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The use of minimally invasive transcranial ports for the resection of deep-seated lesions has been shown to be safe and effective. To date, most of the literature regarding the tubular retractors used in brain surgery is comprised of individual case reports that describe the successful resection of deep-seated lesions such as thalamic pilocytic astrocytomas, colloid cysts in the third ventricle, hematomas, and cavernous angiomas. The authors describe their experience using a tubular retractor system with three different cases involving large intraventricular meningiomas and examine radiographic and patient outcomes. A single-institution, retrospective case series was performed from a skull base database. Patients who underwent resection of intraventricular > 4-cm meningiomas with port technology were identified. The authors reviewed three cases to illustrate the feasibility of minimal access port surgery for the resection of these lesions. Complete resection was achieved in all cases. None of the patients developed permanent neurological deficits. There were no major complications related to surgery and no mortalities. Good clinical and surgical outcomes for atrium meningiomas can be achieved through the minimally invasive port technique and tumor size does not appear to be a limitation.

Background The use of combined positron emission tomography/computed tomography for staging in patients with cancer and the widespread use of magnetic resonance imaging has led to increased detection of incidental sellar masses. The imaging findings can be suggestive of a benign pituitary tumor, but metastasis can never be completely ruled out with noninvasive work-up. Appropriate diagnosis of sellar masses is critical, as the treatment paradigm might change in the presence of a pituitary metastasis. Definitive tissue diagnosis might prevent unnecessary radiotherapy to the skull base or the need for systemic treatment when benign pituitary disease is confirmed. Methods A retrospective chart review from 2010 to 2015 of all patients with recently diagnosed cancer and undergoing surgery for sellar region masses was performed. Results There were 9 patients (3 female and 6 male) identified. Lung cancer was the primary condition in 4 patients; the remaining 5 patients had breast cancer, follicular thyroid cancer, cutaneous melanoma, colorectal carcinoma, and renal cell carcinoma. On final pathology, the sellar mass was a benign pituitary adenoma in 5 patients, metastatic cancer in 3 patients, and a granular cell tumor in 1 patient. Conclusions Surgical resection of a sellar mass in patients with known cancer helps in the definitive diagnosis, relieves compressive symptoms, and avoids unnecessary empiric radiotherapy in cases of confirmed benign pituitary disease.

Objectives The purpose of this study is to demonstrate the potential contribution of positron emission tomography (PET)/computed tomography (CT) to help differentiate olfactory neuroblastoma (ONB) from sinonasal undifferentiated carcinoma (SNUC). Methods Following approval by the institutional review board at the Wexner Medical Center at the Ohio State University, Columbus, Ohio, a pilot study with retrospective review of patients with biopsy-proven diagnosis of ONB s and SNUC s was conducted. Staging PET/CT scans were reviewed to document the maximum standardized uptake value (SUVmax). A statistical comparison of SUVmax was performed. Results We identified 13 patients (7 with ONBs and 6 with SNUCs) with mean age 60.2 years who had undergone staging F-18 fluorodeoxyglucose (18F-FDG) PET/CT of the primary tumor at the time of their diagnosis. Mean SUVmax was found to be five-fold higher in SNUC patients (35.63, range 10.8–77.9) than in ONB patients (7.24, range 4.6–10.7) (P ≤ 0.00169). Conclusion Maximum standardized uptake value of 18F-FDG PET/CT can be used to initially discriminate between ONB and SNUC. This finding may prove helpful to guide diagnostic and treatment planning when the histopathologic diagnosis is inconclusive. Level of Evidence 4. Laryngoscope, 2016

Introduction Malignancies of the clivus and petroclival region are mainly chordomas and chondrosarcomas. Although a spectrum of malignancies may present in this area, a finite group of commonly encountered malignant pathologies will be the focus of this review, as they are recognized to be formidable pathologies due to adjacent critical neurovascular structures and challenging surgical approaches. Objectives The objective is to review the literature regarding medical and surgical management of malignant tumors of the clival and petroclival region with a focus on clinical presentation, diagnostic identification, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to the skull base. Data Synthesis A literature review was conducted, searching for basic science and clinical evidence from PubMed, Medline, and the Cochrane Database. The selection criteria encompassed original articles including data from both basic science and clinical literature, case series, case reports, and review articles on the etiology, diagnosis, treatment, and management of skull base malignancies in the clival and petroclival region. Conclusions The management of petroclival malignancies requires a multidisciplinary team to deliver the most complete surgical resection, with minimal morbidity, followed by appropriate adjuvant therapy. We advocate the combination of endoscopic and open approaches (traditional or minimally invasive) as required by the particular tumor followed by radiation therapy to optimize oncologic outcomes.

