Expanded Endoscopic Endonasal Approach for Treatment of Clival Chordomas

OBJECTIVE We report our recent experience with an expanded purely endoscopic endonasal approach for the treatment of clival chordomas. METHODS Twelve patients underwent an expanded endoscopic approach for excision of cranial base chordomas at Toronto Western Hospital. Two patients had undergone a previous craniotomy for excision of a significant lateral intracranial extension of the tumor. All other patients had mainly centrally located lesions. Three patients had recurrent tumors. This study focused on the surgical approach, results, and complications associated with this approach. RESULTS Diplopia caused by VIth nerve palsy was the most common presenting symptom and was observed in seven patients. Gross total resection of the tumor was achieved in seven patients (58%). Four patients had complete recovery of their preoperative diplopia. One patient (8%) presented with new hemiparesis postoperatively. Four patients (33%) had a cerebrospinal fluid leak postoperatively; two were treated by lumbar drainage, and two required a secondary surgical repair. All newly diagnosed patients underwent adjuvant radiotherapy. There was no mortality. The short-term outcome was excellent in all but one patient. No recurrence was observed at the median follow-up period of 16 months. CONCLUSION The expanded endoscopic endonasal approach is a valid minimally invasive alternative for the treatment of centrally located clival chordomas or as an adjunct for the central part of chordomas with lateral extension. The early results of this technique indicate at least equivalency to more extensive open approaches, and its versatility may widen the horizon of surgical management of these aggressive lesions. The challenge with the cerebrospinal fluid leakage is being addressed with novel local flap repair techniques. This approach should be in the armamentarium of cranial base surgeons as an option in the management of clival chordomas.