Neuronavigation using an image-guided endoscopic transnasal-sphenoethmoidal approach to clival chordomas.
ABSTRACT Surgical approaches described for resection of clival tumors have been complicated, extensive, traumatic, and invasive. They are also associated with significant mortality and morbidity rates. We describe a minimally invasive, endoscopic transsphenoidal surgical treatment for clival tumors.
Three men, aged 43, 46, and 66 years, each presented with a history of headaches, diplopia, and multiple cranial nerve deficits. All preoperative magnetic resonance imaging scans showed large clival tumors. A neuronavigational image-guided endoscopic transnasal-sphenoethmoidal approach was performed to resect the clival tumors.
All three patients had near-total removal of clival tumors using this method, and the histology revealed chordomas. They underwent postoperative adjuvant radiotherapy. No complications were encountered. All patients were able to resume their usual activities on the same day after surgery. Furthermore, this technique greatly reduced patient discomfort, hastened recovery, and shortened the hospital stay.
The neuronavigation image-guided transsphenoidal approach is a viable, minimally invasive alternative for surgical treatment of clival tumors.
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ABSTRACT: Endoscopic treatment of hydrocephalus has in time acquired a primary position in Neurosurgery. Today endoscopy can be employed in the vast majority of neurosurgical procedures in the realization of the so-called endoscope-assisted microneurosurgery. On the basis of the encouraging results obtained by Jho and Carrau, the authors report the pros and cons of the new endoscopic endonasal technique. An endoscopic endonasal transsphenoidal approach to the sella was performed in 50 patients: 33 females and 17 males, of age included between 16 and 76 years; 45 were affected by pituitary adenomas (9 micro and 36 macro; 10 were recurrences), 3 by craniopharyngiomas, 2 by clival chordomas. The new instrumentation was realized through straight devices with a handle shifted 10-30 degrees horizontally. The possible danger to the nasal structures is reduced not only by the elimination of the bayonet-like shape but also by hiding the cutting extremity in the handle. The advantages of this technique have been represented by an easier access to the lesion, especially in recurrent tumors, a more complete excision of voluminous neoplasms, a decrease of ENT post-surgical complications and a reduction of hospitalization times and costs. The main limits have been the reduction of field depth and the lack of adequate instrumentation. In this peculiar surgery the absence of proper instruments has to be overcome because: a) there is less room to work, b) a conflict between the hands of the surgeon and the endoscope may occur, c) the blind introduction of the instruments in the nostril may cause damage to the nasal structures. The secret for the success of the endoscopic endonasal transsphenoidal technique is to create the optimal conditions, in order to avoid improper manoeuvres that may cause potential dangers.Journal of neurosurgical sciences 07/1999; 43(2):85-92. · 0.53 Impact Factor
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ABSTRACT: To determine the patterns of failure and outcome following relapse of chordomas of the base of skull and cervical spine. Between November 1975 and October 1993, 204 patients were treated for chordoma of the base of skull or cervical spine, of which 63 have developed relapse. These 63 patients constitute the main focus of this study. Forty-five patients presented with base of skull and 18 with cervical spine tumors. All patients received combined proton and photon beam radiation. The median prescribed dose was 70.1 cobalt-Gray equivalent (CGE) (range 66.6-77.4). There were 25 males and 38 females, with a median age of 41 years (range 7-66). Median follow-up was 54 months (range 8-158). Sixty-three of the 204 patients treated (31%) had treatment failure. Among the 63 patients who relapsed, 60 (95%) experienced local recurrence, and in 49 patients (78%), this was the only site of failure. Two of 63 patients (3%) developed regional lymph node relapse and 3 of 63 (5%) developed surgical pathway recurrence (1 left neck, 1 palate and 1 nasal cavity). Thirteen of 204 patients relapsed in distant sites, accounting for 20% (13 of 63) of all patients with recurrence in this series. The most common metastatic sites were lungs and bones presenting in 7 of 13 and 6 of 13 patients, respectively. Only 2 of 13 patients failed with isolated distant metastasis. The actuarial 3- and 5-year survival rates after local relapse (60 patients) were 44 and 5%, respectively. Following distant failure (13 patients), the 3- and 5-year survival rates were 25 and 12%, respectively. After any relapse (63 patients) the corresponding survival rates were 43 and 7%. Following local relapse, 49 of 60 patients underwent salvage therapy consisting of subtotal resection in most patients (46 of 49). The remaining 11 of 60 patients received supportive care only. Salvage therapy resulted in stable or improved status without subsequent disease progression in 26 of 49 (53%), and progressive disease in 16 of 49 patients (33%). The actuarial 2- and 5-year overall survival rates following relapse for the 49 patients who underwent salvage treatment were 63 and 6%, which favorably compared to the 2-year survival rate of 21% for those who received supportive care only (p = 0.001). Local relapse is the predominant type of treatment failure for chordomas of the base of skull and cervical spine. Salvage treatment may relieve symptoms; however, most patients will ultimately succumb to their disease. Poor long-term survival rates following relapse emphasize the importance of a combined treatment approach with experienced surgeons and radiation oncologists at the time of primary treatment. For most patients, only permanent local tumor control will offer a chance of cure.International Journal of Radiation OncologyBiologyPhysics 11/1995; 33(3):579-84. · 4.52 Impact Factor
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ABSTRACT: To investigate the treatment outcome of patients suffering from skull base chordoma or chondrosarcoma after fractionated stereotactic radiotherapy. We report 45 patients treated for chordoma or chondrosarcoma with postoperative fractionated stereotactic radiotherapy between 1990 and 1997. Patients had CT and MRI for 3D treatment planning performed under stereotactic guidance. Median dose at isocenter was 66.6 Gy for chordomas and 64.9 Gy for chondrosarcomas. MRI imaging was obtained in intervals after therapy to evaluate local relapse. Survival was calculated according to the Kaplan-Meier method. All chondrosarcomas had achieved and maintained local control and recurrence-free status at follow-up of 5 years. Local control rate of chordomas was 82% at 2 years and 50% at 5 years. Survival was 97% at 2 years and 82% at 5 years. At maximum follow-up of 8 years local control and survival rate of chordomas was 40% (82%). Clinically significant late toxicity developed in one patient. Our results demonstrate the feasibility of fractionated photon beam therapy and its success in the treatment of skull base tumors. Modern 3D treatment techniques provide superior results compared to conventional techniques. The role of high-precision radiotherapy compared to particle beam therapy in the treatment of these tumors is not yet fully clear and further research is needed.International Journal of Radiation OncologyBiologyPhysics 07/2000; 47(3):591-6. · 4.52 Impact Factor