1
|
Huang W, Hu X, Cai W, Cheng M, Fang M, Sun Z, Hu T, Yan W. Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor. J Plast Reconstr Aesthet Surg 2024; 91:173-180. [PMID: 38417394 DOI: 10.1016/j.bjps.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/23/2023] [Accepted: 02/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome. METHODS A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups. RESULTS Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001). CONCLUSIONS This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.
Collapse
Affiliation(s)
- Wending Huang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xianglin Hu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiluo Cai
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Mo Cheng
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Meng Fang
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zhengwang Sun
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Tu Hu
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Wangjun Yan
- Department of Musculoskeletal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China.
| |
Collapse
|
2
|
Goumenos S, Kakouratos G, Trikoupis I, Gavriil P, Gerasimidis P, Soultanis K, Patapis P, Kontogeorgakos V, Papagelopoulos P. Clinical Outcome after Surgical Treatment of Sacral Chordomas: A Single-Center Retrospective Cohort of 27 Patients. Cancers (Basel) 2024; 16:973. [PMID: 38473334 DOI: 10.3390/cancers16050973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Introduction: The aims of our study were (1) to determine disease-specific and disease-free survival after the en-bloc resection of sacral chordomas and (2) to investigate potential risk factors for tumor recurrence and major postoperative wound-related complications. Methods: We retrospectively analyzed 27 consecutive patients with sacral chordomas who were surgically treated in our institution between 2004 and 2022. Three patients (11.1%) had a recurrent tumor and four patients (14.8%) had history of a second primary solid tumor prior to or after their sacral chordoma. A combined anterior and posterior approach, colostomy, plastic reconstruction, and spinopelvic instrumentation were necessitated in 51.9%, 29.6%, 37%, and 7.4% of cases, respectively. The mean duration of follow-up was 58 ± 41 months (range= 12-170). Death-related-to-disease, disease recurrence, and major surgical site complications were analyzed using Kaplan-Meier survival analysis, and investigation of the respective risk factors was performed with Cox hazard regression. Results: The estimated 5-year and 10-year disease-specific survival was 75.3% (95% CI = 49.1-87.5%) and 52.7% (95% CI = 31-73.8%), respectively. The estimated 1-year, 5-year, and 10-year disease-free survival regarding local and distant disease recurrence was 80.4% (95% CI = 60.9-91.1%), 53.9% (95% CI = 24.6-66.3%), and 38.5% (95% CI = 16.3-56.2%), respectively. The mean survival of the recurred patients was 61.7 ± 33.4 months after their tumor resection surgery. Conclusions: Despite the high relapse rates and perioperative morbidity, long-term patient survival is not severely impaired. Positive or less than 2 mm negative resection margins have a significant association with disease progression.
Collapse
Affiliation(s)
- Stavros Goumenos
- 1st Department of Orthopaedic Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| | - Georgios Kakouratos
- 1st Department of Orthopaedic Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| | - Ioannis Trikoupis
- 1st Department of Orthopaedic Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| | - Panagiotis Gavriil
- 1st Department of Orthopaedic Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| | - Pavlos Gerasimidis
- 1st Department of Orthopaedic Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| | - Konstantinos Soultanis
- 1st Department of Orthopaedic Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| | - Pavlos Patapis
- 3rd Department of Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| | - Vasileios Kontogeorgakos
- 1st Department of Orthopaedic Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| | - Panayiotis Papagelopoulos
