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Damante MA, Magill ST, Kreatsoulas D, McGahan BG, Hardesty D, Carrau RL, Prevedello DM. Endoscopic Endonasal Transpterygoid Approach and the Need for Myringotomy. Laryngoscope 2024; 134:1203-1207. [PMID: 38087873 DOI: 10.1002/lary.31221] [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: 08/17/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 02/17/2024]
Abstract
OBJECTIVE The expanded endonasal transpterygoid approach (EETA) is used to access the middle and posterior fossa through the pterygoid process. Traditionally, the eustachian tube (ET) was resected during EETA, which often required subsequent myringotomy for inner ear drainage. Anterolateral transposition of the ET was proposed to decrease potential morbidity associated with resection. However, a comparison of resection versus transposition regarding the need for subsequent myringotomy has not been reported. METHODS This is a retrospective cohort study of patients who underwent an EETA. Patient demographics, tumor characteristics, management of ET with resection versus transposition, and need for subsequent myringotomy were collected. Analysis was performed with JMP software in standard fashion and univariate and multivariate logistic regression analysis performed with a p < 0.05 was considered significant. RESULTS Ninety-one patients underwent EETA for various malignant and benign tumors. Twenty-seven patients required myringotomy, with tumors of the pterygopalatine fossa accounting for the most common location (n = 8). Malignant pathology had the highest myringotomy rate compared to benign tumors (48.9% vs. 10.9%, p < 0.001), as did receiving postoperative radiation (p < 0.001), ET resection (p < 0.001), and increasing CPK class. Multivariate analysis of these variables suggests that only ET resection significantly correlated with the need for myringotomy (LR 7.97, p = 0.005). CONCLUSIONS ET resection during EETA can lead to ET dysfunction and require myringotomy post-operatively, and patients should be counseled of this risk. Radiation treatment, malignant pathology, and CPK class, all reflecting situations where more extensive surgery was needed, were associated with the need for myringotomy on univariate analysis but did not reach significance with multivariate analysis. LEVEL OF EVIDENCE 4 Laryngoscope, 134:1203-1207, 2024.
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Affiliation(s)
- Mark A Damante
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Stephen T Magill
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Daniel Kreatsoulas
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Ben G McGahan
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Douglas Hardesty
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Ricardo L Carrau
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
- Department of Otolaryngology, The Ohio State University Medical Center, Columbus, Ohio, U.S.A
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
- Department of Otolaryngology, The Ohio State University Medical Center, Columbus, Ohio, U.S.A
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Singh AK, Patel BK, Darshan HR, Anand B, Singh A, Biradar H, George T, Easwer HV, Nair P. Endoscopic Transpterygoid Corridor for Petroclival Tumors: Case Series and Technical Nuances. Neurol India 2023; 71:1159-1166. [PMID: 38174451 DOI: 10.4103/0028-3886.391346] [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] [Indexed: 01/05/2024]
Abstract
Background The petroclival area is a technically challenging region to operate owing to the proximity of the internal carotid artery (ICA) and the need to obtain gross total excision of tumors in this area as they are often resistant to radiotherapy. Objective We present our experience with the endonasal endoscopic transpterygoid approach in managing tumors of the petroclival region and discuss various operative nuances for safer resection. Materials and Methods A retrospective study of all consecutive cases of lesions occupying the petroclival region that were operated via endonasal endoscopic transpterygoid approach at our center between January 2016 and December 2021 was performed. Results The study included 14 cases of lesions occupying the petroclival region. Gross total resection by intraoperative observation was achieved in 10 patients, near total decompression was performed in two patients, and the remaining two patients underwent marsupialization of lesion. Postoperatively, one patient had right Lower motor neuron (LMN) facial nerve palsy and one patient required surgery for Cerebrospinal fluid (CSF) rhinorrhea on postoperative day 8. The mean duration of follow-up was 13.8 ± 16.6 months (range: 2-59 months). Four of six patients with visual symptoms on presentation reported improvement in vision, and the other two patients had a stable vision on follow-up. Two patients received radiotherapy postsurgery. No mortality was noted. Conclusion The extended endonasal endoscopic transpterygoid approach can be safely and efficiently used for petroclival lesions. Very sound knowledge of anatomical relationship, use of intraoperative image guidance to avoid injury to ICA, and multilayer reconstruction with a vascularized nasoseptal flap are required to optimize the clinical outcome.
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Affiliation(s)
- Arvind K Singh
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Biren K Patel
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Hirisave Ravikumar Darshan
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Binu Anand
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Ajit Singh
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Harshvardhan Biradar
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Tobin George
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Harihara Venkat Easwer
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Localisation of the petrous internal carotid artery relative to the vidian canal on computed tomography: a case-control study evaluating the impact of petroclival chondrosarcoma. Acta Neurochir (Wien) 2022; 164:1939-1948. [PMID: 35612666 PMCID: PMC9233644 DOI: 10.1007/s00701-022-05254-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/13/2022] [Indexed: 11/11/2022]
Abstract
Background The vidian canal (VC) is normally a reliable anatomical landmark for locating the petrous internal carotid artery (pICA). This study determined the influence of petroclival chondrosarcoma on the relationship between the VC and pICA. Methods Nine patients (3 males, 6 females; median age 49) with petroclival chondrosarcoma, and depiction of the pICA on contrast-enhanced CT, were retrospectively studied. CT-based measurements were performed by two observers, both in the presence of the petroclival chondrosarcoma (case) and on the contralateral control side. The antero-posterior (AP) and craniocaudal (CC) measurements from the posterior VC to the pICA, whether the pICA was in the trajectory of the VC, and the coronal relationship of the pICA anterior genu with the VC were recorded. Results Chondrosarcoma usually displaced the pICA anteriorly (8/9 cases) and superiorly (6/9 cases) relative to the normal side with mean AP and CC measurements of 3.9 mm v 7.2 mm (p = 0.054) and 4.4 mm v 1.4 mm (p = 0.061). The VC trajectory less frequently intersected the pICA cross-section in the presence of chondrosarcoma however it was in the line of the eroded dorsal VC in one case. The anterior genu of the pICA was displaced more laterally by chondrosarcoma but usually remained superior to the VC. Conclusion Petroclival chondrosarcoma variably influences the anatomical relationship between the VC and the pICA, hence requiring an individualised approach. The pICA is usually anterosuperiorly displaced, and the anterior genu remains superior to the VC, however it may be located in the line of the canal.
