Expanded Endoscopic Endonasal Approach for Resection of Recurrent Glioblastoma

Background: Malignant gliomas are the most common malignant primary brain tumor, and despite advances in surgical techniques, chemotherapy and radiation overall survival remains extremely poor. Even with the aggressive combination of surgical resection, radiation, and chemotherapy, recurrence is inevitable. The expanded endoscopic endonasal approach has been used to treat a variety of intracranial pathologies; however, there has not been literature published regarding resection of recurrent malignant gliomas via this technique. Here we present a novel use of a classic skull base approach for surgical resection of a recurrent glioblastoma.

Case Details: The patient is a 29-year-old female initially diagnosed in 2013 after headaches and nausea led to an MRI showing a large right frontal enhancing mass ([Fig. 1]). She underwent subtotal resection at that time and pathology demonstrated WHO grade-IV astrocytoma, IDH-1 wildtype, and MGMT unmethylated. She then proceeded with standard therapy of radiation and chemotherapy with temozolomide. The tumor progressed radiologically prompting further surgical resection a total of four additional times each demonstrating recurrent high-grade glioma with additional treatment effect. Between her surgeries, she underwent several cycles of lomustine and bevacizumab but unfortunately continued to show radiographic progression. Throughout her treatment, she remained high functioning. The medial inferior frontal component of her tumor continued to progress ([Fig. 2]); at this time, it was elected to approach the recurrent tumor via an endoscopic endonasal route with intraoperative MRI. It was a multidisciplinary surgical team with our experienced ENT surgeon assisting with the approach. The bone of the anterior cranial fossa was removed from the right orbit laterally to just past midline, removing the crista galli for adequate exposure. The tumor was immediately encountered and dissected away from the surrounding parenchyma and blood vessels. We were able to achieve a gross total resection ([Fig. 3]). The skull base was reconstructed with an inlay dural substitute, onlay fascia lata graft and a nasal septal flap.

Conclusion: Although a classic craniotomy approach for surgical resection of high-grade gliomas will remain the mainstay of treatment, an endoscopic endonasal approach can be a safe and efficient method for resection of recurrent tumors. With an experienced operative team adequate resection and hemostasis are achievable. Patient selection and tumor location play a key component in success of this novel approach for treating high-grade gliomas.

Fig. 1 Axial (left) and coronal (right) T1 + contrast images of initial MRI in 2013 demonstrating large right frontal heterogeneously enhancing lesion. MRI, magnetic resonance imaging.

Fig. 2 Axial T1 + contrast (left) and 3D coronal T2 cube (right) images of preoperative MRI demonstrating recurrence in the inferior, medial frontal lobe. 3D, three-dimensional; MRI, magnetic resonance imaging.

Fig. 3 Axial T1 + contrast (left) and 3D coronal T2 cube (right) images of intraoperative MRI demonstrating complete resection of the residual tumor. 3D, three-dimensional; MRI, magnetic resonance imaging.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021