SURGICAL-TREATMENT OF CLIVAL CHORDOMAS - THE TRANSSPHENOIDAL APPROACHREVISITED

This is a report of 12 cases of clival chordomas that were surgically treated at the Catholic University Medical School, Rome, Italy, over a 7-year period. The study emphasizes the role of the transsphenoidal a pproach. The study group included seven men and five women whose ages ranged from 26 to 80 years (mean 49.8 years). Diplopia was the most co mmon presenting symptom (eight cases). The tumor involved the upper an d middle clivus in five cases, the middle clivus in five, and the lowe r clivus in two cases. One patient developed spinal metastasis. On his tological examination, eight cases proved to be typical chordomas, thr ee cases had a chondroid component, and one case of chordoma had atypi cal features. Immunohistological staining for vimentin and epithelial membrane antigen was positive in all cases. Follow-up periods ranged f rom 14 to 86 months (mean 40.2 months). The primary treatment consiste d of surgery. Ten patients with chordomas of the upper and middle cliv us underwent a total of 13 transsphenoidal procedures. Total tumor rem oval was achieved in seven cases, subtotal removal in two, and partial removal in one case. In the two cases of lower clival chordomas, tota l removal was accomplished in one and partial removal in the other. Af ter total removal, no recurrence was noted at 14 to 86 months (mean 37 .5 months). In the cases undergoing operation via a transsphenoidal ap proach, there was zero morbidity and one cerebrospinal fluid fistula t hat resolved without surgery. The tumor recurred in two patients after subtotal and partial removal, respectively. The authors opted to reop erate in cases of recurrence. Postoperative radiotherapy was administe red in only two cases in which further surgery was not indicated becau se of medical reasons or because such a procedure was contrary to the patient's wishes. When mortality and morbidity rates of this group are compared to those or chordoma patients who were treated with extensiv e skull-base surgery, the results prompt a reappraisal of the transsph enoidal approach in the treatment of clival chordomas.