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Primary Skull Base Chondrosarcomas: A Systematic Review. Cancers (Basel) 2021; 13:cancers13235960. [PMID: 34885071 PMCID: PMC8656924 DOI: 10.3390/cancers13235960] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary Primary skull base chondrosarcomas (SBCs) may carry significant tumor-burden by causing severe cranial nerve neuropathies. Current treatment strategies mainly focus on surgical resection and radiotherapy protocols, with a wide range of findings in terms of efficacy and safety. The aim of our systematic review was to comprehensively analyze the current literature on primary SBCs, describing clinical and radiological characteristics, available management strategies, treatment outcomes, and prognoses. We found that most primary SBCs show benign slow-growing patterns but may cause neurological deficits by compressing critical neurovascular structures. Open surgical approaches favor maximal resection with acceptable complication rates, but only a few studies reported the use of newer endoscopic approaches. Proton-based, photon-based, and carbon-based radiotherapy protocols may also allow safe and effective local tumor control as adjuvant treatments or stand-alone strategies in patients not eligible to undergo surgery. Overall, primary SBCs’ prognoses proved to be favorable and comparable to benign skull base neoplasms. Abstract Background: Primary skull base chondrosarcomas (SBCs) can severely affect patients’ quality of life. Surgical-resection and radiotherapy are feasible but may cause debilitating complications. We systematically reviewed the literature on primary SBCs. Methods: PubMed, EMBASE, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients with primary SBCs. Clinical characteristics, management strategies, and treatment outcomes were analyzed. Results: We included 33 studies comprising 1307 patients. Primary SBCs mostly involved the middle-fossa (72.7%), infiltrating the cavernous-sinus in 42.4% of patients. Cranial-neuropathies were reported in 810 patients (62%). Surgical-resection (93.3%) was preferred over biopsy (6.6%). The most frequent open surgical approaches were frontotemporal-orbitozygomatic (17.6%) and pterional (11.9%), and 111 patients (21.3%) underwent endoscopic-endonasal resection. Post-surgical cerebrospinal-fluid leaks occurred in 36 patients (6.5%). Radiotherapy was delivered in 1018 patients (77.9%): photon-based (41.4%), proton-based (64.2%), and carbon-based (13.1%). Severe post-radiotherapy complications, mostly hypopituitarism (15.4%) and hearing loss (7.1%) were experienced by 251 patients (30.7%). Post-treatment symptom-improvement (46.7%) and reduced/stable tumor volumes (85.4%) showed no differences based on radiotherapy-protocols (p = 0.165; p = 0.062). Median follow-up was 67-months (range, 0.1–376). SBCs recurrences were reported in 211 cases (16.1%). The 5-year and 10-year progression-free survival rates were 84.3% and 67.4%, and overall survival rates were 94% and 84%. Conclusion: Surgical-resection and radiotherapy are effective treatments in primary SBCs, with acceptable complication rates and favorable local tumor control.
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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: 2] [Impact Index Per Article: 0.7] [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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Endoscopic Endonasal Approach for Clipping Anterior Communicating Artery Aneurysms From Cadaver Studies and Three-Dimensional Printed Models to a Clinical Case. J Craniofac Surg 2021; 32:2854-2858. [PMID: 34238881 DOI: 10.1097/scs.0000000000007848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Anterior communicating artery (ACoA) aneurysm is one of the most common intracranial aneurysms, and it is also the aneurysm with the highest rupture rate. With the improvement of endoscopic techniques, it is possible to use an endoscopic endonasal approach (EEA) to clip ACoA aneurysms. For further analysis of the EEA for clipping ACoA aneurysms, we used cadaver heads and three-dimensional (3D)-printed models to finish the anatomical study, and we finally selected 1 clinical case to complete the clipping through the EEA. MATERIALS AND METHODS We first collected 3 cadaver heads to simulate the EEA. Then, the imaging data of 29 real cases of ACoA aneurysm were collected, and the model of an aneurysm was prepared by 3D printing technology; then, the EEA was used to simulate the clipping of the aneurysm model. Finally, a clinical case with 2 ACoA aneurysms was selected to adopt the EEA for clipping. RESULTS Both the cadaver head and 3D-printed aneurysm model could simulate aneurysm clipping with the EEA. The clinical case of the selected ACoA aneurysm can successfully complete the clipping through the EEA. CONCLUSIONS 3D-printed models are a good method to study the anatomical characteristics of a surgical approach. For specially selected ACoA aneurysms, the EEA is relatively simple method that can be used to clip the aneurysm successfully. The EEA for clipping ACoA aneurysms is a useful complement to the current traditional craniotomy approaches and endovascular embolization.
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Topczewski TE, Di Somma A, Culebras D, Reyes L, Torales J, Tercero A, Langdon C, Alobid I, Torne R, Roldan P, Prats-Galino A, Ensenat J. Endoscopic endonasal surgery to treat intrinsic brainstem lesions: correlation between anatomy and surgery. Rhinology 2021; 59:191-204. [PMID: 33346253 DOI: 10.4193/rhin20.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has been proposed as an alternative in the surgical removal of ventral brainstem lesions. However, the feasibility and limitations of this approach to treat such pathologies are still poorly understood. This study aimed to report our experience in five consecutive cases of intrinsic brainstem lesions that were managed via an EEA, as well as the specific anatomy of each case. METHODS All patients were treated in a single center by a multidisciplinary surgical team between 2015 and 2019. Before surgery, a dedicated anatomical analysis of the brainstem safe entry zone was performed, and proper surgical planning was carried out. Neurophysiological monitoring was used in all cases. Anatomical dissections were performed in three human cadaveric heads using 0° and 30° endoscopes, and specific 3D reconstructions were executed using Amira 3D software. RESULTS All lesions were located at the level of the ventral brainstem. Specifically, one mesencephalic cavernoma, two pontine ca- vernomas, one pontine gliomas, and one medullary diffuse midline glioma were reported. Cerebrospinal fluid leak was the major complication that occurred in one case (medullary diffuse midline glioma). From an anatomical standpoint, three main safe entry zones were used, namely the anterior mesencephalic zone (AMZ), the peritrigeminal zone (PTZ, used in two cases), and the olivar zone (OZ). Reviewing the literature, 17 cases of various brainstem lesions treated using an EEA were found. CONCLUSIONS To our knowledge, this was the first preliminary clinical series of intrinsic brainstem lesions treated via an EEA presented in the literature. The EEA can be considered a valid surgical alternative to traditional transcranial approaches to treat selected intra-axial brainstem lesions located at the level of the ventral brainstem. To achieve good results, surgery must involve comprehensive anatomical knowledge, meticulous preoperative surgical planning, and intraoperative neurophysiological moni- toring.
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Affiliation(s)
- T E Topczewski
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - A Di Somma
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain.,Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - D Culebras
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - L Reyes
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - J Torales
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - A Tercero
- Institut Clínic de Neurociències (ICN), Department of Neurology, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - C Langdon
- Rhinology Unit and Smell Clinic, Otorhinolaryngology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - I Alobid
- Rhinology Unit and Smell Clinic, Otorhinolaryngology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - R Torne
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - P Roldan
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - A Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - J Ensenat
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
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Kong DS, Hong SD, Kang H, Seo Y, Kim MS, Seol HJ, Park CK, Nam DH, Lee JI, Kim YH. Safety and Efficacy of Endoscopic Dorsum Sellar Resection for Access to Retroinfundibular or Upper Clival Tumors (Korean Society of Endoscopic Neurosurgery-008). World Neurosurg 2021; 150:e675-e680. [PMID: 33771748 DOI: 10.1016/j.wneu.2021.03.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The retroinfundibular and upper clival regions are challenging to access using the endoscopic endonasal approach because these regions are obstructed by the dorsum sellae and posterior clinoid processes. We evaluated the safety and clinical efficacy of endoscopic dorsum sellar resection (DSR) and identified the optimal indications for endoscopic DSR in patients with craniopharyngioma. METHODS A retrospective study was conducted of patients who had undergone treatment with an endoscopic endonasal approach from January 2014 to January 2019. We identified a total of 50 patients who had undergone DSR. The indications for DSR included the following: 1) a tumor involving the upper clivus; 2) a tumor located behind the dorsum sellae; and 3) a tumor involving the interpeduncular or prepontine cistern. We evaluated the clinical outcomes, postoperative endocrinological status, and surgical morbidities. RESULTS Of the 50 patients, 16 had been treated for craniopharyngioma, 30 for chordoma, 2 for pituitary adenoma, 1 for schwannoma, and 1 for chondrosarcoma. An extradural approach for DSR with posterior clinoidectomy was performed in 33 patients (66.0%) and an interdural transcavernous approach in 17 patients (34.0%). The overall gross total tumor resection rate was 92.0% (46 of 50 patients). Postoperatively, 28 of 33 patients (84.8%) with normal pituitary function preoperatively showed preservation of hormonal function postoperatively. CONCLUSIONS DSR with or without posterior clinoidectomy is a challenging procedure that requires considerable effort and advanced surgical techniques. However, it can be safely performed with accumulating experience and a thorough knowledge of the surrounding anatomical structures.
