Objective: To study our experience with Endoscopic Endonasal Surgery (EES) in the treatment of clival chordomas.
Methods: We retrospectively reviewed 151 EES performed on 106 patients with clival chordomas from April 2003 to January 2015.
Results: Of 151 procedures performed, 84 (56%) were for recurrences. The overall gross total resection (GTR) rate was 58% (75% for primary tumors vs. 45% for recurrent tumors, p = 0.016). Factors associated with decreased rates of GTRs were: multiple (>1) prior surgeries (OR = 0.13, p < 0.001), involvement of the craniocervical junction (OR = 0.24, p = 0.01) or the lower third of the clivus (OR = 0.32, p = 0.012), and lateral extension of the tumors (OR = 0.37, p = 0.05. Clinical improvement was observed in 40%, whereas 8.7% clinically deteriorated (main risk factor being multiple prior surgeries OR = 5.9, p = 0.016). Cerebrospinal fluid (CSF) leaks were the main source of morbidity with an overall incidence of 22%, for which males were at a higher risk (OR = 4.7, p = 0.001). Average progression-free survival (PFS) was 20 months (1-year PFS = 81%, 5-year PFS = 57%). Complete resections were associated with longer PFS (HR 0.34, p < 0.001). The years of experience significantly correlated with the rates of GTRs (r = 0.199, p = 0.034), and the correlation was stronger when evaluating only recurrent tumors (r = 0.414, p = 0.003). Experience, however, has had no statistically significant correlation with the incidence of CSF leaks.
Conclusion: The EES affords high rates of complete resections in clival chordomas but is associated with a significant learning curve. Surgical limitations include the craniocervical junction and significant lateral extension, which translate into decreased rates of GTRs. CSF leaks remain a main cause of morbidity, for which males may be at a greater risk.
