Extended endoscopic endonasal surgery for clival chordoma and chondrosarcoma: Our experience in 14 cases

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Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Unidad de Cirugía de Base de Cráneo, Hospital Clínic, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Militar Alejandro Dávila Bolaños, Managua, Nicaragua" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cirugía endoscópica endonasal extendida para cordomas y condrosarcomas de clivus: nuestra experiencia en 14 casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2147 "Ancho" => 2000 "Tamanyo" => 345065 ] ] "descripcion" => array:1 [ "en" => "Pre- and post-treatment axial and sagittal slices of chordoma invading the dura mater, sellar and parasellar regions, cavernous sinus, medial fossa, and prepontine region." ] ] ] "textoCompleto" => "IntroductionClival chordomas and chondrosarcomas comprise the second least common category of intracranial tumours, accounting for around 1–4%. Their overall incidence in Spain is 0.51 cases per million. Chordomas and chondrosarcomas appear in the same anatomical sites and share many clinical and radiological characteristics. The essential differences between them are microscopic; each tumour type has its own histological and immunohistochemical characteristics.<a class="elsevierStyleCrossRefs" href="#bib0125">1,2</a>Given the high rate of recurrence of this type of lesion (up to 42% in some series, even with suitable treatment<a class="elsevierStyleCrossRef" href="#bib0130">2</a>), it is essential to achieve maximum resection intraoperatively to improve vital prognosis and disease-free survival in these patients.<a class="elsevierStyleCrossRefs" href="#bib0135">3,4</a>Today, the best treatment for these tumours remains a matter of debate. The goal is to offer a higher rate of resection and thus minimise intra-operative and post-operative morbidity and mortality. The endoscopic technique, developed in the last 15 years, has achieved equal or better extents of resection and in addition has been associated with a lower rate of complications.We present the experience at our centre in managing these tumours using surgery via an extended endonasal endoscopic approach performed by the same surgeons (JE and IA) between 2008 and 2016.Grade 1 chordomas and chondrosarcomas are histologically differentiated entities and therefore have different prognoses. However, like other authors, we see fit to report them together<a class="elsevierStyleCrossRefs" href="#bib0135">3,5,6</a> as they have a very similar anatomical site and therefore receive the same surgical treatment. In addition, both undergo the same treatment with proton beam (PB) therapy or conventional radiotherapy.Material and methodsWe performed a retrospective analysis of all cases of clival lesions diagnosed as grade 1 chordomas or chondrosarcomas which underwent surgery via an extended endonasal endoscopic approach between 2008 and 2016.The regimen offered to all patients was surgery followed by adjuvant treatment (PB therapy or conventional radiotherapy).We collected data such as age, sex, clinical presentation, prior surgical procedures, tumour size and volume, extent of resection, histology, complications, adjuvant treatment, follow-up time and recurrences.All patients underwent magnetic resonance imaging (General Electric SIGNA® TM Pioneer 3.0T) both before surgery for local study of the tumour and after surgery for management of complications and follow-up.Based on pre-operative imaging and intra-operative findings, lesions were classified according to their location in relation to the affected third of the clivus (superior, medial or inferior). The floor of the sella turcica and the lower limit of the sphenoidal sinus were considered arbitrary borders. The presence or absence of intradural and intrasellar invasion was also evaluated.All surgical procedures were assisted by neuronavigation (Medtronic, StealthStation Surgical Navigation Systems® Louisville, CO, United States) and Doppler imaging to locate major vessels (Microdoppler Prove®), as well as continuous neuromonitoring with motor and somatosensory evoked potentials.The extent of post-operative resection was evaluated on the basis of an MRI performed on all patients 3 months after surgery. Resection was deemed total when there was no evidence of tumour, subtotal when the extent of tumour resection was greater than 90% of the initial volume, and partial when less than 90%. We collected data on intra-operative and post-operative complications. The otorhinolaryngology team performed monitoring rhinoscopy 48h after surgery to rule out the presence of a fistula.Tumour volumes were calculated (in cubic centimetres [cc]) using the pre-operative MRI and compared to the extent of resection. Intradural invasion was expressed in binomial terms (1 for yes; 0 for no) and compared to the extent of resection. Both comparisons were made using Fischer's exact test (p<0.05), performed with the software programme STATA® (StataCorp, United States).All patients were followed up on an outpatient basis except for one, who was followed up at a different centre. Adjuvant treatment was administered by means of conventional radiotherapy or PB therapy.Surgical techniqueAll surgeries were performed by the same multidisciplinary team, which consisted of a neurosurgeon (JE) and an otorhinolaryngologist (IA) as well as a neurophysiologist and a neuroanaesthetist.An extended endonasal endoscopic approach was performed with a classic exposure<a class="elsevierStyleCrossRef" href="#bib0155">7</a> through a bilateral medial turbinectomy or, in some cases, an inferior turbinectomy: the Hadad–Bassagaisteguy flap<a class="elsevierStyleCrossRef" href="#bib0160">8</a> was obtained and placed inside the medial meatus to protect it, and a posterior septectomy as well as an anterior and inferior bilateral sphenoidotomy were performed to achieve full exposure of the clivus. A maxillectomy or ethmoidectomy had to be performed, depending on whether the tumour had invaded these sinuses and whether tumour exposure required it.Finally, a partial or complete clivectomy was performed depending on tumour spread, with subsequent exposure of the dura mater and intradural resection, depending on the case.Closure was performed with intradural fat and intradural autologous fascia lata, and the mucosa was replaced using the Hadad–Bassagaisteguy flap obtained earlier.In extended endoscopic approaches with a dural opening, a lumbar drain was placed and maintained for 72h after surgery. Antibiotic prophylaxis was also administered during that time. After 72h, fluorescein was injected through the lumbar drain and an endonasal endoscopic examination was performed. If no leakage of cerebrospinal fluid (CSF) was seen, the lumbar drain was removed. If a low-flow fistula was seen, the drain was maintained for three more days and another fluorescein test was performed. If it was positive, surgery was indicated. If a high-flow fistula was seen, immediate surgical review was indicated.ResultsIn our series, we found a preponderance of males, who accounted for 9 cases (64.3%). The mean age was 49 years (range 29–70) for chordomas and 32 years (range 20–58) for chondrosarcomas. The most common clinical presentation was diplopia, which occurred in 11 cases (78.5%), followed by dysphagia in 4 cases (28.6%), and finally vertigo, amaurosis and hemiparesis with the same number of cases: 2 (14.2%), and headache in one case (7.1%).Of the 14 cases, 10 (71.4%) were classified as chordomas (21.4% chondroid chordoma and 50% conventional chordoma) and 4 (28.6%) were classified as chondrosarcomas, all low-grade. In 8 cases (57.1%) there was intradural invasion; in 5 (35.7%) there was intrasellar invasion; in 6 (42.8%) the tumour invaded two-thirds of the clivus; in 5 (35.7%) it invaded the entire clivus; and in 3 (21.5%) it invaded just one-third of the clivus. There was invasion of the superior third in 71.4% of cases, the medial third in 92.9% and the inferior third in 57.1%.In 6 cases resection was total (42.8%; 4/6 were chordomas and 2/6 were chondrosarcomas), in 3 resection was subtotal (21.5%; all were chordomas) and in 5 resection was partial (35.7%; 3/5 were chordomas and 2/5 were chondrosarcomas). Histology could not be correlated with extent of resection.Complications appeared in 28.6% of cases as a CSF fistula (three were low-flow and one was high-flow), visualised on monitoring rhinoscopy after 72h, of which just one (7.1%) required surgical treatment. The rest spontaneously resolved and delayed the removal of the 72h drain. There was a single case of meningitis in one of the patients with a fistula, which resolved with antibiotic therapy. There were no post-operative neurological deficits, with the exception of one case of transient diplopia. There were no deaths.We attempted to associate the extent of resection to the tumour volume (with an arbitrary threshold at 20cc) and with the presence or absence of intradural invasion. The volume did not significantly influence the extent of resection. However, we did find a significant relationship between the presence of dural invasion and a lower rate of total resections (p<0.05). 