Recovery of vision following treatment of pituitary tumours; application of a new system of assessment to patients treated by transsphenoidal operation

The lack of a standard quantitative method of assessing the degree of visual deficit hinders comparison of the results of the different methods available for treating visual failure due to a pituitary tumour. This report describes a simple, semi-quantitative, and precise approach, and illustrates its use in 34 patients treated by transsphenoidal hypophysectomy and radiotherapy. Visual improvement occurred in 85%, and no patient sustained deterioration of vision. Visual loss before operation was scored at a mean of 51.4%, and was reduced to a mean of 27.4% after a minimum of 12 months follow-up. The factor that had the greatest influence on visual recovery was the degree of visual loss at presentation. It is therefore essential to be able to compare this variable before attempting to assess if outcome is different in patients treated by different methods.

Sacrococcygeal chordoma in young adults

Sacrococcygeal chordoma in young adults is rare. Two patients, aged 29 and 34 years, are presented. Computed tomography plays an important role in delineating the extent of bony destruction and soft-tissue involvement. This information is necessary for treatment which may include surgery, radiotherapy and/or chemotherapy. A review of sacrococcygeal chordomas is presented.

[Prognostic value of various factors in the treatment of patients with primary malignant tumors of the pelvic bones]

The time of life of 219 patients with primary malignant tumors of bones of the pelvis were analyzed in order to study the influence of different factors on the survival rate of the patients. It was shown that a considerable improvement of some results in the treatment of chondrosarcomas and chordomas was achieved after ablative removal of tumors, in reticulosarcoma and Ewing sarcoma--after a combined chemo-radial treatment with prophylactic courses of the therapy during 2 years. The combination of operation and radiotherapy for the treatment of chordomas gave a reliably higher survival of the patients within 5 years of observation. Prognosis in osteogenic sarcoma and angiosarcoma are extremely unfavorable regardless of the method of treatment.

Chordomas: diagnosis and management

Six patients with chordomas, five in the sacral and one in the craniocervical region, are reported along with review of the literature. Two of the patients treated with radiation for macroscopic tumor had palliation of their symptoms and an apparent prolongation of survival. Two other patients with sacral chordomas had resection of the gross tumor and radiation due to inadequate proximal margins. They both remain free of recurrence at 2.5 and 5 years, respectively, suggesting the potential usefulness of combination of modalities in the management of these tumors.

Malignant retrorectal tumors: 28 years' experience at Memorial Sloan-Kettering Cancer Center

From 1949 to 1977, 39 patients with localized malignant retrorectal tumors were treated at Memorial Sloan-Kettering Cancer Center. Chordomas were the most frequent histologic type (38 per cent of patients) followed by neurogenic tumors (15 per cent) chondrosarcomas, hemangiopericytomas, and embryonal adenocarcinomas (8 per cent each). Treatment consisted of surgical excision in 28 patients (18 of whom received adjuvant radiotherapy and/or chemotherapy). Ten patients were treated nonsurgically, receiving radiation and/or chemotherapy alone. Large tumors were most successfully managed by a combined surgical approach consisting of exploratory celiotomy, rectal mobilization, and bilateral hypogastric artery (with middle sacral artery and vein) ligation, followed by transsacral tumor excision with incontinuity sacrectomy. For all treated patients, survival at 5, 10, 15 and 20 years was 69 per cent, 50 per cent, 37 per cent and 20 per cent, respectively. Long-term disease-free survival (17 to 25 years post treatment) was noted in six patients. [Key words: Tumor(s), retrorectal, malignant; Tumor(s), treatment].

Chordoma of the cervical spine

Eight cases of chordoma limited to the cervical spine are presented. The radiological features are analyzed. Although there is no single diagnostic feature, the combination of osteosclerosis and lysis, multiple vertebral involvement, and the presence of a pre- or paracervical mass is strongly suggestive of a chordoma. Although none of our patients can be considered cured, we recommend an anterior cervical approach with radical removal of the tumor and interbody fusion followed by immobilization in a halo vest and postoperative radiation therapy. The biological behavior of the tumor is extremely variable, and multiple operations for symptomatic recurrences may be helpful.

