The evolution towards minimally invasive surgery in craniopharyngiomas and skull base chordomas

INTRODUCTION: Surgery of craniopharyngiomas and skull base chordomas represents a challenge even for experienced surgeons. Although a safe strategy of treatment does not exist, many options can be considered to manage this baffling problem. The aim of this study is to describe the evolution from traditional open surgery to the application of the endoscopic endonasal technique and compare the different surgical approaches establishing the validity of each procedure, in order to propose a valid and safe treatment algorithm. METHODS: A retrospective analysis was conducted on 130 patients aged between 3 and 84 years who underwent surgical procedures for craniopharyngioma in the decade 1993-2013 and 16 patients aged between 13 and 85 years affected by skull base chordomas who underwent surgical treatment at the Besta Neurological Institute in the last four years (2010-2014). The plan of treatment and the surgical procedure used for each patient, were object of critical essay. RESULTS: Overall, 170 surgical procedures were performed for primitive and recurrent craniopharyngiomas on 130 patients. The pterional approach was used in 104 cases, followed by four hands-four eyes endoscopic endonasal in 23 cases, inter-hemipheric trans-lamina terminalis in 19, stereotactic local interferon administration and endoscopic procedures for intracystic fluid drainage in 17 and others approaches in 7. In the skull base chordoma group, 10 patients underwent an endoscopic endonasal approach to the skull base. The other patients were treated as follows: 5 fully microscopic approach (2 facial degloving, 2 far lateral approaches and 1 transpetrous) and one transnasal microscopic endoscopic-assisted approach. CONCLUSIONS: Although the period of the study showed the strong presence of the open microsurgery approaches, the selective analysis of the last four years showed a dramatic change of the surgical options in support of as less invasive as efficacious ones. The use of traditional approaches, still indicated in few cases, is constantly decreasing in recent years. A “maximal safe resection” followed by adjuvant therapies should guarantee a good compromise between survival and quality of life with lower mortality and morbidity for craniopharyngioma and skull base chordoma patients.