Chordoma: the results of megavoltage radiation therapy

Chordoma: results of radiation therapy in eighteen patients

Between 1975 and 1990, eighteen patients with a histologically proven diagnosis of chordoma were treated at our institution. All patients initially underwent a surgical procedure and were referred for irradiation due to residual disease or postsurgical relapse. The mean dose administered was 50.1 Gy (range, 29.9-64.8 Gy). Eight patients were treated according to a hyperfractionated schedule. The overall actuarial 5-year survival and 5-year progression-free survival were 38% and 17%, respectively. The progression-free interval was longer for patients receiving doses greater than 48 Gy when compared with doses below 40 Gy (actuarial 5-year progression-free survival of 31 +/- 35% vs. 0%, respectively; p = 0.04). We conclude that in the treatment of chordoma, the administration of high radiation doses may increase the disease-free interval. The objective response and dose-response relationships were analyzed in twelve patients for whom sequential CT scans were available.

Our approach to the management of congenital presacral tumors in adults

This study reviews the recent overall experience in one colorectal surgery department with congenital presacral tumors in adults. 24 patients greater than 21 years of age, who underwent curative resection between January 1980 and August 1992, were analyzed retrospectively. The growths were divided into two broad categories: developmental cysts and chordomas. The most common presenting symptom was pain (19/24). A preoperative evaluation regimen is outlined in the study and includes use of CT scanning, MRI imaging, and possibly the use of endoluminal ultrasound to document the relationship of presacral tumors to pelvic viscera. There were 20 developmental cysts and 4 chordomas treated in this series. 15 of 19 developmental cysts were excised by a posterior approach alone, 2 were excised by an anterior approach alone, and 3 were treated by a combined approach. Trans-sacral excision was carried out in 4 patients with developmental cysts. One chordoma was resected posteriorly and the other 3 through a combined anterior and posterior approach. Three recurrences were diagnosed after excision of developmental cysts at 8, 18, and 41 months postoperatively. Recurrence occurred in 3 of 4 chordoma patients after 25, 32, and 55 months. Reexcision was carried out in all patients. None of the developmental cyst cases developed a second recurrence but 2 of the 3 chordoma patients have recurred, but have undergone local irradiation, which has controlled their disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Dedifferentiated chordoma. Response to aggressive chemotherapy in two cases

BACKGROUND

Dedifferentiated chordoma is an unusual and aggressive variant of chordoma which is likely to metastasize. Few reports exist of treatment of these tumors with chemotherapy.

METHODS

In 1988, two patients with dedifferentiated sacral chordomas were seen at the University of Chicago Hospitals. Both developed metastatic disease less than a year after sacral resection and radiation therapy. These patients' diagnoses, courses, and treatments were reviewed along with the literature on chemotherapy in both conventional and dedifferentiated chordomas.

RESULTS

Both patients obtained complete remissions, one to a six-drug regimen and the other to ifosfamide.

CONCLUSIONS

A trial of reasonably aggressive chemotherapy is warranted in patients with metastatic dedifferentiated chordoma. The optimum regimen is unclear, but agents active in high-grade sarcomas are logical choices.

Charged particle irradiation of sacral chordomas

PURPOSE

The purpose of this report is determine the impact of charged particle irradiation at Lawrence Berkeley Laboratory (LBL) in treating patients with sacral chordomas. Overall survival, local control, complications, and predictive parameters are analyzed.

METHODS AND MATERIALS

Fourteen patients with sacral chordomas were treated with the charged particles helium and neon between 1977 and 1989. The median dose was 7565 cGyE and the median follow up is 5 years. All patients were treated post-operatively; ten had gross residual disease.

RESULTS

Kaplan-Meier survival at 5 years is 85%. Overall 5-year local control is 55%. A trend to improved local control at 5 years was seen in patients treated with neon when compared to patients treated with helium (62% vs 34%), in patients following complete resection versus patients with gross residual tumor (75% vs 40%), and in patients who had treatment courses under 73 days (61% vs 21%). Distant metastases were seen in two patients (14%). No patient developed neurologic sequelae or pain syndromes. One previously irradiated patient required colostomy, one patient had delayed wound healing following a negative post-radiation biopsy, and one patient developed a second malignancy. There were no genitourinary complications.

CONCLUSION

Our experience indicates that post-operative charged particle irradiation of sacral chordomas appears to result in reasonable local control and survival with acceptable risk, and that additional evaluation on the use of heavy charged particles is warranted.

