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Gupta RK, Reddy TA, Gupta A, Samant R, Perez CA, Haque A. An Ecchordosis Physaliphora, a Rare Entity, Involving the Central Nervous System: A Systematic Review of the Literature. Neurol Int 2023; 15:1200-1211. [PMID: 37873832 PMCID: PMC10594460 DOI: 10.3390/neurolint15040075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/25/2023] Open
Abstract
Ecchordosis physaliphora (EP) is a benign notochordal remnant, which is often an incidental finding; however, it can rarely present with neurological symptoms. We performed a systematic review of the literature for cases of symptomatic EP published in PubMed, Web of Science and Embase from January 1982 to May 2023. This is the largest review to date and revealed 60 cases including ours. Headache (55%) and CSF rhinorrhea (32%) were the most frequent clinical manifestations. The majority of symptomatic EP lesions were located in the prepontine region (77%) and required surgical resection (75%). EP should be considered in patients with neurologic symptoms in the setting of prepontine or posterior sphenoid sinus lesions. While symptomatic patients often require surgical intervention, rare cases may respond to oral corticosteroids.
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Affiliation(s)
- Rajesh K. Gupta
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center, Houston, TX 77030, USA
| | - Thejasvi A. Reddy
- McGovern Medical School, UT Health Science Center, Houston, TX 77030, USA (A.H.)
| | - Ashutosh Gupta
- McGovern Medical School, UT Health Science Center, Houston, TX 77030, USA (A.H.)
| | - Rohan Samant
- Department of Radiology, UT Health Science Center, Houston, TX 77030, USA;
| | - Carlos A. Perez
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Anam Haque
- McGovern Medical School, UT Health Science Center, Houston, TX 77030, USA (A.H.)
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Stuebe CM, Rindler RS, Laack N, Carr CM, Choby G, Inwards CY, Van Gompel JJ. Evaluation of Long-Term Follow-Up in Ecchordosis Physaliphora versus Chordoma. World Neurosurg 2023; 174:157-168. [PMID: 36898627 DOI: 10.1016/j.wneu.2023.03.016] [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: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Ecchordosis physaliphora (EP) is a non-neoplastic notochord remnant with limited literature. We present a review on surgically resected clival EP to evaluate if available follow-up is adequate to distinguish EP from chordomas. METHODS A systematic literature review was completed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Case reports or series of adults with histopathologic and radiographic findings of surgically resected EP were included. Articles including pediatric patients, systematic reviews, chordomas, and without microscopic or radiographic confirmation, or the surgical approach, were excluded. Corresponding authors were contacted twice to further evaluate outcomes. RESULTS Eighteen articles were included (n = 25 patients; mean age 47.5 years ± 12.6 [standard deviation] months). All patients had symptomatic, surgically resected EP, with cerebrospinal fluid leak or rhinorrhea the most common symptom (48%). All but 3 had gross total resection, with endoscopic endonasal transsphenoidal transclival the most common approach (80%). All but 3 reported immunohistochemistry findings, with physaliphorous cells the most common. All but 5 patients had definitive follow-up (80%), with average of 19.5 ± 17.2 months. One corresponding author reported longer-term follow-up for 1 patient (57 months). No recurrence or malignant transformation was reported. Mean time to clival chordoma recurrence (53.9 ± 26.8 months) was also evaluated in a review of 8 studies. CONCLUSIONS Mean follow-up for resected EP was almost 3 times shorter than mean time to recurrence of chordomas. Available literature is likely inadequate to confirm the suspected benign nature of EP especially in reference to chordoma, precluding treatment and follow-up recommendations.
