J Neurosurg 76:878-879, 1992
Transnasal stereotactic biopsy of a clivus tumor Technical note JEFFREY V. ROSENFELD, F.R.C.S.(ED), F.R.A.C.S., DAVID WALLACE,F.R.C.S., F.R.A.C.S., GEOFFREY L. KLUG, F.R.A.C.S., AND ANDREW DANKS, F.R.A.C.S.
Department of Neurosurgery. Royal Children's Hospital, Parkvi!le, Victoria, Australia v, Computerized tomography-guided transnasal stereotactic tissue diagnosis of a lyric lesion in the clivus was performed successfullyusing the Cosman-Roberts-WeUsframe, thus avoiding a major craniotomy. The authors recommend stereotaxis as the preferred technique for biopsy in this region. KEY W O R D S
'
skull-base surgery
PEN skull-base surgery for tumors of the clivus region is complex and prolonged, and carries significant risk of morbidity.l'891J Computerized tomography (CT)-guided transnasal stereotaxis provides an accurate and safe alternative approach to this region when tissue diagnosis alone is required. We describe the technique and present the first case of a transnasal stereotactic biopsy of a clivus lesion reported in the literature.
O
Case Report
This 12-year-old boy presented with a 4-week history of diplopia on right lateral gaze. Examination. On examination, the patient had a complete fight abducens nerve palsy but was otherwise neurologically normal. A CT scan showed a round 1.5cm l~ic lesion in the right side of the clivus at and below the level of the sphenoid sinus (Fig. 1). The lesion was breaching the posterior cortex of the bone and was associated with a small extradural prepontine mass. Operation. The patient was placed under general anesthesia and a repeat CT scan was obtained with a Cosman-Roberts-Wells frame* attached to the skull. The base ring of the frame was applied as low as possible on the skull, with the anterior fixation pins in the supraorbital ridges (Fig. 2). The lower section of the lesion was just within the range of the CT. After the target was checked on a phantom frame, the arc of the frame was attached to the base ring and a trajectory was chosen through the fight nostril. The nasal cavity was prepared with a cocaine (2%) and Betadine (povi* Cosman-Roberts-Wells frame manufactured by Radionics, Inc., Burlington, Massachusetts.
878
9 stereotaxis
9 eosinophilic granuloma
done-iodine) solution. The trajectory of the twist drill passed directly through the posterior nasopharyngeal wall into the right clivus and the lesion. The distance from the anterior wall of the clivus to the lesion was measured to be 1.38 cm on the CT scan, which aided us in determining the depth of drilling required. The lesion was soft and easily entered with a cupped biopsy forceps, and multiple specimens were retrieved. The nasal cavity was then packed with Vaseline-impregnated gauze, which was removed after 24 hours without problem. There was no morbidity from the procedure. Pathological Examination. Pathological examination of the operative specimens showed a lesion composed of a moderate number of histiocytic cells with large ovoid nuclei, some of which exhibited nuclear grooving and abundant eosinophilic cytoplasm. There was a large number of eosinophils; fewer plasma cells and lymphocytes were also seen. The appearance indi-
FI(;. 1. Computerized tomography scan showing a lytic lesion in the right side of the clivus (arrow).