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Affiliation(s)
- Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Duk Hong
- Department of Otolaryngoloy, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Min-Sung Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chul-Kee Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Pituitary Center, Seoul National University Hospital, Seoul, Republic of Korea.
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Shin M, Hasegawa H, Miyawaki S, Kakigi A, Takizawa T, Kondo K, Shiode T, Kin T, Saito N. Endoscopic transmastoid posterior petrosal approach for locally aggressive tumors in the petrous part of the temporal bone involving the internal auditory canal, jugular foramen, and hypoglossal canal. J Neurosurg 2020; 133:1248-1260. [PMID: 31561213 DOI: 10.3171/2019.5.jns19187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The posterior petrosal approach is an established surgical method offering wide access to skull base lesions through mastoid air cells. The authors describe their experience with the endoscopic transmastoid "posterior petrosal" approach (EPPAP) for skull base tumors involving the internal auditory canal (IAC), jugular foramen, and hypoglossal canal. METHODS The EPPAP was performed for 7 tumors (3 chordomas, 2 chondrosarcomas, 1 schwannoma, and 1 solitary fibrous tumor). All surgical procedures were performed under endoscopic visualization with mastoidectomy. The compact bone of the mastoid air cells and posterior surface of the petrous bone are carefully removed behind the semicircular canals. When removal of cancellous bone is extended superomedially through the infralabyrinthine space, the surgeon can expose the IAC and petrous portion of the internal carotid artery to reach the petrous apex (infralabyrinthine route). When removal of cancellous bone is extended inferomedially along the sigmoid sinus, the surgeon can safely reach the jugular foramen (transjugular route). Drilling of the inferior surface of petrous bone is extended further inferoposteriorly behind the jugular bulb to approach the hypoglossal canal and parapharyngeal space through the lateral aspect of the occipital condyle (infrajugular route). RESULTS Of the 7 tumors, gross-total resection was achieved in 4 (57.1%), subtotal resection (> 95% removal) in 2 (28.6%), and partial resection (90% removal) in 1 (14.2%). Postoperatively, 2 of 3 patients with exudative otitis media showed improvement of hearing deterioration, as did 2 patients with tinnitus. Hypoglossal nerve palsy and swallowing difficulty were improved after surgery in 2 patients and 1 patient, respectively. In 1 patient with severe cranial nerve deficits before surgery, symptoms did not show any improvement. CONCLUSIONS The authors present their preliminary experience with EPPAP for skull base tumors in the petrous part of the temporal bone and the lateral part of the occipital condyle involving the cranial nerves and internal carotid arteries. The microscope showed a higher-quality image and illumination in the low-power field. However, the endoscope could offer wider visualization of the surgical field and contribute to minimizing the size of the surgical pathways, necessity of brain retraction, and eventually the invasiveness of surgery. Thus, the EPPAP may be safe and effective for skull base tumors in the petrous region, achieving balance between the radicality and invasiveness of the skull base surgery.
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Affiliation(s)
| | | | | | - Akinobu Kakigi
- 2Otolaryngology, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Kenji Kondo
- 2Otolaryngology, The University of Tokyo Hospital, Tokyo, Japan
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10
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Borghei-Razavi H, Truong HQ, Fernandes Cabral DT, Sun X, Celtikci E, Wang E, Snyderman C, Gardner PA, Fernandez-Miranda JC. Endoscopic Endonasal Petrosectomy: Anatomical Investigation, Limitations, and Surgical Relevance. Oper Neurosurg (Hagerstown) 2020; 16:557-570. [PMID: 30982905 DOI: 10.1093/ons/opy195] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/29/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The endoscopic endonasal approach (EEA) was recently added to the neurosurgical armamentarium as an alternative approach to the petrous apex (PA) region. However, the maximal extension, anatomical landmarks, and indications of this procedure remain to be established. OBJECTIVE To investigate the limitations and suggest a classification of PA lesions for endoscopic petrosectomy. METHODS Five anatomical specimens were dissected with EEA to the PA. Anatomical landmarks for the surgical steps and maximal limits were noted. Pre- and postprocedural computed tomographic scan and image-guidance were used. Relevant surgical cases were reviewed and presented. RESULTS We defined 3 types of petrosectomy: medial, inferior, and inferomedial. Medial petrosectomy was limited within the paraclival internal carotid artery (ICA) anteriorly, lacerum ICA inferiorly, abducens nerve superiorly, and petrous ICA laterally. Among those, abducens nerve and petrous ICA are surgical limits. Full skeletonization of the paraclival ICA and removal of the lingual process are essential for better access to the medial aspect of PA. Inferior petrosectomy was defined by the lacerum foramen synchondrosis anteriorly, jugular foramen inferiorly, internal acoustic canal posteriorly, and PA superolaterally. Those are surgical limits except for the foramen lacerum synchondrosis. The connective tissue at the pterygosphenoidal fissure was a key landmark for the sublacerum approach. Clinical cases in 3 types of PA lesions were presented. CONCLUSION The EEA provides access to the medial and inferior aspects of the PA. Several technical maneuvers, including paraclival and lacerum ICA skeletonization, sublacerum approach, and lingual process removal, are key to maximize PA drilling.
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Affiliation(s)
- Hamid Borghei-Razavi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Huy Q Truong
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David T Fernandes Cabral
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Xicai Sun
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Otolaryngology, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, China
| | - Emrah Celtikci
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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11
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Endoscopic endonasal and transorbital routes to the petrous apex: anatomic comparative study of two pathways. Acta Neurochir (Wien) 2020; 162:2097-2109. [PMID: 32556526 DOI: 10.1007/s00701-020-04451-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 06/08/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Surgical approaches to the petrous apex region are extremely challenging; while subtemporal approaches and variations represent the milestone of the surgical modules to reach such deep anatomical target, in a constant effort to develop minimally invasive neurosurgical routes, the endoscopic endonasal approach (EEA) has been tested to get a viable corridor to the petroclival junction. Lately, another ventral endoscopic minimally invasive route, i.e., the superior eyelid endoscopic transorbital approach, has been proposed to access the most lateral aspect of the skull base, including the petrous apex region. Our anatomic study aims to compare and combine such two endoscopic minimally invasive pathways to get full access to the petrous apex. Three-dimensional reconstructions and quantitative and morphometric data have been provided. MATERIAL AND METHODS Five human cadaveric heads (10 sides) were dissected. The lab rehearsals were run as follows: (i) preliminary pre-operative CT scans of each specimen, (ii) pre-dissection planning of the petrous apex removal and its quantification, (iii) petrous apex removal via endoscopic endonasal route, (iv) post-operative CT scans, (v) petrous apex removal via endoscopic transorbital route, and (v) final post-operative CT scan with quantitative analysis. Neuronavigation was used to guide all dissections. RESULTS The two endoscopic minimally invasive pathways allowed a different visualization and perspective of the petrous apex, and its surrounding neurovascular structures. After both corridors were completed, a communication between the surgical pathways was highlighted, in a so-called connection area, surrounded by the following important neurovascular structures: anteriorly, the internal carotid artery and the Gasserian ganglion; laterally, the internal acoustic canal; superiorly, the abducens nerve, the trigeminal root, and the tentorium cerebelli; inferomedially, the remaining clivus and the inferior petrosal sinus; and posteriorly, the exposed area of the brainstem. Used in a combined fashion, such multiportal approach provided a total of 97% of petrous apex removal. In particular, the transorbital route achieved a mean of 48.3% removal in the most superolateral portion of the petrous apex, whereas the endonasal approach provided a mean of 48.7% bone removal in the most inferomedial part. The difference between the two approaches was found to be not statistically significant (p = 0.67). CONCLUSION The multiportal combined endoscopic endonasal and transorbital approach to the petrous apex provides an overall bone removal volume of 97% off the petrous apex. In this paper, we highlighted that it was possible to uncover a common path between these two surgical pathways (endonasal and transorbital) in a so-called connection area. Potential indications of this multiportal approach may be lesions placed in or invading the petrous apex and petroclival regions that can be inadequately reached via transcranial paths or via an endonasal endoscopic route alone.