Chordoma. A clinicopathologic and prognostic study of a Swedish national series

Chordoma is a rare tumor with slow growth developing from remnants of the notochord and thus appears in close relation to the axial skeleton. A Swedish national series collected over a period of 13 years, comprising 51 patients with a follow-up time of 8-20 years, was studied. Histologically all tumors had a typical appearance except two, which had characteristics of "chondroid chordoma". Fifty-seven per cent of the tumors were located in the sacrococcygeal region, 27 per cent in the spheno-occipital region and 16 per cent in the vertebrae. The peak age incidence was in the 6th and 7th decades. Male: female ratio was 1:1. The main symptoms were pain and neurologic disturbances. Skeletal destruction was noted radiographically in most instances. Intratumoral calcifications were rarely seen. The treatment was surgery, radiotherapy or a combination of these. There was only one long-term survivor without evidence of disease, a patient operated on for cervical chordoma 14 years earlier. Six other patients lived 8-18 years after diagnosis with chordoma. All other patients were dead; 39 died of chordoma, five of unrelated causes. Distant metastases were noted in 29 per cent. Chordoma constituted 17.5 per cent of all primary malignant bone tumors of the axial skeleton. The yearly incidence was 0.51 per million inhabitants in Sweden.

Sacral chordoma: a case study and review

Chordomas are a low grade, tenacious, but eventually lethal neoplasm for which little improvement in outcome has been reported. A current review of the literature and a case report are provided to support his position. The reported sacral chordoma did respond temporarily to chemotherapy. Its rare occurrence precludes controlled studies of chordoma; therefore, any response merits reporting. The authors observed that hyperthermic chemotherapy was feasible for treating some chordomas but has not yet been reported. It was evaluated for the patient in this report.

Nasal and paranasal presentations of chordomas

Eight patients with chordomas whose initial manifestations were caused by nasal and paranasal extension of the tumor are presented. Their ages ranged from 24 to 51 years. Disturbances of vision developed subsequently in all eight patients, and headache was present in each patient. Roentgenograms showed bony erosion of the sphenoid sinus or a nasopharyngeal mass. Because chordomas can be confused with chondrosarcomas histopathologically, differentiation is important. Treatment consists of surgical debulking or radiotherapy (or both). Despite such treatment, six patients died from their disease. The average survival was five years. This emphasizes the well-known poor prognosis for patients with clival chordomas.

[Chordomas in ENT (author's transl)]

Chordomas grow out of intraosseous remnants of the embryonal chorda dorsalis situated most frequently in the clinical and sacrococcygeal regions. In ENT they appear as pharyngeal tumors growing downward from the clivus or forward from the vertebra showing a lobulated pattern with a surface partly soft partly rather firm. From 1965 until 1977 five cases of chordomas were observed and treated in the centre of ENT in Frankfurt. Three patients were treated by surgery only, one by combined radiosurgical therapy and one by radiotherapy with neutron-rays only. The last above mentioned one except all patients did'nt alive three years and died by the tumor or the consequence of therapy. The difficulty in arriving at the best way of treatment is discussed by demonstrating these five cases.

Craniocervical chordomas

In a 20 year period seven cases of craniocervical chordoma were seen and treated. Since it is not possible to completely resect these lesions, the aim of treatment has been to debulk the tumor as much as feasible and employ postoperative irridation. Palliation is the most that can be hoped for, and minimal success in delaying the natural history of the tumor has been achieved. Surgery for relief of symptoms secondary to bulky recurrence is indicated for palliation, as is a repeat course of x-ray therapy. Isolated cases of long-term useful survival have followed doses in the range of 10,000 rads or more [19,20]. This therapy is usually given in smaller increments of an initial dose when there is evidence of recurrent tumor or pain [2]. However, whenever the dosage to the spinal cord or the base of the brain exceeds 4,000 rads, there is a concern about possible permanent radiation damage. These patients are difficult to care for late in the course of their disease when multiple cranial nerve paralysis, long tract signs, and intractable pain become progressively severe. Chordomas usually remain localized; however, about 10% metastasize distally. One case is presented of a large retropharyngeal mass with destruction of the second cervical vertebra that recurred locally in 3 months despite usual treatment; distal bony metastases were found 3 years after initial treatment. The histology of the lesion, its recurrence, and distal bony metastases were essentially indistinguishable from the other lesions that remained localized. Short periods of palliation from severe local pain and exquisite tenderness have been achieved by local resection of the involved bones.

