21 Clival Chordomas

  • Ian F. DunnEmail author
  • Fred Gentili


Clival chordomas are surgically very challenging tumors given their varying biological behavior, central location, and tendency to infiltrate bone. Given to their high recurrence rate, propensity for local invasion, and close relationship to important neurovascular structures, total removal is often challenging with the potential of significant postoperative morbidity. While there are no uniformly accepted guidelines, the current standard for their treatment includes safe, aggressive, maximal surgical removal followed by high-dose radiation therapy. An oncologic approach in their management is required. The clivus may be accessed through a wide range of surgical approaches. Surgery aims for gross total resection of microscopic tumor when anatomically feasible. When complete removal risks neurovascular compromise, the goal should be radical subtotal resection to improve the safety margin between the tumor and critical neural structures to facilitate postoperative radiation. The choice of surgical approach is dictated by the anatomic compartments invaded by tumor, the course of encapsulated or adjacent neurovascular structures, options for reconstruction, and surgeon preference. Given the extradural origin of chordomas, the surgical approach should allow for a primarily extradural corridor for tumor removal, thereby, minimizing contamination of CSF spaces unless mandated by the tumor. Aggressive surgical treatment followed by radiation confers improved long-term disease-free survival in both adults and children with chordoma. In 21.2, we discuss the open transcranial approaches. The transphenoidal approach is considered less invasive, representing the most direct route to the clivus. The introduction of endoscopic endonasal techniques, discussed in 21.3, has further reduced the invasiveness of this approach, allowing for a more detailed visualization of the tumor and surrounding neurovascular structures, thus improving the extent of tumor removal and surgical outcomes. However, the long-term outcomes of chordoma management remains somewhat disappointing, with local control rates at 10 years of only 40%.


Chordoma Transbasal Subfrontal Cranioorbitozygomatic Middle fossa Transcondylar Proton radiation Clivus Endoscopy Expanded endonasal approach Skull base surgery CSF leak Recurrence Image guided 



Anterior inferior cerebellar artery


Cerebrospinal fluid


Computed tomography


External lumbar drainage


Gross total removal


Internal carotid artery


Local control


Local control rate


Magnetic resonance imaging


Overall survival


Progression-free survival


Survival rate

References (Key References Bolded)

