Combined Surgical Approaches for Skull Base Chordomas

Objective: Gross total resection (GTR) is the goal of surgery for skull base chordomas. For extensive, invasive chordomas, a single approach is sometimes not enough to achieve this goal.

Methods: Among 71 patients with skull base chordomas who underwent endoscopic endonasal surgery (EES) in our Department (period: April 2003–September 2011), 12 were treated with combined open and endoscopic approaches. Medical records and radiologic images were retrospectively analyzed and evaluated.

Results: Eight patients were initially treated with combined approaches, while four underwent craniotomy for recurrence after EES. Patients selected for initial management with combined approaches presented with extensive chordomas (mean tumor volume, 66.38 cm³ vs. 31.58 cm³ of the whole cohort) and with tumor located in the lower clivus with lateral extension (in six out of eight patients), which is one of the most challenging areas for endoscopic surgery. The eight patients were treated either with a single (n = 3) or staged surgery (n = 5). EES was combined with transcervical approach (n = 4), far lateral (n = 3) approach, extreme lateral/transcondylar (n = 1) approach, or orbitofrontal approach (n = 1). Despite the tumor size, GTR was achieved in three cases, near total (>95%) in four, and subtotal (>85%) in one. Patients who underwent craniotomy for recurrence had initially presented with extensive chordomas (mean volume, 55.67 cm³) and had an unsuccessful EES (resection <85% of tumor in three out of four patients). As expected, after a midline approach, residual was located at the most lateral aspects of the tumor; recurrence was then accessed with a lateral approach. The recurrent cases underwent a retromastoid (n = 2), subtemporal (n = 1), extreme lateral/transcondylar (n = 1), or orbitofrontal (n = 1) approach. GTR was not possible in these aggressive chordomas.

Conclusion: Disease control is related to the extent of chordoma resection. EES, like any other skull base approach, represents a vital part of the neurosurgical armamentarium for the treatment of skull base chordomas. In selected cases, a combined open and endoscopic approach is mandatory to achieve the maximum degree of resection.