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Vertebrobasilar artery encasement by skullbase chordoma: surgical outcome and management strategies
EANS Academy. Voormolen E. 09/26/19; 276118; EP04099
Eduard Voormolen
Eduard Voormolen

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Abstract
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Background: Vascular encasement by skullbase chordomas is recognised to increase surgical risk and hinder completeness of resection. However, the evidence behind this remains anecdotic. The objective of this study is to give a better portrayal of chordomas encasing vertebrobasilar arteries mainly in regard of surgical vascular risk and its impact on extend of resection (EOR).
Methods: We retrospectively reviewed all skullbase chordomas from our institution's chordoma database operated on between January 1992 and October 2018, selecting for analysis those that harboured encasement (≥180o encirclement) of at least one of the following vessels: intradural right or left vertebral artery and basilar artery. Data gathered involved pre and postoperative volumetric analysis of the tumor (including EOR), degree of encasement of each involved vessel, the occurrence of any complication and progression-free survival (PFS).
Results: 171 Patients were operated on for a skullbase chordoma during the study period. Of those, 35 were included in the study. 54% of patients were previously operated on for their chordoma. One patient (2.9%) suffered from an ischaemic stroke to the brainstem following surgery. Median EOR was 95.4%, with a 20% rate of gross total resection. Residual tumor was voluntary left in place 16% of the time on vertebrobasilar arteries, each time because of chordoma adherence to the vessels. Median PFS was 36.0 (+/- 12.6) months (VS 53 +/- 5.3 for all operated skullbase chordomas during the same period).
Conclusion: Skullbase chordomas encasing vertebrobasilar arteries are highly challenging tumors. Although injury to vascular structures is possible, most of the time the tumor's soft texture make safe resection from the vessels achievable. We advocate letting the tumor's adherence to vessels lead the resection, leaving a small piece of tumor behind if adherent to the vessels. Using this approach, satisfactory EOR can still be attained in a majority of cases.
Background: Vascular encasement by skullbase chordomas is recognised to increase surgical risk and hinder completeness of resection. However, the evidence behind this remains anecdotic. The objective of this study is to give a better portrayal of chordomas encasing vertebrobasilar arteries mainly in regard of surgical vascular risk and its impact on extend of resection (EOR).
Methods: We retrospectively reviewed all skullbase chordomas from our institution's chordoma database operated on between January 1992 and October 2018, selecting for analysis those that harboured encasement (≥180o encirclement) of at least one of the following vessels: intradural right or left vertebral artery and basilar artery. Data gathered involved pre and postoperative volumetric analysis of the tumor (including EOR), degree of encasement of each involved vessel, the occurrence of any complication and progression-free survival (PFS).
Results: 171 Patients were operated on for a skullbase chordoma during the study period. Of those, 35 were included in the study. 54% of patients were previously operated on for their chordoma. One patient (2.9%) suffered from an ischaemic stroke to the brainstem following surgery. Median EOR was 95.4%, with a 20% rate of gross total resection. Residual tumor was voluntary left in place 16% of the time on vertebrobasilar arteries, each time because of chordoma adherence to the vessels. Median PFS was 36.0 (+/- 12.6) months (VS 53 +/- 5.3 for all operated skullbase chordomas during the same period).
Conclusion: Skullbase chordomas encasing vertebrobasilar arteries are highly challenging tumors. Although injury to vascular structures is possible, most of the time the tumor's soft texture make safe resection from the vessels achievable. We advocate letting the tumor's adherence to vessels lead the resection, leaving a small piece of tumor behind if adherent to the vessels. Using this approach, satisfactory EOR can still be attained in a majority of cases.
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