Machine learning prediction of venous thromboembolism after surgeries of major sellar region tumors.

PURPOSE: To describe and predict the risk of venous thromboembolism (VTE) after surgical resection of major sellar region tumors. METHOD: Patients with sellar region tumors were identified from a database. The outcome was VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE) within 60 days after surgery. We trained regression and machine learning models to predict the outcome using baseline characteristics, surgical findings and postoperative laboratory tests. RESULTS: Among 3818 patients included, 124 patients developed VTE after surgery. The total 60-day VTE incidence was 3.2 %, with incidence peak within ten days after the surgery. The risk increased in patients >65 years old (OR 2.96, p < 0.001), in patients with chordoma (OR 3.40, p = 0.006) or craniopharyngioma (OR 1.86, p = 0.036), in patients underwent craniotomy approach (OR 2.78, p = 0.017), in patients with high volume CSF leakage (OR 4.24, p < 0.001), and in patients with longer surgical duration (OR 1.78, p = 0.029). The linear discriminant analysis algorithm had the highest AUC (0.869, 95%CI, 0.840-0.898) in predicting the outcome. The specificity, accuracy, and sensitivity of the best model were 61.8 %, 93.6 %, and 92.8 %, respectively. Risk stratification using our best model suggested that 1.3 % and 24.5 % of the patient developed VTE in the low-risk group and in the high-risk group, respectively. We developed an online decision-support tool available on https://deepvep.shinyapps.io/VTEpred/. CONCLUSION: The overall incidence of VTE after surgical resection of major sellar region tumors was clinically significant, especially in older patients with chordoma or craniopharyngioma.

Late Radiation-Induced Carotid Artery Stenosis and Stroke in Pediatric Patient Treated With Proton Radiation Therapy for Skull-Base Chordoma.

Radiation vasculopathy is a well-recognized late complication of radiation therapy. We present a case of a stroke 29 years after high-dose proton radiation therapy for skull-base chordoma due to occlusion of bilateral internal carotid arteries.

Risk Factors for Postoperative Cerebrospinal Fluid Leak after Graded Multilayer Cranial Base Repair with Suturing via the Endoscopic Endonasal Approach.

This study analyzed risk factors for postoperative cerebrospinal fluid (CSF) leak after graded multilayer cranial base repair method with dural suturing. We performed surgery via the endoscopic endonasal approach (EEA) from 2012.6 to 2018.4, and those consecutive clinical data were prospectively accumulated and retrospectively analyzed. We tailored the repair method according to the intraoperative CSF leak grade. Among 388 surgeries via the EEA, there were 10 (2.6%) cases of postoperative CSF leak after graded repair with suturing. Postoperative CSF leak occurred in two of the 150 cases without intraoperative CSF leak (grade 0), one of the 104 cases with small (grade 1) intraoperative CSF leak, two of the 60 cases with moderate (grade 2) leak, and five of the 74 cases with large (grade 3) leak. Univariate analysis indicated that chordoma (P = 0.023), estimated tumor volume ≥ 7400 mm3 (P = 0.003), and maximum tumor diameter ≥ 32.5 mm (P = 0.001) were significant risk factors for postoperative CSF leak. Additionally, among cases with intraoperative grade 3 CSF leak, chordoma (P = 0.021), estimated tumor volume ≥ 23000 mm3 (P = 0.003), and maximum tumor diameter ≥ 45.5 mm (P = 0.001) were significant risk factors for postoperative CSF leak. Maximum tumor diameter, estimated tumor volume, and chordoma tumor pathology are related to a higher risk of postoperative CSF leak.

Immune Myocarditis Overlapping With Myasthenia Gravis Due to Anti-PD-1 Treatment for a Chordoma Patient: A Case Report and Literature Review.

