Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Skull base chondrosarcomas are slow-growing, locally invasive tumors that arise from the petroclival synchondrosis. These characteristics allow them to erode the clivus and petrous bone and slowly compress the contents of the posterior fossa progressively until the patient becomes symptomatic, typically from cranial neuropathies. Given the site of their genesis, surrounded by the petrous apex and the clival recess, these tumors can project to the middle fossa, cervical area, and posteriorly, toward the cerebellopontine angle (CPA). Expanded endoscopic endonasal approaches are versatile techniques that grant access to the petroclival synchondrosis, the core of these lesions. The ability to access multiple compartments, remove infiltrated bone, and achieve tumor resection without the need for neural retraction makes these techniques particularly appealing in the management of these complex lesions.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Analysis of the authors’ database yielded 19 cases of skull base chondrosarcomas; among these were 5 cases with predominant CPA involvement. The electronic medical records of the 5 patients were retrospectively reviewed for age, sex, presentation, pre- and postoperative imaging, surgical technique, pathology, and follow-up. These cases were used to illustrate the surgical nuances involved in the endonasal resection of CPA chondrosarcomas.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The male/female ratio was 1:4, and the patients’ mean age was 55.2 ±11.2 years. All cases involved petrous bone and apex, with variable extensions to the posterior fossa and parapharyngeal space. The main clinical scenario was cranial nerve (CN) palsy, evidenced by diplopia (20%), ptosis (20%), CN VI palsy (20%), dysphagia (40%), impaired phonation (40%), hearing loss (20%), tinnitus (20%), and vertigo/dizziness (40%). Gross-total resection of the CPA component of the tumor was achieved in 4 cases (80%); near-total resection of the CPA component was performed in 1 case (20%). Two patients (40%) harbored high-grade chondrosarcomas. No patient experienced worsening neurological symptoms postoperatively. In 2 cases (40%), the symptoms were completely normalized after surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Expanded endoscopic endonasal approaches appear to be safe and effective in the resection of select skull base chondrosarcomas; those with predominant CPA involvement seem particularly amenable to resection through this technique. Further studies with larger cohorts are necessary to test these preliminary impressions and to compare their effectiveness with the results obtained with open approaches.</jats:p></jats:sec>

ICAR: endoscopic skull‐base surgery

“…Only retrospective case series and case reports were identified, with a corresponding level of evidence according to the Oxford LOE classification of 4 and 5, respectively. Among the included studies, only 3 were focused solely on ESBS for skull‐base chondrosarcoma, with 3 additional studies including also chordoma cases along with chondrosarcoma operated through an ESBS . The studies published by Carlson et al., Cho et al., and Raza et al .…”

The Endoscopic Endonasal Approach for Removal of Petroclival Chondrosarcomas

“…[1][2][3] Given their usually slow growth rate, they are capable of reaching sizable dimensions, promoting bone erosion and significant displacement of neurovascular structures before causing symptomatology that will eventually lead to diagnosis; cranial neuropathies and headaches are common complaints. From the petroclival region, they may invade the upper clivus and cavernous sinus superiorly, Meckel's cave and the medial middle cranial fossa laterally, the posterior cranial fossa medially and posteriorly, 2 and the craniovertebral junction inferiorly.…”

“…Due to their ventral trajectory, potential advantages of endoscopic endonasal approaches (EEAs) include the possibility of accessing multiple skull base compartments, even bilaterally, in a single procedure while avoiding retraction or manipulation of neurovascular structures; this is exceptionally displayed during endonasal resection of chondrosarcomas. 2,[4][5][6] Hence, herein the authors describe their indications, contraindications, surgical technique and anatomy, complication management, and perioperative care for the endoscopic endonasal resection of skull base chondrosarcomas. Nevertheless, one must be aware that this is a heterogeneous group that may present in a wide variety of scenarios; thus, we will focus on describing the rationale behind surgically addressing those lesions located mainly in the petroclival region with involvement of neighboring compartments.…”

“…Abbreviations: CPA, cerebellopontine angle; CSF, cerebrospinal fluid; GTR, gross total resection; NTR, near total resection; STR, subtotal resection.Data from Refs 2,[4][5][6][27][28][29][30][31][32]. consults are dictated by the patient's response to surgery in terms of nasal healing and crusting.…”

Petroclival Tumors: A Paternalistic Challenge

“…Petroclival pathology provides unique challenges to the surgeon when considering an approach, tumor resection, and reconstruction. There are ample case series of such difficult tumors in the literature (1,(4)(5)(6)(7)9). Jacquesson et al publish their case series from 2010 to 2014 comparing experiences with the expanded endoscopic endonasal approach (EEEA), anterior petrosectomy (AP) and retrosigmoid approach.…”