision in 80% of the cases, no permanent morbidity, a mean hospitalization time of 4.1 days (P=0.01), CSF fistula in 2/10 patients and the PICU was not required. 10/11 patient of group A underwent to blood transfusion vs 4/10 of the group B (P=0.008). The mean pain score of group A was 5.8 ± 1.7 on the contrary in the group B it was 4.1 ± 1.5 (P=0.006).

CONCLUSION

The ETS approach to the sellar and parasellar region has proved its reliability and effectiveness in the adults. The minimal invasiveness makes it ideal for the treatment of pediatric lesion of this region, in which it is essential to preserve the integrity of the hypothalamic-pituitary axis and of the naso-facial structures to assure the correct growth of the child.

Quality of postoperative course in children: endoscopic endonasal surgery versus sublabial microsurgery

BACKGROUND

The practice of endoscopic endonasal surgery is still limited in children because of the relative rarity of sellar lesions in the paediatric population. However, such an approach is increasingly reported in the literature as an alternative option to standard sublabial microsurgery, and its surgical results are being analysed. No information on the trend of the postoperative course is currently available. The goal of this paper is to assess the impact of these two different transsphenoidal approaches on the postoperative course.

METHODS

Thirty-one consecutive paediatric patients were treated for sellar region lesions by transsphenoidal surgery. Fourteen children (group A) underwent surgery with a microsurgical sublabial transsphenoidal approach between 2000 and 2005; the remaining 17 children (group B) underwent surgery with an endoscopic endonasal transsphenoidal approach between 2005 and 2009. The two groups were compared as to rate of admission to the PICU, relief from preoperative symptoms, early surgical complications, postoperative pain (Wong-Baker FACES Pain Scale) and length of postoperative hospital stay.

RESULTS

Children in group B showed decreased rates of admission to the PICU (35% versus 100%) and peroperative blood transfusions (23% versus 71%), and a shorter mean postoperative hospital stay (4 days versus 5.7 days). The pain perception was significantly lower in group B than in group A, as demonstrated by the scores registered during both the early (2.05 ± 0.74 versus 2.92 ± 0.91) and late postoperative period (0.82 ± 0.95 versus 1.64 ± 0.84). No remarkable differences in terms of operative time, symptom improvement and early complications were detected.

CONCLUSIONS

Endoscopic endonasal surgery can improve the quality of the postoperative course in children regardless of the type of lesions treated and the surgical complications.

Loss of SMARCB1/INI1 expression in poorly differentiated chordomas

Chordomas are malignant neoplasms that typically arise in the axial spine and primarily affect adults. When chordomas arise in pediatric patients they are more likely to display unusual histological features and aggressive behavior. We noted the absence of SMARCB1/INI1 expression by immunohistochemistry in an index case of poorly differentiated chordoma of the sacrum, leading us to further examine SMARCB1/INI1 expression as well as that of brachyury, a highly specific marker of notochordal differentiation, in 3 additional poorly differentiated chordomas of the clivus, 10 typical chordomas, and 8 atypical teratoid/rhabdoid tumors (AT/RTs). All 4 poorly differentiated chordomas and all AT/RTs lacked nuclear expression of SMARCB1/INI1, while the 10 typical chordomas maintained strong nuclear SMARCB1/INI1 immunoreactivity. All 10 typical and 4 poorly differentiated chordomas expressed brachyury; all 8 AT/RTs were brachyury immunonegative. Cytogenetic evaluation utilizing FISH probes near the SMARCB1/INI1 locus on chromosome 22q was also performed in all of the poorly differentiated chordomas in this series. Three of the four poorly differentiated chordomas had evidence for deletion of this region by FISH. Analysis of the SMARCB1/INI1 gene sequence was performed using formalin-fixed paraffin-embedded tissue in all cases and no point mutations were observed. In summary, all poorly differentiated chordomas in this series showed the absence of SMARCB1/INI1 expression, and were reliably distinguished from AT/RTs, clinically by their characteristic primary sites of origin and pathologically by strong nuclear brachyury expression. Our findings reveal a likely role for SMARCB1/INI1 in a subset of chordomas with aggressive features.

Endoscopic endonasal transsphenoidal surgery for sellar tumors in children

OBJECTIVE

Endoscopic endonasal transsphenoidal surgery (EETS) is still rarely used in pediatric subjects compared with adults. Reports on EETS in children appeared only recently in the literature, usually regarding small series. The aim of the study is to assess the actual role and the limits of EETS in children with sellar tumors by reporting a two-centers experience.

METHODS

Twenty-seven children (mean age: 12.2 years) were operated on during the last decade. Seventeen patients harbored a sellar mass, 7 a suprasellar tumor, and 3 a clival mass. Laboratory investigations revealed hypopituitarism in 6 children and hormone hypersecretion in 9. All the operations were carried out by a team including both ENT surgeon and neurosurgeon using a dedicated 18-cm long rigid endoscope (2.7 mm and 4 mm diameter) through the direct paraseptal or the transethmoidal or the transpterygoid route.

RESULTS

Overall, 29 operations were performed. Gross total tumor resection was obtained in 22 children (81.5%) while a subtotal and a partial removal in 2 (7.5%) and 3 cases (11%), respectively. Pituitary adenoma was the most common histotype (12 cases), followed by craniopharyngioma (5) and Rathke's cleft cyst (4). No surgical mortality or neurological morbidity or late nasal complications were observed. Postoperative CSF fistula occurred in 3 patients. All children are alive at current follow-up (average: 8.6 years). Preoperative hypopituitarism disappeared or improved in 4 cases and was stable in the remaining 2 (no new hormone deficits appeared).

CONCLUSION

EETS is a safe and effective surgical option also in children. As for adults, it allows to manage most of the tumor lesions of the sellar region with stable long-term results.