Clival Chordoma Management: A Single Centre Experience

Clival chordomas are a rare and difficult to manage disease. There is little consensus on the optimum surgical management and adjuvant therapy. A variety of surgical approaches have been suggested in the literature, and endoscopic approaches have gained popularity in recent years.

Their anatomical location and natural history make them a surgical challenge as well as delivering adequate radiation doses without injury to surrounding structures. We present our experience in managing this difficult disease entity and outcomes in a national health care setting.

A retrospective case note review was performed of all patients who had undergone endoscopic excision of a clival chordoma in our neurosurgical unit. We investigated the timing from presentation to surgical intervention and the symptoms they presented with. Surgical approach, complications and management of CSF leak as well as adjuvant therapy were all recorded.

From 2004–2014, 20 individual patients diagnosed with a clival chordoma were surgically managed via an endoscopic approach. 34 endoscopic procedures were performed. 15 out of 20 patients (75%) were newly diagnosed chordomas and 3 patients (25%) were recurrent tumors referred to our care. In the newly diagnosed group 40% had further recurrence. 67% of all patients went on to receive proton beam therapy. 4 patients were complicated by post operative CSF leak and one patient had meningitis. One patient returned to theater for repair of CSF leak. Overall survival in our group was 85%.

The management of skull base chordomas requires a multi-disciplinary team approach and although current best practice is still being debated we have noticed improved outcomes in those patients who have had proton beam therapy. This is partly confounded by the minimum requirements in the UK for access to proton beam therapy and larger controlled trials are required.