Endoscopic transsphenoidal biopsy of the sphenoid and clival mass

Percutaneous CT-Guided Bone Biopsies: Indications, Feasibility and Diagnostic Yield in the Different Skeletal Sites-From the Skull to the Toe

CT-guided bone biopsies are currently the diagnostic tool of choice for histopathological (and microbiological) diagnoses of skeletal lesions. Several research works have well-demonstrated their safety and feasibility in almost all skeletal regions. This comprehensive review article aims at summarizing the general concepts in regard to bone biopsy procedures, current clinical indications, the feasibility and the diagnostic yield in different skeletal sites, particularly in the most delicate and difficult-to-reach ones. The choice of the correct imaging guidance and factors affecting the diagnostic rate, as well as possible complications, will also be discussed. Since the diagnostic yield, technical difficulties, and complications risk of a CT-guided bone biopsy significantly vary depending on the different skeletal sites, subdivided analyses of different anatomical sites are provided. The information included in the current review article may be useful for clinicians assisting patients with possible bone neoplasms, as well as radiologists involved in the imaging diagnoses of skeletal lesions and/or in performing bone biopsies.

A practical overview of CT and MRI features of developmental, inflammatory, and neoplastic lesions of the sphenoid body and clivus

The sphenoid bone is an unpaired bone that contributes to the formation of the skull base. Despite the enormous progress in transnasal endoscopic visualisation, imaging techniques remain the cornerstones to characterise any pathological condition arising in this area. In the present review, we offer a bird’s-eye view of the developmental, inflammatory, and neoplastic alterations affecting the sphenoid body and clivus, with the aim to propose a practical diagnostic aid for radiologists based on clinico-epidemiological, computed tomography, and magnetic resonance imaging features.

Endoscopic Transnasal Pituitary Surgery: Report on 180 Cases

The endoscopic transnasal approach is an evolving technique for treating lesions in the sella turcica. Since this method was introduced at our institution 4 years ago, the majority of transsphenoidal procedures are performed with it. The records of all patients having endoscopic transnasal hypophysectomy at the Mayo Clinic during the last 4 years were reviewed retrospectively. The criteria analyzed were safety, functional and cosmetic outcome, and complications. During the 4-year period, the operative procedure was modified to improve operative exposure and safety. The results of our review showed a significant decrease in length of hospital stay, reduced operative time, reduced need for nasal packing, and elimination of a sublabial incision. The complication rate was equivalent to that reported for the traditional transseptal transsphenoidal approach. As the neurosurgeons at our institution gained experience with this approach, an increasing number of pituitary microadenomas were resected safely and successfully. In addition, because of the limited septal dissection, this approach is particularly helpful for revision operations. This approach also can be used for the full range of pituitary lesions and in conjunction with adjunctive techniques, including frontal craniotomy and -knife irradiation. Currently, the endoscopic transsphenoidal approach is the method preferred for surgically treating pituitary lesions in adults at our institution.

Isolated clival metastasis: a rare presentation of renal cell carcinoma

Renal cell carcinoma accounts for 3% of all adult malignancies. Usual sites of metastasis are lymph nodes, lungs, bone, liver and brain. We describe a patient who presented with complaints of holocranial headache and diplopia. MRI of the head showed a clival-based lesion with associated bony erosion. With suspicion of a metastatic lesion, an ultrasonogram of the abdomen was done which showed a left renal mass that enhanced on contrast-enhanced CT. There were no other metastatic foci. Patient underwent radiotherapy for the clival lesion. This case report emphasises on the evaluation of clival lesion with cranial neuropathies for a possibility of a renal primary tumour.

Clival Metastasis of a Duodenal Adenocarcinoma: A Case Report and Literature Review

BACKGROUND

Clival metastases of adenocarcinomas are exceptionally rare tumors, especially when they arise from the small intestine. We present the first, to our knowledge, report of a metastasis of a duodenal adenocarcinoma to the clivus. We also present a systematic review detailing metastasis to the clivus.

