Nuances in the Treatment of Malignant Tumors of the Clival and Petroclival Region

Introduction: Malignancies of the clivus and petroclival region are mainly chordomas and chondrosarcomas. Although a spectrum of malignancies may present in this area, a finite group of commonly encountered malignant pathologies will be the focus of this review, as they are recognized to be formidable pathologies due to adjacent critical neurovascular structures and challenging surgical approaches. Objectives: The objective is to review the literature regarding medical and surgical management of malignant tumors of the clival and petroclival region with a focus on clinical presentation, diagnostic identification, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to the skull base. Data Synthesis A literature review was conducted, searching for basic science and clinical evidence from PubMed, Medline, and the Cochrane Database. The selection criteria encompassed original articles including data from both basic science and clinical literature, case series, case reports, and review articles on the etiology, diagnosis, treatment, and management of skull base malignancies in the clival and petroclival region. Conclusions: The management of petroclival malignancies requires a multidisciplinary team to deliver the most complete surgical resection, with minimal morbidity, followed by appropriate adjuvant therapy. We advocate the combination of endoscopic and open approaches (traditional or minimally invasive) as required by the particular tumor followed by radiation therapy to optimize oncologic outcomes...

Tecnica endoscopica endonasal: tratamento de lesoes malignas paranasais e da base do cranio anterior / Endoscopic endonasal technique: treatment of paranasal and anterior skull base malignancies

Inovações técnicas e tecnológicas têm liderado a expansão das indicações de uso das abordagens endoscópicas endonasais para a extirpação de lesões malignas do trato nasossinusal e base do crânio. OBJETIVO: Analisar criticamente a literatura disponível sobre o uso de abordagens endoscópicas endonasais incluindo indicações, limitações, técnicas cirúrgicas, desfecho oncológico e qualidade de vida. MÉTODO: Várias técnicas endoscópicas endonasais foram analisadas segundo a origem e extensão local das lesões malignas nasossinusais e da base do crânio, incluindo a porção anterior da base do crânio, nasofaringe, clívus e fossa infratemporal. A literatura disponível foi também avaliada em função dos desfechos. CONCLUSÃO: As abordagens endoscópicas endonasais são parte integrante do arsenal terapêutico desenvolvido para abordar neoplasias malignas do trato nasossinusais e da base do crânio. Em casos adequadamente selecionados, esta abordagem produz resultados oncológicos semelhantes com menor morbidade do que as abordagens abertas tradicionais. Não obstante, abordagens minimamente invasivas devem ser consideradas como complemento às abordagens abertas estabelecidas, ainda necessárias na maioria dos tumores mais avançados. .

Technical and technological innovations have spearheaded the expansion of the indications for the use of endoscopic endonasal approaches to extirpate malignancies of the sinonasal tract and adjacent skull base. OBJECTIVE: Critical review of the available literature regarding the use of endoscopic endonasal approaches including indications, limitations, surgical techniques, oncologic outcome, and quality of life. METHOD: Various endoscopic endonasal techniques are reviewed according to the origin and local extension of sinonasal and skull base malignancies including anterior cranial base, nasopharynx, clivus, and infratemporal fossa. In addition, the available literature is reviewed to assess outcomes. CONCLUSION: Endoscopic endonasal approaches are an integral part of the armamentarium for the treatment of the sinonasal tract malignancies and skull base. In properly selected cases, it affords similar oncologic outcomes with lower morbidity than traditional open approaches. Nonetheless, these minimal access approaches should be considered a complement to well-established open approaches, which are still necessary in most advanced tumors. .

Presentación clínica y tomográfica de pacientes con displasia fibrosa craneofacial en la Clínica José A. Rivas / Clinical and radiological presentation in patients with fi brous dysplasia craniofacial in José A. Rivas clinic