100% (5/5) of tumours with no dural invasion were totally resected, versus 11.1% (1/9) of tumours with dural invasion.To date, the average length of follow-up for these patients was 53.5±33.9 months. One patient went to a centre in another city and was lost to follow-up.In partially resected lesions, we found invasion of the cavernous sinus, cerebellopontine angle, sellar region, parasellar region and retrosellar region, as seen in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>They were treated with conventional radiotherapy in 21.5% of cases and PB therapy in 35.8% of cases; 6 patients (42.8%) received no adjuvant treatment.Among the patients in whom total resection was achieved, one (reported as having a chondrosarcoma) had a recurrence in the nasal fossae prior to treatment with PB therapy and underwent further surgery by the otorhinolaryngology department. Following this further surgery, the patient was administered PB therapy and has exhibited no further changes. Regarding the rest of the patients with total resection, two (both with chordomas) received PB therapy, and two others (one with a chordoma and the other with a chondrosarcoma) received no adjuvant treatment (both refused it). All other patients had no recurrences. The clinical course of the latter is unknown due to failure to attend follow-up visits.Among the patients with subtotal resection, one received conventional radiotherapy before surgery and the other two received PB therapy after surgery. None experienced subsequent tumour progression.Concerning the patients in whom only partial resection could be achieved, three received no adjuvant treatment (two had chordomas and one had a chondrosarcoma), and to date no tumour progression has been seen. One patient had to undergo total resection via a retromastoid approach in a separate operation. Another patient, reported with a chondrosarcoma, received treatment with conventional radiotherapy, required another operation 4 years after the first due to growth of tumour remnants. Following this, that patient has remained stable. Another patient with a very extended chordoma at the base of the skull has required 7 surgeries and was treated with radiotherapy following the fourth procedure.Therefore, a total of 3 patients (21.5%) experienced tumour progression: two who did not receive adjuvant treatment (one was treated with PB therapy and the other was treated with conventional radiotherapy a posteriori), and one with a very extended tumour which had already progressed 3 times and which following radiotherapy progressed another three times (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>DiscussionThe objective of this study was to compile our experience in managing clival chordomas through endoscopic surgical treatment or adjuvant radiotherapy, depending on the case. The study consisted of retrospective evaluation of 14 patients, whose clinical presentation, histological type, approach, complications, follow-up time and recurrences were collected.In this study, we did not find any difference in terms of epidemiological patterns compared to other series.<a class="elsevierStyleCrossRefs" href="#bib0130">2,9–11</a>The main objective with the patients was to attempt a total resection, followed or not by radiotherapy. Four-hand surgery by neurosurgeons and otorhinolaryngologists enabled suitable care for nasal and sinus structures as well as central nervous system structures. In our study, there were no intra-operative complications in any of the cases, nor was there post-operative neurological worsening in any of them, except for one case of transient diplopia, which resolved during the initial post-operative period (72h).Clinical findings on admission included diplopia in 78.5% of cases. This figure was similar to the 81.8% found by Frank et al.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> and higher than the 36% found by Zhang et al.<a class="elsevierStyleCrossRef" href="#bib0150">6</a> There was dysphagia in 28.6% and hemiparesis in 14.2%; these percentages could be attributed to the presence of more than 50% intradural invasion and some degree of brainstem compression. We found headache in 7.1%; this figure was very different from the usual figures in the literature, which range from 35% to 45%.<a class="elsevierStyleCrossRef" href="#bib0180">12</a>This series laid bare the locally aggressive nature of this type of lesion, since, as noted in the results section, it featured high percentages of intradural involvement and involvement of at least two-thirds of the clivus. These data were not collected in any other series compared.Factors that influence radical tumour resection are extremely important, since both the recurrence rate and the long-term prognosis depend on them.<a class="elsevierStyleCrossRefs" href="#bib0140">4,12,13</a> In our series, we only found that the extent of resection could depend on intradural invasion; we were unable to associated it with tumour volume. Vellutini et al.<a class="elsevierStyleCrossRef" href="#bib0190">14</a> found in their series that the lateral spread of these lesions is associated with a lower rate of total resection. Vaz-Guimaraes et al.<a class="elsevierStyleCrossRef" href="#bib0195">15</a> and Koutourousiou et al.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> found the same in their series (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Other series, such as that of Gui et al.,<a class="elsevierStyleCrossRef" href="#bib0165">9</a> also compared the tumour volume to the extent of resection; in their case they set the threshold at 40cc and found a significant association between a greater extent of resection (total or subtotal) and volumes below 40cc. A series by Koutourousiou et al.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> found volumes above 20cc to be associated with lower resection rates. These authors were also among the few to associate the rate of resection with the rate of prior surgeries, finding the latter to be lower.Comparison with the latest meta-analysis published in 2016 by Labidi et al.<a class="elsevierStyleCrossRef" href="#bib0180">12</a> revealed that the percentage of total resections (39% according to said series) in our patients was similar to or even slightly higher than the mean. Other series have found figures for total resection of 66.7% (Koutourousiou et al.<a class="elsevierStyleCrossRef" href="#bib0200">16</a>), 62.9% (Vaz-Guimaraes et al.<a class="elsevierStyleCrossRef" href="#bib0195">15</a> [chondrosarcomas only]), 48% (Vellutini et al.<a class="elsevierStyleCrossRef" href="#bib0190">14</a>), 46% (Frank et al.<a class="elsevierStyleCrossRef" href="#bib0145">5</a>) and 24% (Gui et al.<a class="elsevierStyleCrossRef" href="#bib0165">9</a>).Regarding the choice of surgical technique, a study by Jho and Carrau<a class="elsevierStyleCrossRef" href="#bib0205">17</a> included several series of clival tumours having undergone surgery exclusively by the endoscopic route. The results reported in the study were similar to the results reported in series of clival tumours having undergone surgery by the traditional route, but with lower rates of complications. Komotar et al.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> also performed a comparison between an endoscopic approach and a transcranial approach in which they found a higher percentage of total resection, fewer neurological deficits, fewer post-operative complications and fewer recurrences in the endoscopic cohort. Sen et al.<a class="elsevierStyleCrossRef" href="#bib0215">19</a> reported a rate of total resection of 53% through a transcranial approach, and Colli and al-Mefty,<a class="elsevierStyleCrossRef" href="#bib0140">4</a> in their series on transcranial and transfacial approaches, reported a rate of 49.2%. Compared to endoscopic series such as those by Garzaro et al.<a class="elsevierStyleCrossRef" href="#bib0220">20</a> and Koutourousiou et al.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> (67%), Vellutini et al.<a class="elsevierStyleCrossRef" href="#bib0190">14</a> (48%), and our own (43%), this does not seem to represent an advantage with respect to extent of resection. These things, plus a lower incidence of intra-operative and post-operative complications, lead to the conclusion that a team experienced in this type of approach should be used whenever possible. As Koutourousiou et al.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> specified in their study, the most important predictive factor for total resection is the experience of the team that performs it and a proper learning curve. In their series, they compared patients having undergone surgery in the first four years to patients having undergone surgery in the last four years, and found a rate of total resection of 36.4% in the first group versus 88.9% in the second group. This reinforces the notion of attempting to centralise this type of disease at experienced centres.The most common complication which we found, and one of the most common arguments for not indicating the transnasal endoscopic approach, was a fistula. We found a rate of fistulas of 28.6%<a class="elsevierStyleCrossRef" href="#bib0140">4</a>; however, only one patient (7.1%) required further surgery. Series by Vellutini et al.<a class="elsevierStyleCrossRef" href="#bib0190">14</a> and Frank et al.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> found rates of 18% and 19%, respectively, but did not specify whether further surgery was required. We believe that, especially in cases of dural invasion, intra-operative reconstruction with a vascularised flap as reported by Hadad in 2006 is the treatment of choice to decrease the incidence of this complication. In addition, post-operative preventive lumbar drain placement plus antibiotics for 72h and a fluorescein test with a rhinoscopy by otorhinolaryngology (ORL) is a safe and effective method for decreasing the incidence of fistula and the potential meningitis deriving therefrom.Post-operative radiotherapy is extremely important in this type of tumour.