Multiportal Access corridors to Para-Jugular Foramen Chordoma, … · 2017-02-28 · Although most...
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Multiportal Access corridors to Para-Jugular Foramen Chordoma, Chondrosarcoma Hôpital Lariboisière, Paris France Kentaro WATANABE M.D., Shunya HANAKITAM.D., PhD., Moujahed LABIDI, M.D., Damien BRESSION M.D., Sébastien FROELICH, M.D., PhD., Although most skull base lesions are benign tumors, in many cases a gross total resection is preferred to reduce the risk of tumor progression; including in clival chordomas, chondrosarcomas, and jugular foramen tumors. Achieving total resection is technically challenging in many of these complex tumors. Conventionally, posterior petrosectomy, transsigmoid, transjugular approach have used for in these lesions. Recently, the transnasal endoscopic approach has been developed and extended transnasal approach provides wide visualization and other possibilities of resection of the clivus lesions. We propose five approaches to medial jugular complex lesions with using endoscopic assisted multi portal transnasal or transcranial approaches. 1.Transmastoid presigmoid Approach, 2. Extended transnasal lower and lateral clivus approach, 3. Anterolateral Approach, 4. Extended Farlateral transcondylar approach, 5. Extended Anterior petrosectomy approach, 6. Retrosigmoid extended inframeatal approach Abstract We reviewed our recent experience with surgical treatment of clival chordomas, chondrosarcoma operated on through these approaches during which there was a need for endoscopic assistance. Our surgical strategy was to obtain maximal safe resection with conventional microscopic techniques and then, when tumor consistency and location were favorable, complete the resection under endoscopic visualization. The selection of the approaches depends on tumor size, tumor extension, tumor axis, pathology, origin of tumors, sinus occlusion, sinus dominancy, and patient’s symptom. Methods and Materials Results: During the years 2005 and 2016, 131 cases of chordoma (98) and chondrosarcoma (47) were operated in our hospital. 28 cases (20/8) of the tumor extended to the medial jugular bulb which is lateral mid clivus lesion. The approaches were chosen carefully depends on the tumor location and extension. The endoscope provided better exposure of portions of the tumor extending medially, anteriorly, superiorly or inferiorly to the JF, the jugular bulb (JB) and to the hypoglossal canal. In all cases, the tumor was soft and easily aspirated in an intra-capsular fashion. We performed maximum tumor resection with preserving of both the sigmoid sinus/JB and lower cranial nerves. Near-total resection (≥90%), as documented by postoperative MRI, was achieved in all cases. Postoperative outcome was favorable in all cases with no new cranial neuropathy. Conclusion; Surgical approaches to deep-seated tumors of the craniovertebral junction should be tailored to each lesion’s specific location and extensions. Use of the endoscope may increase the transcranial corridor and allow for more radial resection of chordomas, chondrosarcomas and jugular foramen schwannomas safely. Results & conclusion Case 1 Extended Retrosigmoid, Infra and Supra meatus Approach 52yo M, Chondrosarcoma Hypoglossal nerve palsy Case 2 27 yo, M, Chondrosarcoma, Hypoglossal nerve palsy Unilateral Uninostoril, Transnasal, Trans lacerum Approach Case 6 Endoscopic assistance Case 4 Extended Farlateral transcondyle + RS approach Case 5 42y.o., Chondrosarcoma, V1-V2 hypoesthesy, Provisos operation 38yo. M, Chordoma, Hypoglossal nerve palsy Cadaveric simulation Six different Approaches for lesions of medial jugular foramen Farlateral Transcondyle, Infrajugular Approach, endoscopic assisted Endoscopic assistance SS FN Endoscopic assistance main lesion; Condyle (until HG), medial jugular (antero medial), limited in bone Endoscopic assistance Main lesion; Petrous apex, middle fossa - medial jugular+ Intradural extension Main lesion; Petrous apex - Foramen magnum, bilateral lesion, intradural extension Retrosigmoid Approach Intra-Extradural Approach Endoscopic assistance Main lesion; Petrous apex - Foramen magnum, bilateral lesion, intradural extension Transmastoid Presigmoid, Anterolateral high cervical, combined approach We could arrive at the level of the tumor of the middle fossa, but small piece of tumor was remained. 95% of the tumor was resected. Case 3 47y.o. M, Chordoma, Hearing lost, Facial palsy H&B G4 47y.o. M, Chordoma, Hearing lost, Facial palsy H&B G4 Extended Anterior petrosectomy Because of small lesion, minimum invasive uninostoril approach was chosen. The tumor was hidden backside of the jugular bulb. However endoscope helped to see the medial jugular bulb without using the presigmoid approach. Even the tumor extended until the sphenoid sinus, endoscope help to access through the condylar corridor. Anterior petrosal corridor can be extended and endoscope assist to see under the internal auditory canal. Anterolateral corridor can be used to access to the lesion of cervical and lower clivus. And the presigmoid corridor can access to the petrous carotid canal untile the posterior part of the cavernous sinus.
Transcript of Multiportal Access corridors to Para-Jugular Foramen Chordoma, … · 2017-02-28 · Although most...
