Endoscopic Endonasal Resection of Clival Chordomas: A Case Series

Chordomas are rare, benign tumors believed to develop from notochordal rest cells and to form along the neuraxis. Clival chordomas often present on invasion of surrounding structures at the skull base, which may cause neurologic deficit. Given their location and extent, their clinical management is often complex. Traditional therapies often involve extensive open skull base procedures that can result in significant morbidity. Recently, we incorporated endoscopic endonasal techniques for resection of clival chordomas at our institution. Between April 2008 and July 2012, nine procedures were performed on eight individuals. Six patients underwent de novo resection, and two patients had one or more previous resections. Mean tumor volume was 31.6 cm³ (range, 4.1-85.1 cm³). One patient had recurrent disease. All patients underwent lumbar drainage as a routine part of the procedure. There were three CSF leaks requiring further intervention, but all ultimately resolved without shunting. Mean length of stay was 11 days (range, 3-21 days). Mean estimated blood loss was 486 mL (range, 150-1200 mL). Mean operative time was 362 minutes (range, 222-590 minutes). Gross total resection occurred in 4/8 patients (50%). One patient died during the follow-up period (mean 12 months, range 1-46 months) after a large cerebral infarct. All newly diagnosed patients underwent postoperative radiation/proton beam therapy to the resection cavity/residual tumor.

The endoscopic endonasal approach for clival chordomas offers direct access to the clival region, which is safe and may be less morbid, compared with the extensive skull base reconstructions of the past. We believe the endoscopic endonasal approach should be the treatment of choice for resection of clival chordomas.