<a class="elsevierStyleCrossRefs" href="#bib0140">4,21,22</a> Therefore, all patients were offered the option of proton beam adjuvant treatment (those who chose this had to go to another country to get it, as it is not yet available in Spain). Given the current lack of a high level of evidence (1, 2),<a class="elsevierStyleCrossRef" href="#bib0235">23</a> they were also offered the option of taking a wait-and-see approach or, if they preferred radiotherapy but could not go to another country, receiving conventional radiotherapy. In the end, 5 patients received proton beam therapy, 6 elected not to receive adjuvant treatment and 3 opted to be treated with conventional radiotherapy. Our rate of tumour progression was 21.5% of cases. This was comparable to that found by Yoneoka et al.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> and higher than those reported by Dehdashti et al.<a class="elsevierStyleCrossRef" href="#bib0175">11</a> and Frank et al.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> It should be noted that the latter two series had a shorter follow-up time (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>ConclusionsThe extended endonasal endoscopic approach by a team experienced in skull base diseases with a proper learning curve for this disease in particular is a good option for managing these lesions. Intradural invasion could be associated with a higher risk of complications and greater clinical impairment on diagnosis, as well as a lower rate of total resection.Conflict of interestsThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1046306" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec998168" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1046307" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec998167" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interests" ] 10 => array:2 [ "identificador" => "xack353186" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-22" "fechaAceptado" => "2018-03-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec998168" "palabras" => array:5 [ 0 => "Skull base" 1 => "Endoscopic endonasal surgery" 2 => "Clivus" 3 => "Chordoma" 4 => "Chondrosarcoma" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec998167" "palabras" => array:5 [ 0 => "Base de cráneo" 1 => "Cirugía endonasal endoscópica" 2 => "Clivus" 3 => "Cordomas" 4 => "Condrosarcomas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo report our experience in the management of chordoma and chondrosarcoma with extended endoscopic endonasal surgery. MethodWe performed a retrospective analysis of a series of 14 patients with clival chordoma or chondrosarcoma who had extended endoscopic endonasal surgery from 2008 to 2016 performed by the same multidisciplinary team. ResultsWe had fourteen patients (male/female 2:1), with a mean age of 49 years for chordoma and 32 for chondrosarcoma. The most common clinical presentation was diplopia in 78.5% of cases, followed by dysphagia in 28.6%. Histologically, 71.4% were chordomas and 28.6% were chondrosarcomas. In addition, invasion of at least two-thirds or more of the clivus was found in 81% of the cases; in 57.1% there was intradural invasion, and in 35.7% invasion of the sella turcica. In 42.8% of cases, the degree of resection was total and in 21.5% subtotal. The most common complication was CSF fistula, occurring in 28.6% of the cases, with only one case requiring surgery to repair it. Adjuvant treatment with Proton Beam was performed in 35.7% of cases and with conventional radiotherapy in 21.5%. Mean follow-up was 53.5 months and tumour recurrence or progression was found in 21.5% of the cases, two of which had not received adjuvant treatment. There were no deaths. ConclusionThe extended endoscopic endonasal approach (EEEA) performed by an experienced team is a good alternative for the management of these lesions. Intradural invasion may be related to an increased risk of complications and worse clinical presentation, in addition to a lower rate of total resection." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoReportar la experiencia del manejo de los cordomas y condrosarcomas por abordaje endoscópico endonasal extendido. MétodoSe realizó un análisis retrospectivo de una serie de 14 pacientes afectos de cordomas o condrosarcomas clivales operados mediante un abordaje endoscópico endonasal extendido por un mismo equipo multidisciplinar, en el intervalo de tiempo desde 2008 hasta 2016. ResultadosCatorce pacientes (hombre/mujer 2:1) con una media de edad de 49años en los cordomas y de 32años en los condrosarcomas. La presentación clínica más frecuente fue la diplopía (78,5% de los casos), seguida de la disfagia (28,6%). Histológicamente se reportaron como cordomas el 71,4% y como condrosarcomas el 28,6%. Además, se encontró en el 81% de los casos invasión de al menos dos o más tercios del clivus, en el 57,1% invasión intradural y en el 35,7% invasión sellar. En el 42,8% de los casos el grado de resección fue total y en el 21,5%, subtotal. La complicación más frecuente fue la fístula de LCR, que se presentó en el 28,6% de los casos, habiendo que intervenir solo a un paciente. En el 35,7% de los casos se indicó tratamiento coadyuvante con Proton Beam y en el 21,5% radioterapia convencional. La media de seguimiento fue de 53,5meses, y se encontró recurrencia o progresión tumoral en el 21,5% de los casos, dos de los cuales no había recibido coadyuvancia. No hubo fallecimientos. ConclusiónEl abordaje endoscópico endonasal extendido, realizado por un equipo experimentado, es una buena alternativa de manejo para estas lesiones. La invasión intradural podría estar relacionada con un mayor riesgo de complicaciones y una mayor afectación clínica al diagnóstico, así como con una menor tasa de resección total." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Culebras D, Torales J, Reyes LA, Zapata L, García S, Roldán P. Cirugía endoscópica endonasal extendida para cordomas y condrosarcomas de clivus: nuestra experiencia en 14 casos. Neurocirugía. 2018;29:201–208." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2147 "Ancho" => 2000 "Tamanyo" => 345065 ] ] "descripcion" => array:1 [ "en" => "Pre- and post-treatment axial and sagittal slices of chordoma invading the dura mater, sellar and parasellar regions, cavernous sinus, medial fossa, and prepontine region." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2148 "Ancho" => 2000 "Tamanyo" => 337906 ] ] "descripcion" => array:1 [ "en" => "Pre- and post-treatment axial and sagittal slices of clival chordoma invading the lower third of the clivus and exhibiting posterior and lateral spread towards the cerebellopontine region." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AP: anteroposterior; CC: craniocaudal; LL: latero-lateral; F: female; PB: proton beam; M: male." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years)/sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Size (AP×LL×CC mm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Intradural \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Intrasellar \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Histology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Resection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III, hemiparesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46×26×34 (20.3cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chondroid chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fistula \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diplopia, hemiparesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40×35×33 (23.1cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chondroid chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">VI, VII, VIII, dysphagia, tumour bleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29×23×33 (11.0cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low-grade chondrosarcoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18×16×13 (1.87cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low-grade chondrosarcoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diplopia, dysphagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40×23×26 (11.9cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chondroid chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Subtotal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43×26×24 (12.5cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Conventional chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diplopia, dysphagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31×22×21 (7.2cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low-grade chondrosarcoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diplopia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42×23×30 (14.5cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low-grade chondrosarcoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fistula \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diplopia, LE amaurosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42×41×32 (27.6cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Conventional chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">LE amaurosis, III, V, VII, VIII \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37×21×27 (10.5cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Conventional chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Subtotal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fistula \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39×23×30 (13.5cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Conventional chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25×15×20 (3.7cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Conventional chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Subtotal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fistula/meningitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dysphagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31×45×58 (40.4cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Conventional chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Transient diplopia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hyposmia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40×37×31 (22.9cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Conventional chordoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1778209.