METHODS

Studies were identified using the search terms "clival metastasis," "skull base metastasis," and "clivus" in PubMed. We collected the following information: histopathology of the primary tumor, symptoms, history, treatment, and follow-up.

RESULTS

A comprehensive review of the literature yielded 56 cases. Patients developed the first symptoms of clival metastasis at a mean age of 58 years. The most common primary neoplasms originated from the prostate, kidney, or liver. Most patients presented with an isolated sixth nerve palsy or diplopia. The time interval from diagnosis of the primary tumor to symptomatic presentation of clival metastasis ranged from 2 months to 33 years. Sixteen patients initially presented with symptoms of clival metastasis without a previously diagnosed primary tumor. Survival data were available for 35 patients, of which 63% died within a range of 2 days to 31 months after initial presentation.

CONCLUSIONS

Most primary neoplasms originated from the prostate, kidney, and liver, which differ from previous reports on skull base metastases. Abducens nerve palsy is often the first presentation of clival metastasis. Clival metastasis from duodenal carcinoma, although very rare, should be considered in the differential diagnosis of bony lesions of the clivus in a patient with a history of duodenal adenocarcinoma.

Stereotactic biopsy approach to the upper clivus through the middle fossa floor that avoids pneumatised cavities and the intradural compartment

BACKGROUND

Biopsies of clival lesions are usually performed, under general anaesthesia, through an anterior endoscopic approach or, alternatively, through a trans-nasal or trans-oral stereotactic approach.

METHODS

A 57-year-old man with a symptomatic osteolytical lesion of the clivus, who refused general anaesthesia, underwent a sterotactically guided biopsy of the lesion by an antero-lateral approach through the temporal and sphenoid bones.

RESULTS

Biopsy was successfully performed and the resulting diagnosis was myeloma. The patient was comfortable during and after surgery and there were no complications.

CONCLUSIONS

The present stereotactic antero-lateral approach to the biopsy of the upper clivus can be considered an useful adjunct to the current trans-oral and transnasal approaches that often require general anaesthesia.

Use of Tissue Glues in Endoscopic Pituitary Surgery: A Cost Comparison

Background:

Post-operative cerebrospinal fluid (CSF) leaks are a common complication of endoscopic pituitary surgery and account for a significant proportion of hospital costs associated with this procedure. Tisseel® is a tissue glue commonly used as an adjunct in dural repair but is not optimal for this purpose. DuraSeal® has several properties advantageous for dural repair but is not widely accepted in Canada partly due to its increased cost.

Objective:

A cost analysis of DuraSeal® versus Tisseel® in endoscopic pituitary surgery.

Methods:

A cost analysis was performed based on typical endoscopic pituitary surgery cases performed at our tertiary care institution. Operating room, hospital admission, and surgical sealant costs were obtained directly while estimates of patient recovery time and post-operative CSF leak rates were based on consensus values reported in the literature. Outcomes were reported for various possible clinical scenarios of sealant use.

Results:

In a model where surgical sealant is employed only in high-risk cases, use of DuraSeal® allows for a yearly cost savings of at least $4486.72. If surgical sealant is used in all cases, regular use of DuraSeal® versus Tisseel® either marginally reduces yearly costs or increases them by a maximum of $7619.25, depending on the case volume and estimated post-operative CSF leak rate.

Conclusion:

In most clinical scenarios, use of DuraSeal® in endoscopic pituitary surgery may reduce overall yearly hospital costs compared to Tisseel®.

A rare case of primary malignant melanoma of clivus with extensive skeletal metastasis demonstrated on 18F-FDG PET/CT

Malignant melanoma of the clivus is a rare entity, for which there is little evidence-based literature for guiding clinicians to understand the importance of disease staging via noninvasive imaging strategy. This report highlights the case of a 55-year-old lady with histopathologically confirmed melanocytic melanoma of the clivus-postoperative status, with multiple skeletal metastasis, demonstrated on 2-deoxy-2-[18F] fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT scan). The experience gained with this patient demonstrates the feasibility and usefulness of this noninvasive application in accurate staging and hence, correct decision making regarding further treatment.

