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Classification and surgical approaches for transnasal endoscopic skull base chordoma resection: a 6-year experience with 161 cases

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Abstract

The aim of this study is to retrospectively analyze 161 cases of surgically treated skull base chordoma, so as to summarize the clinical classification of this tumor and the surgical approaches for its treatment via transnasal endoscopic surgery. Between August 2007 and October 2013, a total of 161 patients (92 males and 69 females) undergoing surgical treatment of skull base chordoma were evaluated with regard to the clinical classification, surgical approach, and surgical efficacy. The tumor was located in the midline region of the skull base in 134 cases, and in the midline and paramedian regions in 27 cases (extensive type). Resection was performed via the transnasal endoscopic approach in 124 cases (77 %), via the open cranial base approach in 11 cases (6.8 %), and via staged resection combined with the transnasal endoscopic approach and open cranial base approach in 26 cases (16.2 %). Total resection was achieved in 38 cases (23.6 %); subtotal resection, 86 cases (53.4 %); partial resection of 80–95 %, 29 cases (18 %); and partial resection <80 %, 8 cases (5 %). The clinical classification method used in this study seems suitable for selection of transnasal endoscopic surgical approach which may improve the resection degree and surgical efficacy of skull base chordoma. Gross total resection of skull base chordoma via endoscopic endonasal surgery (with addition of an open approach as needed) is a safe and viable alternative to the traditional open approach.

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Authors and Affiliations

  1. Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

    Songbai Gui, Xuyi Zong, Xinsheng Wang, Peng Zhao & Lei Cao

  2. Beijing Neurosurgical Institute, Capital Medical University, Beijing, China

    Chuzhong Li & Yazhuo Zhang

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  1. Songbai Gui
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  2. Xuyi Zong
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  3. Xinsheng Wang
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  4. Chuzhong Li
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  5. Peng Zhao
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  7. Yazhuo Zhang
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Correspondence to Yazhuo Zhang.

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Comments

Kiyoshi Saito, Fukushima, Japan

The authors nicely showed surgical results of 161 patients with clival chordomas. They proposed clinical classification of chordomas: midline group including anterior skull base, superior clivus, superior-middle clivus, middle-inferior clivus, inferior clivus and total clivus, and paramedian group. Different approaches were used for different types of chordomas according to the classification. Among 161 cases, transnasal endoscopic approach was selected in 124 and staged transnasal endoscopic and open cranial base approaches in 26. Surgical results such as degree of resection, clinical factors for inadequate resection, and complications were presented.

Since an extended endonasal endoscopic approach has been developed, most skull base chordomas could be removed using this approach. They divided endonasal endoscopic approaches into anterior skull base, superior clival, superior-middle clival, middle-inferior clival, inferior clival, and total clival approaches. The classification is simple and may facilitate the resection of main part of the tumor. However, for a long-term tumor control, total tumor resection with removal or drilling of the surrounding bone should be performed even in the endoscopic surgeries.

The authors have outstanding experience of endonasal endoscopic surgeries for clival chordomas, especially large and extended tumors. It is interesting to know how total clival, extensive, or paramedian chordomas were managed and what was the indication and limitation of staged or combined surgeries. Long-term outcome would elucidate the surgical efficacy of their classification.

Henry W. S. Schroeder, Greifswald, Germany

The authors present their experience of 161 patients undergoing surgical treatment of skull base chordomas and retrospectively evaluated their clinical classification, surgical approach, and surgical efficacy. The tumor resection was performed via a transnasal endoscopic approach in 124 cases (77 %), via an open cranial base approach in 11 cases (6.8 %), and via a combined transnasal endoscopic and transcranial approach in 26 cases (16.2 %). Total resection was achieved in 38 cases (23.6 %), subtotal resection in 86 cases (53.4 %), partial resection of 80–95 % in 29 cases (18 %), and partial resection <80 % in 8 cases (5 %). The authors conclude that the clinical classification used in their study seems to be suitable for the selection of a transnasal endoscopic surgical approach.

This is the largest surgical series of skullbase chordomas reported so far. I agree completely that the endonasal endoscopic approach is the most appropriate surgical access route for the majority of skull base chordomas because they arise usually from the clivus and all important neurovascular structure are lateral to the tumor center. The endoscopic approach provides direct access to the clival origin of the tumor and avoids unnecessary manipulations of the cranial nerves. Since the tumor consistency is usually soft, they can easily be removed by suction and curettage. Therefore, even intradural tumor parts can nicely be resected. Tumor parts which are not visible in straight line can be resected by using angulated endoscopes and instruments. All infiltrated bone of the skullbase has to be drilled to reduce the risk of recurrence. This can be elegantly done via the endonasal approach.

The authors propose the following chordoma classification: midline region types—(a) anterior skull base type, (b) superior clivus type, (c) superior-middle clivus type, (d) middle-inferior clivus type, (e) inferior clivus type, (f) total clivus type, and the extensive type (tumor in midline and paramedian region). In my opinion, this classification has little value in terms of approach selection and outcome. In all types except the last one, the endonasal approach is selected. The differentiation between endoscopic anterior skull base approach, endoscopic superior clival approach, endoscopic superior-middle clival approach, endoscopic middle-inferior clival approach, endoscopic inferior clival approach, and the endoscopic total clival approach has at best little clinical meaning. It is clear that the endonasal approach has to be extended according to the borders of the lesion. Additionally, it is clear that the rate of total resection depends on the size and extension of the lesion.

It is logic that in lesions which extend more laterally the endonasal approach is not sufficient and has to be combined with a transcranial approach. We start in most skullbase chordomas endonasally, and when we recognize that there is residual tumor which cannot be resected via this approach, we add a transcranial approach as a second stage. When the lesions is only laterally located, just a craniotomy is used.

The study nicely shows that total tumor resection is the most important prognostic factor. Sixty-four percent of the residual tumors had progression during the follow-up period. Furthermore, the limited effect of radiation is demonstrated. Nineteen patients among 37 cases (51 %) who had undergone postoperative radiotherapy had progression of the tumor.

Chordomas remain challenging lesion, but with the endoscopic endonasal approach, the resection rate can be improved and the morbidity reduced.

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Gui, S., Zong, X., Wang, X. et al. Classification and surgical approaches for transnasal endoscopic skull base chordoma resection: a 6-year experience with 161 cases. Neurosurg Rev 39, 321–333 (2016). https://doi.org/10.1007/s10143-015-0696-1

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