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Outcomes achieved in the 14 patients." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors and year of publication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Patients, n (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Approach \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total resection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Rate of complications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up time \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Recurrences \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enseñat et al., 2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (2008–2016) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endonasal endoscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.5 (2–112) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Koutourousiou et al., 2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (2003–2011) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endonasal endoscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.8 (1–71) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20% in total resection; 60% in all others \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaz-Guimaraes et al., 2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (2004–2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endonasal endoscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.9% (chondrosarcomas only) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44.6 (13–75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Garzaro et al., 2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (2012–2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endonasal endoscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vellutini et al., 2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (2000–2011) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endonasal endoscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Matteo Soli et al., 2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 (1998–2015) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endonasal endoscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 (7–159) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yoneoka et al., 2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (1982–2002) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EE and microsurgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">122 (37–268) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gui et al., 2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">161 (2007–2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EE and microsurgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.4 (8–82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frank et al., 2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (1998–2004) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Endonasal endoscopic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (15–69) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Al-Mefty et al., 2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">109 (1990–2006) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EE and microsurgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 (1–191) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dehdashti et al., 2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (2005–2007) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EE and microsurgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (4–26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Samii et al., 2007<a class="elsevierStyleCrossRef" href="#bib0240">24</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (1979–2002) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Microsurgical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 (5–134) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1778208.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Review of endoscopic and microscopic series." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cordoma. 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Extended endoscopic endonasal surgery for clival chordoma and chondrosarcoma: Our experience in 14 cases

Cirugía endoscópica endonasal extendida para cordomas y condrosarcomas de clivus: nuestra experiencia en 14 casos

Diego Culebrasa,

Corresponding author

Culebras.palao@gmail.com

Corresponding author.

, Jorge Toralesa, Luis Alberto Reyesa, Luis Zapatac, Sergio Garcíaa, Pedro Roldána, Cristóbal Langdonb, Issam Alobidb, Joaquim Enseñata

a Servicio de Neurocirugía, Unidad de Cirugía de Base de Cráneo, Hospital Clínic, Barcelona, Spain

b Servicio de Otorrinolaringología, Unidad de Cirugía de Base de Cráneo, Hospital Clínic, Barcelona, Spain

c Servicio de Neurocirugía, Hospital Militar Alejandro Dávila Bolaños, Managua, Nicaragua

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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pre- and post-treatment axial and sagittal slices of chordoma invading the dura mater&#44; sellar and parasellar regions&#44; cavernous sinus&#44; medial fossa&#44; and prepontine region&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clival chordomas and chondrosarcomas comprise the second least common category of intracranial tumours&#44; accounting for around 1&#8211;4&#37;&#46; Their overall incidence in Spain is 0&#46;51 cases per million&#46; Chordomas and chondrosarcomas appear in the same anatomical sites and share many clinical and radiological characteristics&#46; The essential differences between them are microscopic&#59; each tumour type has its own histological and immunohistochemical characteristics&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given the high rate of recurrence of this type of lesion &#40;up to 42&#37; in some series&#44; even with suitable treatment<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a>&#41;&#44; it is essential to achieve maximum resection intraoperatively to improve vital prognosis and disease-free survival in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Today&#44; the best treatment for these tumours remains a matter of debate&#46; The goal is to offer a higher rate of resection and thus minimise intra-operative and post-operative morbidity and mortality&#46; The endoscopic technique&#44; developed in the last 15 years&#44; has achieved equal or better extents of resection and in addition has been associated with a lower rate of complications&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the experience at our centre in managing these tumours using surgery via an extended endonasal endoscopic approach performed by the same surgeons &#40;JE and IA&#41; between 2008 and 2016&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Grade <span class="elsevierStyleSmallCaps">1</span> chordomas and chondrosarcomas are histologically differentiated entities and therefore have different prognoses&#46; However&#44; like other authors&#44; we see fit to report them together<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a> as they have a very similar anatomical site and therefore receive the same surgical treatment&#46; In addition&#44; both undergo the same treatment with proton beam &#40;PB&#41; therapy or conventional radiotherapy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We performed a retrospective analysis of all cases of clival lesions diagnosed as grade <span class="elsevierStyleSmallCaps">1</span> chordomas or chondrosarcomas which underwent surgery via an extended endonasal endoscopic approach between 2008 and 2016&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The regimen offered to all patients was surgery followed by adjuvant treatment &#40;PB therapy or conventional radiotherapy&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We collected data such as age&#44; sex&#44; clinical presentation&#44; prior surgical procedures&#44; tumour size and volume&#44; extent of resection&#44; histology&#44; complications&#44; adjuvant treatment&#44; follow-up time and recurrences&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All patients underwent magnetic resonance imaging &#40;General Electric SIGNA<span class="elsevierStyleSup">&#174;</span> TM Pioneer 3&#46;0<span