- 1st Department of Orthopaedic Surgery, "Attikon" University General Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12461 Athens, Greece
| |
Collapse
|
3
|
Redmond KJ, Schaub SK, Lo SFL, Khan M, Lubelski D, Bilsky M, Yamada Y, Fehlings M, Gogineni E, Vajkoczy P, Ringel F, Meyer B, Amin AG, Combs SE, Lo SS. Radiotherapy for Mobile Spine and Sacral Chordoma: A Critical Review and Practical Guide from the Spine Tumor Academy. Cancers (Basel) 2023; 15:cancers15082359. [PMID: 37190287 DOI: 10.3390/cancers15082359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Chordomas are rare tumors of the embryologic spinal cord remnant. They are locally aggressive and typically managed with surgery and either adjuvant or neoadjuvant radiation therapy. However, there is great variability in practice patterns including radiation type and fractionation regimen, and limited high-level data to drive decision making. The purpose of this manuscript was to summarize the current literature specific to radiotherapy in the management of spine and sacral chordoma and to provide practice recommendations on behalf of the Spine Tumor Academy. A systematic review of the literature was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) approach. Medline and Embase databases were utilized. The primary outcome measure was the rate of local control. A detailed review and interpretation of eligible studies is provided in the manuscript tables and text. Recommendations were defined as follows: (1) consensus: approved by >75% of experts; (2) predominant: approved by >50% of experts; (3) controversial: not approved by a majority of experts. Expert consensus supports dose escalation as critical in optimizing local control following radiation therapy for chordoma. In addition, comprehensive target volumes including sites of potential microscopic involvement improve local control compared with focal targets. Level I and high-quality multi-institutional data comparing treatment modalities, sequencing of radiation and surgery, and dose/fractionation schedules are needed to optimize patient outcomes in this locally aggressive malignancy.
Collapse
Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Stephanie K Schaub
- Department of Radiation Oncology, The University of Washington, Seattle, WA 98195, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY 11549, USA
| | - Majid Khan
- Department of Radiology, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurological Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michael Fehlings
- Department of Neurosurgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Emile Gogineni
- Department of Radiation Oncology, The Ohio State University, Columbus, OH 43210, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charite University Hospital, 10117 Berlin, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, 55131 Mainz, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, 80333 Munich, Germany
| | - Anubhav G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA 98115, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, 81675 Munich, Germany
| | - Simon S Lo
- Department of Radiation Oncology, The University of Washington, Seattle, WA 98195, USA
| |
Collapse
|
4
|
Hoppe BS, Petersen IA, Wilke BK, DeWees TA, Imai R, Hug EB, Fiore MR, Debus J, Fossati P, Yamada S, Orlandi E, Zhang Q, Bao C, Seidensaal K, May BC, Harrell AC, Houdek MT, Vallow LA, Rose PS, Haddock MG, Ashman JB, Goulding KA, Attia S, Krishnan S, Mahajan A, Foote RL, Laack NN, Keole SR, Beltran CJ, Welch EM, Karim M, Ahmed SK. Pragmatic, Prospective Comparative Effectiveness Trial of Carbon Ion Therapy, Surgery, and Proton Therapy for the Management of Pelvic Sarcomas (Soft Tissue/Bone) Involving the Bone: The PROSPER Study Rationale and Design. Cancers (Basel) 2023; 15:1660. [PMID: 36980545 PMCID: PMC10046156 DOI: 10.3390/cancers15061660] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/10/2023] Open
Abstract
Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT (n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy (n = 30), and (3) proton therapy (n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.