Intracranial chordomas: a clinicopathological and prognostic study of 51 cases

Fifty-one patients with intracranial chordomas who were surgically treated between 1960 and 1984 were studied. Median patient age was 46 years, and 73% presented with diplopia or headache. Nineteen tumors were classified as the "chondroid" type. The extent of surgical removal was a biopsy in 11 patients and subtotal removal or greater in 40. Thirty-nine patients received postoperative radiation therapy. At the time of analysis, 17 patients were alive, and the estimated 5- and 10-year survival rates were 51% and 35%, respectively, for the group of 51 patients. Univariate analysis showed that: 1) patients undergoing resection lived longer (the 5-year survival rate was 36% for the 11 biopsy patients compared with 55% for the 40 patients who had resection; 2) patients who underwent postoperative radiotherapy tended to have longer disease-free survival times; and 3) overall and disease-free survival data were the same for patients with chondroid tumors and those with typical chordomas. Multivariate analysis showed that: 1) age was the factor most strongly associated with longer overall and disease-free survival; 2) diplopia was associated with longer survival; and 3) tumoral mitotic activity tended to be associated with shorter disease-free survival. One tumor metastasized to the cervical cord, and two tumors underwent anaplastic transformation. These data suggest that the prognosis in patients with chordomas is unfavorable, young age is the single factor most strongly associated with longer survival, surgical resection is beneficial, and postoperative radiotherapy may prolong disease-free survival.

Probable causes of recurrence in patients with chordoma and chondrosarcoma of the base of skull and cervical spine

PURPOSE

141 patients with chordoma and chondrosarcoma of the base of skull and cervical spine were treated with proton and photon irradiation between 1980 and 1989. The local disease was controlled in 111 of these patients. This study reviews the 26 patients who have had their disease recur, and who have evaluable diagnostic studies to examine for probable causes of recurrence.

METHODS AND MATERIALS

The histologies of the recurrent tumors were 21 non-chondroid chordomas, two chondroid chordomas, and three chondrosarcomas. The prescribed doses ranged from 67 Cobalt-Gray-Equivalent (CGE) to 72 CGE (average of 69 CGE). Doses to small regions of the tumor were deliberately reduced where they abutted certain normal tissues (brain stem, spinal cord, optic chiasm, and optic nerves) in order to keep these structures at acceptance dose levels. The first study, CT or MR scan, on which there was evidence of increase in tumor was carefully evaluated and that volume transferred to the CT scan on which the treatment plan had been developed. The 3D dose distribution in the region of recurrence was carefully analyzed and a judgement made as to the most probable cause of recurrence.

RESULTS

Approximately one quarter (6 of 26) of the cases failed in the prescribed dose region. More than half (15 of 26) failed in regions where tumor dose was limited by normal tissue constraints. Approximately 10% of the patients recurred in the surgical pathway and 10% were judged to be marginal misses.

CONCLUSIONS

Overall, 75% of the patients failed in regions receiving less than the prescribed dose. All tumors which failed in the high dose region had volume greater than 75 cc. Patients with cervical spine disease had a higher rate of recurrence (10 or 26) and larger tumors (average volume of 102 cc) than those with base of skull disease (16 of 115) with an average volume of 63 cc.

Cranial chordoma in the first decade

Cranial chordomas are extremely rare in childhood with only 25 cases having been reported in the first decade of life. A 6-year-old female child with cranial chordoma is reported. Literature on the subject is reviewed, with special reference to the management, histopathological features and prognosis in childhood chordomas as compared to the adult variety.

Charged particle radiotherapy of paraspinal tumors

Between 1976 and 1987, 52 patients with tumors adjacent to and/or involving the cervical, thoracic, or lumbar spinal cord were treated with charged particles at the University of California Lawrence Berkeley Laboratory. The histologies included chordoma and chondrosarcoma (24 pts), other bone and soft tissue sarcoma (14 pts), and metastatic or unusual histology tumors (14 pts). Radiation doses ranged from 29 to 80 Gray-equivalent (GyE), with a median dose of 70 GyE. Twenty-one patients received a portion of their treatment with photons. Median followup was 28 months. For 36 previously untreated patients, local control was achieved in 21/36 patients and the 3-year actuarial survival was 61%. Of 16 patients treated for recurrent disease, 7/16 were locally controlled and the 3-year actuarial survival was 51%. For patients treated for chordoma and chondrosarcoma, probability of local control was influenced by tumor volume (less than 100 cc or greater than 150 cc) and whether disease was recurrent or previously untreated. Complications occurred in 6/52 patients, including one spinal cord injury, one cauda equina and one brachial plexus injury, and three instances of skin or subcutaneous fibrosis. Charged particle radiotherapy can safely deliver high tumor doses to paraspinal tumors with good local control.

