Endoscopic Endonasal Interdural Posterior Cilnoidectomy: A Key Step to Achieve Complete Resection in Clival Chordomas
Eric Wang, Paul Gardner, Aldo Eguiluz-Melendez, Sergio Torres-Bayona, Carl Snyderman, Vanessa Hernandez-Hernandez, Maria Belen Vega
Introduction: Skull base chordomas are rare malignant tumors with locally aggressive behavior. Surgical removal is the gold-standard of treatment and extent of resection is the best prognostic factor. Endoscopic endonasal approaches (EEAs) have become a favored approach at many centers. However, the challenging location of the posterior clinoids behind the pituitary gland and cavernous ICA results in variable resection with potential residual in chordomas with upper clival extension.
Objective: To understand the role of endonasal transcavernous posterior clinoidectomy via pituitary transposition in the treatment of clival chordomas.
Methods: All patients with clival chordomas who underwent endoscopic endonasal posterior clinoidectomy and had posterior clinoid(s) identified in surgical pathology reports between January 2012-February 2018 were retrospectively analyzed. Surgical pathology reports and the radiographic tumor location on preoperative neuroimaging were reviewed.
Conclusions: Thirty-three patients underwent endonasal transcavernous posterior clinoidectomy via pituitary transposition during the period reviewed. 23 (70%) patients had tumor histologically documented in at least one posterior clinoid with bilateral involvement found in 39% of cases (9/23 patients). Radiographic analysis showed that upper clivus (87%) and the petroclival region (74%) were the most common chordoma locations associated with posterior clinoid involvement. Complete resection was achieved in 31/33 cases (94%). There were 3 recurrences during a mean follow up period of 20.2 months (3-64 months).
These results confirm the importance of posterior clinoid resection to achieve as radical chordoma removal as possible. During EEA, an interdural pituitary transposition and posterior clinoidectomy should be performed routinely in chordomas with involvement of the upper clivus or petroclival region.