gms | German Medical Science

In the treatment of sellar and clival pathologies the transsphenoidal approaches and its technical variants [Ref. 1], offer an excellent alternative to the standard anterior and/or posterior-lateral skull-base approaches because of the absence of brain retraction and the reduction of an exposure time of the brain [Ref. 2].

Surgery is the most effective treatment for clival chordomas, but literature reports combined multimodality approaches in obtaining a prolong survival of the patient, including chemo-radiotherapy [Ref. 3].

The authors confirm the validity of the transsphenoidal surgery in the treatment of the selected cases of clival chordoma.

Three patients, ranging from 32 to 40 years of age presented a midline clival chordomas with the absence of the macroscopic signs of a dural invasion. The tumour sizes ranged from 2.0 to 3.0 centimetres.

The patients suffered from headache and diplopia. In two cases, IXth cranial nerve palsy and intracranic hypertension were also present. Pre-operative Karnofsky performance score ranged between 60-80.

In the patients, pre-operative M.R.I. (Figure 1a [Fig. 1]) showed a midline location of the chordoma with no macroscopic signs of a dural involvement.

A bilateral transsphenoidal approach was performed in two cases (Figure 1b [Fig. 1]). Only in the last case, 2.0 cm on size, an assisted endoscopy transsphenoidal approach was performed because of the limited tumour size of its upper location in clivus area.

In one case, the posterior wall of the sphenoid sinus and the inter-sinusal septum appeared already destroyed. In two cases a posterior sphenoidotomy was necessary to reach the clivus area.

In all three cases, a macroscopical removal of the chordoma was possible. In two cases, operated on via transsphenoidal approach, an adjuvant fractioned radiotherapy (total dose 6000 cGy) was added.

In the last case, in which the tumour removal was performed by the assisted endoscopy support, adjuvant therapies were avoided.

Patient follow-ups ranged from six months to three years.

In all treated cases no postoperative complications were observed.

On histological examination, all three cases proved to be typical chordomas characterized by the presence of vacuolated physaliferous cells (Figure 1c [Fig. 1]). In all cases the study was completed by the immunohistochemical staining for vimentin and epithelial membrane antigen which all resulted positive.

In the patients no tumour relapses and/or metastasis were observed at the three-year follow-up.

Literature reports many variations to the transsphenoidal approaches with or without assisted endoscopy very useful for a careful removal of midline clival chordomas [Ref. 2], [Ref. 3], [Ref. 4].

Wu Y [Ref. 5] selects the best surgery approach to skull base: in his opinion, the surgeon should consider the following factors:

1.

Tumour position.

2.

Complete tumour removal.

3.

Limited damage to normal structures

4.

Esthetic effect.

5.

Convenience for reliable reconstruction.

The authors considered the transsphenoidal approach as a minimally invasive treatment of upper clivus pathologies.

The application of the assisted endoscopic approach in the last treated case has been justified by the midline location of the clivus chordoma and the sure and complete absence of a dural invasion.

The low incidence of postoperative morbidity, the reduction of postoperative hospitalization as well as the absence of tumor recurrence at three-year follow-up, confirm the transsphenoidal approach with or without endoscopy as a right surgical approach alternative in the mini-invasive treatment of skull-base pathologies especially in the cases of extradural midline clival chordomas [Ref. 6].