  1. 1.
    Lanzino G, et al. Skull base chordomas: overview of disease, management options, and outcome. Neurosurg Focus. 2001;10(3):E12.PubMedCrossRefGoogle Scholar
  2. 2.
    Colli BO, Al-Mefty O. Chordomas of the skull base: follow-up review and prognostic factors. Neurosurg Focus. 2001;10(3):E1.PubMedCrossRefGoogle Scholar
  3. 3.
    al-Mefty O, Borba LA. Skull base chordomas: a management challenge. J Neurosurg. 1997;86(2):182–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Gay E, et al. Chordomas and chondrosarcomas of the cranial base: results and follow-up of 60 patients. Neurosurgery. 1995;36(5):887–96; discussion 896–7PubMedCrossRefGoogle Scholar
  5. 5.
    Colli BO, Al-Mefty O. Chordomas of the skull base: follow-up review and prognostic factors. Neurosurg Focus. 2001;10(3):E1. Google Scholar
  6. 6.
    Jahangiri A, Chin AT, Wagner JR, Kunwar S, Ames C, Chou D, et al. Factors predicting recurrence after resection of clival chordoma using variable surgical approaches and radiation modalities. Neurosurgery. 2015;76(2):179–85; discussion 85–6PubMedCrossRefGoogle Scholar
  7. 7.
    Tamura T, Sato T, Kishida Y, Ichikawa M, Oda K, Ito E, et al. Outcome of clival chordomas after skull base surgeries with mean follow-up of 10 years. Fukushima J Med Sci. 2015;61(2):131–40.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Bi WL, Brown PA, Abolfotoh M, Al-Mefty O, Mukundan S Jr, Dunn IF. Utility of dynamic computed tomography angiography in the preoperative evaluation of skull base tumors. J Neurosurg. 2015;123:1–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Stacchiotti S, Gronchi A, Fossati P, Akiyama T, Alapetite C, Baumann M, et al. Best practices for the management of local-regional recurrent chordoma. a position paper by the Chordoma Global Consensus Group. Ann Oncol. 2017;28(6):1230–1242. Google Scholar
  10. 10.
    al-Mefty O, Borba LA. Skull base chordomas: a management challenge. J Neurosurg. 1997;86(2):182–9. Google Scholar
  11. 11.
    Arnautovic KI, Al-Mefty O. Surgical seeding of chordomas. J Neurosurg. 2001;95(5):798–803.PubMedCrossRefGoogle Scholar
  12. 12.
    Derome PJ. Surgical management of tumours invading the skull base. Can J Neurol Sci. 1985;12(4):345–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Raveh J, Vuillemin T. Advantages of an additional subcranial approach in the correction of craniofacial deformities. J Craniomaxillofac Surg Offi Publ Eur Assoc Cranio-Maxillo-Facial Surg. 1988;16(8):350–8.CrossRefGoogle Scholar
  14. 14.
    Sekhar LN, Nanda A, Sen CN, Snyderman CN, Janecka IP. The extended frontal approach to tumors of the anterior, middle, and posterior skull base. J Neurosurg. 1992;76(2):198–206.PubMedCrossRefGoogle Scholar
  15. 15.
    Feiz-Erfan I, Spetzler RF, Horn EM, Porter RW, Beals SP, Lettieri SC, et al. Proposed classification for the transbasal approach and its modifications. Skull Base Off J N Am Skull Base Soc [et al]. 2008;18(1):29–47.Google Scholar
  16. 16.
    Effendi ST, Rao VY, Momin EN, Cruz-Navarro J, Duckworth EA. The 1-piece transbasal approach: operative technique and anatomical study. J Neurosurg. 2014;121(6):1446–52.PubMedCrossRefGoogle Scholar
  17. 17.
    Alonso WA, Black P, Connor GH, Uematsu S. Transoral transpalatal approach for resection of clival chordoma. Laryngoscope. 1971;81(10):1626–31.PubMedCrossRefGoogle Scholar
  18. 18.
    Uttley D, Moore A, Archer DJ. Surgical management of midline skull-base tumors: a new approach. J Neurosurg. 1989;71(5 Pt 1):705–10.PubMedCrossRefGoogle Scholar
  19. 19.
    Anand VK, Harkey HL, Al-Mefty O. Open-door maxillotomy approach for lesions of the clivus. Skull Base Surg. 1991;1(4):217–25.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    James D, Crockard HA. Surgical access to the base of skull and upper cervical spine by extended maxillotomy. Neurosurgery. 1991;29(3):411–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Janecka IP, Sen CN, Sekhar LN, Arriaga M. Facial translocation: a new approach to the cranial base. Otolaryngol Head Neck Surg. 1990;103(3):413–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Nuss DW, Janecka IP, Sekhar LN, Sen CN. Craniofacial disassembly in the management of skull-base tumors. Otolaryngol Clin N Am. 1991;24(6):1465–97.Google Scholar
  23. 23.
    Hao SP, Pan WL, Chang CN, Hsu YS. The use of the facial translocation technique in the management of tumors of the paranasal sinuses and skull base. Otolaryngol Head Neck Surg. 2003;128(4):571–5.PubMedCrossRefGoogle Scholar
  24. 24.
