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...

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.

Prognostic factors in mesial temporal lobe epilepsy surgery

Eighty-four patients submitted to anterior temporal lobectomy were evaluated retrospectively in order to correlate the different type of simple partial seizure (SPS) and their prognostic implications in patients with mesial temporal sclerosis. The patients were divided in two groups following the classification of Engel; Group 1 (53 patients) included patients Class I (without seizures or of good outcome) and Group 2 (31 patients) included Classes II, III and IV (with seizures or of bad outcome). The two groups were compared and results showed no statistical difference in relation to the demographic aspects as sex, side of surgery, age at onset of seizures and time of the patients' postoperative follow-up. Statistical analysis revealed no relationship between type of SPS and outcome. SPS did not show a statistical value in localizing the side of pathology. However, when the two groups were compared statistically in terms of patients' ages at the time of surgery, and the time elapsed from the onset of the seizures to the surgical intervention, it was observed that Group 1 (of good outcome) had seizures for smaller interval (p<0.05) and was operated at an earlier age (p<0.02) than Group 2 (of bad outcome). The presence or the type of SPS can not be used as a prognostic measure; surgical therapy must be considered as soon as clinical resistance is demonstrated.