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12
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Ohata H, Goto T, Nagm A, Kannepalli NR, Nakajo K, Morisako H, Goto H, Uda T, Kawahara S, Ohata K. Surgical implementation and efficacy of endoscopic endonasal extradural posterior clinoidectomy. J Neurosurg 2020; 133:135-143. [PMID: 31051459 DOI: 10.3171/2019.2.jns183278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) for skull base tumors has become an important topic in recent years, but its use, merits, and demerits are still being debated. Herein, the authors describe the nuances and efficacy of the endoscopic endonasal extradural posterior clinoidectomy for maximal tumor exposure. METHODS The surgical technique included extradural posterior clinoidectomy following lateral retraction of the paraclival internal carotid artery and extradural pituitary transposition. In cases with prominent posterior clinoid process, a midline sellar dura cut was added to facilitate extradural exposure. Forty-four consecutive patients, in whom this technique was performed between 2016 and 2018 at Osaka City University Hospital, were reviewed. The pathology included 19 craniopharyngiomas, 7 chordomas, 6 meningiomas, 6 pituitary adenomas, 4 chondrosarcomas, and 2 miscellaneous. Utilization and effectiveness of this approach were further demonstrated with neuroimaging. RESULTS Extradural posterior clinoidectomies were successfully applied in all patients without permanent neurovascular injury and with better maneuverability and greater resection rate of the tumors. Four patients experienced transient postoperative abducens nerve paresis, and 1 patient experienced transient postoperative oculomotor nerve paresis; however, the patients with deficits recovered within 3 months. On radiological examination, the surgical field was 2.2 times wider in cases with bilateral posterior clinoidectomy than in cases without posterior clinoidectomy. CONCLUSIONS The extended EEA with extradural posterior clinoidectomy creates an extra working space and allows adequate accessibility with safe surgical maneuverability to remove tumors that extend behind the posterior clinoid and dorsum sellae.
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Affiliation(s)
- Hiroki Ohata
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takeo Goto
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Alhusain Nagm
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
- 2Department of Neurosurgery, Al-Azhar University Faculty of Medicine-Nasr City, Cairo, Egypt
- 3Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan; and
| | - Narasinga Rao Kannepalli
- 4Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Kosuke Nakajo
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroki Morisako
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Goto
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takehiro Uda
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinichi Kawahara
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kenji Ohata
- 1Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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13
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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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14
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Quantitative anatomical comparison of transnasal and transcranial approaches to the clivus. Acta Neurochir (Wien) 2020; 162:649-660. [PMID: 31792688 DOI: 10.1007/s00701-019-04152-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/18/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE The clivus was defined as "no man's land" in the early 1990s, but since then, multiple approaches have been described to access it. This study is aimed at quantitatively comparing endoscopic transnasal and microsurgical transcranial approaches to the clivus in a preclinical setting, using a recently developed research method. METHODS Multiple approaches were performed in 5 head and neck specimens that underwent high-resolution computed tomography (CT): endoscopic transnasal (transclival, with hypophysiopexy and with far-medial extension), microsurgical anterolateral (supraorbital, mini-pterional, pterional, pterional transzygomatic, fronto-temporal-orbito-zygomatic), lateral (subtemporal and subtemporal transzygomatic), and posterolateral (retrosigmoid, far-lateral, retrolabyrinthine, translabyrinthine, and transcochlear). An optic neuronavigation system and dedicated software were used to quantify the working volume of each approach and calculate the exposure of different clival regions. Mixed linear models with random intersections were used for statistical analyses. RESULTS Endoscopic transnasal approaches showed higher working volume and larger exposure compared with microsurgical transcranial approaches. Increased exposure of the upper clivus was achieved by the transnasal endoscopic transclival approach with intradural hypophysiopexy. Anterolateral microsurgical transcranial approaches provided a direct route to the anterior surface of the posterior clinoid process. The transnasal endoscopic approach with far-medial extension ensured a statistically larger exposure of jugular tubercles as compared with other approaches. Presigmoid approaches provided a relatively limited exposure of the ipsilateral clivus, which increased in proportion to their invasiveness. CONCLUSIONS This is the first anatomical study that quantitatively compares in a holistic way exposure and working volumes offered by the most used modern approaches to the clivus.
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15
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Raza SM, Gidley PW, Kupferman ME, Hanna EY, Su SY, DeMonte F. Site-Specific Considerations in the Surgical Management of Skull Base Chondrosarcomas. Oper Neurosurg (Hagerstown) 2019; 14:611-619. [PMID: 28962038 DOI: 10.1093/ons/opx171] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 07/04/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Numerous approaches have been reported in the management of skull base chondrosarcomas. Data are lacking for surgical outcomes by the tumor site of origin. OBJECTIVE To provide insight into outcomes by site of origin and factors affecting resection in order to aid in surgical approach selection. METHODS A retrospective review was conducted of 49 patients with chondrosarcoma treated at our institution. Charts were reviewed for tumor- and treatment-related factors. Extent of resection was the primary outcome, while neurological function and surgical complications were secondary outcomes. Statistical analyses were performed assessing variables for their impact on the primary outcome. RESULTS The gross total resection rate for the overall cohort was 67.3%, and 97.8% of patients were either neurologically stable or improved postoperatively. A petroclival site of origin had lower rates of resection vs all other sites (P < .05). Histology and previous surgery did not predict outcome (P > .05), while previous radiotherapy and cavernous sinus invasion correlated with a subtotal resection (P < .05). In the petroclival cohort, clival, jugular tubercle, and soft tissue involvement correlated with a subtotal resection (P < .05). An endoscopic endonasal transpterygoid approach alone or combined with a transcranial approach yielded the highest resection rates for petroclival tumors (P < .05). CONCLUSION Chondrosarcomas pose unique challenges based on the site of origin and pattern of extension. While current surgical strategies appear to yield adequate results at a majority of skull base sites, petroclival tumors represent a particular cohort in which improvement is needed. Based on our analysis, strategies incorporating both endoscopic and transcranial skull base approaches are likely necessary to achieve optimal outcomes.
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Affiliation(s)
- Shaan M Raza
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul W Gidley
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael E Kupferman
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ehab Y Hanna
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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16
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Vaz-Guimaraes F, Fernandez-Miranda JC, Koutourousiou M, Hamilton RL, Wang EW, Snyderman CH, Gardner PA. Endoscopic Endonasal Surgery for Cranial Base Chondrosarcomas. Oper Neurosurg (Hagerstown) 2019; 13:421-434. [PMID: 28838112 DOI: 10.1093/ons/opx020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/24/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Microsurgical resection via open approaches is considered the main treatment modality for cranial base chondrosarcomas (CBCs). The use of endoscopic endonasal approaches (EEAs) has been rarely reported. OBJECTIVE To present the endoscopic endonasal experience with CBCs at our institution. METHODS Retrospective review of the medical records of 35 consecutive patients who underwent EEA for CBC resection between January 2004 and April 2013. Surgical outcomes and variables that might affect extent of resection, complications, and recurrence were analyzed. RESULTS Forty-eight operations were performed (42 EEAs and 6 open approaches). Gross-total resection was achieved in 22 patients (62.9%), near total (≥90% tumor resection) in 11 (31.4%). Larger tumors were associated with incomplete resection in univariate and multivariate analysis ( P = .004, .015, respectively). In univariate analysis, tumors involving the lower clivus and cerebellopontine angle were associated with increased number of complications, especially postoperative cerebrospinal fluid leak ( P = .015) and new cranial neuropathy ( P = .037), respectively. Other major complications included 2 cases of meningitis and deep venous thrombosis, and 1 case of hydrocephalus and carotid injury. Involvement of the lower clivus, parapharyngeal space, and cervical spine required a combination of approaches to maximize tumor resection ( P = .017, .044, .017, respectively). No predictors were significantly associated with increased risk of recurrence. The average follow-up time was 44.6 ± 31 months. CONCLUSIONS EEAs may be considered a good option for managing CBCs without significant posterolateral extension beyond the basal foramina and can be used in conjunction with open approaches for maximal resection with acceptable morbidity.