    de Mello-Filho FV, Mamede RC, Ricz HM, Susin RR, Colli BO. Midfacial translocation, a variation of the approach to the rhinopharynx, clivus and upper odontoid process. J Craniomaxillofac Surg. 2006;34(7):400–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Al-Mefty O. Supraorbital-pterional approach to skull base lesions. Neurosurgery. 1987;21(4):474–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Al-Mefty O. Operative atlas of meningiomas. Philadelphia: Lippincott-Raven; 1998.Google Scholar
  27. 27.
    Kadri PA, Al-Mefty O. The anatomical basis for surgical preservation of temporal muscle. J Neurosurg. 2004;100(3):517–22.PubMedCrossRefGoogle Scholar
  28. 28.
    al-Mefty O, Anand VK. Zygomatic approach to skull-base lesions. J Neurosurg. 1990;73(5):668–73.PubMedCrossRefGoogle Scholar
  29. 29.
    Sen CN, Sekhar LN. An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum. Neurosurgery. 1990;27(2):197–204.PubMedCrossRefGoogle Scholar
  30. 30.
    al-Mefty O, Borba LA, Aoki N, Angtuaco E, Pait TG. The transcondylar approach to extradural nonneoplastic lesions of the craniovertebral junction. J Neurosurg. 1996;84(1):1–6. Google Scholar
  31. 31.
    Hayashi Y, Mizumoto M, Akutsu H, Takano S, Matsumura A, Okumura T, et al. Hyperfractionated high-dose proton beam radiotherapy for clival chordomas after surgical removal. Br J Radiol. 2016;89(1063):20151051.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Pearlman AW, Friedman M. Radical radiation therapy of chordoma. Am J Roentgenol Radium Therapy, Nucl Med. 1970;108(2):332–41.CrossRefGoogle Scholar
  33. 33.
    Lebellec L, Aubert S, Zairi F, Ryckewaert T, Chauffert B, Penel N. Molecular targeted therapies in advanced or metastatic chordoma patients: facts and hypotheses. Crit Rev Oncol Hematol. 2015;95(1):125–31.PubMedCrossRefGoogle Scholar
  34. 34.
    Lee DH, Zhang Y, Kassam AB, Park MJ, Gardner P, Prevedello D, et al. Combined PDGFR and HDAC inhibition overcomes PTEN disruption in chordoma. PLoS One. 2015;10(8):e0134426.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Wang AC, Owen JH, Abuzeid WM, Hervey-Jumper SL, He X, Gurrea M, et al. stat3 inhibition as a therapeutic strategy for chordoma. J Neurol Surg B Skull Base. 2016;77(6):510–20.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Berson AM, Castro JR, Petti P, Phillips TL, Gauger GE, Gutin P, et al. Charged particle irradiation of chordoma and chondrosarcoma of the base of skull and cervical spine: the Lawrence Berkeley Laboratory experience. Int J Radiat Oncol Biol Phys. 1988;15(3):559–65.PubMedCrossRefGoogle Scholar
  37. 37.
    McDonald MW, Linton OR, Moore MG, Ting JY, Cohen-Gadol AA, Shah MV. Influence of residual tumor volume and radiation dose coverage in outcomes for clival chordoma. Int J Radiat Oncol Biol Phys. 2016;95(1):304–11.PubMedCrossRefGoogle Scholar
  38. 38.
    Tzortzidis F, Elahi F, Wright D, Natarajan SK, Sekhar LN. Patient outcome at long-term follow-up after aggressive microsurgical resection of cranial base chordomas. Neurosurgery. 2006;59(2):230–7; discussion-7. Google Scholar
  39. 39.
    Walcott BP, Nahed BV, Mohyeldin A, Coumans JV, Kahle KT, Ferreira MJ. Chordoma: current concepts, management, and future directions. Lancet Oncol. 2012;13(2):e69–76.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Amit M, Na’ara S, Binenbaum Y, Billan S, Sviri G, Cohen JT, et al. Treatment and outcome of patients with skull base chordoma: a meta-analysis. J Neurol Surg B Skull Base. 2014;75(6):383–90.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Koutourousiou M, Snyderman CH, Fernandez-Miranda J, Gardner PA. Skull base chordomas. Otolaryngol Clin N Am. 2011;44(5):1155–71.CrossRefGoogle Scholar
  42. 42.
    Di Maio S, Temkin N, Ramanathan D, Sekhar LN. Current comprehensive management of cranial base chordomas: 10-year meta-analysis of observational studies. J Neurosurg. 2011;115(6):1094–105.PubMedCrossRefGoogle Scholar
  43. 43.
    Jahangiri A, Jian B, Miller L, El-Sayed IH, Aghi MK. Skull base chordomas: clinical features, prognostic factors, and therapeutics. Neurosurg Clin N Am. 2013;24(1):79–88.PubMedCrossRefGoogle Scholar
  44. 44.
    Fernandez-Miranda JC, Gardner PA, Snyderman CH, Devaney KO, Mendenhall WM, Suarez C, et al. Clival chordomas: a pathological, surgical, and radiotherapeutic review. Head Neck. 2014;36(6):892–906.PubMedCrossRefGoogle Scholar
  45. 45.
    Berhouma M, Messerer M, Jouanneau E. Shifting paradigm in skull base surgery: roots, current state of the art and future trends of endonasal endoscopic approaches. Rev Neurol (Paris). 2012;168(2):121–34.CrossRefGoogle Scholar