Metastatic disease to the clivus mimicking clival chordomas

Objectives/Hypothesis A comprehensive review of the literature of clival metastases and presentation of two additional cases. Study Design Literature review and report of two cases. Methods A literature review of the MEDLINE database (1950 to January 19, 2013) was performed to identify all cases of patients with metastatic disease to the clivus. Additionally, two novel cases are presented. Results In total, 47 cases were identified in the literature, including the two cases presented in this study. Metastatic disease to the clivus is the initial presenting symptom of the primary malignancy in 36% (13/36) of the cases. When there was a history of malignancy, the median interval of time to clival metastases was 24 months (range 1 to 172 months). Clinical symptoms manifested often as cranial neuropathies, with at least abducens palsies as the initial presenting symptom in 61.9% (26/42) of patients. Tumor pathology was diverse, but several pathologies were seen more commonly: prostate carcinoma (18.1%, 9/47), hepatocellular carcinoma (10.6%, 5/47), and thyroid follicular carcinoma (8.5%, 4/47). Conclusion Although clival metastases are extremely rare, they are an important part of the differential of clival masses as they can be the presenting symptom of distant malignancy. Level of Evidence 4.

Degenerative Pannus Mimicking Clival Chordoma Resected via an Endoscopic Transnasal Approach

Lesions of the lower clivus represent a technically challenging subset of skull base disease that requires careful treatment. A 75-year-old woman with tongue atrophy was referred for resection of a presumed clival chordoma. The lesion was resected via an endoscopic transnasal transclival approach with no complications. Pathology revealed only chronic inflammatory tissue consistent with a degenerative pannus. Degenerative pannus should be included in the differential diagnosis of lower clival extradural lesions. The endoscopic transnasal transclival corridor should be considered for resection of such lesions as an alternative to larger, more morbid, traditional skull base approaches.

Surgical treatment of a clival-C2 atypical teratoid/rhabdoid tumor

The authors present the case of en bloc resection of a clival-C2 atypical teratoid/rhabdoid tumor. These aggressive lesions of early childhood generally occur in the cerebellum or cerebral hemispheres. This 7-year-old boy presented with pain on turning his head and was found to have a clival-C2 mass. A metastatic workup was negative for disseminated disease. A transoral biopsy procedure revealed an atypical teratoid/rhabdoid tumor on histological examination. The tumor was resected via a transoral approach, and the patient's spine was stabilized with posterior instrumented fusion from the occiput to C-5. Postoperatively, the patient underwent 16 months of chemotherapy along with 6 weeks of overlapping radiation therapy. Twenty-seven months after the initial surgery he presented with leg pain and was found to have a solitary metastatic lesion at the conus medullaris. There was no local recurrence at the clivus. The conus tumor was resected and found to be consistent with the primary tumor. Several months later the patient presented with disseminated intrathecal disease and ultimately died 42 months after the initial resection.

Clivus metastases: report of seven patients and literature review

BACKGROUND

Tumours of the clivus are rare and metastases involving this area have been previously described only as single case reports or included in series with other skull base tumours. Here, we describe seven such examples and review the pertinent literature.

METHOD

Clinical, radiological and follow-up data of patients who had undergone surgery for clivus tumours at our Institution between January 1995 and December 2007 were retrospectively collected. A literature review was performed using PubMed.