Collapse
Affiliation(s)
- Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Ivy A. Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Benjamin K. Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Todd A. DeWees
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Phoenix, AZ 85054, USA
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Reiko Imai
- Division of Radiation Oncology, QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba 263-8555, Japan
| | - Eugen B. Hug
- Department of Radiation Oncology, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria
| | - Maria Rosaria Fiore
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation, German Cancer Research Center, 69120 Heidelberg, Germany
| | - Piero Fossati
- Department of Radiation Oncology, MedAustron Ion Therapy Center, 2700 Wiener Neustadt, Austria
- Department for Basic and Translational Oncology and Hematology, Karl Landsteiner University of Health Sciences, 3500 Krems, Austria
| | - Shigeru Yamada
- Division of Radiation Oncology, QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Chiba 263-8555, Japan
| | - Ester Orlandi
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy
| | - Qing Zhang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai 201102, China
| | - Cihang Bao
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai 201102, China
| | - Katharina Seidensaal
- Department of Radiation Oncology, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation, German Cancer Research Center, 69120 Heidelberg, Germany
| | - Byron C. May
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Anna C. Harrell
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Matthew T. Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Laura A. Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Peter S. Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | - Steven Attia
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Sunil Krishnan
- Department of Radiation Oncology, University of Texas Health Houston Neurosciences-Texas Medical Center, Houston, TX 77030, USA
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Robert L. Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Nadia N. Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Chris J. Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Eric M. Welch
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Mohammed Karim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| |
Collapse
|
5
|
Clinical outcomes and toxicities of 100 patients treated with proton therapy for chordoma on the proton collaborative group prospective registry. Radiother Oncol 2023; 183:109551. [PMID: 36813169 DOI: 10.1016/j.radonc.2023.109551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND We present efficacy and toxicity outcomes among patients with chordoma treated on the Proton Collaborative Group prospective registry. METHODS Consecutive chordoma patients treated between 2010-2018 were evaluated. One hundred fifty patients were identified, 100 had adequate follow-up information. Locations included base of skull (61%), spine (23%), and sacrum (16%). Patients had a performance status of ECOG 0-1 (82%) and median age of 58 years. Eighty-five percent of patients underwent surgical resection. The median proton RT dose was 74 Gy (RBE) (range 21-86 Gy (RBE)) using passive scatter proton RT (PS-PBT) (13%), uniform scanning proton RT (US-PBT) (54%) and pencil beam scanning proton RT (PBS-PBT) (33%). Rates of local control (LC), progression-free survival (PFS), overall survival (OS) and acute and late toxicities were assessed. RESULTS 2/3-year LC, PFS, and OS rates are 97%/94%, 89%/74%, and 89%/83%, respectively. LC did not differ based on surgical resection (p = 0.61), though this is likely limited by most patients having undergone a prior resection. Eight patients experienced acute grade 3 toxicities, most commonly pain (n = 3), radiation dermatitis (n = 2), fatigue (n = 1), insomnia (n = 1) and dizziness (n = 1). No grade ≥ 4 acute toxicities were reported. No grade ≥ 3 late toxicities were reported, and most common grade 2 toxicities were fatigue (n = 5), headache (n = 2), CNS necrosis (n = 1), and pain (n = 1). CONCLUSIONS In our series, PBT achieved excellent safety and efficacy outcomes with very low rates of treatment failure. CNS necrosis is exceedingly low (<1%) despite the high doses of PBT delivered. Further maturation of data and larger patient numbers are necessary to optimize therapy in chordoma.
Collapse
|
6
|
Tobert DG, Kelly SP, Xiong GX, Chen YL, MacDonald SM, Bongers ME, Lozano-Calderon SA, Newman ET, Raskin KA, Schwab JH. The impact of radiotherapy on survival after surgical resection of chordoma with minimum five-year follow-up. Spine J 2023; 23:34-41. [PMID: 35470086 DOI: 10.1016/j.spinee.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/20/2022] [Accepted: 04/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Local control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up. PURPOSE The purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up. STUDY DESIGN/SETTING Retrospective, single-center, cohort study. PATIENT SAMPLE Patients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral. OUTCOME MEASURES The outcome measures were local recurrence-free interval (LRFI) and overall survival (OS). METHODS Demographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method. FUNDING STATEMENT No funding was obtained for this work. RESULTS Seventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1-24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810). CONCLUSION Chordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence.
Collapse
Affiliation(s)
- Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sean P Kelly
- Department of Orthopaedic Surgery, Pali Moma Medical Center, Honolulu, HI, USA
| | - Grace X Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michiel E Bongers
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Santiago A Lozano-Calderon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Erik T Newman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin A Raskin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
7
|
Jae-Min Park A, McDowell S, Mesfin A. Management of Chordoma of the Sacrum and Mobile Spine. JBJS Rev 2022; 10:01874474-202212000-00004. [PMID: 36639876 DOI: 10.2106/jbjs.rvw.22.00162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
➢ Chordomas account for 1% to 4% of primary tumors of the spine and sacrum. ➢ En bloc resection is the preferred surgical treatment for the management of chordomas. ➢ Proton beam radiation is increasingly being used as a postoperative radiation modality for the treatment of chordomas.