  46. 46.
    Frank G, Sciarretta V, Calbucci F, Farneti G, Mazzatenta D, Pasquini E. The endoscopic transnasal transsphenoidal approach for the treatment of cranial base chordomas and chondrosarcomas. Neurosurgery. 2006;59(1 Suppl 1):ONS50-7; discussion ONS-7.Google Scholar
  47. 47.
    Cavallo LM, Cappabianca P, Messina A, Esposito F, Stella L, de Divitiis E, et al. The extended endoscopic endonasal approach to the clivus and cranio-vertebral junction: anatomical study. Childs Nerv Syst. 2007;23(6):665–71.PubMedCrossRefGoogle Scholar
  48. 48.
    de Notaris M, Cavallo LM, Prats-Galino A, Esposito I, Benet A, Poblete J, et al. Endoscopic endonasal transclival approach and retrosigmoid approach to the clival and petroclival regions. Neurosurgery. 2009;65(6 Suppl):42–50; discussion -2.PubMedGoogle Scholar
  49. 49.
    Stamm AC, Pignatari SS, Vellutini E. Transnasal endoscopic surgical approaches to the clivus. Otolaryngol Clin N Am. 2006;39(3):639–56. xiCrossRefGoogle Scholar
  50. 50.
    Kassam AB, Snyderman C, Gardner P, Carrau R, Spiro R. The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery. 2005;57(1 Suppl):E213; discussion E.PubMedGoogle Scholar
  51. 51.
    Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. Neurosurgery. 2010;67(3 Suppl Operative):ons150-8; discussion ons8.Google Scholar
  52. 52.
    Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Endoscopic endonasal transclival resection of chordomas: operative technique, clinical outcome, and review of the literature. J Neurosurg. 2010;112(5):1061–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Colli B, Al-Mefty O. Chordomas of the craniocervical junction: follow-up review and prognostic factors. J Neurosurg. t;95(6):933–43. Google Scholar
  54. 54.
    Gay E, Sekhar LN, Rubinstein E, Wright DC, Sen C, Janecka IP, et al. Chordomas and chondrosarcomas of the cranial base: results and follow-up of 60 patients. Neurosurgery. 1995;36(5):887–96; discussion 96–7.Google Scholar
  55. 55.
    Ito E, Saito K, Okada T, Nagatani T, Nagasaka T. Long-term control of clival chordoma with initial aggressive surgical resection and gamma knife radiosurgery for recurrence. Acta Neurochir. 2010;152(1):57–67; discussion.PubMedCrossRefGoogle Scholar
  56. 56.
    Pamir MN, Ozduman K. Analysis of radiological features relative to histopathology in 42 skull-base chordomas and chondrosarcomas. Eur J Radiol. 2006;58(3):461–70.PubMedCrossRefGoogle Scholar
  57. 57.
    Derome PJ. The transbasal approach to tumors invading the skull base. In: Schmidek HHSH, editor. Operative neurosurgical techniques: indications, methods, and results. Philadelphia: W.B. Saunders Company; 1993. p. 427–41.Google Scholar
  58. 58.
    Harsh G, Ojemann R, Varvares M, Swearingen B, Cheney M, Joseph M. Pedicled rhinotomy for clival chordomas invaginating the brain stem. Neurosurg Focus. 2001;10(3):E8.PubMedCrossRefGoogle Scholar
  59. 59.
    Maira G, Pallini R, Anile C, Fernandez E, Salvinelli F, La Rocca LM, et al. Surgical treatment of clival chordomas: the transsphenoidal approach revisited. J Neurosurg. 1996;85(5):784–92.PubMedCrossRefGoogle Scholar
  60. 60.
    Laws ER Jr. Transsphenoidal surgery for tumors of the clivus. Otolaryngol Head Neck Surg. 1984;92(1):100–1.PubMedCrossRefGoogle Scholar
  61. 61.
    Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery. 2004;55(3):539–47; discussion 47–50.PubMedCrossRefGoogle Scholar
  62. 62.
    Price JC, Holliday MJ, Johns ME, Kennedy DW, Richtsmeier WJ, Mattox DE. The versatile midface degloving approach. Laryngoscope. 1988;98(3):291–5.PubMedCrossRefGoogle Scholar
  63. 63.
    DeMonte F, Diaz E Jr, Callender D, Suk I. Transmandibular, circumglossal, retropharyngeal approach for chordomas of the clivus and upper cervical spine. Technical note. Neurosurg Focus. 2001;10(3):E10.PubMedCrossRefGoogle Scholar
  64. 64.
    Crockard HA, Sen CN. The transoral approach for the management of intradural lesions at the craniovertebral junction: review of 7 cases. Neurosurgery. 1991;28(1):88–97; discussion -8.PubMedCrossRefGoogle Scholar
  65. 65.
    Delgado TE, Garrido E, Harwick RD. Labiomandibular, transoral approach to chordomas in the clivus and upper cervical spine. Neurosurgery. 1981;8(6):675–9.PubMedCrossRefGoogle Scholar
  66. 66.
    Stevenson GC, Stoney RJ, Perkins RK, Adams JE. A transcervical transclival approach to the ventral surface of the brain stem for removal of a clivus chordoma. J Neurosurg. 1966;24(2):544–51.PubMedCrossRefGoogle Scholar
