Chordomas of the skull base: surgical management and outcome

OBJECT: The goal of this study was to report on the surgical management of skull base chordomas and to evaluate both the short- and long-term treatment outcomes. METHODS: The authors retrospectively studied data from 49 patients who had undergone consecutive surgeries at a single institution. They also analyzed patterns of chordoma extension. Complications and surgery-related morbidity were recorded. A Kaplan-Meier analysis was performed to determine survival rates in patients 5 and 10 years after their first surgery. Operative approaches were selected on the basis of the predominant tumor extension. RESULTS: The approach used most frequently was the transethmoidal in 36.3%, followed by the pterional in 23.4% and the retrosigmoid in 23.4%. The tumor was totally removed in 49.4% and subtotally in 50.6%. The rate of total removal was highest at initial surgery (78%) and progressively declined thereafter. In 11.8% of cases a new neurological deficit developed, while the preoperative deficit remained unchanged. In 20% of cases the preoperative deficits improved, but new deficits also appeared. The 5- and 10-year survival rates are 65 and 39%, respectively. CONCLUSIONS: With an individually tailored surgical approach, total tumor removal in 78% of the cases was achieved at the initial surgery. Radical surgery appears to increase slightly the surgical morbidity, but at the same time prolongs the recurrence-free interval. Chordomas cannot be regarded as surgically curable tumors given the 5- and 10-year survival rates in patients harboring such lesions.     

Chordomas and chondrosarcomas of the skull base: comparative analysis of clinical results in 30 patients

Chordomas and chondrosarcomas occur rarely in the skull base and have been often considered commonly with respect to the management. The aim of this study was to investigate the clinical results in each series of these tumors and analyze comparative outcome. Between 1991 and 2005, 30 consecutive patients with pathological diagnosis of chordoma (n = 19) or chondrosarcoma (n = 11) of the skull base were managed by multimodal treatment combining surgical resection with conventional photon radiotherapy and/or gamma knife radiosurgery. A retrospective analysis was conducted on these patients (aged 3 to 69 years; mean age of 37.3 years; 17 females and 13 males; mean follow-up of 56.1 months). Four deaths occurred among the patients with chordoma. The progression-free survival rate at 3 and 5 years was 61.5 and 40.0% in chordoma. In contrast, no mortalities were observed, and there was only one recurrence among the patients with chondrosarcoma. The progression-free survival rate at 3 and 5 years was 88.9 and 80.0% in chondrosarcoma. Among 15 survivors with chordoma, four patients were suffering from severe disability with progressive disease. On the other hand, most patients with chondrosarcoma harbored stable disease and less disabling symptoms except one instance of recurrence. As the biological behavior of chordoma is much more aggressive than that of chondrosarcoma in the skull base, one should make a distinction between these entities to plan an optimal treatment strategy. Presented at the Second International Neurosurgical Winter Meeting, Zermatt, Switzerland, 13–20 January 2007.     

对颈腰综合征患者施行一期颈腰椎减压手术的临床效果分析

目的回顾性分析一期颈、腰椎减压手术治疗颈腰综合征的临床效果。方法 2010年10月～2012年10月收治的15例颈腰综合征患者,男10例,女5例;年龄45～83岁,平均67.3岁。行一期颈、腰椎减压手术并进行随访,从手术时间、出血量、日本骨科学会(Japanese Orthopaedic Association,JOA)评分、Oswestry功能障碍指数(Oswestry disability index,ODI)、住院时间、住院总费用、围手术期并发症、患者满意度等方面来探讨该手术的临床疗效。结果患者手术时间平均为156 min;术中失血量平均为628 mL。术后15例患者均得到随访(6～27个月),JOA(颈椎疾病)、JOA(腰痛)评分术后平均改善率分别为55.10%、36.84%;ODI从术前57.6到术后28.3;患者总体满意度为12/15(80%)。结论对颈腰综合征患者行一期颈、腰椎减压手术,临床效果显著,明显改善患者生活质量;还能降低住院费用,缩短住院时间,减轻心理负担。     

Classical surgical resection of osteoid osteoma of the cervical spine

Osteoid osteoma is a benign primary skeletal neoplasm occurring mainly in the cortex of long bones, but also in the spine. It occurs most often in young adult males and causes pain in the affected area. It presents as a nidus surrounded by reactive osteosclerosis or less often as a cancellous lesion with only a slight osteosclerosis. Osteoid osteoma may occur in basically any bone of the body, but the strategy of treatment has to be considered carefully, especially when it occurs in the spine. We report about a 38 year old female diagnosed with an osteoid osteoma located in the posterior element of the 5th cervical vertebra. She presented with persisting neck pain over one and a half years. An MRI and CT scan was performed. Due to the vicinity seen in the MRI imaging to neural structures and the slim rest of cortex in this area we decided to use the classical surgical excision through a minimal invasive approach to resect the lesion. Histological examination revealed the typical structures for osteoid osteoma. The patient was immediately free of symptoms and still is nine months after treatment. Surgical excision of an osteoid osteoma is still a good alternative to percutaneous radiofrequency ablation when treating osteoid osteoma located in close vicinity to neural structures.     

