Skull Base Approaches for and Long-Term Control of Clival Chordomas

Introduction: Treatment of patients with clival chordomas is still a challenge. We present our strategy using skull base approaches and long-term results of skull base chordomas. Patients and Methods: From 1992, we operated on 23 patients with clival chordomas. In this study, we investigated 17 patients (age range, 7–75 years; 10 men and 7 women) who underwent initial surgical resection in our institution, with a follow-up of more than 2 years. All tumors with surrounding bone were aggressively removed using one of the following approaches according to their extensions: transsphenoidal approach for 5 localized tumors, anterior craniofacial approach for 7 tumors with mainly anterior extension, petrosal approach for 2 with lateral or posterior extension, 3-stage (right and left transcondylar and transfacial) approaches for 2 with inferior extension, and orbitozygomatic approach for 1 with lateral extension. Three patients in our early series underwent conventional radiotherapy after surgical resection. Gamma-knife radiosurgery was used for local recurrence. Result: Total resection was achieved in 13 cases and subtotal resection in 4. During follow-up periods (range, 32–154 months; mean, 87 months), 11 patients (total 24 tumors) showed recurrence. Five-year recurrence-free rate was 47%. The MIB-1 labeling index (range, 1.3–8.7%; mean 4.5%) showed statistically significant correlation with tumor recurrence. All recurrent tumors were surgically removed or controlled with gamma-knife radiosurgery. All patients were in their active lives (Karnofsky scale 70 to 100). Conclusion: The MIB-1 labeling index was useful for predicting recurrence. After aggressive resection, recurrent tumors were small with restricted extension and could be controlled with high-dose radiation using gamma-knife radiosurgery. Initial aggressive resection using skull base approaches is the most important treatment for skull base chordomas.