Skull Base Chordoma: Results and Outcomes of Minimally Invasive Approaches in a Single Institution

Objectives: The purpose of this study is to provide analysis of early outcomes of patients with skull base chordoma treated with a minimally invasive surgical approach.

Methods: A retrospective cohort analysis was performed based on consecutive patients presenting with chordoma to a tertiary care academic medical center from 2009 to 2011.

Results: Seven patients were included with a median follow-up time of 12 months (range, 2–27 months). The mean age at diagnosis was 56 years (range, 40–76 yrs). Facial pain and/or headache were presenting symptoms in six patients (86%). Preoperative cranial nerve palsies were seen in four patients (57%). The tumor epicenter was the sellar/suprasellar region in two patients (29%) and clivus in five patients (71%), with intradural extension noted in four patients (57%).

Six patients (86%) underwent an expanded endoscopic endonasal approach (EEA), and one patient underwent a transoral-transpalatal approach. Mean preoperative tumor volume based on MR imaging was 40.5 cc (range, 1.3–145 cc). Post-resection, the mean tumor volume was 5.8 cc (range, 0–15.8 cc), representing a mean volume reduction of 86% (range, 47–100%). Gross total resection was achieved in two patients (29%). Tumor volume reduction was most limited with the transoral-transpalatal approach.

Two patients (29%) required intraoperative placement of a lumbar drain. One patient with a suprasellar cisternal tumor developed a persistent CSF leak requiring CSF diversion and three revision endoscopic surgeries, complicated by pneumocephalus and meningitis. No other postoperative complications were observed.

Six patients (86%) received adjuvant proton or photon therapy. One patient refused adjuvant therapy and was the only patient to experience an early disease recurrence.

Conclusions: Tumor volume can be effectively and accurately calculated using MR imaging, and resection efficacy derived from these data. The EEA can safely be used to effectively resect skull base chordoma, including lesions with limited intradural extension. This surgical resection should be combined with adjuvant radiation. Long-term follow-up will be needed to determine disease-free survival.