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Coutinho da Silva MB, Hernández Hernández V, Gupta P, Lavinsky J, Zenonos GA, Wang EW, Snyderman CH, Gardner PA. Anteromedial Petrous (Gardner's) Triangle: Surgical Anatomy and Relevance for Endoscopic Endonasal Approach to the Petrous Apex and Petroclival Region. Oper Neurosurg (Hagerstown) 2024; 26:330-340. [PMID: 37856762 DOI: 10.1227/ons.0000000000000959] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 08/13/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Triangular corridors have been used as reliable surgical entry points for open transcranial approaches to the petrous apex (PA) and petroclival region (PCR). The endoscopic endonasal approaches have grown rapidly in the last decade, and the indications have advanced. The knowledge of accurate and reliable anatomic landmarks through endoscopic endonasal route is essential and remain to be established. The purpose of this study was to describe the feasibility and surgical exposure of the anteromedial petrous (Gardner's) triangle as a novel corridor to the PA and PCR. METHODS Five anatomic specimens were dissected. The PA and PCR were accessed through endoscopic endonasal approaches and contralateral transmaxillary approach. The limits of the anteromedial petrous (Gardner's) triangle were identified and dissected and associated measurements performed. RESULTS The dissection was divided into 6 steps. The limits of the anteromedial petrous (Gardner's) triangle were identified and defined by the paraclival internal carotid artery anterolaterally, the abducens nerve posteromedially, and the petroclival synchondrosis inferiorly. Three lines were established following the limits of the triangle. The mean distance of the anterolateral limit was 10.03 mm (SD = 0.94), of the posteromedial limit was 20.06 mm (SD = 2.90), and of the inferior limit was 17.99 mm (SD = 2.99). The mean area was 87.56 mm 2 (SD = 20.06). The 3 anatomic landmarks with a critical role to safely define the triangle were the pterygosphenoidal fissure, the petrosal process of the sphenoid bone, and the petroclival synchondrosis. CONCLUSION The anteromedial (Gardner's) triangle is a well-defined bone corridor which provides access to the entire petrous bone and petroclival junction through endoscopic endonasal route. Regardless of the anatomic variations or tumor location, the landmarks of the abducens nerve, paraclival internal carotid artery, and petroclival synchondrosis are key for understanding lateral access to tumors extending from the clivus.
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Affiliation(s)
- Martin B Coutinho da Silva
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
- Postgraduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre , Rio Grande do Sul , Brazil
| | - Vanessa Hernández Hernández
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Prakash Gupta
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Joel Lavinsky
- Postgraduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre , Rio Grande do Sul , Brazil
| | - Georgios A Zenonos
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
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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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Snyder R, Gadot R, Gidley PW, Nader ME, Hanna EY, Su SY, DeMonte F, Raza SM. Patient, Disease, and Treatment-Related Factors Affecting Progression-Free and Disease-Specific Survival in Recurrent Chondrosarcomas of the Skull Base. Oper Neurosurg (Hagerstown) 2023; 24:33-43. [PMID: 36519877 DOI: 10.1227/ons.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Recurrent skull base chondrosarcomas (CSA) are difficult to treat, and limited data are available to help guide subsequent therapy. OBJECTIVE To further characterize the natural history of CSA and identify treatment modalities that were most effective in prolonging progression-free (PFS) and disease-specific survival (DSS). METHODS We conducted a single-institution retrospective review of patients with recurrent skull base CSA from 1993 to 2021. Kaplan-Meier survival analyses for PFS and DSS were completed. Univariable and multivariable Cox proportional hazards regression models were used to identify patient-related, treatment-related, and disease-related factors that predicted PFS and DSS. RESULTS A total of 28 patients and 84 episodes of recurrence were included. One-year PFS was 70.6%, 5-year PFS was 28.9%, and 10-year DSS was 78.5%. The median time to first progression was 23.9 months (range, 2.8-282 months). In univariable Cox proportional hazards regression, male sex, higher grade histology, fourth or greater progression episode status, distal pattern of recurrence, and treatment of recurrence without surgery or with chemotherapy alone predicted worse PFS. Multivariable regression predicted shortened DSS in male patients (hazard ratio [HR] 0.16; P = .021) and higher-grade tumors (HR 0.22; P = .039). Treatment of recurrence with surgery was associated with, but did not significantly predict, improved DSS (HR 1.78; P = .11). CONCLUSION Several patient and disease-specific factors were associated with shorter PFS and DSS in recurrent skull base chondrosarcoma. For recurrences amenable to resection, surgery is recommended for treatment of recurrent CSA. Local recurrence management without surgery results in shorter PFS and DSS.