Immunotherapy begins to be widely used due to the increasing exploration and gratifying effects in multiple cancers. Chordoma, as a rare bone malignant tumor, often recurs and metastasizes after undergoing surgery and radiotherapy. Therefore, immunotherapy can be explored as an emerging, potentially effective treatment to improve the survival rate and clinical benefit of patients. However, a variety of immune-related adverse events (irAEs) cannot be avoided completely. And the immunotherapy-induced myocarditis, as a rare but fatal irAE, has been increasingly reported. Understanding the mechanism involved in irAEs can inform best practices for side effects management. Here, we firstly reported a case of immune myocarditis and subsequent myasthenia gravis (MG) following anti-PD-1 treatment for chordoma.

Spontaneous CSF rhinorrhea as a presenting symptom of a clival chordoma.

CSF rhinorrhea is a rare presenting symptom of a clival chordoma as these tumors do not tend to show dural invasion as a histological feature. Here we discuss the case of a 61 years old female with spontaneous rhinorrhea secondary to a clival chordoma, and the value of some specific MRI sequences in accurate identification of a tumor with such atypical presentation, enabling the surgeon to plan accordingly.

Sellar Region Lesions and Intracranial Aneurysms in the Era of Endoscopic Endonasal Approach.

In the clinical practice of neurosurgery, the endoscopic endonasal approach (EEA) has been the mainstream approach in the management of sellar region diseases. However, clinicians have come to realize that EEA procedure is associated with intraoperative hemorrhage. Due to the limited surgical field and poor proximal control under endoscope, massive hemorrhage always leads to severe complication or even perioperative death. Previously, intraoperative hemorrhage used to be attributed to endoscopic intervention of cavernous sinus or internal carotid artery, but our recent understanding of EEA indicated that preoperatively complicated intracranial aneurysms (IAs) may play a role. In this article, we retrospectively reviewed the baseline characteristics, treatment strategy, pathology, intraoperative findings, as well as radiological profiles of sellar region lesions complicated with IAs. With the focus put on the high comorbidity rate of sellar region lesions and IAs, we did further statistical analysis to sketch the outline of this coexisting circumstance and to emphasize the importance of computed tomography angiography (CTA) as routine EEA preoperative examination. Thorough patient-surgeon communication should be proceeded before the formulation of an individualized treatment strategy.

Exophytic Lumbar Vertebral Body Mass in an Adult with Back Pain.

Chordomas are rare primary bone malignancies derived from notochord remnants. The tumors often are slow-growing and often present with indolent, nonspecific symptoms. Nevertheless, chordomas are locally aggressive and highly prone to local recurrence, necessitating precise planning before biopsy and/or surgical resection. Familiarity with the imaging features of chordomas is, therefore, essential. This case highlights the typical imaging and pathologic features of a spinal chordoma as well as the surgical approach and the patient's subsequent outcome.

Stent-Assisted Coil Embolization of a Basilar Artery Dissecting Aneurysm Involved in Skull Base Chordoma Before Endoscopic Transsphenoidal Transclival Resection.

BACKGROUND: Skull base chordomas will occasionally penetrate the clival dura mater and extend into the prepontine cistern, involving the basilar artery. Few reports have described cases of skull base chordoma accompanying a dissecting aneurysm of the basilar artery, and the treatment strategies have remained largely unknown. CASE DESCRIPTION: A 28-year-old man was referred to our hospital with a complaint of severe headache. A skull base chordoma involving a basilar artery dissecting aneurysm was diagnosed. We initially performed endovascular surgery for the dissecting aneurysm after dual antiplatelet therapy before surgical resection of the tumor, which was successfully achieved without complications. Follow-up angiography 3 months after endovascular surgery disclosed obliteration of the dissecting aneurysm. We then stopped the dual antiplatelet therapy, and performed judicious resection using an endoscopic transclival approach. The residual tumor was treated with radiosurgery. At the last follow-up examination, the patient was stable, and the tumor remained sufficiently controlled. CONCLUSIONS: We have reported a case of a dissecting aneurysm of the basilar artery with clival chordoma. Our findings suggest that chordoma with intradural vascular encasement has the potential to invade the vessel wall. To avoid rupture of those critical vascular structures, treatment strategies that minimize stress on the involved arteries and offer safe and sufficient surgical resection should be considered.