class="elsevierStyleHsp" style=""></span>T&#41; both before surgery for local study of the tumour and after surgery for management of complications and follow-up&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Based on pre-operative imaging and intra-operative findings&#44; lesions were classified according to their location in relation to the affected third of the clivus &#40;superior&#44; medial or inferior&#41;&#46; The floor of the sella turcica and the lower limit of the sphenoidal sinus were considered arbitrary borders&#46; The presence or absence of intradural and intrasellar invasion was also evaluated&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">All surgical procedures were assisted by neuronavigation &#40;Medtronic&#44; StealthStation Surgical Navigation Systems<span class="elsevierStyleSup">&#174;</span> Louisville&#44; CO&#44; United States&#41; and Doppler imaging to locate major vessels &#40;Microdoppler Prove<span class="elsevierStyleSup">&#174;</span>&#41;&#44; as well as continuous neuromonitoring with motor and somatosensory evoked potentials&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The extent of post-operative resection was evaluated on the basis of an MRI performed on all patients 3 months after surgery&#46; Resection was deemed total when there was no evidence of tumour&#44; subtotal when the extent of tumour resection was greater than 90&#37; of the initial volume&#44; and partial when less than 90&#37;&#46; We collected data on intra-operative and post-operative complications&#46; The otorhinolaryngology team performed monitoring rhinoscopy 48<span class="elsevierStyleHsp" style=""></span>h after surgery to rule out the presence of a fistula&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Tumour volumes were calculated &#40;in cubic centimetres &#91;cc&#93;&#41; using the pre-operative MRI and compared to the extent of resection&#46; Intradural invasion was expressed in binomial terms &#40;1 for yes&#59; 0 for no&#41; and compared to the extent of resection&#46; Both comparisons were made using Fischer&#39;s exact test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; performed with the software programme STATA<span class="elsevierStyleSup">&#174;</span> &#40;StataCorp&#44; United States&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">All patients were followed up on an outpatient basis except for one&#44; who was followed up at a different centre&#46; Adjuvant treatment was administered by means of conventional radiotherapy or PB therapy&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0075" class="elsevierStylePara elsevierViewall">All surgeries were performed by the same multidisciplinary team&#44; which consisted of a neurosurgeon &#40;JE&#41; and an otorhinolaryngologist &#40;IA&#41; as well as a neurophysiologist and a neuroanaesthetist&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">An extended endonasal endoscopic approach was performed with a classic exposure<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> through a bilateral medial turbinectomy or&#44; in some cases&#44; an inferior turbinectomy&#58; the Hadad&#8211;Bassagaisteguy flap<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> was obtained and placed inside the medial meatus to protect it&#44; and a posterior septectomy as well as an anterior and inferior bilateral sphenoidotomy were performed to achieve full exposure of the clivus&#46; A maxillectomy or ethmoidectomy had to be performed&#44; depending on whether the tumour had invaded these sinuses and whether tumour exposure required it&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally&#44; a partial or complete clivectomy was performed depending on tumour spread&#44; with subsequent exposure of the dura mater and intradural resection&#44; depending on the case&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Closure was performed with intradural fat and intradural autologous fascia lata&#44; and the mucosa was replaced using the Hadad&#8211;Bassagaisteguy flap obtained earlier&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In extended endoscopic approaches with a dural opening&#44; a lumbar drain was placed and maintained for 72<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; Antibiotic prophylaxis was also administered during that time&#46; After 72<span class="elsevierStyleHsp" style=""></span>h&#44; fluorescein was injected through the lumbar drain and an endonasal endoscopic examination was performed&#46; If no leakage of cerebrospinal fluid &#40;CSF&#41; was seen&#44; the lumbar drain was removed&#46; If a low-flow fistula was seen&#44; the drain was maintained for three more days and another fluorescein test was performed&#46; If it was positive&#44; surgery was indicated&#46; If a high-flow fistula was seen&#44; immediate surgical review was indicated&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">In our series&#44; we found a preponderance of males&#44; who accounted for 9 cases &#40;64&#46;3&#37;&#41;&#46; The mean age was 49 years &#40;range 29&#8211;70&#41; for chordomas and 32 years &#40;range 20&#8211;58&#41; for chondrosarcomas&#46; The most common clinical presentation was diplopia&#44; which occurred in 11 cases &#40;78&#46;5&#37;&#41;&#44; followed by dysphagia in 4 cases &#40;28&#46;6&#37;&#41;&#44; and finally vertigo&#44; amaurosis and hemiparesis with the same number of cases&#58; 2 &#40;14&#46;2&#37;&#41;&#44; and headache in one case &#40;7&#46;1&#37;&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Of the 14 cases&#44; 10 &#40;71&#46;4&#37;&#41; were classified as chordomas &#40;21&#46;4&#37; chondroid chordoma and 50&#37; conventional chordoma&#41; and 4 &#40;28&#46;6&#37;&#41; were classified as chondrosarcomas&#44; all low-grade&#46; In 8 cases &#40;57&#46;1&#37;&#41; there was intradural invasion&#59; in 5 &#40;35&#46;7&#37;&#41; there was intrasellar invasion&#59; in 6 &#40;42&#46;8&#37;&#41; the tumour invaded two-thirds of the clivus&#59; in 5 &#40;35&#46;7&#37;&#41; it invaded the entire clivus&#59; and in 3 &#40;21&#46;5&#37;&#41; it invaded just one-third of the clivus&#46; There was invasion of the superior third in 71&#46;4&#37; of cases&#44; the medial third in 92&#46;9&#37; and the inferior third in 57&#46;1&#37;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In 6 cases resection was total &#40;42&#46;8&#37;&#59; 4&#47;6 were chordomas and 2&#47;6 were chondrosarcomas&#41;&#44; in 3 resection was subtotal &#40;21&#46;5&#37;&#59; all were chordomas&#41; and in 5 resection was partial &#40;35&#46;7&#37;&#59; 3&#47;5 were chordomas and 2&#47;5 were chondrosarcomas&#41;&#46; Histology could not be correlated with extent of resection&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Complications appeared in 28&#46;6&#37; of cases as a CSF fistula &#40;three were low-flow and one was high-flow&#41;&#44; visualised on monitoring rhinoscopy after 72<span class="elsevierStyleHsp" style=""></span>h&#44; of which just one &#40;7&#46;1&#37;&#41; required surgical treatment&#46; The rest spontaneously resolved and delayed the removal of the 72<span class="elsevierStyleHsp" style=""></span>h drain&#46; There was a single case of meningitis in one of the patients with a fistula&#44; which resolved with antibiotic therapy&#46; There were no post-operative neurological deficits&#44; with the exception of one case of transient diplopia&#46; There were no deaths&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">We attempted to associate the extent of resection to the tumour volume &#40;with an arbitrary threshold at 20<span class="elsevierStyleHsp" style=""></span>cc&#41; and with the presence or absence of intradural invasion&#46; The volume did not significantly influence the extent of resection&#46; However&#44; we did find a significant relationship between the presence of dural invasion and a lower rate of total resections &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; 100&#37; &#40;5&#47;5&#41; of tumours with no dural invasion were totally resected&#44; versus 11&#46;1&#37; &#40;1&#47;9&#41; of tumours with dural invasion&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">To date&#44; the average length of follow-up for these patients was 53&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>33&#46;9 months&#46; One patient went to a centre in another city and was lost to follow-up&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In partially resected lesions&#44; we found invasion of the cavernous sinus&#44; cerebellopontine angle&#44; sellar region&#44; parasellar region and retrosellar region&#44; as seen in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">They were treated with conventional radiotherapy in 21&#46;5&#37; of cases and PB therapy in 35&#46;8&#37; of cases&#59; 6 patients &#40;42&#46;8&#37;&#41; received no adjuvant treatment&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Among the patients in whom total resection was achieved&#44; one &#40;reported as having a chondrosarcoma&#41; had a recurrence in the nasal fossae prior to treatment with PB therapy and underwent further surgery by the otorhinolaryngology department&#46; Following this further surgery&#44; the patient was administered PB therapy and has exhibited no further changes&#46; Regarding the rest of the patients with total resection&#44; two &#40;both with chordomas&#41; received PB therapy&#44; and two others &#40;one with a chordoma and the other with a