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Affiliation(s)
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Maria Koutourousiou
- Department of Neurolog-ical Surgery, University of Louisville, Louisville, Kentucky
| | | | - Eric W Wang
- Department of Oto-laryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Department of Oto-laryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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17
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Mehta GU, DeMonte F, Su SY, Kupferman ME, Hanna EY, Raza SM. Endoscopic endonasal transpterygoid transnasopharyngeal management of petroclival chondrosarcomas without medial extension. J Neurosurg 2019; 131:184-191. [PMID: 30074455 DOI: 10.3171/2018.3.jns172722] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 03/01/2018] [Indexed: 11/06/2022]
Abstract
Chondrosarcomas of the skull base are malignant tumors for which surgery is the primary therapeutic option. Gross-total resection has been demonstrated to improve survival in patients with these tumors. Chondrosarcomas arising from the petroclival synchondrosis harbor particularly unique anatomical considerations that have long been a barrier to achieving such a resection. Endoscopic endonasal transpterygoid approaches have been recently used to gain improved access to such lesions; however, these approaches have classically relied on a medial to lateral transclival trajectory, which provides limited exposure for complete resection of lateral disease. In this paper the authors describe an endoscopic endonasal transpterygoid transnasopharyngeal approach that provides comprehensive access to the petroclival region through dissection of the eustachian tube with resection of the cartilaginous torus tubarius. Of note, the authors have previously demonstrated the superior outcomes and validity of this approach relative to other cranial base techniques for petroclival chondrosarcomas. Surgical outcomes in 5 cases of chondrosarcoma without medial extension are detailed. Gross-total resection was achieved in 4 of 5 patients. Postoperative complications included transient palatal numbness in all patients and eustachian tube dysfunction due to the approach. With tympanostomy tube placement, no patient had persistent hearing loss. Overall, this approach appears to be a safe and effective technique for resection of petroclival chondrosarcomas.
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Affiliation(s)
| | | | - Shirley Y Su
- 2Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Michael E Kupferman
- 2Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Ehab Y Hanna
- 2Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
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18
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The Evolution of Endoscopic Skull Base Surgery Outcomes: Defining the Edge of the Envelope. World Neurosurg 2019. [DOI: 10.1016/j.wneu.2019.01.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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19
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Schwartz TH, Morgenstern PF, Anand VK. Lessons learned in the evolution of endoscopic skull base surgery. J Neurosurg 2019; 130:337-346. [PMID: 30717035 DOI: 10.3171/2018.10.jns182154] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/01/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVEEndoscopic skull base surgery (ESBS) is a relatively recent addition to the neurosurgical armamentarium. As with many new approaches, there has been significant controversy regarding its value compared with more traditional approaches to ventral skull base pathology. Although early enthusiasm for new approaches that appear less invasive is usually high, these new techniques require rigorous study to ensure that widespread implementation is in the best interest of patients.METHODSThe authors compared surgical results for ESBS with transcranial surgery (TCS) for several different pathologies over two different time periods (prior to 2012 and 2012-2017) to see how results have evolved over time. Pathologies examined were craniopharyngioma, anterior skull base meningioma, esthesioneuroblastoma, chordoma, and chondrosarcoma.RESULTSESBS offers clear advantages over TCS for most craniopharyngiomas and chordomas. For well-selected cases of planum sphenoidale and tuberculum sellae meningiomas, ESBS has similar rates of resection with higher rates of visual improvement, and more recent results with lower CSF leaks make the complication rates similar between the two approaches. TCS offers a higher rate of resection with fewer complications for olfactory groove meningiomas. ESBS is preferred for lower-grade esthesioneuroblastomas, but higher-grade tumors often still require a craniofacial approach. There are few data on chondrosarcomas, but early results show that ESBS appears to offer clear advantages for minimizing morbidity with similar rates of resection, as long as surgeons are familiar with more complex inferolateral approaches.CONCLUSIONSESBS is maturing into a well-established approach that is clearly in the patients' best interest when applied by experienced surgeons for appropriate pathology. Ongoing critical reevaluation of outcomes is essential for ensuring optimal results.
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Affiliation(s)
- Theodore H Schwartz
- Departments of1Neurological Surgery and
- 2Otorhinolaryngology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York; and
- 3Department of Neuroscience, Weill Cornell Medical College, New York, New York
| | | | - Vijay K Anand
- 2Otorhinolaryngology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York; and
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20
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Banaz F, Edem I, Moldovan ID, Kilty S, Jansen G, Alkherayf F. Chondrosarcoma in the Petrous Apex: Case Report and Review. J Neurol Surg Rep 2018; 79:e83-e87. [PMID: 30473986 PMCID: PMC6193802 DOI: 10.1055/s-0038-1673627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/28/2018] [Indexed: 11/12/2022] Open
Abstract
Introduction Surgical treatment of petrous apex chondrosarcoma is challenging due to the location of the tumor. Using an endoscopic technique for tumor resection is favored since it provides a minimally invasive approach. Case Presentation A 57 years old female was admitted for acute onset of left abducens nerve palsy and occasional headache mainly on the left side of the retro-orbital area with some radiation to the left occiput. Magnetic resonance imaging (MRI) and computed tomography (CT), at the time of admission, were showed lytic lesion on the left petrous apex and left part of the clivus. Results of metastatic workup were negative. The surgical procedure considered was expanded endoscopic endonasal transclival approach to the left of the petrous apex and reconstruction with a pedicled nasoseptal flap with image guidance system. The pathology confirmed chondrosarcoma on myxoid background. The surgical procedure was uncomplicated. The abducens nerve palsy was resolved in few weeks and no new deficits occurred. Postoperative MRI showed complete resection of the tumor. Conclusion Expanded endoscopic endonasal transclival approach to petrous apex and reconstruction appears to be safe and feasible technique, capable of achieving total removal of identified lesions near the petrous apex. Nonetheless, future studies with a greater number of patients are crucial to confirm and consolidate this initial impression.
