Departments of1Neurosurgery and.
Departments of2Neurosurgery and.
J Neurosurg. 2018 May;128(5):1454-1462. doi: 10.3171/2016.12.JNS161920. Epub 2017 Jun 2.
OBJECTIVE The endoscopic endonasal approach for treating primary skull base malignancies involving the clivus is a formidable task. The authors hypothesized that tumor involvement of nearby critical anatomical structures creates hurdles to endoscopic gross-total resection (GTR). The aim of this study was to retrospectively review the clinical outcomes of patients who underwent an endoscopic endonasal approach to treat primary malignancies involving the clivus and to analyze prognostic factors for GTR. METHODS Between January 2009 and November 2015, 42 patients underwent the endoscopic endonasal approach for resection of primary skull base malignancies involving the clivus at 2 independent institutions. Clinical data; tumor locations within the clivus; and anatomical involvement of the cavernous or paraclival internal carotid artery, cisternal trigeminal nerve, hypoglossal canal, and dura mater were investigated to assess the extent of resection. Possible prognostic factors affecting GTR were also analyzed. RESULTS Of the 42 patients, 37 were diagnosed with chordomas and 5 were diagnosed with chondrosarcomas. The mean (± SD) preoperative tumor volume was 25.2 ± 30.5 cm (range 0.8-166.7 cm). GTR was achieved in 28 patients (66.7%) and subtotal resection in 14 patients (33.3%). All tumors were classified as upper (n = 17), middle (n = 17), or lower (n = 8) clival tumors based on clival involvement, and as central (24 [57.1%]) or paramedian (18 [42.9%]) based on laterality of the tumor. Univariate analysis identified the tumor laterality (OR 6.25, 95% CI 1.51-25.86; p = 0.011) as significantly predictive of GTR. In addition, the laterality of the tumor was found to be a statistically significant predictor in multivariate analysis (OR 41.16, 95% CI 1.12-1512.65; p = 0.043). CONCLUSIONS An endoscopic endonasal approach can provide favorable clinical and surgical outcomes. However, the tumor laterality should be considered as a potential obstacle to total removal.
经鼻内镜治疗累及斜坡的原发性颅底恶性肿瘤是一项艰巨的任务。作者假设肿瘤累及附近的关键解剖结构会给内镜下大体全切除（GTR）带来障碍。本研究旨在回顾性分析 2 家独立机构采用经鼻内镜治疗累及斜坡的原发性恶性肿瘤患者的临床结果，并分析 GTR 的预后因素。
2009 年 1 月至 2015 年 11 月，在 2 家独立机构，42 例患者采用经鼻内镜治疗累及斜坡的原发性颅底恶性肿瘤。调查临床资料、斜坡内肿瘤位置、海绵窦或斜坡旁颈内动脉、颅神经Ⅴ、Ⅵ、Ⅶ、Ⅷ、舌下神经管和硬脑膜的解剖学受累情况，以评估切除范围。还分析了可能影响 GTR 的预后因素。
42 例患者中，37 例诊断为脊索瘤，5 例诊断为软骨肉瘤。术前平均（±SD）肿瘤体积为 25.2±30.5cm³（范围 0.8-166.7cm³）。28 例患者（66.7%）达到 GTR，14 例患者（33.3%）行次全切除术。所有肿瘤根据斜坡受累程度分为上斜坡（n=17）、中斜坡（n=17）或下斜坡（n=8）肿瘤，根据肿瘤的侧别分为中央肿瘤（24 例[57.1%]）或旁正中肿瘤（18 例[42.9%]）。单因素分析发现肿瘤侧别（OR 6.25，95%CI 1.51-25.86；p=0.011）是 GTR 的显著预测因素。此外，肿瘤侧别在多因素分析中也是一个有统计学意义的预测因素（OR 41.16，95%CI 1.12-1512.65；p=0.043）。
经鼻内镜入路可获得良好的临床和手术效果。然而，肿瘤侧别应被视为完全切除的潜在障碍。
