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  • Updated 08.18.2020
  • Released 12.22.1999
  • Expires For CME 08.18.2023

Tumors of the skull base

Introduction

Overview

Skull base tumors are diverse in their origin, histology, treatment, and prognosis. Patients may present with a variety of neurologic symptoms caused by compression of neurologic or vascular structures. Differential diagnosis for skull base pathology is broad. Patient care is highly individual and multifactorial. These characteristics make treating skull base pathology both challenging and rewarding. Ongoing research involving targeted therapies and evidence-based advances predicated on clinical trials add to rapidly evolving treatment approaches.

Key points

• Masses involving the skull base have a broad differential diagnosis, each entity characterized by unique biology and cellular origins.

• Standard radiographic evaluation involves the use of magnetic resonance imaging (MRI) and computed tomography (CT). Each skull base location has a relatively defined differential diagnosis in terms of neoplasms, varying depending on the anatomic site.

• Care for patients with skull base masses is highly individual. Tumor histology, size, location, and patient demographics strongly influence overall prognosis for each skull base tumor type and determine treatment approach.

• Genetic characterization and targeted molecular therapies are emerging as primary or adjunct treatment options for some skull base tumors.

• Novel imaging techniques as well as advanced surgical adjuncts such as virtual and augmented realty technologies and 3-D printed prosthetics are under active investigation for the surgical treatment of challenging skull base pathology.

Historical note and terminology

Skull base tumors are located in the vicinity of the brainstem or beneath the cerebral cortex, making their treatment technically challenging. Skull (cranial) base surgery has been driven by pioneers in neurosurgery and otolaryngology. Sir Charles Balance and Harvey Cushing both had a special interest in vestibular schwannomas. Interdisciplinary cooperation for treatment of skull base tumors started at the University of Mainz many years ago (33), and consists of neurosurgery, otolaryngology, plastic surgery, ophthalmology, radiation oncology, and neuroradiology. This clinical focus has been represented by formal journals (eg, Skull Base Surgery created in 1990 and is available as part of the Journal of Neurological Surgery Part B – Skull Base as of 2012), and skull base societies.

Until recently, many deep seated, skull base tumors were either entirely inoperable or could be exposed by damaging normal brain structures. This could result in brain injury affecting movement, feeling, speech, mental abilities, and other adverse neurologic consequences. The basic concept that underlies cranial base surgery is removal of bone, often in a clever and anatomically complex manner, to reduce or even eliminate the need for brain retraction. Skull base procedures, for example, may be designed to traverse the bone containing the ear (petrous bone), around the eye (orbit), through the nose or paranasal sinuses, low on the temple beneath the brain, or even upwardly directly from the neck region. Fundamentally, these are techniques afford the highest possible degree of tumor removal while preserving neurologic function to the greatest extent possible. Adjuvant treatments and advances in stereotactic radiosurgery have allowed skull base surgeons to enable more safe and effective treatments.

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