Collapse
Affiliation(s)
- Andrew Jae-Min Park
- Department of Orthopedic Surgery and Physical Performance, University of Rochester School of Medicine & Dentistry, Rochester, New York
| | | | | |
Collapse
|
8
|
Rose PS. The management of sacral tumours. Bone Joint J 2022; 104-B:1284-1291. [DOI: 10.1302/0301-620x.104b12.bjj-2022-0734.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours. Cite this article: Bone Joint J 2022;104-B(12):1284–1291.
Collapse
Affiliation(s)
- Peter S. Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Journal of the American Academy of Orthopaedic Surgeons, Rosemont, Illinois, USA
| |
Collapse
|
9
|
Court C, Briand S, Mir O, Le Péchoux C, Lazure T, Missenard G, Bouthors C. Management of chordoma of the sacrum and mobile spine. Orthop Traumatol Surg Res 2022; 108:103169. [PMID: 34890865 DOI: 10.1016/j.otsr.2021.103169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023]
Abstract
Chordoma is a very rare, poorly known malignancy, with slow progression, mainly located in the sacrum and spine. All age groups may be affected, with a diagnostic peak in the 5th decade of life. Clinical diagnosis is often late. Histologic diagnosis is necessary, based on percutaneous biopsy. Specific markers enable diagnosis and prediction of response to novel treatments. New radiation therapy techniques can stabilize the tumor for 5 years in inoperable patients, but en-bloc resection is the most effective treatment, and should be decided on after a multidisciplinary oncology team meeting in an expert reference center. The type of resection is determined by fine analysis of invasion. According to the level of resection, the patients should be informed and prepared for the expected vesico-genito-sphincteral neurologic sequelae. In tumors not extending above S3, isolated posterior resection is possible. Above S3, a double approach is needed. Anterior release of the sacrum is performed laparoscopically or by robot; resection uses a posterior approach. Posterior wall reconstruction is performed, with an associated flap. Spinopelvic stabilization is necessary in trans-S1 resection. Total or partial sacrectomy shows high rates of complications: intraoperative blood loss, infection or mechanical issues. Neurologic sequelae depend on the level of root sacrifice. No genital-sphincteral function survives S3 root sacrifice. Patient survival depends on initial resection quality and the center's experience. Immunotherapy is an ongoing line of research.
Collapse
Affiliation(s)
- Charles Court
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France.
| | - Sylvain Briand
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Olivier Mir
- Service d'Oncologie, Institut Gustave Roussy, Université Paris Saclay, 114, rue Edouard-Vaillant, 94805 Villejuif Cedex, France
| | - Cécile Le Péchoux
- Service d'Oncologie, Institut Gustave Roussy, Université Paris Saclay, 114, rue Edouard-Vaillant, 94805 Villejuif Cedex, France
| | - Thierry Lazure
- Service d'Anatomopathologie de l'Hôpital de Bicêtre, Université Paris Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Gilles Missenard
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Charlie Bouthors
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| |
Collapse
|
10
|
Yolcu YU, Zreik J, Wahood W, Bhatti AUR, Bydon M, Houdek MT, Rose PS, Mahajan A, Petersen IA, Haddock MG, Ahmed SK, Laack NN, Jethwa K, Jeans EB, Imai R, Yamada S, Foote RL. Comparison of Oncologic Outcomes and Treatment-Related Toxicity of Carbon Ion Radiotherapy and En Bloc Resection for Sacral Chordoma. JAMA Netw Open 2022; 5:e2141927. [PMID: 34994795 PMCID: PMC8742192 DOI: 10.1001/jamanetworkopen.2021.41927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Maximal resection is the preferred management for sacral chordomas but can be associated with unacceptable morbidity. Outcomes with radiotherapy are poor. Carbon ion radiotherapy (CIRT) is being explored as an alternative when surgery is not preferred. OBJECTIVE To compare oncologic outcomes and treatment-related toxicity of CIRT and en bloc resection for sacral chordoma. DESIGN, SETTING, AND PARTICIPANTS Univariable logistic regression was performed to evaluate the association between treatment type and oncologic and toxicity outcomes in this retrospective cohort study. Nearest-neighbor propensity score matching was used to match the CIRT cohort with the en bloc resection cohort and 10 National Cancer Database (NCDB) cohorts separately, with the objective of obtaining more homogeneous cohorts when comparing treatments. Patient- and tumor-related characteristics from 2 