Iatrogenic seeding of skull base chordoma following endoscopic endonasal surgery

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OBJECTIVE

Iatrogenic tumor seeding after open surgery for chordoma has been well described in the literature. The incidence and particularities related to endoscopic endonasal surgery (EES) have not been defined.

METHODS

The authors retrospectively reviewed their experience with EES for clival chordoma, focusing on cases with iatrogenic seeding. The clinical, radiographic, pathological, and molecular characterization data were reviewed.

RESULTS

Among 173 EESs performed for clival chordomas at the authors’ institution between April 2003 and May 2016, 2 cases complicated by iatrogenic seeding (incidence 1.15%) were identified. The first case was a 10-year-old boy, who presented 21 months after an EES for a multiply recurrent clival chordoma with a recurrence along the left inferior turbinate, distinct from a right petrous apex recurrence. Both appeared as a T2-hypertintense, T1-isointense, and heterogeneously enhancing lesion on MRI. Resection of the inferior turbinate recurrence and debulking of the petrous recurrence were both performed via a purely endoscopic endonasal approach. Unfortunately, the child died 2 years later due progression of disease at the primary site, but with no sign of progression at the seeded site. The second patient was a 79-year-old man with an MRI-incompatible pacemaker who presented 19 months after EES for his clival chordoma with a mass involving the floor of the left nasal cavity that was causing an oro-antral fistula. On CT imaging, this appeared as a homogeneously contrast-enhancing mass eroding the hard palate inferiorly, the nasal septum superiorly, and the nasal process of the maxilla, with extension into the subcutaneous tissue. This was also treated endoscopically (combined transnasal-transoral approach) with resection of the mass, and repair of the fistula by using a palatal and left lateral wall rotational flap. Adjuvant hypofractionated stereotactic CyberKnife radiotherapy was administered using 35 Gy in 5 fractions. No recurrence was appreciated endoscopically or on imaging at the patient’s last follow-up, 12 months after this last procedure. In both cases, pathological investigation of the original tumors revealed a fairly aggressive biology with 1p36 deletions, and high Ki-67 levels (10%–15%, and > 20%, respectively). The procedures were performed by a team of right-handed surgeons (otolaryngology and neurosurgery), using a 4-handed technique (in which the endoscope and suction are typically passed through the right nostril, and other instruments are passed through the left nostril without visualization).

CONCLUSIONS

Although uncommon, iatrogenic seeding occurs during EES for clival chordomas, probably because of decreased visualization during tumor removal combined with mucosal trauma and exposure of subepithelial elements (either inadvertently or because of mucosal flaps). In addition, tumors with more aggressive biology (1p36 deletions, elevated Ki-67, or both) are probably at a higher risk and require increased vigilance on surveillance imaging and endoscopy. Further prospective studies are warranted to evaluate the authors’ proposed strategies for decreasing the incidence of iatrogenic seeding after EES for chordomas.

ABBREVIATIONS EES = endoscopic endonasal surgery.
Article Information

Contributor Notes

Correspondence Georgios A. Zenonos, Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop St., Ste. B400, Pittsburgh, PA 15213. email: zenonosg@upmc.edu.INCLUDE WHEN CITING Published online December 22, 2017; DOI: 10.3171/2017.6.JNS17111.

Drs. Fernandes Cabral and Zenonos contributed equally to this study.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Abbas AKLichtman AHPillai S: Cellular and Molecular Immunology. Philadelphia: Elsevier2014

  • 2

    Al-Tameemi MChaplain Md’Onofrio A: Evasion of tumours from the control of the immune system: consequences of brief encounters. Biol Direct 7:312012

  • 3

    Arnautović KIAl-Mefty O: Surgical seeding of chordomas. J Neurosurg 95:7988032001

  • 4

    Barloon TJYuh WTSato YSickels WJ: Frontal lobe implantation of craniopharyngioma by repeated needle aspirations. AJNR Am J Neuroradiol 9:4064071988

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Chibbaro SCornelius JFFroelich STigan LKehrli PDebry C: Endoscopic endonasal approach in the management of skull base chordomas—clinical experience on a large series, technique, outcome, and pitfalls. Neurosurg Rev 37:2172252014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Cole GW JrSindelar WF: Iatrogenic transplantation of osteosarcoma. South Med J 88:4854881995

  • 7

    Curran AJSmyth DKane BToner MTimon CI: Exfoliated malignant cells in glove and instrument washings following head and neck surgery. Clin Otolaryngol Allied Sci 21:2812831996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Di Maio SRostomily RSekhar LN: Current surgical outcomes for cranial base chordomas: cohort study of 95 patients. Neurosurgery 70:135513602012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Fischbein NJKaplan MJHolliday RADillon WP: Recurrence of clival chordoma along the surgical pathway. AJNR Am J Neuroradiol 21:5785832000

  • 10

    Hines JPAshmead MGStringer SP: Clival chordoma of the nasal septum secondary to surgical pathway seeding. Am J Otolaryngol 35:4314342014

  • 11

    Iloreta AMNyquist GGFriedel MFarrell CRosen MREvans JJ: Surgical pathway seeding of clivo-cervical chordomas. J Neurol Surg Rep 75:e246e2502014

    • Search Google Scholar
    • Export Citation
  • 12

    Kindt TJGoldsby RAOsborne BA: Kuby Immunology. New York: W. H. Freeman2007

  • 13

    Koutourousiou MGardner PATormenti MJHenry SLStefko STKassam AB: Endoscopic endonasal approach for resection of cranial base chordomas: outcomes and learning curve. Neurosurgery 71:6146252012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Paolucci VSchaeff BSchneider MGutt C: Tumor seeding following laparoscopy: international survey. World J Surg 23:9899971999

  • 15

    Salisbury JR: [Embryology and pathology of the human notochord.] Ann Pathol 21:4794882001 (Fr)

  • 16

    Salisbury JR: The pathology of the human notochord. J Pathol 171:2532551993

  • 17

    Sen CTriana AIBerglind NGodbold JShrivastava RK: Clival chordomas: clinical management, results, and complications in 71 patients. J Neurosurg 113:105910712010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Töpfer KKempe SMüller NSchmitz MBachmann MCartellieri M: Tumor evasion from T cell surveillance. J Biomed Biotechnol 2011:9184712011

    • Search Google Scholar
    • Export Citation
  • 19

    Walcott BPNahed BVMohyeldin ACoumans JVKahle KTFerreira MJ: Chordoma: current concepts, management, and future directions. Lancet Oncol 13:e69e762012

    • Search Google Scholar
    • Export Citation
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