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Bosman EM, Keizer ME, van Aalst J, Broen MP, Postma AA, Vernemmen AI, Kunst HP, Temel Y. Spontaneous Shrinking and Growing Skull Base Chordoma. J Neurol Surg Rep 2025; 86:e107-e111. [PMID: 40352577 PMCID: PMC12064314 DOI: 10.1055/a-2587-6573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2025] [Accepted: 04/09/2025] [Indexed: 05/14/2025] Open
Abstract
Background Chordomas are rare slow-growing tumors occurring in the axial skeleton and can demonstrate local aggressive behavior, typically extending from the median axis, compressing surrounding tissue. Complete surgical resection and adjuvant radiotherapy are the preferred treatments. We present an unusual case of a spontaneously shrinking and growing off-midline petroclival chordoma. Case Description A 23-year-old woman presented with right abducens nerve palsy. Computed tomography and magnetic resonance imaging (MRI) revealed an off-midline petroclival lesion compressing the abducens nerve with characteristics of a chondrosarcoma. Preoperative MRI indicated spontaneous lesion regression, and the abducens nerve showed clinical improvement. Hence, the planned surgery was canceled. During the wait-and-scan period, abducens nerve palsy recurred. MRI confirmed lesion growth and showed an intratumoral linear structure indicative of blood. Even though preoperative MRI again demonstrated shrinkage, the lesion was surgically removed. Despite the unusual presentation, histopathological examination diagnosed a conventional chordoma. A second surgery was required to remove the residual tumor, after which the patient received high-dose photon beam therapy. Conclusion This article discusses the uncommon presentation and behavior of a petroclival chordoma, showing fluctuating cycles of off-midline growth and spontaneous regression. While intratumoral hemorrhage is hypothesized to explain this tumor behavior, the exact etiology needs further investigation. The case presented here emphasizes the importance of considering chordoma in the differential diagnosis despite an atypical disease course.
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Affiliation(s)
- Esmée M. Bosman
- Department of Neurosurgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+ and Radboud University Medical Center, Maastricht and Nijmegen, The Netherlands
| | - Max E. Keizer
- Department of Neurosurgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+ and Radboud University Medical Center, Maastricht and Nijmegen, The Netherlands
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Jasper van Aalst
- Department of Neurosurgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+ and Radboud University Medical Center, Maastricht and Nijmegen, The Netherlands
| | - Martinus P.G. Broen
- Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+ and Radboud University Medical Center, Maastricht and Nijmegen, The Netherlands
- Department of Neurology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Alida A. Postma
- Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+ and Radboud University Medical Center, Maastricht and Nijmegen, The Netherlands
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
- Department of Radiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Astrid I.P. Vernemmen
- Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+ and Radboud University Medical Center, Maastricht and Nijmegen, The Netherlands
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Henricus P.M. Kunst
- Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+ and Radboud University Medical Center, Maastricht and Nijmegen, The Netherlands
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
- Department of Otorhinolaryngology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Otorhinolaryngology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center+ and Radboud University Medical Center, Maastricht and Nijmegen, The Netherlands
- School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
- Istanbul Atlas University, Faculty of Medicine, Istanbul, Türkiye
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Stamenović J, Živadinović B, Đurić V. Case report: Unilateral paralysis of the hypoglossal nerve as the only clinical sign of clivus meningioma - a case report and literature review. Front Oncol 2024; 14:1337680. [PMID: 38327744 PMCID: PMC10847574 DOI: 10.3389/fonc.2024.1337680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction Clivus meningiomas are benign tumors that occur at the skull base in the posterior cranial fossa. Symptoms usually progress several months or years before diagnosis and may include: headache, vertigo, hearing impairment, ataxia with gait disturbances, sensory problems. In the neurological findings, paralysis of the lower cranial nerves is most often seen, which in the later course can be accompanied by cerebellar and pyramidal signs until the development of a consciousness impairment. Case presentation We presented the case of a patient who at the time of diagnosis had only unilateral hypoglossal nerve paralysis with dysarthria and mild dysphagia. After the neurosurgical procedure, pathohistological analysis confirmed meningothelial meningioma. Conclusion Early recognition of clivus tumors, which include meningiomas, is necessary in order to implement an adequate therapeutic procedure and prevent further deterioration of the patient's condition.