institutional cohorts were collected for patients diagnosed with sacral chordomas between April 1, 1994, and July 31, 2017. The NCDB was queried for data on patients with sacral chordoma from January 1, 2004, to December 31, 2016, as a comparator in overall survival (OS) analyses. Data analysis was conducted from February 24, 2020, to January 16, 2021. EXPOSURES En bloc resection, incomplete resection, photon radiotherapy, proton radiotherapy, and CIRT. MAIN OUTCOMES AND MEASURES Overall survival was estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model. Peripheral motor nerve toxic effects were scored using Common Terminology Criteria for Adverse Events, version 4.03. RESULTS A total of 911 patients were included in the study (NCDB: n = 669; median age, 64 [IQR, 52-74] years; 410 [61.3%] men; CIRT: n = 188; median age, 66 [IQR, 58-71] years; 128 [68.1%] men; en bloc surgical resection: n = 54; median age, 53.5 [IQR 49-64] years, 36 [66.7%] men). Comparison of the propensity score-matched institutional en bloc resection and CIRT cohorts revealed no statistically significant difference in OS (CIRT: median OS, 68.1 [95% CI, 44.0-102.6] months; en bloc resection: median OS, 58.6 [95% CI, 25.6-123.5] months; P = .57; hazard ratio, 0.71 [95% CI, 0.25-2.06]; P = .53). The CIRT cohort experienced lower rates of peripheral motor neuropathy (odds ratio, 0.13 [95% CI, 0.04-0.40]; P < .001). On comparison of the propensity score-matched NCDB cohorts with the CIRT cohort, significantly higher OS was found for CIRT compared with margin-positive surgery without adjuvant radiotherapy (CIRT: median OS, 64.7 [95% CI, 57.8-69.7] months; margin-positive surgery without adjuvant radiotherapy: median OS, 60.6 [95% CI, 44.2-69.7] months, P = .03) and primary radiotherapy alone (CIRT: median OS, 64.9 [95% CI 57.0-70.5] months; primary radiotherapy alone: 31.8 [95% CI, 27.9-40.6] months; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that CIRT can be used as treatment for older patients with high performance status and sacral chordoma in whom surgery is not preferred. CIRT might provide additional benefit for patients who undergo margin-positive resection or who are candidates for primary photon radiotherapy.
Collapse
Affiliation(s)
- Yagiz U Yolcu
- Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jad Zreik
- Central Michigan University College of Medicine, Mount Pleasant
| | - Waseem Wahood
- Dr Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida
| | | | - Mohamad Bydon
- Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Krishan Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Reiko Imai
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Inageku, Chiba, Japan
| | - Shigeru Yamada
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, Inageku, Chiba, Japan
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
11
|
Brinkmann EJ, Wenger DE, Johnson JD, Karim SM, Blezek DJ, Rose PS, Houdek MT. Impact of preoperative sarcopenia in patients undergoing sacral tumor resection. J Surg Oncol 2021; 125:790-795. [PMID: 34932215 DOI: 10.1002/jso.26776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/21/2021] [Accepted: 12/12/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Sacral tumor resection is known for a high rate of complications. Sarcopenia has been found to be associated with wound complications; however, there is a paucity of data examining the impact of sarcopenia on the outcome of sacral tumor resection. METHODS Forty-eight patients (31 primary sarcomas, 17 locally recurrent carcinomas) undergoing sacrectomy were reviewed. Central sarcopenia was assessed by measuring the psoas:lumbar vertebra index (PLVI), with the 50th percentile (0.97) used to determine which patients were high (>0.97) versus low (<0.97). RESULTS Twenty-four (50%) patients had a high PLVI and 24 (50%) had a low PLVI (sarcopenic). There was no difference (p > 0.05) in the demographics of patients with or without sarcopenia. There was no difference in the incidence of postoperative wound complications (odds ratio [OR] = 1.0, p = 1.0) or deep infection (OR = 0.83, p = 1.0). Sarcopenia was not associated with death due to disease (hazard ratio [HR] = 2.04, p = 0.20) or metastatic disease (HR = 2.47, p = 0.17), but was associated with local recurrence (HR = 6.60, p = 0.01). CONCLUSIONS Central sarcopenia was not predictive of wound complications or infection following sacral tumor resection. Sarcopenia was, however, an independent risk factor for local tumor recurrence following sacrectomy and should be considered when counseling patients on the outcome of sacrectomy.
