gms | German Medical Science

Objective: Clival chordomas are rare malignant tumors of the skull base. A significant longer survival is found in those cases with gross total resection compared to partial resection. Furthermore, the pure endoscopic transnasal approach was described to be associated with fewer complications such as cranial nerve deficits or CSF leaks compared to open approaches. In this small series, the personal experience with the pure endoscopic transnasal skull base approach is described.

Method: Between 2006 and 2014, 10 patients (6 female/4 male, median age 53 y, range 28/79) with clivus chordomas underwent 13 resections. 7 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 nasal obstruction, and one with unilateral palsy of the caudal cranial nerves and craniocervical instability. Two patients were biopsied before. The maximal tumor diameter ranged from 14 to 54 mm. A pure endoscopic transnasal approach including extended sphenoidotomy, and if needed extension to the pyramid apex, condyles or nasopharynx, was used in all of the patients. All surgeries were navigated based on CT fused to MRI. Reconstruction was achieved with a pedicled nasoseptal flap in 6/10 cases.

Results: Gross total resection was achieved in 9 and subtotal resection in 1 case during primary surgery. 6/6 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 cranial nerve deficit was encountered, as well as no CSF leakage or carotid artery injury. One patient complains prolonged nasal discomfort with crusting. 5 patients underwent irradiation with protons, 3 with heavy ions, and the remaining with photons. All patients are alive after a median follow-up of 38 months, range 4-96. One patient presented with a regrowth 11 months after primary surgery, after secondary surgery and photon therapy no regrowth was found during 34 months follow-up. Two patients presented with irradiation induced necrosis of the mesial temporal lobe.

Conclusions: Using the pure endoscopic transnasal approach, an excellent rate (9/10) of gross total resection of clival chordomas was achieved. Furthermore, the approach related morbidity is low, no new cranial nerve deficit was encountered in this series. This technique has become the personal preference for clival chordomas.