FINDINGS

Of 46 patients who underwent surgery for clivus bone tumours, seven proved to harbour a metastasis. This figure represents 0.18% and 0.42% respectively of intracranial and skull base tumours which were treated in our Institution in the study period. The primary tumours associated were lung adenocarcinoma (n = 2), prostate carcinoma (n = 2), skin melanoma (n = 1), hepatocarcinoma (n = 1) and lung squamous cell carcinoma (n = 1). All patients presented with a sixth nerve palsy as the symptom. Histopathology was obtained via a trans-sphenoidal biopsy. In spite of radiotherapy and chemotherapy, the mean survival was 12 months. On literature review, 27 examples of metastases located in the clival bone were found. Including our series, the most common primary tumours were prostate cancer (26.4%), thyroid carcinoma (11.7%) and hepatocarcinoma (11.7%).

CONCLUSION

Though exceedingly rare, metastases involving the clivus should be considered in the differential diagnosis with clivus chordoma. The metastatic lesion might be a late and single expression of the primary tumour. The trans-sphenoidal approach is the ideal procedure to establish a histopathological diagnosis. Prognosis is poor.

Back to the Egyptians: neurosurgery via the nose. A five-thousand year history and the recent contribution of the endoscope

The possibility of removing the brain through the nose without disfiguring the face was already known to the ancient Egyptians, who were experts in using this approach in the mummification process. A similar route through the nose and the sphenoid bone has been developed in the last century as a surgical procedure for the treatment of tumors of the pituitary region, which makes the more invasive craniotomy unnecessary in most cases. This has resulted in a significant decrease of the overall mortality and morbidity rates and has led to the great popularity of such minimally invasive surgery both for patients and doctors. The recent advent of the endoscope in this specific field and the development of further possibilities and instrumentation has contributed to a new renaissance of this old treatment modality.

Minimally invasive biopsy of parasellar lesions: safety and clinical applications of the endoscopic, transnasal approach

The base of the skull can be affected by a variety of tumours requiring a wide range of treatment modalities. In formulating a management plan, histological diagnosis can play an essential role. Existing methods of skull base biopsy, especially in the anatomically critical parasellar region, include either prolonged open skull base approaches or image-guided needle biopsies. The latter methods can be time-consuming and cannot reliably avoid surrounding critical neurovascular structures. The experience with an endoscopic, transnasal biopsy of parasellar tumours in selected patients is presented. A preliminary series of 11 patients harbouring parasellar lesions with some degree of extension to the sphenoid or maxillary sinus underwent endoscopic, transnasal biopsy. The procedure was diagnostic in all cases. There was no operative mortality and minimal morbidity only recorded. The biopsy results affected the patients' management and, based on these results, major skull base surgery was avoided in four cases. Direct endoscopic visualization prompted avoidance of a vascular catastrophe of an atypical vascular lesion. The endoscopic, transnasal biopsy appears to offer a number of advantages over existing methods in selected patients. It is minimally invasive as it employs the use of natural osseous corridors. Tissue sampling under direct visualization minimizes the risks of negative biopsies or damage to critical neurovascular structures. The use of additional imaging employed by image-guided needle biopsies in not necessary. When planning treatment of parasellar tumours, the endoscopic, transnasal route should be considered.

Endoscopic sinus surgery: where we are-and where we're going

PURPOSE OF REVIEW

Improved understanding of sinonasal mucociliary function as well as technological advancements have led to a renaissance in the management of sinonasal disease. The current techniques, and adjunctive intraoperative technologies, have allowed for a more precise and safer surgical dissection, extending this surgical application to include the routine endoscopic management of skull base lesions and sinonasal malignancies. The anatomic boundaries of the nasal endoscope continue to be redefined. This paper will review the recent advances in the field of surgical rhinology as well as discuss directions for the future.

RECENT FINDINGS

Advancements in imaging technology including image acquisition, three-dimensional reconstruction, stereotactic navigation, and CT-MRI fusion have aided in more thorough preoperative planning, enabling safer and more precise endoscopic surgical dissection. Refinement of endonasal powered instrumentation including microdebriders and high-speed suction irrigation drills have minimized trauma to normal tissues and accelerated postoperative healing. Increased experience with the endoscope has broadened the endoscopic ventral skull base exposure from the odontoid process to foramen ovale to the olfactory bulb.

