Mayo Clinic Clival Chordoma Case Series: Impact of Endoscopic Training on Clinical Care

SIMPLE SUMMARY: Clival chordoma is a rare malignant tumor that commonly arises near the center of the brain. In 2013, multidisciplinary team was introduced in our facility to manage clival chordoma effectively. We analyzed its effect by comparing the outcomes of patients from “before 2013” (19 patients) and “after 2013” (39 patients). After 2013, the endoscopic endonasal approach was more commonly used (90%; “before 2013”, 32%) to achieve gross to near total resections (64%; “before 2013”, 16%) with less post-operative new cranial nerve deficits (3%; “before 2013”, 32%). Gross to near total resection was associated with less recurrence (hazard ratio, 0.31; 95% confidence interval, 0.11 to 0.91; p = 0.033). The multidisciplinary team led to improved tumor resection rate, less tumor recurrence rate, and less morbidity. ABSTRACT: The management of clival chordoma in our group shifted around 2013 to mostly endoscopic, and proton beam was introduced for our multidisciplinary team. Consecutive patients who had surgical resection from 1987 to 2021 were reviewed. A total of 58 patients (39 patients after 2013) were analyzed. The mean tumor size was 3.7 cm, and the most common location was the upper clivus (43%). Compared to before 2013, after 2013, the endoscopic endonasal approach was more common (90%, p < 0.001), and more gross or near total resections (64%, p = 0.002) were attained. Ten cases (17%) were revision surgeries referred from elsewhere, and three cases (5%) underwent additional surgery elsewhere before adjuvant radiation. The postoperative cerebrospinal fluid leak occurred in 7%. Post-operative new cranial nerve deficits occurred in 32% before 2013, compared to 2.6% after 2013 (p = 0.004). For cases before 2013, 10 patients (53%) recurred during the median follow-up of 144 months (mean, 142 months), whereas for cases after 2013, seven patients (18%) recurred with a median follow-up of 35 months (mean, 42 months). 5-year progression-free survival was 58%, and 5-year overall survival was 87%. A specialized multidisciplinary team improved the resection rate compared to a historical cohort with an excellent morbidity profile.