J. Neurosurg. / Volume 76/May, 1992
Transnasal stereotactic biopsy of a citrus tumor
FIG. 2. Operative photograph (h!/i) and schematic diagram (right) showing the Cosman-Roberts-WeUs flame in position, v,.ith the anterior fi,~ation pins of the base ring attached to the supraorbital ridges of the skull and the probe passing through the right nostril to the target lesion in the right clivus. cared histiocytosis X. Staging revealed the lesion to be solitary. Postoperative Course. The patient was managed conservatively and his diplopia had virtually resolved by 1 month after the biopsy. Discussion
The avoidance of major open skull-base surgery is desirable if tissue diagnosis alone is required. Free-hand transfacial needle biopsy of an extracerebral middle fossa mass under fluoroscopic guidance has been described j~ but is not accurate enough for a small clival lesion. Alternatively, CT-guided stereotactic techniques provide a high degree of accuracy with minimal operative trauma to selected extracerebral sites. Stereotactic surgical approaches described in the literature include a transorbital stereotactic approach to the orbital apex for retrobulbar anesthesia,~2 transnasal stereotactic approaches to the pituitary gland, 4 transfacial stereotactic approaches to the trigeminal ganglion, 3~ and a transoral stereotactic approach to a metastatic lesion of the C-2 vertebral archf An arc-centered stereotactic system such as the Cosman-Roberts-Wells frame is suitable for transnasal approaches because of the flexibility of trajectory available to the operator. It is critical that the base ring of the frame is set as low as possible. The fixation pins are placed in the supraorbital ridges for an approach to the upper clivus through or immediately below the sphenoid sinus, as in our case. However, if the target is in the mid- to lower clivus, it would be necessary to apply the anterior pins to the zygomatic bones in order to achieve a low transnasal or transoral trajectory using the Cosman-Roberts-Wells frame. Biopsy followed by adjuvant therapy may be applicable to some of the clival or paraclival lesions encountered. With the increasing use of stereotactic radiosurgery 6 or brachytherapy 2 to the skull base, an effective means of obtaining a stereotactic biopsy in this region will be advantageous and may avoid major open surgery. Transnasal stereotactic biopsy of selected clival tumors could also be used to make a histological diagnosis so that careful planning of the operative ap-
J. Neurosurg. / Volume 76/May, 1992
proach can be undertaken. The dura is not breached using this technique, thus preventing the risk of seeding tumor cells intracranially from the procedure. In conclusion, we recommend this technique for tissue diagnosis of clival lesions. Acknowledgment
We thank Frances De Niese for typing the manuscript. References
1. Al-Mefty O, Fox JL, Smith RR: Petrosal approach for petroclival meningiomas. Neurosurgery 22:510-517, 1988 2. Gutin PH, Leibel SA, Hosobuchi Y, et at: Brachytherapy of recurrent tumors of the skull base and spine with Iodine-125 sources. Neurosurgery 20:938-945, 1987 3. Kandel El: Functional and Stereotactic Neurosurgery. New York: Plenum Press, 1989, pp 419-423 4. Ibid., pp 492-500 5. Laitinen LV: Trigeminus stereoguide: an instrument for stereotactic approach through the foramen ovate and foramen jugulare. Surg Neurol 22:519-523, 1984 6. LunsfordLD, FlickingerJ, CoffeyRJ: Stereotacticgamma knife radiosurgery: initial North American experience in 207 patients. Arch Nenro147:169-175, 1990 7. Patil AA: Transoral stereotactic biopsy of the second cervical vertebral body: case report with technical note. Nenrosurgery 25:999-1002, 1989 8. Samii M, Ammirati M, Mahran A, et ah Surgery of petroclival meningiomas: report of 24 cases. Nenrosnrgary 24:12-17, 1989 9. Sen CN, Sekhar LN, Schramm VL, et al: Chordoma and chondrosarcoma of the cranial base: an 8-year experience. Neurosurgery 25:931-941, 1989 10. Stechison MT, Bemstein M: Percutaneous transfaeial needle biopsy of a middle cranial fossa mass: case report and technical note. Neurosurgery 25:996-999, 1989 11. Uttley D, Moore A, Archer DJ: Surgical management of midline skull-base tumors: a new approach. J Neurosurg 71:705-710, 1989 12. Vogl G, Schimek F, Ozdoba C, et at: Stereotactic retrobulbar anesthesia using CT. J Comput Assist Tomogr 14: 859-861, 1990 Manuscript received August 6, 1991. Address reprint requests to: Jeffrey V. Rosenfeld, F.R.C.S. (Ed)., F.R.A.C.S., Department of Neurosurgery, Royal Children's Hospital, Parkville, Victoria 3052, Australia. 879
Transnasal stereotactic biopsy of a clivus tumor Technical note JEFFREY V. ROSENFELD, F.R.C.S.(ED), F.R.A.C.S., DAVID WALLACE,F.R.C.S., F.R.A.C.S., GEOFFREY L. KLUG, F.R.A.C.S., AND ANDREW DANKS, F.R.A.C.S.