Collapse
Affiliation(s)
- Elyse J Brinkmann
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Doris E Wenger
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua D Johnson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Syed M Karim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Blezek
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
12
|
Labott JR, Brinkmann EJ, Hevesi M, Couch CG, Rose PS, Houdek MT. The ACS-NSQIP surgical risk calculator is a poor predictor of postoperative complications in patients undergoing oncologic distal femoral replacement. Knee 2021; 33:17-23. [PMID: 34536764 DOI: 10.1016/j.knee.2021.08.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/20/2021] [Accepted: 08/31/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Distal femur replacement (DFR) has become a preferred reconstruction for tumors involving the femur but is associated with known complications. The ACS-NSQIP surgical risk calculator is an online tool developed to estimate postoperative complications in the first 30-days, however, has not been used in patients undergoing DFR. The purpose of this study was determining the utility of the ACS-NSQIP calculator to predict postoperative complications. METHODS 56 (30 male, 26 female) patients who underwent DFR were analyzed using the CPT codes: 27,365 (Under Excision Procedures on the Femur and Knee Joint), 27,447 (Arthroplasty, knee, condyle and plateau), 27,486 (Revision of total knee arthroplasty, with or without allograft), 27,487 (Revision of total knee arthroplasty, with or without allograft) and 27,488 (Repair, Revision, and/or Reconstruction Procedures on the Femur [Thigh Region] and Knee Joint). The predicted rates of complications were compared to the observed rates. RESULTS Complications were noted in 30 (54%) of patients. The predicted risk of complications based off the CPT codes were: 27,356 (14%); 27,447 (5%); 27,486 (7%); 27,487 (8%) and 27,488 (12%). Based on ROC curves, the use of the ACS-NSQIP score were poor predictors of complications (27356, AUC 0.54); (27447, AUC 0.45); (27486, AUC 0.45); (27487, AUC 0.46); (27488, AUC 0.46). CONCLUSIONS Distal femur arthroplasty performed in the setting of oncologic orthopedics is a complex procedure in a "high risk" surgical group. The ACS-NSQIP does not adequately predict the incidence of complications in these patients and cannot be reliably used in the shared decision-making process.
Collapse
Affiliation(s)
- Joshua R Labott
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Elyse J Brinkmann
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Mario Hevesi
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Cory G Couch
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Peter S Rose
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States
| | - Matthew T Houdek
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN, United States.
