gms | German Medical Science

Objective: Clivus Chordomas are rare malignant tumors of the skull base. Best tumor control can be achieved by aggressive resection followed by proton irradiation. Different microsurgical approaches can be used for best possible tumor excision. The experience with the pure endoscopic transnasal skull base approach is described.

Method: Between 2006 and 2012, 6 patients (3 female / 3 male, median age 45±22) with clivus chordomas underwent 8 resections. 3 of these patients presented with double vision due to abducens palsy, one with deterioration of visual acuity and field as well as pituitary insufficiency, one with problems breathing through the nose, and one with unilateral palsy of the caudal cranial nerves and craniocervical instability. Two patients were biopsied before. Tumor size was in max diameter mean 38 mm, range 18–54 mm. A pure endoscopic transnasal approach was used in all of the patients. The binostril, 4 handed, 2 surgeons technique with wide opening of the sphenoid sinus including vomer resection was applied. All surgeries were navigated based on CT fused to MRI. Reconstruction was achieved with a pedicled nasoseptal flap in 3/6 cases, and fibrin glue overlay in the remaining 3 cases.

Results: GTR was achieved in 5 and subtotal resection in 1 case during primary surgery. One patient with a large regrowth was subtotally resected a second time 11 months after primary treatment. This 80 y old patient underwent photon therapy thereafter. 3/3 abducens palsies resolved, visual acuity and field improved and pituitary insufficiency remained, breathing improved, caudal cranial nerve palsies remained unchanged, neck pain resolved after dorsal craniocervical fusion. No new deficit was encountered, no csf leakage, no carotid artery injury. One patient complains prolonged nasal discomfort with crusting. 3 patients underwent irradiation with protons, 2 with heavy ions, and the remaining with photons. All cases irradiated with protons or heavy ions remained progression free during the follow-up (mean 29 months, range 3–73). The patients undergoing photon therapy remained progression free 9 months after irradiation.

Conclusions: The pure endoscopic transnasal approach enables an excellent access in the craniocaudal axis from planum sphenoidale to axis and lateral direction to petrous apex and condyles and allows a radical resection of clivus chordomas with no new deficits in this series.