Introduction: Skull base chordomas are relatively rare malignant tumors with locally aggressive
behavior. Surgical removal is the gold-standard of treatment and the extent of resection
is the best prognostic factor. The challenging location of posterior clinoids behind
the pituitary gland results in them not being resected very often and hence, potentially
leaving residual in chordomas with upper clival extension. Favorable endocrinological
outcomes and technical nuances of the interdural pituitary transposition have been
described, but its routine use has not spread. The purpose of this study was to understand
the role of endonasal transcavernous posterior clinoidectomy approach with pituitary
transposition for the treatment of clival chordomas.
Methods: All patients with skull base chordomas who underwent endoscopic endonasal posterior
clinoidectomy with interdural pituitary transposition and had posterior clinoid(s)
identified in surgical pathology reports between January 2012 and February 2018 were
included and retrospectively analyzed. Surgical pathology reports of the posterior
clinoid(s) and the radiographic location of the tumor on preoperative neuroimaging
(CT and MRI) were reviewed.
Results: Thirty-three patients underwent endonasal transcavernous posterior clinoidectomy
approach with pituitary transposition during the period reviewed. 23 (69.7%) patients
had tumor documented by pathology in the posterior clinoid. Bilateral involvement
was found in 39.1% of cases (9/23 patients). The radiographic analysis showed that
upper clivus (96%) and the petroclival region (65%) were the most common locations
of chordomas associated with posterior clinoid tumor involvement. Complete resection
was achieved in 22/23 cases (95.7%). There was only one recurrence in this group of
patients with a mean follow-up period of 18 months (6–64 months).
Conclusion: These results confirm the importance of posterior clinoid resection to achieve as
much tumor removal as possible in chordoma surgery. Hence, the endoscopic endonasal
interdural pituitary transposition and posterior clinoidectomy should be performed
routinely in chordomas with involvement of the upper clivus or petroclival region.