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Affiliation(s)
- Caren M Stuebe
- Department of Neurosurgery, Texas A&M School of Medicine, Bryan, Texas, USA
| | - Rima S Rindler
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nadia Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie M Carr
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Garret Choby
- Department of Otolaryngology (ENT)/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie Y Inwards
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Hasegawa H, Van Gompel JJ, Choby G, Raghunathan A, Little JT, Atkinson JL. Unrecognized notochordal lesions as a likely cause of idiopathic clival cerebrospinal fluid leaks. Clin Neurol Neurosurg 2022; 224:107562. [PMID: 36549221 DOI: 10.1016/j.clineuro.2022.107562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine an association between idiopathic transclival cerebrospinal fluid (CSF) leak and notochordal lesions. METHODS This study consisted of the illustrations of institutional patients who underwent surgery for transclival CSF leak between January 1, 2009 and April 25, 2020 and comprehensive review of the existing literature conducted on April 25, 2020. The cases were classified based on the presumed etiologies that were originally proposed in the articles ("idiopathic" vs. "secondary"). The baseline characteristics were compared between the groups, and the surgical outcomes were summarized. RESULTS In 3 institutional cases, ecchordosis physaliphora (EP) was confirmed at the fistula either pathologically (1) or radiologically (2). Among 42 literature cases, 28 were recognized as idiopathic, while 14 were secondary cases with histologically (n = 12) or radiologically (n = 2) confirmed notochordal lesion at the fistula. Thus, any notochordal lesions were histologically confirmed in 13 among a total of 45 cases (28.9%). Fourteen of the idiopathic cases had undescribed radiographic signs suggestive of small ecchordosis physaliphora at the fistula. Both idiopathic and secondary cases demonstrated resemblance in their ages (mean, 51.4 and 56.6 years; p = 0.102), female predominance (male, 36% vs. 25%; P = 0.521), no association with obesity (7% vs. 18%; P = 0.350) or increased intracranial pressure (7% vs. 6%; P = 1.000). All the fistulas were in the midline or paramidline clivus within several millimeters below the dorsum sellae. All the patients were treated surgically with a multilayer closure, resulting in a success rate of 93% with one surgery. CONCLUSION Our analyses suggest the association of transclival CSF leak and notochord lesions. A prospective study is needed for definitive conclusion.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, the University of Tokyo Hospital, Tokyo, Japan
| | | | - Garret Choby
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA
| | - Aditya Raghunathan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jason T Little
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John L Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 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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Veiceschi P, Arosio AD, Agosti E, Bignami M, Pistochini A, Cerati M, Castelnuovo P, Locatelli D. Symptomatic ecchordosis physaliphora of the upper clivus: an exceedingly rare entity. Acta Neurochir (Wien) 2021; 163:2475-2486. [PMID: 33900480 DOI: 10.1007/s00701-021-04857-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This paper highlights the management of 5 patients affected by symptomatic ecchordosis physaliphora (EP), treated via endoscopic endonasal transsphenoidal-transclival approach and contextual multilayer skull base reconstruction. A detailed analysis of each case is provided, along with the review of the current body of literature. METHODS A retrospective review of patients treated by means of endoscopic endonasal approach for EP from 2010 to 2020 in the Otolaryngology and Neurosurgery Departments of a tertiary-care referral center for endoscopic skull base surgery was analyzed. Only adult patients with a definitive histopathological and immunohistochemical diagnosis of EP were included in the study. A systematic literature review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed for EP. RESULTS Five cases of EP were retrieved and included in the study. Four patients presented with CSF leakage: in two cases after minor head trauma, in one case with associated bacterial meningitis, and in one case as only referred symptom. One patient complained diplopia due to VI cranial nerve palsy. No complications or recurrences of the disease were observed after a median follow-up of 37.2 months (range, 18-72 months). A total of 27 studies were identified with the systematic literature review, encompassing 30 patients affected by symptomatic EP who were addressed to surgical treatment. Twenty-five patients underwent complete surgical removal of the EP, while in 5 cases, only subtotal resection was performed. CONCLUSIONS EP might result in a "locus minoris resistentiae" of the skull base, predisposing, in rare cases, to CSF leakage and meningitis, spontaneously or after minor trauma. In cases of symptomatic EP, endoscopic endonasal transsphenoidal-transclival approach represents a safe and effective technique for both EP resection and contextual skull base reconstruction.