  67. 67.
    Cloward RB, Passarelli P. Removal of giant clival chordoma by an anterior cervical approach. Surg Neurol. 1979;11(2):129–34.PubMedGoogle Scholar
  68. 68.
    Seifert V, Raabe A, Zimmermann M. Conservative (labyrinth-preserving) transpetrosal approach to the clivus and petroclival region–indications, complications, results and lessons learned. Acta Neurochir. 2003;145(8):631–42; discussion 42.PubMedCrossRefGoogle Scholar
  69. 69.
    Blevins NH, Jackler RK, Kaplan MJ, Gutin PH. Combined transpetrosal-subtemporal craniotomy for clival tumors with extension into the posterior fossa. Laryngoscope. 1995;105(9 Pt 1):975–82.PubMedCrossRefGoogle Scholar
  70. 70.
    House WF, De la Cruz A, Hitselberger WE. Surgery of the skull base: transcochlear approach to the petrous apex and clivus. Otolaryngology. 1978;86(5):ORL-770-9.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    Mortini P, Mandelli C, Franzin A, Giugni E, Giovanelli M. Surgical excision of clival tumors via the enlarged transcochlear approach. Indications and results. J Neurosurg Sci. 2001;45(3):127–39; discussion 40.PubMedPubMedCentralGoogle Scholar
  72. 72.
    Menezes AH, Gantz BJ, Traynelis VC, McCulloch TM. Cranial base chordomas. Clin Neurosurg. 1997;44:491–509.PubMedPubMedCentralGoogle Scholar
  73. 73.
    Sen CN, Sekhar LN. The subtemporal and preauricular infratemporal approach to intradural structures ventral to the brain stem. J Neurosurg. 1990;73(3):345–54.PubMedCrossRefPubMedCentralGoogle Scholar
  74. 74.
    Sekhar LN, Janecka IP, Jones NF. Subtemporal-infratemporal and basal subfrontal approach to extensive cranial base tumours. Acta Neurochir. 1988;92(1–4):83–92.PubMedCrossRefGoogle Scholar
  75. 75.
    Tamaki N, Nagashima T, Ehara K, Motooka Y, Barua KK. Surgical approaches and strategies for skull base chordomas. Neurosurg Focus. 2001;10(3):E9.PubMedCrossRefGoogle Scholar
  76. 76.
    Babu RP, Sekhar LN, Wright DC. Extreme lateral transcondylar approach: technical improvements and lessons learned. J Neurosurg. 1994;81(1):49–59.PubMedCrossRefGoogle Scholar
  77. 77.
    Goel A, Muzumdar D. Conventional posterior fossa approach for surgery on petroclival meningiomas: a report on an experience with 28 cases. Surg Neurol. 2004;62(4):332–8; discussion 8–40.PubMedCrossRefGoogle Scholar
  78. 78.
    Zhu W, Mao Y, Zhou LF, Zhang R, Chen L. Combined subtemporal and retrosigmoid keyhole approach for extensive petroclival meningiomas surgery: report of experience with 7 cases. Minim Invasive Neurosurg. 2008;51(2):95–9.PubMedCrossRefGoogle Scholar
  79. 79.
    Vellutini Ede A, Balsalobre L, Hermann DR, Stamm AC. The endoscopic endonasal approach for extradural and intradural clivus lesions. World Neurosurg. 2014;82(6 Suppl):S106–15.PubMedCrossRefGoogle Scholar
  80. 80.
    Weber AL, Liebsch NJ, Sanchez R, Sweriduk ST Jr. Chordomas of the skull base. Radiologic and clinical evaluation. Neuroimaging Clin N Am. 1994;4(3):515–27.PubMedGoogle Scholar
  81. 81.
    Erdem E, Angtuaco EC, Van Hemert R, Park JS, Al-Mefty O. Comprehensive review of intracranial chordoma. Radiographics. 2003;23(4):995–1009.PubMedCrossRefGoogle Scholar
  82. 82.
    Mikami T, Minamida Y, Yamaki T, Koyanagi I, Nonaka T, Houkin K. Cranial nerve assessment in posterior fossa tumors with fast imaging employing steady-state acquisition (FIESTA). Neurosurg Rev. 2005;28(4):261–6.PubMedCrossRefGoogle Scholar
  83. 83.
    Meyers SP, Hirsch WL Jr, Curtin HD, Barnes L, Sekhar LN, Sen C. Chondrosarcomas of the skull base: MR imaging features. Radiology. 1992;184(1):103–8.PubMedCrossRefGoogle Scholar
  84. 84.
    Muller U, Kubik-Huch RA, Ares C, Hug EB, Low R, Valavanis A, et al. Is there a role for conventional MRI and MR diffusion-weighted imaging for distinction of skull base chordoma and chondrosarcoma? Acta Radiol. 2016;57(2):225–32.PubMedCrossRefGoogle Scholar
  85. 85.
    Yeom KW, Lober RM, Mobley BC, Harsh G, Vogel H, Allagio R, et al. Diffusion-weighted MRI: distinction of skull base chordoma from chondrosarcoma. AJNR Am J Neuroradiol. 2013;34(5):1056–61. S1PubMedCrossRefGoogle Scholar
  86. 86.
    Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg. 2007;106(3):400–6.PubMedCrossRefGoogle Scholar
  87. 87.
    Stippler M, Gardner PA, Snyderman CH, Carrau RL, Prevedello DM, Kassam AB. Endoscopic endonasal approach for clival chordomas. Neurosurgery. 2009;64(2):268–77; discussion 77–8.PubMedCrossRefGoogle Scholar
  88. 88.