[Chordoma of the base of the skull. Clinical and histological study. Therapeutic possibilities (author's transl)]

A Case of chordoma of the base of the skull is reported. It had been present with minimal symptoms for six years during which the clinical picture was limited to nasal obstruction and headache. Comparison of initial X-rays and the preoperative assessment revealed progressive destruction of the base of the skull which indicated the likelihood of considerable difficulties in excision. Surgical treatment posed the problem of the approach and emphasised the absence of encapsulation and the incomplete nature of the operation. The development of new symptoms (diplopia, dysphagia) resulted in complementary radiotherapy. The authors take the opportunity to point out the polymorphous clinical nature of these tumours in relation to their site and the criteria of the histological diagnosis. The possibilities of treatment are discussed. Abstention from treatment is formally rejected and, on the contrary, the emphasis is placed upon the need for early treatment. The consequences of excision should be limited by using a minimal surgical technique when possible. Complementary radiotherapy is necessary and may be repeated, up to certain limits, in the case of recurrence if the first irradiation is felt to be effective. There is no parallel between histological appearances and the response to treatment. The possibilities of chemotherapy would appear to be limited.

Spinal chordomas

A series of 54 patients with spinal chordomas were treated at Memorial Sloan-Kettering Cancer Center between 1949 and 1976. Thirty-six lesions were located in the sacrococcygeal region and 18 involved the vertebral column at a higher level. The male to female ratio was 35:19. Vertebral chordomas generally occurred in a younger age group. Our radiological findings suggest that there is marked soft-tissue extension anterior to the vertebral column at the time of initial diagnosis. Eleven of 18 vertebral chordomas and 10 of 36 sacral chordomas were found to have disseminated metastases during their course. Analysis of the various modes of therapy reveals that the median survival for both groups is approximately 6 years. However, the 5-year survival for the sacrococcygeal group was 66% as opposed to 50% for the vertebral group. Radiation therapy produced significant palliation but objective evidence of tumor regression was difficult to assess. Chemotherapy in a small number of patients did not have any effect on the tumor. With the advent of computerized tomography scanning, further studies should be done to document the response of this tumor to radiation therapy.

[Chordoma - a review and report of two cases (author's transl)]

Chordomas can be categorized into those of clival, cervical and sacrococcygeal origin. The clival chordomas are primarily discussed in this report. In defining pathological anatomy or histology, a differentiation of benign from malignant chordomas by histological means alone is impossible. A preoperative diagnosis is only possible if tumor grows into the nasopharynx and allows a tissue biopsy to be taken. These tumors are clinically malignant though strict anatomic criteria for malignancy such as nuclear polymorphia or atypia, mitoses and metastases are rarely observed. The therapeutic results of operation and radiation are compared. Each alone fails because of the high recurrence rate of the tumor so that their combination is preferred. Although the prognosis of this disease is poor, one of our patients who was treated with radiation and surgery had a survival time of 14 years.

Chordoma: radiologic evaluation of 20 cases

Experience with 20 cases of chordoma is summarized. Three of four intracranial tumors presented as sellar tumors. The clivus remained intact for 2, 3 1/2, and 4 years, respectively, in three patients despite extensive destructive lesions of the sellar region. Our data and those of others indicate that approximately half the patients with chordomas have erosion of the clivus at the time of initial medical evaluation. The other half mainly have sellar destructive lesions with or without associated clival erosion. Calcification occurs in 50%-70% of intracranial chordomas. A nasopharyngeal mass is present in one-third. Vertebral chordomas often involve two or more vertebrae, producing destructive lesions which often have a sclerotic rim. The intervertebral discs are commonly affected. A paraspinal soft tissue mass, half the time containing calcification, is often present. Sacral lesions are characterized by a midline destructive lesion, occasionally associated with expansion, with or without osteosclerosis. A firm, fixed, extrarectal, presacral mass which may contain calcification or fragments of bone is almost always present.

Chordoma in Finland

During the period 1953-1971, 20 cases of chordoma were reported to the Finnish Cancer Registry. Twelve of the patients were males. The mean annual (crude) incidence of chordoma in Finland was 0.30/10(6) in males, and 0.18/10(6) in females. Fifteen of the tumours were sacral, three vertebral, and two cranial. Local recurrences were common, and distant metastases were observed in 60 per cent of the cases; this exceeds the proportion usually mentioned in the literature. The commonest treatment was surgery combined with postoperative high-dose irradiation. The relative 5-year survival rate was 35 per cent, and the 10-year rate 18 per cent.