| |
Collapse
|
13
|
Siavashpour Z, Aghili M, Anjidani S, Zayeri F, Moghani MM, Maleki M, Jaberi R. Dose to pelvic lymph nodes during brachytherapy of locally advanced cervical cancer with 60Co HDR source. Brachytherapy 2021; 21:158-169. [PMID: 34750084 DOI: 10.1016/j.brachy.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE This study investigated the correlation between the prescription dose and dose to the Manchester and International Commission on Radiation Units and Measurements-report 38 (ICRU-38) lymphatic trapezoid points during high-dose-rate (HDR) brachytherapy of locally advanced cervical cancer with (Cobalt-60) 60Co . METHODS AND MATERIALS A retrospective study was designed for; patients with locally advanced cervical cancer, treated by external beam radiotherapy and concurrent weekly Cisplatin-based chemotherapy, had no extended parametrial invasion and was treated by tandem-ovoid set, from 2017 to 2020. Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology (GEC-ESTRO) based target's volume, ICRU-89 revised version of Manchester points A and B, and ICRU-38 lymph node surrogate points were determined, and their dose was recorded. Paired sample t-test, linear regression analysis, and Pearson correlation analyses were done considering a statistical significance level of 0.05 and using IBM SPSS statistics (Version 23, IBM Crop.). RESULTS Seventy-four brachytherapy cases were included. A positive and strong correlation was observed between D90 of clinical target volume (CTVHR) and points A and B dose for CTVHR〈 15 cc and 〉 35 cc. Strong and significant (p < 0.05) correlations were achieved between pelvic wall points dose and D90 and D100 of the obturator and between D50 and hot points of internal iliac lymph nodes. A strong correlation was obtained between D50 and D90 of external iliac lymph nodes and their ICRU points. CONCLUSIONS Strong correlations were obtained between dose to the pelvic lymphatic chains and their historical ICRU-38 surrogate points during HDR brachytherapy of locally advanced cervical cancer patients with 60Co tandem-ovoid applicator sets. The correlation strength between point A and prescription dose highly depends on the CTVHR volume.
Collapse
Affiliation(s)
- Zahra Siavashpour
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Clinical Research Development Unit of Shohadaye Tajrish Hospital, Tehran, Iran
| | - Mahdi Aghili
- Radiation Oncology Research Center, Iran Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shabnam Anjidani
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Zayeri
- Proteomics Research Center and Biostatics Department, School of Allied Medical Sciences, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mona Molekzadeh Moghani
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Clinical Research Development Unit of Shohadaye Tajrish Hospital, Tehran, Iran.
| | - Maedeh Maleki
- Brachytherapy Department, Rasoul Akram Educational Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ramin Jaberi
- Radiation Oncology Research Center, Iran Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Physics, University of Surrey, Guildford, UK
| |
Collapse
|
14
|
FERRONATO DANILODESOUZA, TAVARES JUNIOR MAUROCOSTAMORAIS, NARAZAKI DOUGLASKENJI, GHILARDI CESARSALGE, TEIXEIRA WILLIAMGEMIOJACOBSEN, CRISTANTE ALEXANDREFOGAÇA, BARROS FILHO TARCISIOELOYPESSOADE. COMPLICATIONS AFTER PARTIAL, TOTAL OR EXTENDED SACRECTOMY: A CASE SERIES. COLUNA/COLUMNA 2021. [DOI: 10.1590/s1808-185120212003235738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective The aim of this study was to conduct a survey of the different complications of partial, total or extended sacrectomy for the treatment of spinal tumors. Method This study is a descriptive analysis of medical records from a series of 18 patients who underwent sacrectomy between 2010 and 2019 at a tertiary center specializing in spinal tumor surgeries. The variables analyzed were sex, age, hospitalization time, oncologic diagnosis, posterior fixation pattern, rate of complications, and Frankel, ASA and ECOG scales. Results Of the 18 patients, 10 (55.5%) were male and 8 (44.5%) were female, and the mean age was 48 years. The mean hospitalization time was 23 days. Of the 18 patients, 8 (44.5%) contracted postoperative infections requiring surgery. Perioperative complications included liquoric fistula (22.25%), hemodynamic instability requiring vasoactive drugs in the immediate postoperative period (22.25%), wound dehiscence (11.1%), acute obstructive abdomen (11.1%), occlusion of the left external iliac artery (11.1%), immediate postoperative death due to acute myocardial infarction (11.1%), and intraoperative death due to hemodynamic instability (11.1%). Conclusions Partial, total or extended sacrectomy is a complex procedure with high morbidity and mortality, even in centers specializing in the treatment of spinal tumors. Level of evidence IV; case series study.