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Affiliation(s)
- F. Banaz
- Department of Otolaryngology- Head & Neck Surgery, The Ottawa Hospital, Ottawa, Canada
| | - I. Edem
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Canada
| | - I. D. Moldovan
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - S. Kilty
- Department of Otolaryngology- Head & Neck Surgery, The Ottawa Hospital, Ottawa, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - G. Jansen
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Canada
| | - F. Alkherayf
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
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21
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Gao HB, Wang LQ, Zhou JY, Sun W. Investigating the application of diving endoscopic technique in determining the extent of pituitary adenoma resection via the trans-nasal-sphenoidal approach. Exp Ther Med 2018; 15:3815-3819. [PMID: 29581739 PMCID: PMC5863581 DOI: 10.3892/etm.2018.5922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/15/2017] [Indexed: 11/26/2022] Open
Abstract
The aim of the present study was to investigate the advantages and disadvantages of the diving endoscopic technique in pituitary adenoma surgery, and the application value in determining the extent of tumor resection. A total of 37 patients with pituitary adenoma initially underwent tumor resection under an endoscope-assisted microscope via standard trans-nasal-sphenoidal approach, and tumor cavity structure was observed by applying the diving endoscopic technique. Surgery was subsequently performed again under a microscope or endoscope. The diving endoscopic technique allowed surgeons to directly observe the structure inside a tumor cavity in high-definition. In the present study, 24 patients had pituitary macroadenomas or microadenomas that did not invade the cavernous sinus, and were considered to have undergone successful total resection. Among these patients, no tumor residues were observed through the diving endoscopic technique. Some white lichenoid or fibrous cord-like tissues in the tumor cavity were considered to be remnants of tumors. However, pathology confirmed that these were not tumor tissues. For tumors that invaded the cavernous sinus in 13 patients, observation could only be conducted under the angulation endoscope of the diving endoscope; i.e., the operation could not be conducted under an endoscope. The present study suggests that the diving endoscopic technique may be used to directly observe the resection extent of tumors within the tumor cavity, especially the structure of the tumor cavity inside the sella turcica. The present study also directly validates the reliability of pituitary adenoma resection under endoscope-assisted microscope. In addition, the diving endoscopic technique also allows the surgeon to observe the underwater environment within the sella turcica.
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Affiliation(s)
- Hai-Bin Gao
- Department of Neurosurgery, Beijing Boai Hospital, China Rehabilitation Research Centre, Beijing 100068, P.R. China.,College of Rehabilitation, Capital Medical University, Beijing 100068, P.R. China.,Institute of Nerve Injury and Repair, Beijing Institute for Brain Disorders, Beijing 100069, P.R. China
| | - Li-Qing Wang
- Department of Neurosurgery, Beijing Boai Hospital, China Rehabilitation Research Centre, Beijing 100068, P.R. China
| | - Jian-Yun Zhou
- Department of Neurosurgery, Beijing Boai Hospital, China Rehabilitation Research Centre, Beijing 100068, P.R. China
| | - Wei Sun
- Department of Neurosurgery, Beijing Boai Hospital, China Rehabilitation Research Centre, Beijing 100068, P.R. China.,College of Rehabilitation, Capital Medical University, Beijing 100068, P.R. China.,Institute of Nerve Injury and Repair, Beijing Institute for Brain Disorders, Beijing 100069, P.R. China
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22
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Doglietto F, Ferrari M, Mattavelli D, Belotti F, Rampinelli V, Kheshaifati H, Lancini D, Schreiber A, Sorrentino T, Ravanelli M, Buffoli B, Hirtler L, Maroldi R, Nicolai P, Rodella LF, Fontanella MM. Transnasal Endoscopic and Lateral Approaches to the Clivus: A Quantitative Anatomic Study. World Neurosurg 2018; 113:e659-e671. [PMID: 29499424 DOI: 10.1016/j.wneu.2018.02.118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/18/2018] [Accepted: 02/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transnasal endoscopic approaches to the clivus have been established recently. Comparative analyses with classic lateral approaches are limited. In this study, we compared transnasal endoscopic and lateral approaches to the clivus, quantifying the exposure and working volume of each approach in the anatomy laboratory. METHODS High-resolution computed tomography scans were performed on 5 injected specimens (10 sides). In each specimen, transnasal endoscopic approaches (i.e., paraseptal, transrostral, extended transrostral, transethmoidal, and extended transclival without and with intradural hypophysiopexy) and lateral approaches (i.e., retrosigmoid, far-lateral, presigmoid retrolabyrinthine and translabyrinthine) to the clivus were performed. An optic neuronavigation system and dedicated software (ApproachViewer; Guided Therapeutics Program, University Health Network, Toronto, Ontario, Canada) were used to quantify the working volume and exposed clival area of each approach. Statistical evaluation was performed with the Kruskal-Wallis test and Steel-Dwass-Critchlow-Fligner post hoc test. RESULTS Endoscopic transnasal transclival approaches showed higher working volume and larger clival exposure compared with lateral approaches. Incremental volumetric values were evident for transnasal approaches; presigmoid approaches provided less working volume than retrosigmoid approaches. A transnasal transclival approach with hypophysiopexy provided significant exposure of the upper clivus (84.4%). The transrostral approach was the first transnasal approach providing satisfactory access to the midclivus (66%); retrosigmoid and far-lateral approaches provided exposure of approximately one half of the midclivus. The lower clivus was optimally exposed with endoscopic transclival approaches (83%), whereas access to this region was limited with lateral approaches. CONCLUSIONS This quantitative anatomic study shows that endoscopic transnasal approaches to the clivus provide a larger working volume and wider exposure of the clivus compared with lateral approaches.
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Affiliation(s)
- Francesco Doglietto
- Department of Neurosurgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Ferrari
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Belotti
- Department of Neurosurgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Hussein Kheshaifati
- Department of Neurosurgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy; Department of Neurosurgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Davide Lancini
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Schreiber
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Tommaso Sorrentino
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Department of Radiology, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Barbara Buffoli
- Department of Anatomy and Physiopathology, Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Lena Hirtler
- Department of Systematic Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Roberto Maroldi
- Department of Radiology, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Fabrizio Rodella
- Department of Anatomy and Physiopathology, Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Maria Fontanella
- Department of Neurosurgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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23
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Komune N, Matsuo S, Miki K, Akagi Y, Kurogi R, Iihara K, Nakagawa T. Surgical Anatomy of the Eustachian Tube for Endoscopic Transnasal Skull Base Surgery: A Cadaveric and Radiologic Study. World Neurosurg 2018; 112:e172-e181. [PMID: 29325963 DOI: 10.1016/j.wneu.2018.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/29/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach to the anatomically complex lateral skull base presents technical challenges. The use of the eustachian tube as a landmark to identify the petrous internal carotid artery has recently been reported, and this study aims to define the anatomic relationship between the eustachian tube and its surrounding structures using cadaveric dissection and radiologic analysis. METHODS To clarify the relationship of the eustachian tube with its surrounding structures, we performed endoscopic and microscopic dissection of 4 adult cadaveric heads and analyzed computed topography scans from 20 patients. RESULTS The eustachian tube is divided into the osseous and cartilaginous parts. The cartilaginous part can be further subdivided into the posterolateral, middle, and anteromedial parts, based on its relationship to the skull base. The eustachian tube is closely related to the pterygoid process of the sphenoid bone, the foramen lacerum, and the petrosal apex and is directed away from the oblique sagittal plane almost parallel to the vidian canal at 12.2° ± 6.2° (mean ± standard deviation). The relationship between the course of the vidian canal and the eustachian tube can aid the estimation of the anatomic course of the horizontal segment of the petrous carotid artery. CONCLUSIONS The eustachian tube is a useful landmark for predicting the course of the internal carotid artery when accessing the lateral skull base regions via an endonasal route. A profound understanding of the relationship between the eustachian tube and the surrounding skull base structures is important for endoscopic endonasal skull base surgeries.
