Staged Transcrusal and Transsphenoidal Endoscopic Resection of an Atypical Clival Melanoma: A Case Report and Literature Review

ABSTRACT

We present a case of an atypical clival meningeal melanoma treated with a multidisciplinary staged transcrusal and transsphenoidal endoscopic surgical approach. A 45-year-old woman presented with a 15-month history of visual symptoms, neck pain, and unsteadiness. Magnetic resonance imaging of the head revealed a clival mass with both intracranial and extracranial involvement. Endoscopic clival biopsy suggested a melanocytic tumor. Extensive imaging and dermatological workup did not demonstrate a primary source. A multidisciplinary staged surgical resection included a transcrusal approach to resect the intracranial component, followed by transsphenoidal endoscopic resection of the extracranial component. Postoperatively, she received adjuvant radiation. At 1 year following surgery, the patient retains full preservation of hearing, facial nerve function, and extraocular movements. To our knowledge, this is the first case report of a combined surgical approach for a primary clival meningitic melanoma.

KEYWORDS

Melanoma - clival lesion - transcrusal - transsphenoidal - endoscopic

REFERENCES

• 1 Stamm A C, Pignatari S S, Vellutini E. Transnasal endoscopic surgical approaches to the clivus.  Otolaryngol Clin North Am. 2006;  39 639-656, xi
• 2 Bailey B J, Johnson J T. Head & Neck Surgery – Otolaryngology. 4th ed. Philadelphia, PA; Lippincott Williams & Wilkins 2006
• 3 Davis M DP, Harris K R, Earnest IV F, Gibson L E. Malignant blue nevus.  Eur J Dermatol. 1997;  7 53-55
• 4 Hirsch B E, Cass S P, Sekhar L N, Wright D C. Translabyrinthine approach to skull base tumors with hearing preservation.  Am J Otol. 1993;  14 533-543
• 5 Horgan M A, Delashaw J B, Schwartz M S, Kellogg J X, Spektor S, McMenomey S O. Transcrusal approach to the petroclival region with hearing preservation. Technical note and illustrative cases.  J Neurosurg. 2001;  94 660-666
• 6 Kaylie D M, Horgan M A, Delashaw J B, McMenomey S O. Hearing preservation with the transcrusal approach to the petroclival region.  Otol Neurotol. 2004;  25 594-598, discussion 598
• 7 Sekhar L N, Schessel D A, Bucur S D, Raso J L, Wright D C. Partial labyrinthectomy petrous apicectomy approach to neoplastic and vascular lesions of the petroclival area.  Neurosurgery. 1999;  44 537-550, discussion 550–552
• 8 Horgan M A, Anderson G J, Kellogg J X et al.. Classification and quantification of the petrosal approach to the petroclival region.  J Neurosurg. 2000;  93 108-112
• 9 Weiss M. The transnasal transsphenoidal approach. In: Apuzzo MLF Surgery of the Third Ventricle. Baltimore, MD; Williams & Wilkins 1987: 476-494
• 10 Cappabianca P, Cavallo L M, Esposito F, De Divitis O, Messina A, De Divitis E. Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. In: Pickard JD Advances and Technical Standards in Neurosurgery. New York; Springer 2008: 151-199
• 11 Buchmann L, Larsen C, Pollack A, Tawfik O, Sykes K, Hoover L A. Endoscopic techniques in resection of anterior skull base/paranasal sinus malignancies.  Laryngoscope. 2006;  116 1749-1754
• 12 Zak F G, Lawson W. The presence of melanocytes in the nasal cavity.  Ann Otol Rhinol Laryngol. 1974;  83 515-519
• 13 Batsakis J G, Regezi J A, Solomon A R, Rice D H. The pathology of head and neck tumors: mucosal melanomas, part 13.  Head Neck Surg. 1982;  4 404-418
• 14 Busaba N Y. Primary melanoma of the sphenoid sinus.  Otolaryngol Head Neck Surg. 2000;  123 748-749
• 15 Batra K, Chhabra A, Rampure J, Tang S, Koenigsberg R, Gonzales C CT. CT and MRI appearances of primary sphenoid melanoma: a rare case.  AJNR Am J Neuroradiol. 2005;  26 2642-2644
• 16 Lynch S C, Lee A G, Graham S M, Kirby P A. Primary melanoma of the sphenoid sinus presenting with a third cranial nerve palsy.  J Neuroophthalmol. 2005;  25 289-292
• 17 Solares C A, Fakhri S, Batra P S, Lee J, Lanza D C. Transnasal endoscopic resection of lesions of the clivus: a preliminary report.  Laryngoscope. 2005;  115 1917-1922
• 18 Fatemi N, Dusick J R, Gorgulho A A et al.. Endonasal microscopic removal of clival chordomas.  Surg Neurol. 2008;  69 331-338
• 19 Cha S T, Jarrahy R, Yong W H, Eby T, Shahinian H K. A rare symptomatic presentation of ecchordosis physaliphora and unique endoscope-assisted surgical management.  Minim Invasive Neurosurg. 2002;  45 36-40
• 20 Carrau R L, Kassam A B, Snyderman C H. Pituitary surgery.  Otolaryngol Clin North Am. 2001;  34 1143-1155, ix
• 21 Presentation abstracts. 16th Annual Meeting of the North American Skull Base Society.  Skull Base. 2005;  15(Suppl 1)
• 22 Presentation abstracts. 7th European Skull Base Society Congress.  Skull Base. 2005;  15:(Suppl 2)
• 23 Kassam A, Snyderman C H, Mintz A et al.. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica.  Neurosurg Focus. 2005;  19 E3
• 24 Kassam A, Snyderman C H, Mintz A, Gardner P, Carrau R L. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum.  Neurosurg Focus. 2005;  19 E4
• 25 Kassam A, Gardner P, Snyderman C H, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa.  Neurosurg Focus. 2005;  19 E6