Salvage Free Tissue Transfer for Clival Osteoradionecrosis After Repeat Proton Beam Therapy.

BACKGROUND: Craniocervical junction chordoma treated with surgery and Proton Beam Therapy evolved with Osteonecrosis and CSF leak. As the vascularization of the head was compromised, we harvested an Anterolateral thigh musculofascial flap to seal the leak. CASE DESCRIPTION: A 56-year-old man presented with a history of chronic headaches and dysarthria with tongue deviation to the right. Magnetic resonance imaging showed a lesion at the craniocervical junction with imaging characteristics compatible with chordoma. Endoscopic endonasal resection was followed by proton beam therapy. Recurrence of the chordoma was subsequently resected via far lateral approach again followed by proton beam therapy accumulating a total dose of 75 Gy. Unfortunately, this led to osteoradionecrosis of the skull base resulting in a cerebrospinal fluid (CSF) leak more than 1 year after treatment. After multiple failed attempts to seal the defect using local vascularized tissue and free fat grafts, the defect was reconstructed with a vastus lateralis free tissue transfer. Six weeks later, the flap had mucosalized, the patient was pain free, and there was no evidence of a CSF leak. CONCLUSIONS: In select cases, vascularized free flaps offer a superior reconstruction for osteoradionecrosis because radiotherapy often compromises the blood supply of local tissues.

The timing of fusion surgery for clival chordoma with occipito-cervical joint instability: before or after tumor resection?

Clival chordoma with occipito-cervical (OC) joint invasion can result in preoperative and postoperative instability. The authors investigate the appropriate timing of OC fusion to prevent instability-, fusion-, and surgery time-related morbidity. Twenty-two consecutive patients underwent surgery for clival chordoma from December 2008 to September 2014. OC fusion was performed for patients with OC joint invasion and instability due to preoperative destruction of the occipital condyle or extensive postoperative condylectomy. The data in relation to OC joint instability, fusion, and surgery time were analyzed retrospectively and compared between OC fusion before and after tumor resection. Of the 22 patients, 8 with tumor invasion of the OC joint underwent OC fusion. OC fusion was performed after tumor resection in one-stage for four patients and before tumor resection in two-stage for four patients. There was OC joint instability from tumor destruction of the occipital condyle in seven patients (87.5%). Patients with OC fusion after tumor resection encountered complications such as surgery site wound dehiscence, encephalitis, and cardiac arrest with consequent mortality in one patient. These complications were avoided in subsequent patients where OC fusion was performed before tumor resection. There were no differences in the extent of tumor resection between OC fusion before and after tumor resection. Two-stage OC fusion before tumor resection can reduce instability-, fusion-, and surgery time-related morbidity and achieve feasible tumor resection when OC joint instability is expected. The extent of tumor invasion and brain stem compression should be considered when fusion precedes tumor resection.

Clivus Intraosseous Meningioma Mimicking Chordoma.

A 78-year-old woman with progressive worsening vertigo and new onset of diplopia. Neurological examination revealed bilateral abducens nerve paralysis and gait disturbance with truncal ataxia. Neuroimaging revealed a mass lesion within the clivus with brain stem compression. The patient was operated with provisional diagnosis of clivus chordoma by neuro-navigation-guided extended endoscopic endonasal approach. Subtotal resection of the tumor was achieved with no intra- or postoperative complications. Histopathologic examination revealed intraosseous meningioma (WHO grade I). To the authors' best knowledge this is the first case reporting clivus site of intraosseous meningioma.

A Rare Presentation of Axial Chordoma and the Approach to Management.