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Affiliation(s)
- Rita Snyder
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ron Gadot
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul W Gidley
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marc-Elie Nader
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Schur S, Passer JZ, Hanna EY, Su SY, Kupferman ME, DeMonte F, Raza SM. The impact of expanded endoscopic approaches on oncologic and functional outcomes for clival malignancies:a case series. J Neurooncol 2022; 159:627-635. [PMID: 35972674 DOI: 10.1007/s11060-022-04103-7] [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: 06/16/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Clival malignancies pose particular surgical challenges due to complex skull base anatomy and the involvement of vital neurovascular structures. While endoscopic endonasal approached are widely used, the outcomes for clival malignancies remain poorly understood. In this study we assessed the impact of endoscopic and open surgical approaches on PFS, time to initiation of radiotherapy, KPS, and GTR rates for clival malignancies. METHODS A retrospective case series for clival malignancies operated between 1993 and 2019 was conducted. Inclusion criteria were age over 18 and a follow-up of at least a 6 months. Statistical analyses were conducted using STATA version 15 statistical software package StataCorp. RESULTS For the whole cohort (113 patients), and for upper and middle lesions, open surgical approaches increased odds of disease progression, compared to EEA (HR 2.10 to HR 2.43), p < 0.05. EEA had a shorter time interval from surgery to initiation of radiotherapy. No difference in 6 and 12 month KPS was found between surgical groups. Patients undergoing open surgery were less likely to achieve GTR for upper clival lesions. CONCLUSIONS EEA was found to be associated with increased PFS, for upper and middle clival malignancies. The time to initiation of radiotherapy was shorter for patients undergoing EEA compared to open surgery for patients with middle clival involvement. GTR rates were found to be significantly better with EEA for patients with upper clival malignancies.
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Affiliation(s)
- Solon Schur
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Joel Z Passer
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Michael E Kupferman
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
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Edem I, DeMonte F, Raza SM. Advances in the management of primary bone sarcomas of the skull base. J Neurooncol 2020; 150:393-403. [PMID: 32306199 DOI: 10.1007/s11060-020-03497-6] [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: 02/19/2020] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
Abstract
Skull base primary malignancies represent a heterogeneous group of histologic diagnoses and sarcomas of the skull base are specific malignant tumors that arise from mesenchymal cells and can be classified by site of origin into bony and soft tissue sarcomas. The most common bony sarcomas include: chondrosarcoma, osteosarcoma, chordoma, Ewing's sarcoma. Given the relative rarity of each histologic diagnosis, especially in the skull base, there is limited published data to guide the management of patients with skull base sarcomas. An electronic search of the literature was performed to obtain key publications in the management of bony sarcomas of the skull base published within the last decade. This article is thus a review of the multi-disciplinary management principles of primary bony sarcomas of the skull base. Of note, there have been several recent advancements in the realm of skull base sarcoma management that have resulted in improved survival. These include advances in: imaging and diagnostic techniques, surgical techniques that incorporate oncologic surgical principles, conformal radiation paradigms and targeted systemic therapies. Early access to coordinated multi-disciplinary subspecialty care immediately at suspicion of diagnosis has further improved outcomes. There are several ongoing trials in the realms of radiation therapy and systemic therapy that will hopefully provide further insight about the optimal management of bony sarcomas of the skull base.
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Affiliation(s)
- Idara Edem
- Departments of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Franco DeMonte
- Departments of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shaan M Raza
- Departments of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Departments of Neurosurgery, The University of Texas MD Anderson Cancer Center, 1400 Holcombe Blvd, Rm FC7.2000, Unit 442, Houston, TX, 77030, USA.
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Almeida JP, Cappello Z, Borghei-Razavi H, Recinos PF, Sindwani R, Kshettry VR. Endoscopic endonasal translacerum approach for resection of petroclival chondrosarcoma. NEUROSURGICAL FOCUS: VIDEO 2020; 2:V11. [PMID: 36284791 PMCID: PMC9542297 DOI: 10.3171/2020.4.focusvid.19978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/07/2020] [Indexed: 12/02/2022]
Abstract
Petroclival chondrosarcomas are a formidable surgical challenge given the close relationship to critical neurovascular structures. The endoscopic endonasal approach can be utilized for many petroclival chondrosarcomas. However, tumors that extend to the inferior petrous apex require working behind the internal carotid artery (ICA). We present a case of a 33-year-old with a 1-year history of complete abducens palsy, with imaging showing an enhancing mass centered at the left petroclival fissure and inferior petrous apex behind the paraclival carotid artery and extending down into the nasopharynx abutting the cervical ICA. In this video, we describe the surgical steps of the endoscopic endonasal translacerum approach with ICA skeletonization and mobilization. We also highlight the relevant surgical anatomy with anatomical dissections to supplement the surgical video. The patient did well without complications. Postoperative MRI demonstrated complete resection and pathology revealed grade II chondrosarcoma. He underwent adjuvant proton beam radiotherapy. The video can be found here: https://youtu.be/80QXALJW9ME.
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Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Neurologic Institute, Cleveland Clinic, Cleveland
| | - Zachary Cappello
- Charlotte Eye, Ear, Nose and Throat Associated, Charlotte, North Carolina
| | | | - Pablo F. Recinos
- Department of Neurosurgery, Neurologic Institute, Cleveland Clinic, Cleveland
| | - Raj Sindwani
- Department of Otolaryngology, Head & Neck Institute, Cleveland Clinic, Cleveland
| | - Varun R. Kshettry
- Department of Neurosurgery, Neurologic Institute, Cleveland Clinic, Cleveland
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