Treatment of a Clival Chordoma Using Magnetic Resonance–Guided, Laser-Induced Thermal Therapy (LITT): Case Report

Introduction: Chordomas are rare tumors that are difficult to treat and have high recurrence rates despite aggressive therapy. The authors present the first case of a patient with a newly diagnosed clival chordoma in which tumor ablation was achieved with magnetic resonance–guided laser-induced thermal therapy (LITT). The purpose of this report is to demonstrate the feasibility of this technique and describe the response of this pathology to thermal energy.

Methods: A 54-year-old woman presented with difficulty swallowing and changes in her voice. Workup included an MRI that showed an enhancing clival mass extending into the nasopharynx. The diagnosis of chordoma was made after a needle biopsy. After a detailed discussion of treatment options, the patient elected MRI-guided LITT. She underwent placement of the laser catheter into the chordoma via an endoscopic endonasal approach. With real-time MR thermometry monitoring, 12 watts of laser-generated thermal energy was delivered to the tumor for 311 seconds. The patient remained neurologically intact during and after the procedure and was discharged on postoperative day 1. Response to treatment was assessed using serial contrast enhanced MRI scans.

Results: The initial volume of the tumor was 1.65 cm³. Periprocedural MRI demonstrated a complete thermal ablation of the mass radiographically. The volume of the tumor increased on day 1 to 2.47 cm³ due to swelling, but then began to retract to 1.34 cm³ by day 25. At most recent follow-up (136 days postprocedure) the mass is now 0.35 cm³. The patient tolerated the procedure well and has had resolution of her symptoms since surgery.

Conclusions: The endoscopic endonasal approach to MR-guided laser ablation is both technically feasible and safe. Chordoma cells seem to be sensitive to thermal energy as reflected by the substantial decrease in the size of the tumor post LITT. As a result, this therapy may be a useful alternative in hard-to-reach chordomas, or in recurrent cases that have failed other conventional treatment modalities. Further follow-up will be needed to assess the long-term outcome after LITT and the role for this novel technology in the treatment of chordomas and other CNS neoplasms.