Clival Chordomas in the Endoscopic Endonasal Era: Clinical Management, Outcomes, and Complications

Surgical management of skull base chordomas has changed significantly in the past 2 decades, most notably with use of the endoscopic endonasal approach (EEA), although high quality outcome data using these modern approaches remain scarce. To evaluate outcomes in a large series of patients treated by a single surgeon, using primarily the EEA. Between 2006 and 2020, 68 patients with skull base chordoma underwent resection using mostly the EEA. Complications, outcomes, and potential contributing factors were evaluated using Kaplan-Meier survival analysis and univariable and multivariable Cox proportional hazards models. Overall 5-year survival was 76.3% (95% CI 61.5%-86.0%), and 5-year progression-free survival was 55.9% (95% CI 40.0%-69.0%). In multivariable analysis, radical resection was associated with significant reduction in risk of death (hazard ratio [HR] 0.04, 95% CI 0.005-0.33, P = .003) and disease progression (HR 0.05, 95% CI 0.01-0.18, P < .001). Better preoperative function status reduced risk of death (HR 0.42 per 10-point increase in Karnofsky Performance Scale, 95% CI 0.28-0.63, P < .001) and progression (HR 0.60 per 10-point increase in Karnofsky Performance Scale, 95% CI 0.45-0.78, P < .001). Localization at the clivus reduced risk of death (HR 0.02, 95% CI 0.002-0.15, P < .001) and progression (HR 0.24, 95% CI 0.09-0.68, P = .007) compared with tumors at the craniovertebral junction. In multivariable analysis, overall survival and progression-free survival of chordoma resection was most positively affected by radical resection, better preoperative functional status, and tumor location at the clivus rather than craniovertebral junction

Transnasal Transsphenoidal Endoscopic Repair of CSF Leakage Using Multilayer Acellular Dermis

Cerebrospinal fluid (CSF) leaks result from a communication between the subarachnoid space and the upper aerodigestive tract. Because of the risk of complications such as meningitis, brain abscess, and pneumocephalus, all persistent CSF leaks should be repaired. Surgical repair may be achieved transcranially or extracranially using a wide variety of autogenous, allogenic, and synthetic patching materials. We report our results with a transnasal transsphenoidal endoscopic approach for the repair of CSF leaks coupled with a multilayer closure using acellular dermis (Alloderm™). We conducted a retrospective review of all patients presenting to our institution over the past 5 years with isolated sphenoid sinus CSF fistulas. Results: Twenty-one patients were included in the study. Nineteen patients (90.5%) had their sphenoid sinus CSF fistula repaired during the first attempt; 2 patients (9.5%) needed a second attempt. The multilayer repair of the CSF leak using acellular dermis via a transsphenoidal endoscopic approach is an effective and successful method of surgical repair of the fistula site. Neither the number, size, nor cause of the CSF fistula affected surgical outcomes. However, the presence of hydrocephalus was a significant negative variable, altering the surgical outcomes of our patients. The acellular dermis offers the advantage of not requiring autogenous tissue for the effective repair of CSF leaks in the sphenoid sinus

Clival Chordomas in the Endoscopic Endonasal Era: Comparison With Management With Open Skull Base Approaches

The most significant paradigm shift in surgical management of skull base chordomas has been the adoption of the endoscopic endonasal approach, but the impact on patient outcomes compared with open skull base approaches remains unclear. To compare a large series of patients treated by a single surgeon using primarily endoscopic endonasal approaches with previously published outcomes by the same surgeon using open skull base approaches. Between 2006 and 2020, 68 patients with skull base chordoma underwent resection using primarily endoscopic endonasal approaches. Outcomes and complications were compared with previously published results of resection of chordomas from 1991 to 2005 using open skull base approaches. Compared with the prior cohort, the current principally endoscopic cohort demonstrated similar rates of OS ( P = .86) and progression-free survival ( P = .56), but patients undergoing first-time resection had significantly higher rates of radical resection (82.9% compared with 64.3%, P = .05) and required fewer staged surgeries (9.8% compared with 33.3%, P = .01). There was no difference in survival rates for patients treated in the current era, primarily using endoscopic endonasal techniques, compared with previously published results using open skull-base approaches by the same surgeon. Although use of endoscopic endonasal approach resulted in higher rates of radical resection, patients undergoing first-time resection and fewer staged surgeries were required