    Nyquist GG, Anand VK, Brown S, Singh A, Tabaee A, Schwartz TH. Middle turbinate preservation in endoscopic transsphenoidal surgery of the anterior skull base. Skull Base. 2010;20(5):343–7.PubMedPubMedCentralCrossRefGoogle Scholar
  89. 89.
    Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):1882–6.PubMedCrossRefGoogle Scholar
  90. 90.
    Kassam AB, Prevedello DM, Thomas A, Gardner P, Mintz A, Snyderman C, et al. Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery. 2008;62(3 Suppl 1):57–72; discussion -4.PubMedGoogle Scholar
  91. 91.
    Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery. 2008;63(1 Suppl 1):ONS44-52; discussion ONS-3.Google Scholar
  92. 92.
    Kassam AB, Vescan AD, Carrau RL, Prevedello DM, Gardner P, Mintz AH, et al. Expanded endonasal approach: vidian canal as a landmark to the petrous internal carotid artery. J Neurosurg. 2008;108(1):177–83.PubMedCrossRefGoogle Scholar
  93. 93.
    Charalampaki P, Heimann A, Kockro RA, Kohnen W, Kempski O. A new model of skull base reconstruction following expanded endonasal or transoral approaches–long-term results in primates. Eur Surg Res. 2008;41(2):208–13.PubMedCrossRefGoogle Scholar
  94. 94.
    Iaconetta G, Fusco M, Cavallo LM, Cappabianca P, Samii M, Tschabitscher M. The abducens nerve: microanatomic and endoscopic study. Neurosurgery. 2007;61(3 Suppl):7–14; discussion.PubMedGoogle Scholar
  95. 95.
    Barges-Coll J, Fernandez-Miranda JC, Prevedello DM, Gardner P, Morera V, Madhok R, et al. Avoiding injury to the abducens nerve during expanded endonasal endoscopic surgery: anatomic and clinical case studies. Neurosurgery. 2010;67(1):144–54; discussion 54.PubMedCrossRefGoogle Scholar
  96. 96.
    George B, Bresson D, Bouazza S, Froelich S, Mandonnet E, Hamdi S, et al. Chordoma. Neurochirurgie. 2014;60(3):63–140.PubMedCrossRefGoogle Scholar
  97. 97.
    Taniguchi M, Kohmura E. Endoscopic endonasal removal of laterally extended clival chordoma using side-viewing scopes. Acta Neurochir. 2012;154(4):627–32.PubMedCrossRefGoogle Scholar
  98. 98.
    Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery. 2008;62(5 Suppl 2):ONSE342-3; discussion ONSE3.Google Scholar
  99. 99.
    Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E, et al. Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg. 2007;107(4):713–20.PubMedCrossRefGoogle Scholar
  100. 100.
    Carrabba G, Dehdashti AR, Gentili F. Surgery for clival lesions: open resection versus the expanded endoscopic endonasal approach. Neurosurg Focus. 2008;25(6):E7.PubMedCrossRefGoogle Scholar
  101. 101.
    Dehdashti AR, Karabatsou K, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for treatment of clival chordomas: early results in 12 patients. Neurosurgery. 2008;63(2):299–307; discussion -9.PubMedCrossRefGoogle Scholar
  102. 102.
    Kasemsiri P, Carrau RL, Ditzel Filho LF, Prevedello DM, Otto BA, Old M, et al. Advantages and limitations of endoscopic endonasal approaches to the skull base. World Neurosurg. 2014;82(6 Suppl):S12–21.PubMedCrossRefGoogle Scholar
  103. 103.
    Cobb MI, Nimjee S, Gonzalez LF, Jang DW, Zomorodi A. Direct repair of iatrogenic internal carotid artery injury during endoscopic endonasal approach surgery with temporary endovascular balloon-assisted occlusion: technical case report. Neurosurgery. 2015;11 Suppl 3:E483-6; discussion E6–7.Google Scholar
  104. 104.
    Dusick JR, Esposito F, Malkasian D, Kelly DF. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery. 2007;60(4 Suppl 2):322–8. discussion 8–9.PubMedGoogle Scholar
  105. 105.
    Nerva JD, Morton RP, Levitt MR, Osbun JW, Ferreira MJ, Ghodke BV, et al. Pipeline Embolization Device as primary treatment for blister aneurysms and iatrogenic pseudoaneurysms of the internal carotid artery. J Neurointerv Surg. 2015;7(3):210–6.PubMedCrossRefGoogle Scholar
  106. 106.
    Tomio R, Toda M, Sutiono AB, Horiguchi T, Aiso S, Yoshida K. Gruber’s ligament as a useful landmark for the abducens nerve in the transnasal approach. J Neurosurg. 2015;122(3):499–503.PubMedCrossRefGoogle Scholar
  107. 107.
    Alkan A, Sigirci A, Ozveren MF, Kutlu R, Altinok T, Onal C, et al. The cisternal segment of the abducens nerve in man: three-dimensional MR imaging. Eur J Radiol. 2004;51(3):218–22.PubMedCrossRefGoogle Scholar
  108. 108.
    Kaptain GJ, Vincent DA, Sheehan JP, Laws ER Jr. Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery. 2001;49(1):94–100; discussion -1.PubMedGoogle Scholar
  109. 109.
    Kato T, Sawamura Y, Abe H, Nagashima M. Transsphenoidal-transtuberculum sellae approach for supradiaphragmatic tumours: technical note. Acta Neurochir. 1998;140(7):715–8; discussion 9.PubMedCrossRefGoogle Scholar