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Affiliation(s)
- Jelena Stamenović
- Faculty of Medicine, University of Niš, Niš, Serbia
- Neurology Clinic, University Clinical Center Niš, Niš, Serbia
| | - Biljana Živadinović
- Faculty of Medicine, University of Niš, Niš, Serbia
- Neurology Clinic, University Clinical Center Niš, Niš, Serbia
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Li B, Kim MG, Dominguez JF, Feldstein E, Kleinman G, Al-Mufti F, Kim M, Hanft S. Intrasellar hemorrhagic chordoma masquerading as pituitary apoplexy: case report and review of the literature. Br J Neurosurg 2023; 37:1685-1688. [PMID: 34148480 DOI: 10.1080/02688697.2021.1941761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND IMPORTANCE Chordomas are centrally located, expansile soft tissue neoplasms that arise from the remnants of the embryological notochord. Hemorrhagic presentation is exceedingly rare and can resemble pituitary apoplexy. Moreover, a purely intrasellar location of a chordoma is extremely uncommon. We report a case of a hemorrhagic intrasellar chordoma in an adult male, which presented similarly to pituitary apoplexy and was resolved with surgical resection. CLINICAL PRESENTATION A 69-year-old male presented with a 4 week history of acute onset headache and concurrent diplopia, with significantly reduced testosterone and slightly reduced cortisol. His left eye demonstrated a sixth cranial nerve palsy. Magnetic resonance imaging of the brain showed a large hemorrhagic mass in the pituitary region with significant compression of the left cavernous sinus and superior displacement of the pituitary gland. The patient underwent an endoscopic endonasal transsphenoidal approach for the resection of the lesion. Near total resection was achieved. Final pathology revealed chordoma with evidence of intratumoral hemorrhage, further confirmed by immunopositive stain for brachyury. Post-operatively, the patient had improved diplopia and was discharged home on low dose hydrocortisone. At 3-month follow-up, his diplopia was resolved and new MRI showed stable small residual disease. CONCLUSIONS Apoplectic chordomas are uncommon given chordoma's characteristic lack of intralesional vascularity and represent a diagnostic challenge in the sellar region. Our unique case demonstrates that despite our initial impression of pituitary apoplexy, this was ultimately a case of apoplectic chordoma that responded well to endoscopic endonasal surgery.
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Affiliation(s)
- Boyi Li
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Michael G Kim
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Eric Feldstein
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - George Kleinman
- Department of Pathology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Matthew Kim
- Department of Otolaryngology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Sooltangos A, Bodi I, Ghimire P, Barkas K, Al-Barazi S, Thomas N, Maratos EC. Do All Notochordal Lesions Require Proton Beam Radiotherapy? A Proposed Reclassification of Ecchordosis Physaliphora as Benign Notochord Cell Tumor. Skull Base Surg 2022; 83:e96-e104. [DOI: 10.1055/s-0040-1722717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 11/27/2020] [Indexed: 10/21/2022]
Abstract
Abstract
Objectives Ecchordosis physaliphora (EP) is a benign notochord lesion of the clivus arising from the same cell line as chordoma, its malignant counterpart. Although usually asymptomatic, it can cause spontaneous cerebrospinal fluid (CSF) rhinorrhea. Benign notochordal cell tumor (BNCT) is considered another indolent, benign variant of chordoma. Although aggressive forms of chordoma require maximal safe resection followed by proton beam radiotherapy, BNCT and EP can be managed with close imaging surveillance without resection or radiotherapy. However, while BNCT and EP can be distinguished from more aggressive forms of chordoma, differentiating the two is challenging as they are radiologically and histopathologically identical. This case series aims to characterize the clinicopathological features of EP and to propose classifying EP and BNCT together for the purposes of clinical management.
Design Case series.
Setting Tertiary referral center, United Kingdom.
Participants Patients with suspected EP from 2015 to 2019.
Main Outcome Measures Diagnosis of EP.
Results Seven patients with radiological suspicion of EP were identified. Five presented with CSF rhinorrhea and two were asymptomatic. Magnetic resonance imaging features consistently showed T1-hypointense, T2-hyperintense nonenhancing lesions. Diagnosis was made on biopsy for patients requiring repair and radiologically where no surgery was indicated. The histological features of EP included physaliphorous cells of notochordal origin (positive epithelial membrane antigen, S100, CD10, and/or MNF116) without mitotic activity.
Conclusion EP is indistinguishable from BNCT. Both demonstrate markers of notochord cell lines without malignant features. Their management is also identical. We therefore propose grouping EP with BNCT. Close imaging surveillance is required for both as progression to chordoma remains an unquantified risk.
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Affiliation(s)
| | - Istvan Bodi
- Department of Neuropathology, King's College Hospital, London, United Kingdom
| | - Prajwal Ghimire
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | | | - Sinan Al-Barazi
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Eleni C. Maratos
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
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Uysal E, Cohen MA, Abou-Al-Shaar H, Palmer C, Couldwell W. Hemorrhagic Skull Base Chordoma Presenting As Chordoma Apoplexy. Cureus 2021; 13:e19187. [PMID: 34873527 PMCID: PMC8635681 DOI: 10.7759/cureus.19187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
Intratumoral hemorrhage/apoplexy in clival chordomas is extremely uncommon, with only 16 reported cases. The average age of patients was 46.2 years and slightly more than half were men. In cases published before 1990, all patients died from their disease without any intervention. Since then, 11 patients have undergone resection by a variety of approaches and there have been no deaths. The diagnosis of skull base chordomas relies on a combination of clinical presentation and radiographic features related to the location and invasion of the tumor. Chordomas presenting with sudden-onset symptoms should alarm the surgeon of a possible hemorrhage. As an illustration of this presentation, we describe a 58-year-old woman who presented with acute-onset headache and cranial nerve deficits. Computed tomography and magnetic resonance imaging demonstrated a hemorrhagic clival lesion with cavernous sinus extension. The patient underwent transsphenoidal resection of the lesion that resulted in the resolution of her symptoms. Histopathological evaluation of the lesion was consistent with chordoma with acute hemorrhagic components. Although intratumoral hemorrhage is rarely detected in chordomas, it should be considered a differential diagnosis of such lesions because prompt recognition and treatment are critical for patient survival.
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Affiliation(s)
- Ece Uysal
- Neurosurgery, University of Utah, Salt Lake City, USA
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