chondrosarcoma&#41; received no adjuvant treatment &#40;both refused it&#41;&#46; All other patients had no recurrences&#46; The clinical course of the latter is unknown due to failure to attend follow-up visits&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Among the patients with subtotal resection&#44; one received conventional radiotherapy before surgery and the other two received PB therapy after surgery&#46; None experienced subsequent tumour progression&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Concerning the patients in whom only partial resection could be achieved&#44; three received no adjuvant treatment &#40;two had chordomas and one had a chondrosarcoma&#41;&#44; and to date no tumour progression has been seen&#46; One patient had to undergo total resection via a retromastoid approach in a separate operation&#46; Another patient&#44; reported with a chondrosarcoma&#44; received treatment with conventional radiotherapy&#44; required another operation 4 years after the first due to growth of tumour remnants&#46; Following this&#44; that patient has remained stable&#46; Another patient with a very extended chordoma at the base of the skull has required 7 surgeries and was treated with radiotherapy following the fourth procedure&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Therefore&#44; a total of 3 patients &#40;21&#46;5&#37;&#41; experienced tumour progression&#58; two who did not receive adjuvant treatment &#40;one was treated with PB therapy and the other was treated with conventional radiotherapy a posteriori&#41;&#44; and one with a very extended tumour which had already progressed 3 times and which following radiotherapy progressed another three times &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">The objective of this study was to compile our experience in managing clival chordomas through endoscopic surgical treatment or adjuvant radiotherapy&#44; depending on the case&#46; The study consisted of retrospective evaluation of 14 patients&#44; whose clinical presentation&#44; histological type&#44; approach&#44; complications&#44; follow-up time and recurrences were collected&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In this study&#44; we did not find any difference in terms of epidemiological patterns compared to other series&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#44;9&#8211;11</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The main objective with the patients was to attempt a total resection&#44; followed or not by radiotherapy&#46; Four-hand surgery by neurosurgeons and otorhinolaryngologists enabled suitable care for nasal and sinus structures as well as central nervous system structures&#46; In our study&#44; there were no intra-operative complications in any of the cases&#44; nor was there post-operative neurological worsening in any of them&#44; except for one case of transient diplopia&#44; which resolved during the initial post-operative period &#40;72<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Clinical findings on admission included diplopia in 78&#46;5&#37; of cases&#46; This figure was similar to the 81&#46;8&#37; found by Frank et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> and higher than the 36&#37; found by Zhang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> There was dysphagia in 28&#46;6&#37; and hemiparesis in 14&#46;2&#37;&#59; these percentages could be attributed to the presence of more than 50&#37; intradural invasion and some degree of brainstem compression&#46; We found headache in 7&#46;1&#37;&#59; this figure was very different from the usual figures in the literature&#44; which range from 35&#37; to 45&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">This series laid bare the locally aggressive nature of this type of lesion&#44; since&#44; as noted in the results section&#44; it featured high percentages of intradural involvement and involvement of at least two-thirds of the clivus&#46; These data were not collected in any other series compared&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Factors that influence radical tumour resection are extremely important&#44; since both the recurrence rate and the long-term prognosis depend on them&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;12&#44;13</span></a> In our series&#44; we only found that the extent of resection could depend on intradural invasion&#59; we were unable to associated it with tumour volume&#46; Vellutini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> found in their series that the lateral spread of these lesions is associated with a lower rate of total resection&#46; Vaz-Guimaraes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> and Koutourousiou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> found the same in their series &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Other series&#44; such as that of Gui et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> also compared the tumour volume to the extent of resection&#59; in their case they set the threshold at 40<span class="elsevierStyleHsp" style=""></span>cc and found a significant association between a greater extent of resection &#40;total or subtotal&#41; and volumes below 40<span class="elsevierStyleHsp" style=""></span>cc&#46; A series by Koutourousiou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> found volumes above 20<span class="elsevierStyleHsp" style=""></span>cc to be associated with lower resection rates&#46; These authors were also among the few to associate the rate of resection with the rate of prior surgeries&#44; finding the latter to be lower&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Comparison with the latest meta-analysis published in 2016 by Labidi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> revealed that the percentage of total resections &#40;39&#37; according to said series&#41; in our patients was similar to or even slightly higher than the mean&#46; Other series have found figures for total resection of 66&#46;7&#37; &#40;Koutourousiou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a>&#41;&#44; 62&#46;9&#37; &#40;Vaz-Guimaraes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> &#91;chondrosarcomas only&#93;&#41;&#44; 48&#37; &#40;Vellutini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a>&#41;&#44; 46&#37; &#40;Frank et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a>&#41; and 24&#37; &#40;Gui et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a>&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Regarding the choice of surgical technique&#44; a study by Jho and Carrau<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> included several series of clival tumours having undergone surgery exclusively by the endoscopic route&#46; The results reported in the study were similar to the results reported in series of clival tumours having undergone surgery by the traditional route&#44; but with lower rates of complications&#46; Komotar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> also performed a comparison between an endoscopic approach and a transcranial approach in which they found a higher percentage of total resection&#44; fewer neurological deficits&#44; fewer post-operative complications and fewer recurrences in the endoscopic cohort&#46; Sen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> reported a rate of total resection of 53&#37; through a transcranial approach&#44; and Colli and al-Mefty&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> in their series on transcranial and transfacial approaches&#44; reported a rate of 49&#46;2&#37;&#46; Compared to endoscopic series such as those by Garzaro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> and Koutourousiou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> &#40;67&#37;&#41;&#44; Vellutini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> &#40;48&#37;&#41;&#44; and our own &#40;43&#37;&#41;&#44; this does not seem to represent an advantage with respect to extent of resection&#46; These things&#44; plus a lower incidence of intra-operative and post-operative complications&#44; lead to the conclusion that a team experienced in this type of approach should be used whenever possible&#46; As Koutourousiou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> specified in their study&#44; the most important predictive factor for total resection is the experience of the team that performs it and a proper learning curve&#46; In their series&#44; they compared patients having undergone surgery in the first four years to patients having undergone surgery in the last four years&#44; and found a rate of total resection of 36&#46;4&#37; in the first group versus 88&#46;9&#37; in the second group&#46; This reinforces the notion of attempting to centralise this type of disease at experienced centres&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The most common complication which we found&#44; and one of the most common arguments for not indicating the transnasal endoscopic approach&#44; was a fistula&#46; We found a rate of fistulas of 28&#46;6&#37;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a>&#59; however&#44; only one patient &#40;7&#46;1&#37;&#41; required further surgery&#46; Series by Vellutini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> and Frank et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> found rates of 18&#37; and 19&#37;&#44; respectively&#44; but did not specify whether