Cavallo Luigi Maria, Mazzatenta Diego, d'Avella Elena, Catapano Domenico, Fontanella Marco Maria, Locatelli Davide, Luglietto Davide, Milani Davide, Solari Domenico, Vindigni Marco, Zenga Francesco, Zona Gianluigi, Cappabianca Paolo
1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples.
2Department of Biomedical and Neuromotor Sciences, University of Bologna, IRCCS Institute of Neurological Sciences of Bologna, "Bellaria" Hospital, Bologna.
J Neurosurg. 2020 Sep 4;135(1):93-102. doi: 10.3171/2020.5.JNS20925. Print 2021 Jul 1.
In the last 2 decades, the endoscopic endonasal approach in the treatment of clival chordomas has evolved to be a viable strategy to achieve maximal safe resection of this tumor. Here, the authors present a multicentric national study, intending to analyze the evolution of this approach over a 20-year time frame and its contribution in the treatment of clival chordomas.
Clival chordoma cases surgically treated between 1999 and 2018 at 10 Italian neurosurgical departments were included in this retrospective study. Clinical, radiological, and surgical findings, adjuvant therapy, and outcomes were evaluated and compared according to classification in the treatment eras from 1999 to 2008 and from 2009 to 2018.
One hundred eighty-two surgical procedures were reviewed, with an increase in case load since 2009. The endoscopic endonasal transclival approach (EETA) was performed in 151 of 182 cases (83.0%) and other approaches were performed in 31 cases (17%). There was an increment in the use of EETA, neuronavigation, and Doppler ultrasound after 2008. The overall postoperative complication rate was 14.3% (26 of 182 cases) consisting of 9 CSF leaks (4.9%), 7 intracranial hemorrhages (3.8%), 5 cases of meningitis (2.7%), and 5 cerebral ischemic injuries (2.7%). Gross-total resection (GTR) was achieved in 93 of 182 cases (51.1%). Extent of resection (EOR) improved in the second era of the study. Signs and/or symptoms at presentation worsened in 27 cases (14.8%), and the Katz Index worsened in 10 cases (5.5%). Previous treatment, dural involvement, EETA, and intraoperative Doppler ultrasound correlated with GTR. Patients received adjuvant proton beam radiation in 115 of 182 cases (63.2%), which was administered more in the latter era. Five-year progression-free survival (PFS) and overall survival (OS) were 62.3% and 73.5%, respectively. GTR, EETA, proton beam therapy, and the chondroid subtype correlated with a better survival rate. The mean follow-up was 62 months.
Through multicentric data collection, this study encompasses the largest series in the literature of clival chordomas surgically treated through an EETA. An increase in the use of this approach was found among Italian neurosurgical departments together with an improved extent of resection over time. The satisfactory rate of GTR was marked by low surgical morbidity and the preservation of patient quality of life. Surgical outcome was reinforced, in terms of PFS and OS, by the use of proton beam therapy, which was increasingly performed along the period of study.
在过去20年中，经鼻内镜入路治疗斜坡脊索瘤已发展成为一种可行的策略，能够最大程度安全地切除该肿瘤。在此，作者开展了一项全国多中心研究，旨在分析该入路在20年时间框架内的发展演变及其在斜坡脊索瘤治疗中的作用。
本回顾性研究纳入了1999年至2018年期间在意大利10个神经外科科室接受手术治疗的斜坡脊索瘤病例。根据1999年至2008年以及2009年至2018年治疗时期的分类，对临床、放射学和手术结果、辅助治疗及预后进行评估和比较。
共回顾了182例手术病例，自2009年起病例数量有所增加。182例中有151例（83.0%）采用了经鼻内镜经斜坡入路（EETA），31例（17%）采用了其他入路。2008年后，EETA、神经导航和多普勒超声的使用有所增加。术后总体并发症发生率为14.3%（182例中的26例），包括9例脑脊液漏（4.9%）、7例颅内出血（3.8%）、5例脑膜炎（2.7%）和5例脑缺血性损伤（2.7%）。182例中有93例（51.1%）实现了全切除（GTR）。在研究的第二个时期，切除范围（EOR）有所改善。27例（14.8%）患者就诊时的体征和/或症状加重，10例（5.5%）患者的Katz指数恶化。既往治疗、硬脑膜受累情况、EETA及术中多普勒超声与GTR相关。182例中有115例（63.2%）患者接受了辅助质子束放疗，在后一个时期应用更多。5年无进展生存期（PFS）和总生存期（OS）分别为62.3%和73.5%。GTR、EETA、质子束治疗及软骨样亚型与更好的生存率相关。平均随访时间为62个月。
通过多中心数据收集，本研究涵盖了文献中经EETA手术治疗斜坡脊索瘤的最大病例系列。意大利神经外科科室对该入路的使用有所增加，且随着时间推移切除范围有所改善。GTR的满意率表现为手术发病率低且患者生活质量得以保留。在研究期间，质子束治疗的使用越来越多，从PFS和OS方面强化了手术效果。