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Affiliation(s)
- Pierlorenzo Veiceschi
- Scuola di Specializzazione in Neurochirurgia, Università di Pavia, Pavia, Italy.,Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Alberto Daniele Arosio
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.
| | - Maurizio Bignami
- Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy.,Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Como, Italy
| | - Andrea Pistochini
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy
| | - Michele Cerati
- Department of Surgical Pathology, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy
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Sun R, Ajam Y, Campbell G, Masel T. A Rare Case of Ecchordosis Physaliphora Presenting With Headache, Abducens Nerve Palsy, and Intracranial Hypertension. Cureus 2020; 12:e8843. [PMID: 32754387 PMCID: PMC7386083 DOI: 10.7759/cureus.8843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
We report a rare case of ecchordosis physaliphora presenting with headache, nausea, and diplopia. On neurological examination, the patient was found to have left abducens nerve palsy. CT of the head without contrast was unremarkable. Brain MRI demonstrated a non-enhancing retroclival mass with a mass effect upon the ventral pons. The mass had increased signal intensity on T2 and decreased signal intensity on T1-weighted sequences. Lumbar puncture revealed an opening pressure of 37 cm H2O. The patient underwent an endoscopic endonasal approach for retroclival mass resection three weeks later. The tissue analysis of the mass was consistent with ecchordosis physaliphora. This could have been misdiagnosed as idiopathic intracranial hypertension had the MRI of the brain not been performed.
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Affiliation(s)
- Ruiqing Sun
- Neurology, University of Texas Medical Branch, Galveston, USA
| | - Yousaf Ajam
- Neurology, University of Texas Medical Branch, Galveston, USA
| | - Gerald Campbell
- Pathology, University of Texas Medical Branch, Galveston, USA
| | - Todd Masel
- Neurology, University of Texas Medical Branch, Galveston, USA
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Abstract
BACKGROUND Ecchordosis physaliphora is a congenital, benign lesion originating from notochordal remnants along the craniospinal axis, most frequently located at the level of the clivus and sacrum. Sometimes ecchordosis physaliphora is difficult to recognise and treat, with a total of twenty-six cases described in the literature. METHODS This study reports on three cases of previously undiagnosed ecchordosis physaliphora presenting with cerebrospinal fluid rhinorrhoea and meningitis. CONCLUSION Endoscopic transclival or transsphenoid surgery including three-layer (fat, fascia and nasoseptal flap) reconstruction was used in all cases with complete resolution of the symptoms.
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Usher I, Flanagan AM, Choi D. Systematic Review of Clinical, Radiologic, and Histologic Features of Benign Notochordal Cell Tumors: Implications for Patient Management. World Neurosurg 2019; 130:13-23. [PMID: 31421435 DOI: 10.1016/j.wneu.2019.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are no absolute defining criteria for benign notochordal cell tumors; the diagnosis is usually based on small size and the absence of aggressive features. Therefore, by definition, the diagnosis is subjective and usually determined by multidisciplinary consensus. A benign notochordal cell tumor should not grow during surveillance, and this may be used to confirm the diagnosis, but is a tautologic definition. Diagnostic ambiguity leads to uncertainty in management. If a tumor is a small chordoma then early surgery is likely to provide a better outcome. However, unnecessary treatment of a benign tumor may incur unjustified risk. OBJECTIVE To propose clearer guidelines for the definition and management of benign notochordal tumors. METHODS We performed a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) review of the reported definitions for benign notochordal tumors and their management. RESULTS The accepted features of benign notochordal tumors vary considerably: a typical tumor may be diagnosed in the absence of neurology, radiologically well-corticated bony margins, size <35 mm, no enhancement with contrast, no soft tissue extension, no dural penetration, no progression on scans, histologic absence of extracellular myxoid matrix, and low Ki67 index. If these criteria are fulfilled, it is reasonable to use radiologic surveillance in the first instance. Biopsy may be offered depending on the relative risks of performing the biopsy, or if there are atypical features. CONCLUSIONS We suggest a clearer definition for a benign notochordal tumor and a management algorithm that incorporates a level of diagnostic uncertainty.
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Affiliation(s)
- Inga Usher
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London.
| | - Adrienne M Flanagan
- Department of Histopathology, The Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - David Choi
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London
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