further surgery was required&#46; We believe that&#44; especially in cases of dural invasion&#44; intra-operative reconstruction with a vascularised flap as reported by Hadad in 2006 is the treatment of choice to decrease the incidence of this complication&#46; In addition&#44; post-operative preventive lumbar drain placement plus antibiotics for 72<span class="elsevierStyleHsp" style=""></span>h and a fluorescein test with a rhinoscopy by otorhinolaryngology &#40;ORL&#41; is a safe and effective method for decreasing the incidence of fistula and the potential meningitis deriving therefrom&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Post-operative radiotherapy is extremely important in this type of tumour&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">4&#44;21&#44;22</span></a> Therefore&#44; all patients were offered the option of proton beam adjuvant treatment &#40;those who chose this had to go to another country to get it&#44; as it is not yet available in Spain&#41;&#46; Given the current lack of a high level of evidence &#40;<span class="elsevierStyleSmallCaps">1</span>&#44; <span class="elsevierStyleSmallCaps">2</span>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> they were also offered the option of taking a wait-and-see approach or&#44; if they preferred radiotherapy but could not go to another country&#44; receiving conventional radiotherapy&#46; In the end&#44; 5 patients received proton beam therapy&#44; 6 elected not to receive adjuvant treatment and 3 opted to be treated with conventional radiotherapy&#46; Our rate of tumour progression was 21&#46;5&#37; of cases&#46; This was comparable to that found by Yoneoka et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> and higher than those reported by Dehdashti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> and Frank et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> It should be noted that the latter two series had a shorter follow-up time &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0210" class="elsevierStylePara elsevierViewall">The extended endonasal endoscopic approach by a team experienced in skull base diseases with a proper learning curve for this disease in particular is a good option for managing these lesions&#46; Intradural invasion could be associated with a higher risk of complications and greater clinical impairment on diagnosis&#44; as well as a lower rate of total resection&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2017-08-22"
    "fechaAceptado" => "2018-03-17"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Skull base"
            1 => "Endoscopic endonasal surgery"
            2 => "Clivus"
            3 => "Chordoma"
            4 => "Chondrosarcoma"
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      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:5 [
            0 => "Base de cr&#225;neo"
            1 => "Cirug&#237;a endonasal endosc&#243;pica"
            2 => "Clivus"
            3 => "Cordomas"
            4 => "Condrosarcomas"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To report our experience in the management of chordoma and chondrosarcoma with extended endoscopic endonasal surgery&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective analysis of a series of 14 patients with clival chordoma or chondrosarcoma who had extended endoscopic endonasal surgery from 2008 to 2016 performed by the same multidisciplinary team&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We had fourteen patients &#40;male&#47;female 2&#58;1&#41;&#44; with a mean age of 49 years for chordoma and 32 for chondrosarcoma&#46; The most common clinical presentation was diplopia in 78&#46;5&#37; of cases&#44; followed by dysphagia in 28&#46;6&#37;&#46; Histologically&#44; 71&#46;4&#37; were chordomas and 28&#46;6&#37; were chondrosarcomas&#46; In addition&#44; invasion of at least two-thirds or more of the clivus was found in 81&#37; of the cases&#59; in 57&#46;1&#37; there was intradural invasion&#44; and in 35&#46;7&#37; invasion of the sella turcica&#46; In 42&#46;8&#37; of cases&#44; the degree of resection was total and in 21&#46;5&#37; subtotal&#46; The most common complication was CSF fistula&#44; occurring in 28&#46;6&#37; of the cases&#44; with only one case requiring surgery to repair it&#46; Adjuvant treatment with Proton Beam was performed in 35&#46;7&#37; of cases and with conventional radiotherapy in 21&#46;5&#37;&#46; Mean follow-up was 53&#46;5 months and tumour recurrence or progression was found in 21&#46;5&#37; of the cases&#44; two of which had not received adjuvant treatment&#46; There were no deaths&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The extended endoscopic endonasal approach &#40;EEEA&#41; performed by an experienced team is a good alternative for the management of these lesions&#46; Intradural invasion may be related to an increased risk of complications and worse clinical presentation&#44; in addition to a lower rate of total resection&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Reportar la experiencia del manejo de los cordomas y condrosarcomas por abordaje endosc&#243;pico endonasal extendido&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis retrospectivo de una serie de 14 pacientes afectos de cordomas o condrosarcomas clivales operados mediante un abordaje endosc&#243;pico endonasal extendido por un mismo equipo multidisciplinar&#44; en el intervalo de tiempo desde 2008 hasta 2016&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Catorce pacientes &#40;hombre&#47;mujer 2&#58;1&#41; con una media de edad de 49<span class="elsevierStyleHsp" style=""></span>a&#241;os en los cordomas y de 32<span class="elsevierStyleHsp" style=""></span>a&#241;os en los condrosarcomas&#46; La presentaci&#243;n cl&#237;nica m&#225;s frecuente fue la diplop&#237;a &#40;78&#44;5&#37; de los casos&#41;&#44; seguida de la disfagia &#40;28&#44;6&#37;&#41;&#46; Histol&#243;gicamente se reportaron como cordomas el 71&#44;4&#37; y como condrosarcomas el 28&#44;6&#37;&#46; Adem&#225;s&#44; se encontr&#243; en el 81&#37; de los casos invasi&#243;n de al menos dos o m&#225;s tercios del clivus&#44; en el 57&#44;1&#37; invasi&#243;n intradural y en el 35&#44;7&#37; invasi&#243;n sellar&#46; En el 42&#44;8&#37; de los casos el grado de resecci&#243;n fue total y en el 21&#44;5&#37;&#44; subtotal&#46; La complicaci&#243;n m&#225;s frecuente fue la f&#237;stula de LCR&#44; que se present&#243; en el 28&#44;6&#37; de los casos&#44; habiendo que intervenir solo a un paciente&#46; En el 35&#44;7&#37; de los casos se indic&#243; tratamiento coadyuvante con <span class="elsevierStyleItalic">Proton Beam</span> y en el 21&#44;5&#37; radioterapia convencional&#46; La media de seguimiento fue de 53&#44;5<span class="elsevierStyleHsp" style=""></span>meses&#44; y se encontr&#243; recurrencia o progresi&#243;n tumoral en el 21&#44;5&#37; de los casos&#44; dos de los cuales no hab&#237;a recibido coadyuvancia&#46; No hubo fallecimientos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El abordaje endosc&#243;pico endonasal extendido&#44; realizado por un equipo experimentado&#44; es una buena alternativa de manejo para estas lesiones&#46; La invasi&#243;n intradural podr&#237;a estar relacionada con un mayor riesgo de complicaciones y una mayor afectaci&#243;n cl&#237;nica al diagn&#243;stico&#44; as&#237; como con una menor tasa de resecci&#243;n total&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Culebras D&#44; Torales J&#44; Reyes LA&#44; Zapata L&#44; Garc&#237;a S&#44; Rold&#225;n P&#46; Cirug&#237;a endosc&#243;pica endonasal extendida para cordomas y condrosarcomas de clivus&#58; nuestra experiencia en 14 casos&#46; Neurocirug&#237;a&#46; 2018&#59;29&#58;201&#8211;208&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pre- and post-treatment axial and sagittal slices of chordoma invading the dura mater&#44; sellar and parasellar regions&#44; cavernous sinus&#44; medial fossa&#44; and prepontine region&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pre- and post-treatment axial and sagittal slices of clival chordoma invading the lower third of the clivus and exhibiting posterior and lateral spread towards the cerebellopontine region&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AP&#58; anteroposterior&#59; CC&#58; craniocaudal&#59; LL&#58; latero-lateral&#59; F&#58; female&#59; PB&#58; proton beam&#59; M&#58; male&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age &#40;years&#41;&#47;sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Size &#40;AP<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>LL<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>CC mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Intradural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Intrasellar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">III&#44; hemiparesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>26<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>34<br>&#40;20&#46;3<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chondroid chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diplopia&#44; hemiparesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>33<br>&#40;23&#46;1<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chondroid chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">VI&#44; VII&#44; VIII&#44; dysphagia&#44; tumour bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>23<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>33<br>&#40;11&#46;0<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low-grade chondrosarcoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>13<br>&#40;1&#46;87<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low-grade chondrosarcoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diplopia&#44; dysphagia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>23<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>26<br>&#40;11&#46;9<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chondroid chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Subtotal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>26<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>24<br>&#40;12&#46;5<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conventional chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diplopia&#44; dysphagia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>22<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>21<br>&#40;7&#46;2<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low-grade chondrosarcoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>23<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>30<br>&#40;14&#46;5<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low-grade chondrosarcoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diplopia&#44; LE amaurosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>41<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>32<br>&#40;27&#46;6<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conventional chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LE amaurosis&#44; III&#44; V&#44; VII&#44; VIII&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>27<br>&#40;10&#46;5<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conventional chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Subtotal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>23<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>30<br>&#40;13&#46;5<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conventional chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">VI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20<br>&#40;3&#46;7<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conventional chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Subtotal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fistula&#47;meningitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dysphagia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>58<br>&#40;40&#46;4<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conventional chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Transient diplopia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hyposmia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>37<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>31<br>&#40;22&#46;9<span class="elsevierStyleHsp" style=""></span>cc&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Conventional chordoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors and year of publication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&#44; n &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Approach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Rate of complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Recurrences&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ense&#241;at et al&#46;&#44; 2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;2008&#8211;2016&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endonasal endoscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;5 &#40;2&#8211;112&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Koutourousiou et al&#46;&#44; 2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;2003&#8211;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endonasal endoscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;8 &#40;1&#8211;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#37; in total resection&#59; 60&#37; in all others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaz-Guimaraes et al&#46;&#44; 2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;2004&#8211;2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endonasal endoscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62&#46;9&#37; &#40;chondrosarcomas only&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#46;6 &#40;13&#8211;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Garzaro et al&#46;&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;2012&#8211;2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endonasal endoscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vellutini et al&#46;&#44; 2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;2000&#8211;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endonasal endoscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Matteo Soli et al&#46;&#44; 2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;1998&#8211;2015&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endonasal endoscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52 &#40;7&#8211;159&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yoneoka et al&#46;&#44; 2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;1982&#8211;2002&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EE and microsurgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">122 &#40;37&#8211;268&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gui et al&#46;&#44; 2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">161 &#40;2007&#8211;2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EE and microsurgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#46;4 &#40;8&#8211;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frank et al&#46;&#44; 2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;1998&#8211;2004&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Endonasal endoscopic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;15&#8211;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Al-Mefty et al&#46;&#44; 2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">109 &#40;1990&#8211;2006&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EE and microsurgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48 &#40;1&#8211;191&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dehdashti et al&#46;&#44; 2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;2005&#8211;2007&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EE and microsurgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;4&#8211;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Samii et al&#46;&#44; 2007<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49 &#40;1979&#8211;2002&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microsurgical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;5&#8211;134&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cordoma&#46; Sus variantes y diagn&#243;stico diferencial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "F&#46;J&#46; Mart&#237;nez Tello"
                            1 => "E&#46; Conde Gallego"
                            2 => "P&#46; Manj&#243;n Luengo"
                            3 => "J&#46;R&#46; Ricoy Campo"
                            4 => "A&#46; P&#233;rez Barrios"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
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                        "tituloSerie" => "Rev Esp Patol"
                        "fecha" => "2007"
                        "volumen" => "40"
                        "paginaInicial" => "135"
                        "paginaFinal" => "145"
                      ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chordoma and chondrosarcoma&#58; similar&#44; but quite different&#44; skull base tumors"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "K&#46; Almefty"
                            1 => "S&#46; Pravdenkova"
                            2 => "B&#46;O&#46; Colli"
                            3 => "O&#46; al-Mefty"
                            4 => "M&#46; Gokden"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/cncr.23073"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cancer"
                        "fecha" => "2007"
                        "volumen" => "110"
                        "paginaInicial" => "2457"
                        "paginaFinal" => "2467"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17894390"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0135"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skull base chordomas&#58; a management challenge"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "O&#46; Al-Mefty"
                            1 => "L&#46;A&#46; Borba"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/jns.1997.86.2.0182"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg"
                        "fecha" => "1997"
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        "identificador" => "xack353186"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0220" class="elsevierStylePara elsevierViewall">We would like to thank the Neurosurgery and Otorhinolaryngology department at Hospital Cl&#237;nic de Barcelona&#44; the Skull Base Surgery unit&#44; the Neuroscience Institute at Hospital Cl&#237;nic de Barcelona and the surgical teams who treated the patients&#46;</p>"
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Article information

ISSN: 25298496
Original language: English

DOI:10.1016/j.neucie.2018.03.001

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