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Affiliation(s)
- Noritaka Komune
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Satoshi Matsuo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | - Koichi Miki
- Department of Neurosurgery, Graduate School of Medical Sciences, Fukuoka University, Fukuoka, Japan
| | - Yojiro Akagi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Nakagawa
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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24
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Ghazwani Y, Qaddoumi I, Bass JK, Wu S, Chiang J, Boop F, Gajjar A, Sadighi Z. Profound hearing loss following surgery in pediatric patients with posterior fossa low-grade glioma. Neurooncol Pract 2017; 5:96-103. [PMID: 29770223 DOI: 10.1093/nop/npx025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Hearing loss may occur in patients with posterior fossa low-grade glioma who undergo surgery. Methods We retrospectively reviewed 217 patients with posterior fossa low-grade glioma, including 115 for whom results of hearing tests performed after surgery and before chemotherapy or radiation therapy were available. We explored the association of UHL with age at diagnosis, sex, race, tumor location, extent of resection, posterior fossa syndrome, ventriculoperitoneal shunt placement, and histology. Results Of the 115 patients, 15 (13.0%: 11 male, 6 black, 8 white, 1 multiracial; median age 7 years [range, 1.3-17.2 years]) had profound UHL after surgery alone or before receiving ototoxic therapy. Median age at tumor diagnosis was 6.8 years (range, 0.7-14.1 years), and median age at surgery was 6.8 years (range, 0.7-14.1 years). Patients with UHL had pathology characteristic of pilocytic astrocytoma (n = 10), ganglioglioma (n = 4), or low-grade astrocytoma (n = 1). Of these 15 patients, 4 underwent biopsy, 1 underwent gross total resection, 1 underwent near-total resection, and 9 underwent subtotal resection. UHL was more frequent in black patients than in white patients (OR 7.3, P = .007) and less frequent in patients who underwent gross total resection or near-total resection than in those who underwent subtotal resection (OR 0.11, P = .02). Conclusions Children undergoing surgery for posterior fossa low-grade glioma are at risk for UHL, which may be related to race or extent of resection. These patients should receive postoperative audiologic testing, as earlier intervention may improve outcomes.
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Affiliation(s)
- Yahya Ghazwani
- Department of Oncology, St. Jude Children's Research Hospital, USA
| | - Ibrahim Qaddoumi
- Department of Oncology, St. Jude Children's Research Hospital, USA
| | - Johnnie K Bass
- Rehabilitation Services, St. Jude Children's Research Hospital, USA
| | - Shengjie Wu
- Department of Biostatistics, St. Jude Children's Research Hospital, USA
| | - Jason Chiang
- Department of Pathology, St Jude Children's Research Hospital, USA
| | - Frederick Boop
- Department of Neurosurgery, University of Tennessee Health Science Center, USA.,Le Bonheur Neuroscience Institute, Le Bonheur Children's Hospital, USA.,Semmes Murphey Neurologic and Spine Institute, USA.,Division of Neurosurgery, St Jude Children's Research Hospital, USA
| | - Amar Gajjar
- Department of Oncology, St. Jude Children's Research Hospital, USA
| | - Zsila Sadighi
- Department of Pediatric Medicine, Division of Neurology, St. Jude Children's Research Hospital, USA
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25
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Proposed Treatment Paradigm for Intracranial Chondrosarcomas Based on Multidisciplinary Coordination. World Neurosurg 2017; 109:e517-e530. [PMID: 29033377 DOI: 10.1016/j.wneu.2017.10.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/02/2017] [Accepted: 10/04/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES There was no consensus regarding the treatment of intracranial chondrosarcoma (CSA). The study aimed to evaluate the adverse factors for progression-free survival (PFS) and overall survival (OS) and to propose a treatment strategy for CSA. METHODS The clinical chart and radiographic data of 106 consecutive cases (mesenchymal and conventional CSA in 18 and 88 patients, respectively) of surgically treated CSAs were retrospectively reviewed. RESULTS Gross total resection was achieved in 43 patients (40.6%), and adjuvant radiotherapy was administered in 45 patients. After a mean follow-up duration of 47.8 months, 38 patients (37.3%) experienced recurrence. PFS and disease-specific OS at 5 years was 57.7% and 74.4%. Independent adverse factors for PFS were previous surgery (hazard ratio [HR] 2.261; P = 0.028), increased lesion size (HR, 1.298; P = 0.026), extent of surgical resection (HR, 3.226; P < 0.001), malignant pathology (HR, 2.018; P = 0.003), and postoperative radiotherapy (HR, 3.246; P = 0.001). The stereotactic radiosurgery subgroup presented best 5-year PFS of 88.9%, and a linear accelerator prolonged the mean PFS time (57.0 months) compared with no radiation (38.1 months). In the incomplete resection subgroup (n = 63), radiotherapy significantly benefited tumor control (HR, 2.101; P = 0.016). Extent of surgical resection (HR, 1.797; P = 0.026) and malignant disease (HR, 1.717; P = 0.030) were associated with OS. CONCLUSIONS Intracranial CSAs were not completely amendable by surgery alone. Gross total resection as far as possible plus radiation were necessary for mesenchymal CSA and conventional CSA with active growth or residual tumor. Stereotactic radiosurgery was an alternative if proton therapy was unavailable. A future study with a large cohort is required to verify our findings.
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26
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Abstract
OBJECTIVE To analyze clinical outcomes after treatment of petroclival chondrosarcoma and to propose a novel staging system. STUDY DESIGN Retrospective case review, 1995 to 2015. SETTING Multicenter study. PATIENTS Consecutive patients with histopathologically proven petroclival chondrosarcoma. INTERVENTION(S) Microsurgery, endoscopic endonasal surgery, radiation therapy, observation. MAIN OUTCOME MEASURES Disease- and treatment-associated morbidity, recurrence, mortality. RESULTS Fifty-five patients (mean age 42 years; 56% women) presenting with primary or recurrent petroclival chondrosarcoma were analyzed. The mean duration of follow-up was 74 months. Among 47 primary cases, the most common presenting symptoms were headache (55%) and diplopia (49%) and the mean tumor size at diagnosis was 3.3 cm. Subtotal resection was performed in 33 (73%) patients and gross total resection in 12 (27%). Adjuvant postoperative radiation was administered in 30 (64%) cases. Preoperative cranial neuropathy improved in 13 (29%), worsened in 11 (24%), and remained stable in 21 (47%) patients; notably, 11 preoperative sixth nerve palsies resolved after treatment. Nine recurrences occurred at a mean of 42 months. The 1-, 3-, 5- and 10-year recurrence-free survival rate for all 45 patients who underwent primary microsurgery with or without adjuvant radiation therapy was 97%, 89%, 70%, and 56%, respectively. Higher tumor stage, larger categorical size (<4 versus ≥4 cm), lack of adjuvant radiation, and longer duration of follow-up were associated with greater risk of recurrence. The overall mortality rate was 2% for patients presenting with primary disease.Analyzing the cohort of 17 cases with 20 recurrences, 3 received salvage surgery alone, 5 radiation therapy alone, 11 multimodality treatment, and one patient has been observed. Tumor control was ultimately achieved in 15 of 17 patients with recurrent disease. One patient (6%) with grade 3 petroclival chondrosarcoma died as a result of rapidly progressive disease within 6 months of salvage treatment. The overall mortality rate was 6% for patients with recurrent disease. CONCLUSION Gross total or subtotal resection with adjuvant radiation provides durable tumor control with minimal morbidity in most patients. Surgery may improve preoperative cranial nerve dysfunction, particularly in the case of cranial nerve 6 paralysis.