Recent technological advances and growing cooperation between otorhinolaryngologists and neurosurgeons, coupled with an increasing knowledge of the anatomy of the ventral skull base, have led to the development of a series of surgical approaches to this region. Utilizing the nasal corridor, these expanded endonasal approaches (EEAs) benefit from the increased luminosity and definition provided by the endoscope to navigate through this corridor and reach a multitude o pathologies, both neoplastic and degenerative in nature. One of their common uses is to address tumors that arise from or invade the anterior cranial fossa; these lesions may include olfactory groove meningiomas, esthesioneuroblastomas and sinonasal malignancies. In order to safely resect these tumors through EEAs the surgical team must adhere to a series of steps, while planning the procedure as well as carrying it out. In this review article, the authors present these steps and describe the main patient selection criteria and complication avoidance strategies related to expanded endonasal approaches to the anterior skull base.

Purpose of review Clival chordomas are rare malignant tumors associated with a poor prognosis. In this article, we review the current literature to identify a variety of strategies that provide guidelines toward the optimal management for this aggressive tumor. Recent findings Molecular disease, particularly, the development of characterized chordoma cell lines, has become one of the new cornerstones for the histological diagnosis of chordomas and for the development of effective chemotherapeutic agents against this tumor. Brachyury, a transcription factor in notochord development, seems to provide an excellent diagnostic marker for chordoma and may also prove to be a valuable target for chordoma therapy. Aggressive cytoreductive surgery aiming for gross total resection with maintenance of key neurovascular structures, followed by proton beam or hadron radiation, provides the best local recurrence and overall survival rates. Summary Clival chordomas are locally aggressive tumors that are challenging to treat because of their unique biology, proximity to key neurovascular structures and poor prognosis. Currently, chordomas are optimally managed with aggressive surgery, whilst preserving key structures, and postoperative radiation in a multidisciplinary setting with an experienced team. The advancement of molecular techniques offers exciting future diagnostic and therapeutic options in the management of chordomas.

Introduction: The frequency of lymphoma involving the central nervous system has been increasing over the last few decades, even among immunocompetent patients. Radiographically, lymphoma has been known to mimic different disease processes. Therefore, surgeons of the head and neck usually include this disease when formulating a differential diagnosis. We describe multiple cases of intracranial lymphoma that were initially consistent with other types of tumors and their surgical management as done via an endoscopic endonasal approach (EEA). Case Reports: Case #1: 69-year-old female presented with a several month history of headache and an associated 2 week history of double vision. An MRI of her brain showed a clival tumor with associated mass effect onto the cavernous sinuses bilaterally; the lesion was consistent with a chordoma. Via an EEA, a successful debulking of her cavernous sinus was achieved after her frozen section result showed evidence of lymphoma. Her final pathology was found to be diffuse large B cell lymphoma. Case #2: 57-year-old male presented with a history of headache and diplopia. A brain MRI was ordered that showed a heterogeneously enhancing clivus that appeared abnormally expanded. There was also extraosseous enhancement into the cavernous sinuses and superior orbital fissures bilaterally, the sella, as well as Meckel's cave on the left. He proceeded with an EEA and his superior orbital fissures were decompressed successfully. Final pathology was consistent with diffuse large B cell lymphoma. Case #3: 76-year-old male presented with a history of recent epistaxis. An MRI of his orbits was obtained which showed a mostly homogenously enhancing mass involving the left nasal cavity and bilateral ethmoid air cells. There was extension of this mass into the left sphenoid sinus and left orbit with associated enhancement of the skull base involving the cribiform plate and planum sphenoidale. He presented for an EEA to resect the mass. Frozen section was consistent with esthesioneuroblastoma. However, final pathology proved to be large B cell lymphoma. Case #4: 58-year-old male presented with a one-month history of deteriorating left eye function. He had an MRI of his brain completed which showed a large, heterogeneously enhancing lesion of his sella with invasion into the bilateral cavernous sinuses, greater on the left than the right. The most likely diagnosis given to the lesion based on imaging was a pituitary macroadenoma. He had an EEA done and frozen section corroborated this diagnosis. During the procedure, the left cavernous sinus and the superior orbital fissures were decompressed. Final histologic analysis revealed diffuse B cell lymphoma. Conclusion: Lymphoma should always be included in the differential when considering tumors that invade and expand normal osseous components and dural compartments of the intracranial space. Because patients with expansile skull base lesions typically have cranial nerve involvement, decompressing foramen or bone passages through which these nerve pass is an important goal during surgery to regain function. In our opinion, often biopsy alone is not sufficient to manage these patients' disease process.

