  Citation: Essayed, W.I.; Juvekar, P.; Bernstock, J.D.; Rassi, M.S.; Almefty, K.; Zamani, A.A.; Golby,A.J.; Al-Mefty, O. Multimodal Intraoperative Image-Driven Surgery for Skull Base Chordomas and Chondrosarcomas. Cancers 2022, 14, 966. https:// doi.org/10.3390/cancers14040966 Academic Editor: Jorn Fierstra Received: 10 January 2022 Accepted: 7 February 2022 Published: 15 February 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). cancers Article Multimodal Intraoperative Image-Driven Surgery for Skull Base Chordomas and Chondrosarcomas Walid I. Essayed 1 , Parikshit Juvekar 1 , Joshua D. Bernstock 1 , Marcio S. Rassi 2 , Kaith Almefty 3 , Amir Arsalan Zamani 4 , Alexandra J. Golby 1,4 and Ossama Al-Mefty 1, * 1 Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; wibnessayed@bwh.harvard.edu (W.I.E.); pjuvekar@bwh.harvard.edu (P.J.); jbernstock@bwh.harvard.edu (J.D.B.); agolby@bwh.harvard.edu (A.J.G.) 2 Department of Neurosurgery, A. C. Camargo Cancer Center, São Paulo 01509-001, Brazil; marcio.rassi@accamargo.org.br 3 Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; kaith.almefty@barrowbrainandspine.com 4 Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; azamani@bwh.harvard.edu * Correspondence: almeftyossama@bwh.harvard.edu; Tel.: +1-(617)-525-9451; Fax: +1-(617)-743-8342 Simple Summary: Achieving gross total resection during the first surgical intervention is particularly important for chondrosarcomas and chordomas, as recurrences are frequently impossible to resect due to post-surgical and post-radiation scarring and vascular fragility. Despite overall survival and progression-free survival being strongly dictated by gross total resection, it is reportedly achieved in less than 70% of patients. While the individual utility of several imaging modalities such as intraoperative CT, MRI, ultrasound, endoscopy, fluoroscopy and neuronavigation has already been demonstrated in previous literature; our case series highlights the importance and methodology of their simultaneous, real-time integration in the Advanced Multimodality Image-Guided Operating (AMIGO) suite at our institution to maximize of resection and mitigate complications. Abstract: Given the difficulty and importance of achieving maximal resection in chordomas and chondrosarcomas, all available tools offered by modern neurosurgery are to be deployed for planning and resection of these complex lesions. As demonstrated by the review of our series of skull base chordoma and chondrosarcoma resections in the Advanced Multimodality Image-Guided Operating (AMIGO) suite, as well as by the recently published literature, we describe the use of advanced multimodality intraoperative imaging and neuronavigation as pivotal to successful radical resection of these skull base lesions while preventing and managing eventual complications. Keywords: chordomas; chondrosarcoma; intraoperative MRI; multimodal imaging; neuronavigation; resection; skull base 1. Introduction Recent advances in technology have enabled considerable progress in neurosurgical practice and associated clinical outcomes. This revolution has in part been driven by the ever-expanding armamentarium of imaging tools available in the operating room. In skull base surgery, widespread adoption and use of neuronavigation, endoscopes, and intraoperative imaging represent the core of such advances [1,2]. In line with such advances, our institution has developed the Advanced Multimodality Image-Guided Operating (AMIGO) suite in an effort to maximize the potential of modern imaging tools to guide challenging procedures [3]. The AMIGO suite consists of three interconnected rooms with a 3T intraoperative magnetic resonance imaging (MRI) scanner, a positron emission tomography (PET)/computed tomography (CT) scanner, endoscope(s), an endovascular Cancers 2022, 14, 966. https://doi.org/10.3390/cancers14040966 https://www.mdpi.com/journal/cancers