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27
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Hasegawa H, Shin M, Kondo K, Hanakita S, Mukasa A, Kin T, Saito N. Role of endoscopic transnasal surgery for skull base chondrosarcoma: a retrospective analysis of 19 cases at a single institution. J Neurosurg 2017; 128:1438-1447. [PMID: 28686110 DOI: 10.3171/2017.1.jns162000] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Skull base chondrosarcoma is one of the most intractable tumors because of its aggressive biological behavior and involvement of the internal carotid artery and cranial nerves (CNs). One of the most accepted treatment strategies for skull base chondrosarcoma has been surgical removal of the tumor in conjunction with proactive extensive radiation therapy (RT) to the original tumor bed. However, the optimal strategy has not been determined. The goal of this study was to evaluate the early results of endoscopic transnasal surgery (ETS). METHODS The authors retrospectively analyzed 19 consecutive patients who underwent ETS at their institution since 2010. Adjuvant stereotactic radiosurgery (SRS) was performed only for the small residual tumors that were not resected to avoid critical neurological complications. Histological confirmation and evaluation of the MIB-1 index was performed in all cases. The Kaplan-Meier method was used to determine the actuarial rate of tumor-free survival. RESULTS The median tumor volume and maximal diameter were 14.5 cm3 (range 1.4-88.4 cm3) and 3.8 cm (range 1.5-6.7 cm), respectively. Nine patients (47%) had intradural extension of the tumor. Gross-total resection was achieved in 15 (78.9%) of the 19 patients, without any disabling complications. In 4 patients, the surgery resulted in subtotal (n = 2, 11%) or partial (n = 2, 11%) resection because the tumors involved critical structures, including the basilar artery or the lower CNs. These 4 patients were additionally treated with SRS. The median follow-up duration was 47, 28, and 27 months after the diagnosis, ETS, and SRS, respectively. In 1 patient with an anterior skull base chondrosarcoma, the tumor relapsed in the optic canal 1 year later and was treated with a second ETS. Favorable tumor control was achieved in all other patients. The actuarial tumor control rate was 93% at 5 years. At the final follow-up, all patients were alive and able to perform independent activities of daily living without continuous neurological sequelae. CONCLUSIONS These preliminary results suggest that ETS can achieve sufficient radical tumor removal, resulting in comparative resection rates with fewer neurological complications to those in previous reports. Although the follow-up periods of these cases were relatively short, elective SRS to the small tumor remnant may be rational, achieving successful tumor control in some cases, instead of using proactive extensive RT. Thus, the addition of RT should be discussed with each patient, after due consideration of histological grading and biological behavior. To determine the efficacy of this strategy, a larger case series with a longer follow-up period is essential. However, this strategy may be able to establish evidence in the management of skull base chondrosarcoma, providing less-invasive and effective options as an initial step of treatment.
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Affiliation(s)
| | | | - Kenji Kondo
- 2Otorhinolaryngology, University of Tokyo Hospital, Tokyo, Japan
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28
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Mason E, Rompaey JV, Solares CA, Figueroa R, Prevedello D. Subtemporal Retrolabyrinthine (Posterior Petrosal) versus Endoscopic Endonasal Approach to the Petroclival Region: An Anatomical and Computed Tomography Study. J Neurol Surg B Skull Base 2016; 77:231-7. [PMID: 27175318 DOI: 10.1055/s-0035-1566123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 09/03/2015] [Indexed: 10/22/2022] Open
Abstract
Background The petroclival region seats many neoplasms. Traditional surgical corridors to the region can result in unacceptable patient morbidity. The combined subtemporal retrolabyrinthine transpetrosal (posterior petrosal) approach provides adequate exposure with hearing preservation; however, the facial nerve and labyrinth are put at risk. Approaching the petroclival region with an endoscopic endonasal approach (EEA) could minimize morbidity. Objective To provide an anatomical and computed tomography (CT) comparison between the posterior petrosal approach and EEA to the petroclival region. Methods The petroclival region was approached transclivally with EEA. Different aspects of dissection were compared with the posterior petrosal approach. The two approaches were also studied using CT analysis. Results A successful corridor medial to the internal auditory canal (IAC) was achieved with EEA. Wide exposure was achieved with no external skin incisions, although significant sinonasal resection was required. The posterior petrosal was comparable in terms of exposure medially; however, the dissection involved more bone removal, greater skill, and a constricting effect upon deeper dissection. Importantly, access lateral to the IAC was obtained, whereas EEA could not reach this area. Conclusion An EEA to the petroclival region is feasible. This approach can be considered in lesions medial to the IAC.
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Affiliation(s)
- Eric Mason
- Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, United States; Center for Cranial Base Surgery, Georgia Regents University, Augusta, Georgia, United States
| | - Jason Van Rompaey
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, United States
| | - C Arturo Solares
- Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, United States; Center for Cranial Base Surgery, Georgia Regents University, Augusta, Georgia, United States
| | - Ramon Figueroa
- Department of Radiology, Georgia Regents University, Augusta, Georgia, United States
| | - Daniel Prevedello
- Department of Neurosurgery, Ohio State University, Columbus, Ohio, United States
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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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30
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Taniguchi M, Akutsu N, Mizukawa K, Kohta M, Kimura H, Kohmura E. Endoscopic endonasal translacerum approach to the inferior petrous apex. J Neurosurg 2015; 124:1032-8. [PMID: 26252453 DOI: 10.3171/2015.1.jns142526] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The surgical approach to lesions involving the inferior petrous apex (IPA) is still challenging. The purpose of this study is to demonstrate the anatomical features of the IPA and to assess the applicability of an endoscopic endonasal approach through the foramen lacerum (translacerum approach) to the IPA. METHODS The surgical simulation of the endoscopic endonasal translacerum approach was conducted in 3 cadaver heads. The same technique was applied in 4 patients harboring tumors involving the IPA (3 chordomas and 1 chondro-sarcoma). RESULTS By removing the fibrocartilaginous component of the foramen lacerum, a triangular space was created between the anterior genu of the petrous portion of the carotid artery and the eustachian tube, through which the IPA could be approached. The range of the surgical maneuver reached laterally up to the internal auditory canal, jugular foramen, and posterior vertical segment of the petrous portion of the carotid artery. In clinical application, the translacerum approach provided sufficient space to handle tumors at the IPA. Gross-total and partial removal was achieved in 3 and 1 cases, respectively, without permanent surgery-related morbidity and mortality. CONCLUSIONS The endoscopic endonasal translacerum approach provides reliable access to the IPA. It is indicated alone for lesions confined to the IPA and in combination with other approaches for more extensive lesions.
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Affiliation(s)
- Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Nobuyuki Akutsu
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Katsu Mizukawa
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Masaaki Kohta
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Ditzel Filho LFS, Prevedello DM, Dolci RL, Jamshidi AO, Kerr EE, Campbell R, Otto BA, Carrau RL. The Endoscopic Endonasal Approach for Removal of Petroclival Chondrosarcomas. Neurosurg Clin N Am 2015; 26:453-62. [PMID: 26141363 DOI: 10.1016/j.nec.2015.03.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chondrosarcomas of the skull base are rare, locally invasive tumors that typically arise in the petroclival region, from degenerated chondroid cells located within the synchondrosis. Given their usually slow growth rate, they are capable of reaching sizable dimensions, promoting bone erosion and significant displacement of neurovascular structures before causing symptomatology that will eventually lead to diagnosis; cranial neuropathies and headaches are common complaints. This article discusses the pertinent surgical anatomy, patient selection criteria, technical nuances and complication management of the endonasal resection of skull base chondrosarcomas.
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Affiliation(s)
- Leo F S Ditzel Filho
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA.
| | - Ricardo L Dolci
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA
| | - Ali O Jamshidi
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Edward E Kerr
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Raewyn Campbell
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA
| | - Bradley A Otto
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA
| | - Ricardo L Carrau
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, 410 West 10th Avenue, N-1049 Doan Hall, Columbus, OH 43210, USA
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32
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Petroclival Tumors: A Paternalistic Challenge. World Neurosurg 2015; 84:231-2. [PMID: 25888810 DOI: 10.1016/j.wneu.2015.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 04/08/2015] [Indexed: 11/21/2022]
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