Pituitary adenomas are the most common sellar pathology. They can be classified according to size (micro vs. macroadenomas) and according to endocrine function (active vs. inactive). Indications for surgical removal include macroadenomas causing compression of neighboring structures and endocrine-active adenomas that cause detrimental systemic effects, as seen in acromegaly and Cushing’s disease. The majority of pituitary tumors can be safely and effectively removed through an endonasal, transsphenoidal route. Historically, this procedure has been performed under microscopic visualization; however, the recent emergence and evolution of endoscopic techniques have gained acceptance among skull base surgeons managing these lesions. The endoscope may be used as the sole source of visualization or as an adjunct in the microscopic approach. Its increased luminosity and angled profile grants the surgeon the possibility of visualization of lateral and posterior components of the sellar compartment, a feature particularly useful in macroadenomas invading the cavernous sinuses. In this chapter we describe the surgical technique, indications and complication avoidance strategies of the microscopic, endoscope-assisted transsphenoidal removal of pituitary adenomas.

Background: olfactory groove meningiomas can grow insidiously and significantly compress the adjacent cerebral structures. One of the main challenges in their surgical management is achieving complete removal without further damage to the frontal lobes. Objective: The purpose of this study is to analyze and describe cerebral edema and FLAIR signal changes in MR imaging of olfactory groove meningiomas totally resected through EEA. Methods: Pre- and postoperative films of 20 consecutive olfactory groove meningiomas completely removed through EEA were reviewed. Tumor volume as well as pre- and postoperative FLAIR signal change volumes, was assessed using the DICOM image viewer OsiriX. Results: Mean tumor volume was 26.2 cm3 (±22.7), mean preoperative FLAIR change volume was 39.1 cm3 (±44.9), and mean postoperative FLAIR change volume was 4.2 cm3 (±5.9). In1 of the 20 cases analyzed (5%) there was increase of signal changes postoperatively, all other patients demonstrated image improvement. Conclusions: EEA appears to be a safe and effective method for total removal of olfactory groove meningiomas. FLAIR signal changes tend to resolve after tumor resection and do not seem to worsen with this operative technique. Further comparative studies are necessary to determine whether this feature differs from open approaches.

Craniopharyngiomas are dysembriogenetic, benign tumors responsible for a variety of aspects with unpredictable biological behavior, whose surgical management still represents a challenging matter in neurosurgery. Their treatment classically required different transcranial approaches, whereas the transsphenoidal route was reserved for pure intrasellar-infradiaphragmatic, preferably cystic lesions and/or patients already presenting with panhypopituitarism. Recently, with the progressive use of endoscopes in endonasal surgery, the interest for extended transsphenoidal approaches has been renewed. The expanded endoscopic endonasal transtuberculum and transplanum approaches have been proposed as alternative surgical route for removal of different types of suprasellar tumors including solid craniopharyngiomas, in patients with normal pituitary function and small sella. We present a detailed report of the technique we use for the endoscopic endonasal approach for the resection of primary and recurrent craniopharyngiomas, providing hints and anatomical keypoints throughout each step of the procedure for different types of these tumors, referring to our classification based on the infundibulum. The expanded endoscopic endonasal approach (EEA) for suprasellar craniopharyngiomas is a valid surgical option for the management of these lesions. It provides a wide and multi-angled, close-up view, of the surgical field allowing a safe dissection and removal of the tumor without any brain and/or optic apparatus retraction, even with a normal sized sella. On one hand, the EEA requires a thorough knowledge of ventral skull base anatomy, on the other it definitely facilitates intraoperative understanding of tumor inner features such as growth pattern, adhesion and invasion in regards to the surrounding vital structures.

Skull base lesions that involve the middle and posterior cerebral fossae have been historically managed through extensive transcranial approaches. The development of endoscopic endonasal techniques during the past decade has made possible a vast array of alternative routes to the ventral skull base, providing the ability to expose lesions in difficult-to-access regions of the cranial base in a less invasive manner. In this review, the authors detail the endoscopic surgical anatomy and the operative nuances of the expanded endoscopic endonasal approaches to tumors of the middle and posterior cranial fossae. These techniques offer excellent exposure of the targeted regions yielding optimal resections, while avoiding the morbidity associated with transcranial surgical approaches.