Objetivo: describir las manifestaciones clínicas y radiológicas de los pacientes con diagnóstico de displasia fi brosa craneofacial en el Servicio de Rinología y Base de Cráneo de la Clínica José A. Rivas, entre enero del 2009 y enero del 2012. Diseño: estudio tipo serie de casos con análisis prospectivo Métodos: se incluyeron diez pacientes entre los ocho y 36 años con diagnóstico de displasia fi brosa craneofacial, en los que se tuvieron en cuenta variables demográfi cas, manifestaciones clínicas, presentación tomográfi ca, y se revisó el tipo de tratamiento realizado, al igual que la recidiva de la enfermedad. Resultados: se encontró que la manifestación preponderante ocurría en el sexo masculino (60%), con una media de 17 años, y la condición clínica común fue la asimetría facial (ocho pacientes). Además, el seno etmoidal fue el que evidenció mayor compromiso (60% de los casos); dos pacientes registraron lesión de la base del cráneo, uno de ellos reportó ceguera y compromiso del nervio óptico. En la tomografía, el tipo 2, con compromiso de más de dos senos paranasales, fue el que se halló con más frecuencia, y la variedad mixta, con respecto al tipo de lesión, tuvo mayor porcentaje que la de vidrio esmerilado, la homogénea y la quística. Al 90% de los pacientes se les sometió a tratamiento quirúrgico ciento por ciento endoscópico, y se detectó un 20% de recidivas.

Objective: To describe the clinical and radiological diagnosis of patients with craniofacial fibrous dysplasia in the Service of Rhinology and Skull Base Clinic José A. Rivas, between January 2009 and January 2012. Design: case series with prospective analysis. Methods: Ten patients between eight and 36 years diagnosed with craniofacial fibrous dysplasia, which took into account demographic, clinical, tomographic presentation, and revised the type of treatment, as well as recurrence of disease. Results: We found that the predominant manifestation occurred in males (60%), with a mean of 17 years, and the common clinical condition was facial asymmetry (eight patients). In addition, the ethmoid sinus was evident that greater commitment (60% of cases), two patients reported injury skull base, one of them reported blindness and optic nerve involvement. On CT, type 2, with involvement of more than two sinuses, was the one most frequently found, and the mixed variety, with respect to the type of injury, had the highest percentage of frosted glass, the homogeneous the cystic. 90% of patients underwent surgical treatment hundred percent endoscopic and detected 20% of recurrences. Conclusions: There are few studies in Colombia about craniofacial fibrous dysplasia. For this reason, we present statistics about the pathology own study, proposing a new tomographic classification as a basis for future research.

The expanded endoscopic endonasal approaches for the skull base / Abordagens endonasais endoscópicas expandidas para a base do crânio

Antecedentes: Abordagem endoscópica endonasal expandida (AEEE) em cirurgia de base de crânio (CBC) é uma alteração significativa das práticas atuais. Métodos: Analisamos nossa experiência na Universidade de Pittsburgh com AEEE para 800 pacientes de 1998 a julho de 2007. Resultados: Acessos modulares para múltiplas patologias de base do crânio foram concebidos totalmente baseados na anatomia intrínseca da região. Fases de treinamento foram estabelecidas em função do nível de dificuldade técnica e o potencial de risco de lesões vasculares e neurais. Cinco níveis foram definidos de forma incremental. Conclusões: Padronização prática, com formação modular e incremental, é projetada com o intuito de proporcionar aprendizado de modo organizado e seguro das AEEE para a base do crânio. Sugerimos adesão a um programa sistemático de aquisição de habilidades endoscópicas, trabalhar em equipe integrada de cirurgiões e ter amplo domínio tanto da CBC convencional quanto de cirurgia endoscópica. Por isso, a escolha do método cirúrgico deve ser em função específica da anatomia e patologia e não decorrente de viés ou falha de experiência do cirurgião com abordagens alternativas.

Background: Endoscopic endonasal approach (EEA) for skull base surgery (SBS) is a significant modification of the current practice.Methods: We reviewed our experience at the University of Pittsburgh with EEAs for 800 patients from 1998 to July 2007. Results: Modular approaches to multiple pathologies of the skull base were designed totally based on intrinsic anatomy. Stages of training were established based on the level of technical difficulty and potential risk of vascular and neural injury. ive levels were defined in an incremental manner. Conclusions: Practice standardization with modular, incremental training is projected to facilitate the gaining of knowledge and skills to safely master EEAs for SBS in an organized manner. We suggest adherence to the systematic acquisition of ndoscopic skills, to work as an integrated team of surgeons and to have a thorough perspective of conventional SBS and endoscopic surgery. Therefore, the choice of approach must be a specific function of the anatomy and pathology rather than the surgeon’s bias or lack of experience with alternative approaches.