Chordoma-natural history, treatment and prognosis. The Florence Radiotherapy Department experience (1956-1990) and a critical review of the literature

Fifteen cases of chordoma, seen between 1956 and 1990 at the Florence Radiotherapy Department are reported. Twelve of them were treated with radiotherapy and surgery, while one was left untreated. We analyzed the course of the disease in the treated cases, with particular emphasis on the problem of symptom control. The natural history of the disease seemed to be only marginally affected by the treatment and new therapeutic options are strongly needed. While actuarial survival rates at 5 and 10 years were 58% and 35% respectively (owing to the slow growth rate of this neoplasm), 10 years' symptomatic progression-free, symptom-free, and disease-free survival rates were only 25%, 17% and 8% respectively.

Diagnosis and management of sacrococcygeal chordoma

Chordoma is a rare, slow-growing but locally aggressive malignant tumor derived from the primitive notochord and located along the axial skeleton. Between 1973 and 1991, of 15 patients with chordomas treated at the Medical College of Virginia, eight originated in the sacrococcygeal area. There was a median one year interval between the onset of symptoms and diagnosis (range of four months to six years) for this latter group. Two patients had undergone coccygectomies and one patient a lumbar discectomy prior to establishing the correct diagnosis of sacral chordoma. Seven patients underwent resection and one refused therapy. The four patients who had an initial wide radical resection had a longer disease-free survival than the three who underwent local excision. Three of four patients had metastatic disease at the time of death. Early diagnosis and aggressive initial surgical resection are necessary for long-term survival.

Retrospective long-term follow-up analysis in 21 patients with chordomas of various sites treated at a single institution

Twenty-one patients with chordoma were treated at the Radiation Oncology Center, Mallinckrodt Institute of Radiology, between 1949 and 1986. Thirteen patients had sacrococcygeal tumors, five had clival tumors, two had nasopharyngeal tumors, and one had a lumbar spine tumor. Nine patients were treated with surgery alone, eight patients with subtotal resection and postoperative irradiation, and four patients with radiotherapy alone after biopsy. The 5- and 10-year actuarial survival rates were 74% and 46%, respectively. The 10-year actuarial survival rate was significantly better in patients treated with surgery alone or surgery and irradiation than in those treated with radiotherapy alone (52%, 32%, and 0%, respectively, p = 0.02). Although all patients ultimately suffered a recurrence, those with lumbosacral tumors treated with surgery and irradiation had a longer mean disease-free survival period (6.6 years) than those treated with surgery alone (4.1 years) (p = 0.08). Disease-free survival times of patients with base of the skull tumors was not significantly different between the treatment groups. Irradiation after resection of chordomas appears to increase the time to first relapse in lumbosacral tumors and should be considered after subtotal resection.

Translumbar amputation

Six patients underwent translumbar amputation (TLA), a life-saving procedure, after standard modalities of therapy failed to control the progression of the disease. The primary diagnoses were as follows: pelvic arterial-venous (A-V) malformation, 1; sacral chordoma, 3; giant cell tumor of the sacrum, 1; and paraplegia with squamous cell cancer arising in intractable decubitus, 1. There were no operative deaths. The following postoperative complications developed in five patients: urinary fistulae, 2; small bowel obstruction, 1; intraabdominal bleeding, 1; hypertension, 2; small bowel fistula, 1; and dehiscence of skin closure, 1. Two patients died with distant metastases (24 months) and distant metastases with local recurrence (6 months). The remaining four patients were alive and well 72, 56, 48, and 18 months after the surgical procedure. All of these patients have reached the rehabilitation goals.

Considerations in fractionated proton radiation therapy: clinical potential and results

Protons have a finite range in tissue and can provide a better concentration of radiation dose in the tumor than conventional X-rays in certain situations. The development of optimized treatment plans for X-rays and protons followed by a comparative evaluation is one method of selecting tumor sites best suited for proton treatment. The preliminary results of comparative treatment planning for base of skull tumors and carcinoma of the prostate are discussed. These comparisons suggest a clinical gain for proton treatment of tumors in these locations. The clinical experience with fractionated proton treatment of several tumor sites is also discussed. The results of high dose proton treatment of chordomas and low grade chondrosarcomas of the base of skull is particularly promising: an actuarial 5-year local control of 78% has been obtained in 50 patients followed for a minimum of 22 months.