Multiportal Access corridors to
Para-Jugular Foramen Chordoma, Chondrosarcoma
Hôpital Lariboisière, Paris France
Kentaro WATANABE M.D.,
Shunya HANAKITAM.D., PhD., Moujahed LABIDI, M.D., Damien BRESSION M.D.,Sébastien FROELICH, M.D., PhD.,
Although most skull base lesions are benign tumors, in many cases a gross total resection is preferred to reduce the
risk of tumor progression; including in clival chordomas, chondrosarcomas, and jugular foramen tumors. Achieving total
resection is technically challenging in many of these complex tumors. Conventionally, posterior petrosectomy,
transsigmoid, transjugular approach have used for in these lesions. Recently, the transnasal endoscopic approach has
been developed and extended transnasal approach provides wide visualization and other possibilities of resection of
the clivus lesions.
We propose five approaches to medial jugular complex lesions with using endoscopic assisted multi portal transnasal
or transcranial approaches.
1.Transmastoid presigmoid Approach, 2. Extended transnasal lower and lateral clivus approach, 3. Anterolateral
Approach, 4. Extended Farlateral transcondylar approach, 5. Extended Anterior petrosectomy approach, 6.
Retrosigmoid extended inframeatal approach
Abstract
We reviewed our recent experience with surgical treatment of clival chordomas, chondrosarcoma operated on through
these approaches during which there was a need for endoscopic assistance. Our surgical strategy was to obtain
maximal safe resection with conventional microscopic techniques and then, when tumor consistency and location were
favorable, complete the resection under endoscopic visualization. The selection of the approaches depends on tumor
size, tumor extension, tumor axis, pathology, origin of tumors, sinus occlusion, sinus dominancy, and patient’s
symptom.
Methods and Materials
Results: During the years 2005 and 2016, 131 cases of chordoma (98) and chondrosarcoma (47)
were operated in our hospital. 28 cases (20/8) of the tumor extended to the medial jugular bulb
which is lateral mid clivus lesion. The approaches were chosen carefully depends on the tumor
location and extension. The endoscope provided better exposure of portions of the tumor extending
medially, anteriorly, superiorly or inferiorly to the JF, the jugular bulb (JB) and to the hypoglossal
canal. In all cases, the tumor was soft and easily aspirated in an intra-capsular fashion. We
performed maximum tumor resection with preserving of both the sigmoid sinus/JB and lower cranial
nerves. Near-total resection (≥90%), as documented by postoperative MRI, was achieved in all
cases. Postoperative outcome was favorable in all cases with no new cranial neuropathy.
Conclusion; Surgical approaches to deep-seated tumors of the craniovertebral junction should be
tailored to each lesion’s specific location and extensions. Use of the endoscope may increase the
transcranial corridor and allow for more radial resection of chordomas, chondrosarcomas and
jugular foramen schwannomas safely.
Results & conclusion
Case 1
Extended Retrosigmoid, Infra and Supra meatus Approach
52yo M, Chondrosarcoma Hypoglossal nerve palsy
Case 2
27 yo, M, Chondrosarcoma, Hypoglossal nerve palsy
Unilateral Uninostoril, Transnasal, Trans lacerum Approach
Case 6
Endoscopic assistance
Case 4 Extended Farlateral transcondyle + RS approach
Case 5
42y.o., Chondrosarcoma, V1-V2 hypoesthesy, Provisos operation
38yo. M, Chordoma, Hypoglossal nerve palsy
Cadaveric simulation
Six different Approachesfor lesions of medial jugular foramen
Farlateral Transcondyle, Infrajugular Approach, endoscopic assisted
Endoscopic assistance
FN
SS
FN
Endoscopic assistance
main lesion; Condyle (until HG), medial jugular (antero medial), limited in bone
Endoscopic assistance Main lesion; Petrous apex, middle fossa - medial jugular+ Intradural extension
Main lesion; Petrous apex - Foramen magnum, bilateral lesion, intradural extension
Retrosigmoid ApproachIntra-Extradural Approach
Endoscopic assistance
Main lesion; Petrous apex - Foramen magnum, bilateral lesion, intradural extension
Transmastoid Presigmoid, Anterolateral high cervical, combined approach
We could arrive at the level of the tumor of the middle fossa, but small piece of tumor was remained. 95% of the tumor was resected.
Case 3
47y.o. M, Chordoma, Hearing lost, Facial palsy H&B G447y.o. M, Chordoma, Hearing lost, Facial palsy H&B G4
Extended Anterior petrosectomy
Because of small lesion, minimum invasive uninostoril approach was chosen.
The tumor was hidden backside of the jugular bulb. However endoscope helped to see the medial jugular bulb without using the presigmoid approach.
Even the tumor extended until the sphenoid sinus, endoscope help to access through the condylar corridor.
Anterior petrosal corridor can be extended and endoscope assist to see under the internal auditory canal.
Anterolateral corridor can be used to access to the lesion of cervical and lower clivus. And the presigmoid corridor can access to the petrous carotid canal untile the posterior part of the cavernous sinus.