SUMMARY

Endoscopic sinus surgery is no longer exclusively for the management of chronic rhinosinusitis and nasal polyposis. Sinonasal malignancies, as well as anterior skull base lesions have become part of the rhinologist's responsibility. Furthermore, selective lesions managed through traditional craniotomies may now be accessed via trans-sinonasal transcranial endoscopic routes.

Endoscopy and Transsphenoidal Surgery

ENDOSCOPY OFFERS INTERNAL visualization of many different cavities of the human body, with its specific vision inside the anatomy, close to the target area. The view of the surgical field in transsphenoidal surgery had been obtained with the naked eye from its beginning in 1907 up to the introduction of the operating microscope by Jules Hardy in the 1960s, which represented a great advance in terms of magnification and illumination. In the past decade, modern rigid endoscopes, with their wider view near the relevant anatomy, have permitted minimally traumatic transsphenoidal procedures in and around the sellar area, thus representing a "new wave" in transsphenoidal history. An overview of the evolution of the endoscope as a visualizing and operating instrument particularly related to the transsphenoidal approach is presented here. The current possibilities of transsphenoidal endoscopy, with its related advantages and limitations, are presented.

Endoscopic approach to lesions of the sphenoid sinus, orbital apex, and clivus

OBJECTIVE

The expanding role of endoscopic management of sinonasal disorders includes approaches to the skull base. In this report, we review our experience approaching lesions of the sphenoid sinus, orbital apex, and clivus via a transnasal endoscopic technique.

DESIGN

A retrospective, case series review of 15 patients presenting with skull base lesions approached via an endoscopic approach was performed. Emphasis was placed on analyzing the preoperative planning strategy and the surgical technique.

SETTING

Academic referral center.

RESULTS

We reviewed the medical records of 15 patients who underwent an endoscopic approach to the sphenoid sinus, orbital apex, or clivus. Ten patients presented with lesions of the sphenoid sinus and clivus. The lesions in this patient group included metastasis to the cavernous sinus and clivus (3); fibrous dysplasia (2); plasmacytoma of the clivus (2); and 1 patient each with cholesterol granuloma, meningoencephalocele, and recurrent teratoma. Five patients presented with lesions of the orbital apex. These included invasive fungal sinusitis (2), mucopyocele (2), and pseudotumor (1). Image-guided surgical navigation was used in each case, and all approaches consisted of entirely endoscopic transnasal techniques.

CONCLUSIONS

Endoscopic approaches to the skull base are possible because of advancements in technology now available to the rhinologic surgeon. This report highlights the preoperative strategies and surgical techniques used in approaching lesions of the sphenoid sinus, orbital apex, and clivus. These extended techniques should provide a more direct, less invasive, and more cost-effective method for approaching select skull base lesions.

The superior turbinectomy approach to isolated sphenoid sinus disease and to the sella turcica

Sphenoidotomy or sphenoidectomy are most commonly performed as part of a more extensive pansinus procedure. However, rhinologists may find themselves occasionally in a need to surgically treat an isolated sphenoid sinus disease. With the introduction of endoscopic sinus techniques and instrumentation, intranasal sphenoidotomy has become increasingly popular. The most common approach used is the intranasal, transethmoid sphenoidectomy. Alternatively, many surgeons perform middle turbinectomy to approach the sphenoid sinus transnasally. We describe our direct transnasal, nontransethmoid, nontransseptal approach to the sphenoid sinus. Superior tubinectomy is performed to enhance the exposure of the anterior sphenoid wall. Seventy patients underwent sphenoid sinus exploration for isolation sphenoid sinus disease or for pituitary lesions. Surgical goals were achieved in all patients and there were no complications related to the technique. The superior turbinectomy approach to isolated sphenoid sinus disease provides excellent exposure and avoids the sequelae of total ethmoidectomy or middle turbinectomy.