Fractionated proton radiation therapy of chordoma and low-grade chondrosarcoma of the base of the skull

Sixty-eight patients with chordoma or low-grade chondrosarcoma at the base of the skull received fractionated high-dose postoperative radiation delivered with a 160-MeV proton beam. Protons have favorable physical characteristics which allow the delivery of high doses of radiation to these critically located tumors. The methods employed for these treatments are described. These patients have been followed for at least 17 months and for a median of 34 months. The median tumor dose was 69 CGE (cobalt Gy equivalent): CGE is the dose in proton Gy multiplied by 1.1, which is the relative biological effectiveness for protons compared to cobalt-60. The daily dose was 1.8 to 2.1 CGE. For this group the 5-year actuarial local control rate is 82% and disease-free survival rate is 76%. The incidence of treatment-related morbidity has been acceptable.

Radiotherapy for chordoma

Twenty-five patients with gross residual chordoma after partial excision or biopsy were treated by radical radiotherapy at Royal Marsden Hospital between 1952 and 1981. The median duration of freedom from local progression following radiotherapy was 32 months. Twenty-four of the 25 patients (96%) had stabilization or reduction in symptoms. All 19 patients in whom pain was a major symptom had relief. The overall actuarial 5- and 10-year survival rates were 44% and 17%, respectively. The corresponding progression--free survival rates were 33% and 20%. Permanent cure was unusual with any radiotherapy dose, but doses higher than 55 Gy or a TDF of 90 were associated with a statistically significant improvement in duration of local control. Seven of 17 (41%) patients who received greater than 55 Gy had freedom from local progression for 5 or more years compared with only 1 of 8 patients receiving less than 50 Gy. Subtotal excision prior to radiotherapy did not appear to improve median survival or probability of long-term local control. Distant metastases were seen in 16% of the patients, derived entirely from sacrococcygeal lesions, but only half of these caused significant morbidity or death. Local control is obviously the overwhelming problem. High dose, generous volume radiotherapy is advocated.

Clivus chordoma in childhood

A 9-year-old boy with mild left hemiparesis and left abducens nerve palsy was found to have chordoma of the clivus. Magnetic resonance imaging (MRI) was most useful not only for diagnosis but also for selection of operative approaches. The tumor was subtotally resected by a transoral-transpharyngeal approach followed by a retroauricular retromastoid craniotomy, and postoperative radiation therapy was administered. Intracranial chordomas are rare in children; only 12 cases have previously been reported in detail. Eleven patients were male and one was female. Progressive cranial nerve involvement and long tract signs without increased intracranial pressure constitute the cardinal symptomatology of intracranial chordomas, but a separation of cranial sutures and enlargement of the head may be seen in children. The role of MRI in diagnosis and patient management cannot be overemphasized.

Clivus chordoma in a 9-year-old child: case report and review of the literature

Chordomas are bone tumors of the axial skeleton. They arise from notochordal remnants. In children these tumors are extremely rare and are predominantly located in the skull base. The authors report on a clivus chordoma in a 9 7/12-year-old girl. It presented as a nasopharyngeal mass with destruction of the clivus and paralyses of the ninth, tenth, and eleventh cranial nerves on the right side. After incomplete resection by a transoral transclival route, high-dose radiotherapy was added. This treatment was effective as demonstrated by follow-up CAT scans. A short review of the current literature is given. The local recurrence rate is extremely high, and distant metastases may occur. Complete resection is rarely possible, and combined management with postoperative radiotherapy is propagated. Permanent cure is rare, and at the present time, chemotherapy appears to be of no value in the primary treatment of chordomas.

Operative management of tumors involving the cavernous sinus

In the past, neurosurgeons have been reluctant to operate on tumors involving the cavernous sinus because of the possibility of bleeding from the venous plexus or injury to the internal carotid artery (ICA) or the third, fourth, or sixth cranial nerves. The authors describe techniques for a more aggressive surgical approach to neoplasms in this area that are either benign or locally confined malignant lesions. During the last 2 years, seven tumors involving the cavernous sinus have been resected: six totally and one subtotally. The preoperative evaluation included axial and coronal computerized tomography, cerebral angiography, and a balloon-occlusion test of the ICA. Intraoperative monitoring of the third, fourth, sixth, and seventh cranial nerves was used to assist in locating the nerves and in avoiding injury to them. The first major step in the operative procedure was to obtain proximal control of the ICA at the petrous apex and distal control in the supraclinoid segment. The cavernous sinus was then opened by a lateral, superior, or inferior approach for tumor resection. Temporary clipping and suture of the ICA was necessary in one patient. None of the patients died or suffered a stroke postoperatively. Permanent trigeminal nerve injury occurred in three patients; in two, this was the result of tumor invasion. One patient suffered temporary paralysis of the third, fourth, and sixth cranial nerves, and in another the sixth cranial nerve was temporarily paralyzed. Preoperative cranial nerve deficits were improved postoperatively in three patients. Radiation therapy was administered postoperatively to four patients. These seven patients have been followed for 6 to 18 months to date and none has shown evidence of recurrence of the intracavernous tumor.