Characteristics and outcomes of hepatocellular carcinoma patients with macrovascular invasion following surgical resection: a meta-analysis of 40 studies and 8,218 patients

BackgroundGuidelines recommend that hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) and/or hepatic vein tumor thrombosis (HVTT) should undergo systemic therapy. However, recent data suggest that surgical resection may be beneficial in selected cases, but outcomes are heterogenous. We aimed to estimate pooled overall survival (OS), recurrence free survival (RFS) and complication rates in HCC patients with macrovascular invasion (MVI) following surgical resection.MethodsIn this systematic review and meta-analysis, two investigators independently searched PubMed, Embase, and Cochrane databases from inception to Nov 10, 2020, without language restrictions, for studies reporting outcomes of adult HCC patients with MVI who underwent liver resection with curative intent.ResultsWe screened 8,598 articles and included 40 studies involving 8,218 patients. Among all patients with MVI, the pooled median OS was 14.39 months [95% confidence interval (CI): 10.99–18.84], 1-year OS was 54.47% (95% CI: 46.12–62.58%) and 3-year OS was 23.20% (95% CI: 16.61–31.42%). Overall, 1- and 3-year RFS were 27.70% (95% CI: 21.00–35.57%) and 10.06% (95% CI: 6.62–15.01%), respectively. Among patients with PVTT, median OS was 20.41 months in those with segmental/2nd order involvement compared to 12.91 months if 1st order branch was involved and 6.41 months if the main trunk was involved. The pooled rate of major complications was 6.17% (95% CI: 3.53–10.56%).ConclusionsOverall median survival was 14.39 months for HCC patients with MVI following resection. Median survival was higher in PVTT with segmental/2nd order involvement at 20.41 versus 6.41 months if the main trunk was involved.     

Surgical access to the base of skull and upper cervical spine by extended maxillotomy

An extended maxillotomy has been developed to permit wider surgical access to the base of the skull. It has proven particularly useful in the management of the previously untreatable neuraxial compression caused by basilar invagination in cases of osteogenesis imperfecta. In addition, patients with extensive extradural space-occupying lesions have been treated. The surgical technique is described and the results of its use in nine patients are presented.     

带有颅底的全颈椎三维有限元模型的建立及分析

【摘要】 目的：建立带有颅底的全颈椎三维有限元模型并验证模型有效性,为分析颈椎疾患的生物力学机制提供帮助。方法：选取一31岁健康男性志愿者进行颈椎（包括颅底）薄层CT扫描,并将CT原始数据以Dicom格式存贮。运用建模软件Simpleware3.0把CT数据转化为STL格式数据,通过Geomagic 8.0对数据中的图像进行修补、去噪、铺面并转化为NURB曲面模型,得到带有颅底的全颈椎（C0-C7）三维有限元实体模型。应用软件Hypermesh 9.0进行前处理,包括接触定义、网格划分、材料属性设定及载荷与边界条件设定。应用Abaqus 6-9-1大型有限元计算软件进行计算,将屈曲、伸展、左右侧弯和左右旋转工况下的活动范围（ROM）与Panjabi的实验数据进行比较,对模型进行验证。结果：建立的正常全颈椎三维有限元模型共包含664026单元,228557节点,具有逼真的几何外观。通过与Panjabi的实验数据进行对比验证,发现该模型在屈伸、侧弯及旋转工况下的ROM与Panjabi的数据基本一致,只有在C2-C3旋转活动度方面存在差异（6.03° vs 3°±2.5°,P＜0.05）。结论：所建立的带有颅底的正常全颈椎三维有限元模型满足有限元分析的几何相似性和力学相似性,可用于颈椎的生物力学分析。     

Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection

BACKGROUND: The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing a wide range of colorectal procedures. METHODS: Thirty-nine patients undergoing major elective colonic resection were recruited prospectively. Patients were randomized to receive a ten-point multimodal optimization package or conventional perioperative care. All patients were administered epidural analgesia and opiates were avoided. Outcome measures recorded related to length of hospital stay, physical and mental function, and gut function. RESULTS: Optimization was associated with a significantly shorter median (interquartile range) hospital stay compared with conventional care (5 (4-9) versus 7.5 (6-10) days; P = 0.027). Duration of catheterization (P = 0.022) and duration of intravenous infusion (P = 0.007) were also less. Optimization was associated with a quicker recovery of gut function (P = 0.042). Grip strength was maintained in the postoperative period in the optimized group (P = 0.241) but not in the control group (P = 0.049). There were no differences in morbidity or mortality between the groups. CONCLUSION: Optimization is safe and results in a significant reduction in postoperative stay along with other improved endpoints. This cannot be directly attributed to improvement in any single outcome measure or to the use of epidural analgesia. Improvements are more likely to be multifactorial and may relate to an earlier return of gut function.     

Relation of surgical results and proposed skull base meningioma grading system: analysis of clinical series with 42 patients

Anatomical localisation of skull base meningioma link, their growth and relations with neurovascular structures reduce possibility for radical operation, and offten request additional preoperative or postoperative radiotherapy. We compared personal results of extent surgical resection and skull base meningioma treating outcome with predispose factors scale for surgical radicality and postoperative outcome. We present 42 patients, who were operated in Institute of neurosurgery CCS during the period from 2004 to 2006. RESULTS: Radical resection was possible in 29 cases, and in 13 cases reduction of tumor mass has been performed. Statistical significant predispose factor for radical resection were: absance of preoperative radiotherapy, intact functions of n.III, n.VI, tumor borders inside one skull base fossa and outside of magistral blood vessels. Karnofsky index at the end of following period statistical significant higher in patients with radical resection of skull base meningeioma. Preoperative radiological finding is singificant guide in planning of therapeutic protocol for skull base meningioma. Growth of tumor and relation with neurovascular structures restrict extent of resection and often request additional postoperative radiotherapy or reoperation.     

Classification and surgical approaches for transnasal endoscopic skull base chordoma resection: a 6-year experience with 161 cases

The aim of this study is to retrospectively analyze 161 cases of surgically treated skull base chordoma, so as to summarize the clinical classification of this tumor and the surgical approaches for its treatment via transnasal endoscopic surgery. Between August 2007 and October 2013, a total of 161 patients (92 males and 69 females) undergoing surgical treatment of skull base chordoma were evaluated with regard to the clinical classification, surgical approach, and surgical efficacy. The tumor was located in the midline region of the skull base in 134 cases, and in the midline and paramedian regions in 27 cases (extensive type). Resection was performed via the transnasal endoscopic approach in 124 cases (77 %), via the open cranial base approach in 11 cases (6.8 %), and via staged resection combined with the transnasal endoscopic approach and open cranial base approach in 26 cases (16.2 %). Total resection was achieved in 38 cases (23.6 %); subtotal resection, 86 cases (53.4 %); partial resection of 80–95 %, 29 cases (18 %); and partial resection <80 %, 8 cases (5 %). The clinical classification method used in this study seems suitable for selection of transnasal endoscopic surgical approach which may improve the resection degree and surgical efficacy of skull base chordoma. Gross total resection of skull base chordoma via endoscopic endonasal surgery (with addition of an open approach as needed) is a safe and viable alternative to the traditional open approach.     

Gorham’s disease of skull base and cervical spine – confusing picture in a two year old

Summary The unusual presentation of Gorham’s disease of skull base and cervical spine in a two-year-old female child with radiological signs mimicking those of raised intracranial pressure is discussed. The differential diagnosis consists of skull base tumours, meningitis, osteomyelitis of the base of skull, congenital hydrocephalaus and congenital syndromes involving the skull base. Pathologically it can be very difficult to differentiate it from lymphangioma of the bone. Difficulty in establishing the diagnosis is discussed along with failure of radiotherapy and palmidronate therapy to cause arrest of the disease process and failure of surgery to provide stabilisation. We describe the course of the disease in this child over the period of last eight years. To the best of our knowledge this is the youngest case of Gorham’s described so far.     

Occult ligamentous injury of the cervical spine associated with cervical spine fracture

We report the case of a 20-year-old patient with a C5 cervical spine fracture and an undetected ligamentous lesion between C1 and C2. Cervical spine lesion protocols and the rates of lesions that are not diagnosed with standard evaluation protocols are reviewed, with particular emphasis on comatose patients. Dynamic studies during the surgical procedure for fixation of the fracture are recommended to increase the detection of ligamentous lesions.