Figure 5.

Illustrative case of Level IV strategy. (A,B) Preoperative sagittal MR images showing clival chordoma extensively occupying nasopharynx, and elongated from the lower pons to cervicomedullar area. At first, it looks hard to remove completely in one stage surgery. (C) Remnant tumor after initial ETCA that showed progression at 40 months after PBRT. (D) Final postoperative MR images showing fat graft inserted at surgical bed and cervicomedullary junction relieved after reoperation (ETCA). Level IV need combined treatment strategy in overall. (C: clivus; F: fat graft; M: medulla oblongata; P: pons; SC: spinal cord; Tm: tumor).