BACKGROUND Chordoma is a primary bone tumor that most commonly arises in the sacrococcygeal vertebrae and the spheno-occipital areas. Chordoma is a malignant tumor that should be distinguished from benign notochordal cell tumor (BNCT) of the spine. This report is of a rare case of axial chordoma and describes the challenging approach to diagnosis and management. CASE REPORT A 50-year-old woman presented with a one-year history of a slowly growing swelling in the sacral region. She complained of numbness and progressive weakness in both lower limbs, and urinary incontinence. Computed tomography (CT) imaging showed a large destructive lesion involving the sacrum and coccyx with cranial extension to level S2 and invasion of the right and left S2-S3 neural foramina, sacral nerves, left gluteus maximums muscle, and adjacent subcutaneous tissue. The management approach included the early involvement of a multidisciplinary clinical team. En bloc resection of the tumor through an anterior and posterior approach was performed, and the defect was reconstructed later using bilateral rotational gluteal fascial flaps. CONCLUSIONS Axial chordoma is a very rare, locally aggressive, and highly recurrent primary tumor of bone. The clinical management is challenging and requires early involvement of a multidisciplinary team. Following surgical resection, careful selection from limited available reconstructive surgical options is necessary to ensure that the surgical defect is repaired.

[A case of chordoma presenting as recurrent bacterial meningitis with cerebrospinal fluid leakage].

A 52-year-old man was admitted to our hospital because of two episodes of bacterial meningitis within a 6-month period. CSF examination showed neutrophilic pleocytosis with marked elevation of protein and hypoglycorrhachia, but the inflammatory reaction was mild and blood and CSF cultures were negative. At the time of the second admission, intermittent watery nasal discharge caused by CSF rhinorrhea was evident. CT and MR imaging revealed a tiny clival bone defect, and transnasal endoscopic repair was performed successfully. The pathological diagnosis was chordoma based on immunohistochemical staining for brachyury. Although chordoma presenting as recurrent bacterial meningitis occurs extremely rare, asking patients detailed questions about the CSF rhinorrhea must be essential for disclosing unclear infection sources.

Neuronavigation-guided Endoscopic Endonasal Excision of Schwannoma-like Chordoma of Meckel's Cave: A Case Report.

Chordomas are locally aggressive malignant tumors due to their recurrence potential and originate from embryonic notochord remnants. Chordomas can originate anywhere on the axial skeleton. They are extradural and spread by bone destruction. Chordomas are locally aggressive tumors that invade the dura mater, and may also present with secondary intradural growth. The Meckel's cave location of chordomas has been very rarely reported in the literature. Chordomas located in Meckel's cave can be radiologically confused with trigeminal schwannomas. Herein, we report a case of Meckel's cave chordoma that was successfully excised through neuronavigation-guided endoscopic endonasal excision, a technique commonly used in skull base surgeries.

Clinical and Histopathological Findings of Chordomas: a Case Report.

Chordomas are rare malignant tumors that develop from the residual of embryonic notochord. These tumors may be seen along the spine and have a local aggressive progression. Skull base chordomas often originate from the clivus as localization. These tumors are usually found to be overgrown when they are diagnosed. They are locally invasive and rarely develop distant metastasis. These chordomas cannot usually be completely removed due to their localization. Because these tumors are advanced at the time of diagnosis and are adjacent to important structures, they are among the tumors with high rates of mortality and morbidity. Surgery and/or radiotherapy is administered for the treatment.

The Sellar Tumor: Metastasis or Chordoma?

Chordomas are uncommon, locally invasive chordate tumors, which are mostly observed in the axial skeleton. Numerous papers have described similar patients around different anatomic locations; however, rare document previously reported that intracranial chordoma was associated with clear cell renal cell carcinoma (ccRCC). The authors report a 51-year-old male patient with a history of right radical nephrectomy for ccRCC presented to us with progressive blurred vision. Ophthalmic examination showed vision loss and visual field defects. Magnetic resonance imaging demonstrated pituitary tumor with hemorrhage, which was compressing the optic chiasm. He underwent a transnasal endoscope resection of the sellar mass. The immediate postoperative pathologic result was simply considered to be pituitary metastasis from ccRCC. After further immunohistochemical study, pathology diagnosis was made the necessary corrections to be the sellar chordoma. The authors summarize this exceptional patient and review the pertinent literature briefly.