  110. 110.
    Dusick JR, Esposito F, Kelly DF, Cohan P, DeSalles A, Becker DP, et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg. 2005;102(5):832–41.PubMedCrossRefPubMedCentralGoogle Scholar
  111. 111.
    Cook SW, Smith Z, Kelly DF. Endonasal transsphenoidal removal of tuberculum sellae meningiomas: technical note. Neurosurgery. 2004;55(1):239–44; discussion 44–6.PubMedCrossRefPubMedCentralGoogle Scholar
  112. 112.
    Spencer WR, Levine JM, Couldwell WT, Brown-Wagner M, Moscatello A. Approaches to the sellar and parasellar region: a retrospective comparison of the endonasal-transsphenoidal and sublabial-transsphenoidal approaches. Otolaryngol Head Neck Surg. 2000;122(3):367–9.PubMedCrossRefPubMedCentralGoogle Scholar
  113. 113.
    Tan NC, Naidoo Y, Oue S, Alexander H, Robinson S, Wickremesekera A, et al. Endoscopic surgery of skull base chordomas. J Neurol Surg B Skull Base. 2012;73(6):379–86.PubMedPubMedCentralCrossRefGoogle Scholar
  114. 114.
    Jho HD. The expanding role of endoscopy in skull-base surgery. Indications and instruments. Clin Neurosurg. 2001;48:287–305.PubMedPubMedCentralGoogle Scholar
  115. 115.
    Campbell RG, Prevedello DM, Ditzel Filho L, Otto BA, Carrau RL. Contemporary management of clival chordomas. Curr Opin Otolaryngol Head Neck Surg. 2015;23(2):153–61.PubMedCrossRefGoogle Scholar
  116. 116.
    Sen CN, Sekhar LN, Schramm VL, Janecka IP. Chordoma and chondrosarcoma of the cranial base: an 8-year experience. Neurosurgery. 1989;25(6):931–40; discussion 40–1.PubMedCrossRefGoogle Scholar
  117. 117.
    Sen C, Triana A. Cranial chordomas: results of radical excision. Neurosurg Focus. 2001;10(3):E3.PubMedCrossRefGoogle Scholar
  118. 118.
    Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg. 2002;97(2):293–8.PubMedCrossRefGoogle Scholar
  119. 119.
    Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery. 1997;40(2):225–36; discussion 36–7.PubMedCrossRefPubMedCentralGoogle Scholar
  120. 120.
    Kooshkabadi A, Choi PA, Koutourousiou M, Snyderman CH, Wang EW, Fernandez-Miranda JC, et al. Atlanto-occipital instability following endoscopic endonasal approach for lower clival lesions: experience with 212 cases. Neurosurgery. 2015;77(6):888–97; discussion 97.PubMedCrossRefGoogle Scholar
  121. 121.
    Krengli M, Poletti A, Ferrara E, Fossati P. Tumour seeding in the surgical pathway after resection of skull base chordoma. Rep Pract Oncol Radiother. 2016;21(4):407–11.PubMedPubMedCentralCrossRefGoogle Scholar
  122. 122.
    Hines JP, Ashmead MG, Stringer SP. Clival chordoma of the nasal septum secondary to surgical pathway seeding. Am J Otolaryngol. 2014;35(3):431–4.PubMedCrossRefGoogle Scholar
  123. 123.
    Smith KA, Crabtree K, Chamoun R. Delayed intraventricular metastasis of clival chordoma. Surg Neurol Int. 2016;7:3.PubMedPubMedCentralCrossRefGoogle Scholar
  124. 124.
    Zemmoura I, Ben Ismail M, Travers N, Jan M, Francois P. Maxillary surgical seeding of a clival chordoma. Br J Neurosurg. 2012;26(1):102–3.PubMedCrossRefGoogle Scholar
  125. 125.
    Martin MP, Olson S. Intradural drop metastasis of a clival chordoma. J Clin Neurosci. 2009;16(8):1105–7.PubMedCrossRefGoogle Scholar
  126. 126.
    Asano S, Kawahara N, Kirino T. Intradural spinal seeding of a clival chordoma. Acta Neurochir. 2003;145(7):599–603; discussion.PubMedCrossRefGoogle Scholar
  127. 127.
    Labidi M, Watanabe K, Bouazza S, Bresson D, Bernat AL, George B, et al. Clivus chordomas: a systematic review and meta-analysis of contemporary surgical management. J Neurosurg Sci. 2016;60(4):476–84.PubMedGoogle Scholar
  128. 128.
    Garzaro M, Zenga F, Raimondo L, Pacca P, Pennacchietti V, Riva G, et al. Three-dimensional endoscopy in transnasal transsphenoidal approach to clival chordomas. Head Neck. 2016;38(Suppl 1):E1814–9.PubMedCrossRefGoogle Scholar
  129. 129.
    Messerer M, Cossu G, Pasche P, Ikonomidis C, Simon C, Pralong E, et al. Extended endoscopic endonasal approach to clival and paraclival tumors: indications and limits. Neurochirurgie. 2016;62(3):136–45.PubMedCrossRefGoogle Scholar
  130. 130.
    Boari N, Gagliardi F, Cavalli A, Gemma M, Ferrari L, Riva P, et al. Skull base chordomas: clinical outcome in a consecutive series of 45 patients with long-term follow-up and evaluation of clinical and biological prognostic factors. J Neurosurg. 2016;125(2):450–60. Google Scholar
  131. 131.