Department of Neurosurgery. Royal Children's Hospital, Parkvi!le, Victoria, Australia v, Computerized tomography-guided transnasal stereotactic tissue diagnosis of a lyric lesion in the clivus was performed successfullyusing the Cosman-Roberts-WeUsframe, thus avoiding a major craniotomy. The authors recommend stereotaxis as the preferred technique for biopsy in this region. KEY W O R D S
'
skull-base surgery
PEN skull-base surgery for tumors of the clivus region is complex and prolonged, and carries significant risk of morbidity.l'891J Computerized tomography (CT)-guided transnasal stereotaxis provides an accurate and safe alternative approach to this region when tissue diagnosis alone is required. We describe the technique and present the first case of a transnasal stereotactic biopsy of a clivus lesion reported in the literature.
O
Case Report
This 12-year-old boy presented with a 4-week history of diplopia on right lateral gaze. Examination. On examination, the patient had a complete fight abducens nerve palsy but was otherwise neurologically normal. A CT scan showed a round 1.5cm l~ic lesion in the right side of the clivus at and below the level of the sphenoid sinus (Fig. 1). The lesion was breaching the posterior cortex of the bone and was associated with a small extradural prepontine mass. Operation. The patient was placed under general anesthesia and a repeat CT scan was obtained with a Cosman-Roberts-Wells frame* attached to the skull. The base ring of the frame was applied as low as possible on the skull, with the anterior fixation pins in the supraorbital ridges (Fig. 2). The lower section of the lesion was just within the range of the CT. After the target was checked on a phantom frame, the arc of the frame was attached to the base ring and a trajectory was chosen through the fight nostril. The nasal cavity was prepared with a cocaine (2%) and Betadine (povi* Cosman-Roberts-Wells frame manufactured by Radionics, Inc., Burlington, Massachusetts.
878
9 stereotaxis
9 eosinophilic granuloma
done-iodine) solution. The trajectory of the twist drill passed directly through the posterior nasopharyngeal wall into the right clivus and the lesion. The distance from the anterior wall of the clivus to the lesion was measured to be 1.38 cm on the CT scan, which aided us in determining the depth of drilling required. The lesion was soft and easily entered with a cupped biopsy forceps, and multiple specimens were retrieved. The nasal cavity was then packed with Vaseline-impregnated gauze, which was removed after 24 hours without problem. There was no morbidity from the procedure. Pathological Examination. Pathological examination of the operative specimens showed a lesion composed of a moderate number of histiocytic cells with large ovoid nuclei, some of which exhibited nuclear grooving and abundant eosinophilic cytoplasm. There was a large number of eosinophils; fewer plasma cells and lymphocytes were also seen. The appearance indi-
FI(;. 1. Computerized tomography scan showing a lytic lesion in the right side of the clivus (arrow).