Skull base chordoma with cavernous sinus involvement. Partial or radical tumour-removal?

A report of eight cases of skull base chordoma is given and the related literature reviewed. From disappointing experience with incomplete tumour removal and radiation the conclusion is drawn, that radical tumour removal at the first attempt should be strived for, even if the operative risk seems to be high. Cavernous sinus invasion should not be a reason to omit operation. Loss of function of one eye appears to be justified if radical tumour removal can be achieved. Possibly, the operative strategy can be improved by combining a frontal transbasal with a frontotemporal subtemporal approach, thus creating a chance for preservation of oculomotor function even in patients whose tumour has invaded the cavernous sinus region.

Early results of ion beam radiation therapy for sacral chordoma. A Northern California Oncology Group Study

The authors report on eight patients with sacral chordoma treated with ion beam radiation therapy. Ion beams have favorable physical and biological characteristics when compared to conventional radiation therapy beams of x-rays, gamma rays, or electrons. This treatment technique has been developed to exploit those advantages. With this technique it is possible to deliver a much higher tumor dose than that usually given with conventional beams, and to date no significant normal-tissue morbidity has been noted. Seven of the eight patients currently have local control of their tumor; however, follow-up time is too short to judge the long-term local control rate of this treatment technique.

Chordoma. Report on treatment results in eighteen cases

Eighteen patients with a proven histologic diagnosis of chordoma were treated between 1949 and 1982. Four patients received only surgery, 4 patients only radiation therapy, and 10 patients received surgery and postoperative radiation therapy to a varying dose. The results suggest that a higher radiation dose gives longer recurrence-free survival, and that the best long term results can be achieved by combining surgery--as radically as possible--with radiation therapy to a dose level of 60 to 65 Gy. In view of the number of marginal recurrences (2 out of the 14 patients who received radiation therapy), the importance of choosing the right treatment volume is stressed.

Radiation therapy of tumours involving the skull base

The author reviews the Princess Margaret Hospital (Ontario Cancer Institute) experience with radiation therapy in certain tumours involving the skull base including meningiomas, chordomas, craniopharyngiomas and other less common tumours. Radiation therapy offers an effective supplementary or alternative treatment for such lesions.

Interstitial irradiation of skull base tumours

The rationale for interstitial irradiation of tumours in and around the skull base is reviewed, and the experience accumulated with pituitary adenomas, meningiomas, and chordomas is summarized. Intracystic irradiation for craniopharyngiomas is also reviewed.

Precision, high dose radiotherapy. II. Helium ion treatment of tumors adjacent to critical central nervous system structures

In this paper we present a technique for treating relatively small, low grade tumors located very close to critical, radiation sensitive central nervous system structures such as the spinal cord and the brain stem. A beam of helium ions is used to irradiate the tumor. The nearby normal tissues are protected by exploiting the superb dose localization properties of this beam, particularly its well defined and controllable range in tissue, the increased dose deposited near the end of this range (i.e., the Bragg peak), the sharp decrease in dose beyond the Bragg peak, and the sharp penumbra of the beam. To execute this type of treatment, extreme care must be taken in localization of the tumor and normal tissues, as well as in treatment planning and dosimetry, patient immobilization, and verification of treatment delivery. To illustrate the technique, we present a group of 19 patients treated for chordomas, meningiomas and low grade chondrosarcomas in the base of the skull or spinal column. We have been able to deliver high, uniform doses to the target volumes (doses equivalent to 60 to 80 Gy of cobalt-60) while keeping the doses to the nearby critical tissues below the threshold for radiation damage. Follow-up on this group of patients is short, averaging 22 months (2 to 75 months). Currently, 15 patients have local control of their tumor. Two major complications, a spinal cord transection and optic tract damage, are discussed in detail. Our treatment policies have been modified to minimize the risk of these complications in the future, and we are continuing to use this method to treat such patients. We are enthusiastic about this technique, since we believe there is no other potentially curative treatment for these patients.