    Sen C, Triana AI, Berglind N, Godbold J, Shrivastava RK. Clival chordomas: clinical management, results, and complications in 71 patients. J Neurosurg. 2010;113(5):1059–71.PubMedCrossRefGoogle Scholar
  132. 132.
    Koutourousiou M, Gardner PA, Tormenti MJ, Henry SL, Stefko ST, Kassam AB, et al. Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery. 2012;71(3):614–24; discussion 24–5. Google Scholar
  133. 133.
    Little RE, Taylor RJ, Miller JD, Ambrose EC, Germanwala AV, Sasaki-Adams DM, et al. Endoscopic endonasal transclival approaches: case series and outcomes for different clival regions. J Neurol Surg B Skull Base. 2014;75(4):247–54.PubMedPubMedCentralCrossRefGoogle Scholar
  134. 134.
    Saito K, Toda M, Tomita T, Ogawa K, Yoshida K. Surgical results of an endoscopic endonasal approach for clival chordomas. Acta Neurochir. 2012;154(5):879–86.PubMedCrossRefGoogle Scholar
  135. 135.
    Tatagiba M, Rigante L, Mesquita Filho P, Ebner FH, Roser F. Endoscopic-assisted posterior intradural petrous apicectomy in petroclival meningiomas: a clinical series and assessment of perioperative morbidity. World Neurosurg. 2015;84(6):1708–18.PubMedCrossRefGoogle Scholar
  136. 136.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005;19(1):E3.PubMedGoogle Scholar
  137. 137.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus. 2005;19(1):E4.PubMedGoogle Scholar
  138. 138.
    Iloreta AM, Nyquist GG, Friedel M, Farrell C, Rosen MR, Evans JJ. Surgical pathway seeding of clivo-cervical chordomas. J Neurol Surg Rep. 2014;75(2):e246–50.PubMedPubMedCentralCrossRefGoogle Scholar
  139. 139.
    Bilginer B, Turk CC, Narin F, Hanalioglu S, Oguz KK, Ozgen B, et al. Enigmatic entity in childhood: clival chordoma from a tertiary center’s perspective. Acta Neurochir. 2015;157(9):1587–93.PubMedCrossRefGoogle Scholar
  140. 140.
    Ares C, Hug EB, Lomax AJ, Bolsi A, Timmermann B, Rutz HP, et al. Effectiveness and safety of spot scanning proton radiation therapy for chordomas and chondrosarcomas of the skull base: first long-term report. Int J Radiat Oncol Biol Phys. 2009;75(4):1111–8.PubMedCrossRefGoogle Scholar
  141. 141.
    Fagundes MA, Hug EB, Liebsch NJ, Daly W, Efird J, Munzenrider JE. Radiation therapy for chordomas of the base of skull and cervical spine: patterns of failure and outcome after relapse. Int J Radiat Oncol Biol Phys. 1995;33(3):579–84.PubMedCrossRefGoogle Scholar
  142. 142.
    van de Water TA, Lomax AJ, Bijl HP, de Jong ME, Schilstra C, Hug EB, et al. Potential benefits of scanned intensity-modulated proton therapy versus advanced photon therapy with regard to sparing of the salivary glands in oropharyngeal cancer. Int J Radiat Oncol Biol Phys. 2011;79(4):1216–24.PubMedCrossRefGoogle Scholar
  143. 143.
    Holliday EB, Frank SJ. Proton radiation therapy for head and neck cancer: a review of the clinical experience to date. Int J Radiat Oncol Biol Phys. 2014;89(2):292–302.PubMedCrossRefGoogle Scholar
  144. 144.
    Stacchiotti S, Sommer J, Chordoma Global Consensus G. Building a global consensus approach to chordoma: a position paper from the medical and patient community. Lancet Oncol. 2015;16(2):e71–83. Google Scholar
  145. 145.
    Uhl M, Edler L, Jensen AD, Habl G, Oelmann J, Roder F, et al. Randomized phase II trial of hypofractionated proton versus carbon ion radiation therapy in patients with sacrococcygeal chordoma-the ISAC trial protocol. Radiat Oncol. 2014;9:100.PubMedPubMedCentralCrossRefGoogle Scholar
  146. 146.
    Mima M, Demizu Y, Jin D, Hashimoto N, Takagi M, Terashima K, et al. Particle therapy using carbon ions or protons as a definitive therapy for patients with primary sacral chordoma. Br J Radiol. 2014;87(1033):20130512.PubMedCrossRefGoogle Scholar
  147. 147.
    Kyoshima K, Oikawa S, Kanaji M, Zenisaka H, Takizawa T, Goto T, et al. Repeat operations in the management of clival chordomas: palliative surgery. J Clin Neurosci. 2003;10(5):571–8.PubMedCrossRefGoogle Scholar
  148. 148.
    McDonald MW, Linton OR, Shah MV. Proton therapy for reirradiation of progressive or recurrent chordoma. Int J Radiat Oncol Biol Phys. 2013;87(5):1107–14.PubMedCrossRefGoogle Scholar
  149. 149.
    Yamada Y, Gounder M, Laufer I. Multidisciplinary management of recurrent chordomas. Curr Treat Options in Oncol. 2013;14(3):442–53.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosugeryBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA
  2. 2.University Health Network, Toronto Western HospitalTorontoCanada
  3. 3.Department of SurgeryUniversity of TorontoTorontoCanada

Personalised recommendations