J. Neurosurg. / Volume 76/May, 1992
Transnasal stereotactic biopsy of a citrus tumor
FIG. 2. Operative photograph (h!/i) and schematic diagram (right) showing the Cosman-Roberts-WeUs flame in position, v,.ith the anterior fi,~ation pins of the base ring attached to the supraorbital ridges of the skull and the probe passing through the right nostril to the target lesion in the right clivus. cared histiocytosis X. Staging revealed the lesion to be solitary. Postoperative Course. The patient was managed conservatively and his diplopia had virtually resolved by 1 month after the biopsy. Discussion
The avoidance of major open skull-base surgery is desirable if tissue diagnosis alone is required. Free-hand transfacial needle biopsy of an extracerebral middle fossa mass under fluoroscopic guidance has been described j~ but is not accurate enough for a small clival lesion. Alternatively, CT-guided stereotactic techniques provide a high degree of accuracy with minimal operative trauma to selected extracerebral sites. Stereotactic surgical approaches described in the literature include a transorbital stereotactic approach to the orbital apex for retrobulbar anesthesia,~2 transnasal stereotactic approaches to the pituitary gland, 4 transfacial stereotactic approaches to the trigeminal ganglion, 3~ and a transoral stereotactic approach to a metastatic lesion of the C-2 vertebral archf An arc-centered stereotactic system such as the Cosman-Roberts-Wells frame is suitable for transnasal approaches because of the flexibility of trajectory available to the operator. It is critical that the base ring of the frame is set as low as possible. The fixation pins are placed in the supraorbital ridges for an approach to the upper clivus through or immediately below the sphenoid sinus, as in our case. However, if the target is in the mid- to lower clivus, it would be necessary to apply the anterior pins to the zygomatic bones in order to achieve a low transnasal or transoral trajectory using the Cosman-Roberts-Wells frame. Biopsy followed by adjuvant therapy may be applicable to some of the clival or paraclival lesions encountered. With the increasing use of stereotactic radiosurgery 6 or brachytherapy 2 to the skull base, an effective means of obtaining a stereotactic biopsy in this region will be advantageous and may avoid major open surgery. Transnasal stereotactic biopsy of selected clival tumors could also be used to make a histological diagnosis so that careful planning of the operative ap-
J. Neurosurg. / Volume 76/May, 1992
proach can be undertaken. The dura is not breached using this technique, thus preventing the risk of seeding tumor cells intracranially from the procedure. In conclusion, we recommend this technique for tissue diagnosis of clival lesions. Acknowledgment
We thank Frances De Niese for typing the manuscript. References
1. Al-Mefty O, Fox JL, Smith RR: Petrosal approach for petroclival meningiomas. Neurosurgery 22:510-517, 1988 2. Gutin PH, Leibel SA, Hosobuchi Y, et at: Brachytherapy of recurrent tumors of the skull base and spine with Iodine-125 sources. Neurosurgery 20:938-945, 1987 3. Kandel El: Functional and Stereotactic Neurosurgery. New York: Plenum Press, 1989, pp 419-423 4. Ibid., pp 492-500 5. Laitinen LV: Trigeminus stereoguide: an instrument for stereotactic approach through the foramen ovate and foramen jugulare. Surg Neurol 22:519-523, 1984 6. LunsfordLD, FlickingerJ, CoffeyRJ: Stereotacticgamma knife radiosurgery: initial North American experience in 207 patients. Arch Nenro147:169-175, 1990 7. Patil AA: Transoral stereotactic biopsy of the second cervical vertebral body: case report with technical note. Nenrosurgery 25:999-1002, 1989 8. Samii M, Ammirati M, Mahran A, et ah Surgery of petroclival meningiomas: report of 24 cases. Nenrosnrgary 24:12-17, 1989 9. Sen CN, Sekhar LN, Schramm VL, et al: Chordoma and chondrosarcoma of the cranial base: an 8-year experience. Neurosurgery 25:931-941, 1989 10. Stechison MT, Bemstein M: Percutaneous transfaeial needle biopsy of a middle cranial fossa mass: case report and technical note. Neurosurgery 25:996-999, 1989 11. Uttley D, Moore A, Archer DJ: Surgical management of midline skull-base tumors: a new approach. J Neurosurg 71:705-710, 1989 12. Vogl G, Schimek F, Ozdoba C, et at: Stereotactic retrobulbar anesthesia using CT. J Comput Assist Tomogr 14: 859-861, 1990 Manuscript received August 6, 1991. Address reprint requests to: Jeffrey V. Rosenfeld, F.R.C.S. (Ed)., F.R.A.C.S., Department of Neurosurgery, Royal Children's Hospital, Parkville, Victoria 3052, Australia. 879