Collapse
|
15
|
Chen X, Lo SFL, Bettegowda C, Ryan DM, Gross JM, Hu C, Kleinberg L, Sciubba DM, Redmond KJ. High-dose hypofractionated stereotactic body radiotherapy for spinal chordoma. J Neurosurg Spine 2021; 35:674-683. [PMID: 34388713 DOI: 10.3171/2021.2.spine202199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal chordoma is locally aggressive and has a high rate of recurrence, even after en bloc resection. Conventionally fractionated adjuvant radiation leads to suboptimal tumor control, and data regarding hypofractionated regimens are limited. The authors hypothesized that neoadjuvant stereotactic body radiotherapy (SBRT) may overcome its intrinsic radioresistance, improve surgical margins, and allow preservation of critical structures during surgery. The purpose of this study is to review the feasibility and early outcomes of high-dose hypofractionated SBRT, with a focus on neoadjuvant SBRT. METHODS Electronic medical records of patients with spinal chordoma treated using image-guided SBRT between 2009 and 2019 at a single institution were retrospectively reviewed. RESULTS Twenty-eight patients with 30 discrete lesions (24 in the mobile spine) were included. The median follow-up duration was 20.8 months (range 2.3-126.3 months). The median SBRT dose was 40 Gy (range 15-50 Gy) in 5 fractions (range 1-5 fractions). Seventeen patients (74% of those with newly diagnosed lesions) received neoadjuvant SBRT, of whom 15 (88%) underwent planned en bloc resection, all with negative margins. Two patients (12%) developed surgical wound-related complications after neoadjuvant SBRT and surgery, and 4 (two grade 3 and two grade 2) experienced postoperative complications unrelated to the surgical site. Of the remaining patients with newly diagnosed lesions, 5 received adjuvant SBRT for positive or close surgical margins, and 1 received SBRT alone. Seven recurrent lesions were treated with SBRT alone, including 2 after failure of prior conventional radiation. The 2-year overall survival rate was 92% (95% confidence interval [CI] 71%-98%). Patients with newly diagnosed chordoma had longer median survival (not reached) than those with recurrent lesions (27.7 months, p = 0.006). The 2-year local control rate was 96% (95% CI 74%-99%). Among patients with radiotherapy-naïve lesions, no local recurrence was observed with a biologically effective dose ≥ 140 Gy, maximum dose of the planning target volume (PTV) ≥ 47 Gy, mean dose of the PTV ≥ 39 Gy, or minimum dose to 80% of the PTV ≥ 36 Gy (5-fraction equivalent doses). All acute toxicities from SBRT were grade 1-2, and no myelopathy was observed. CONCLUSIONS Neoadjuvant high-dose, hypofractionated SBRT for spinal chordoma is safe and does not increase surgical morbidities. Early outcomes at 2 years are promising, although long-term follow-up is pending.
Collapse
Affiliation(s)
- Xuguang Chen
- Departments of1Radiation Oncology and Molecular Radiation Sciences
| | | | | | | | - John M Gross
- 4Pathology, Johns Hopkins University School of Medicine; and
| | - Chen Hu
- 5Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | |
Collapse
|
16
|
Chordoma: 18F-FDG PET/CT and MRI imaging features. Skeletal Radiol 2021; 50:1657-1666. [PMID: 33521875 DOI: 10.1007/s00256-021-03723-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/21/2021] [Accepted: 01/21/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Examine the 18F-FDG PET/CT and MRI imaging characteristics of chordoma. MATERIALS AND METHODS Biopsy-proven chordoma with a pre-therapy 18F-FDG PET/CT from 2001 through 2019 in patients > 18 years old were retrospectively reviewed. Multiple PET/CT and MRI imaging parameters were assessed. RESULTS A total of 23 chordoma patients were included (16 M, 7 F; average age of 60.1 ± 13.0 years) with comparative MRI available in 22 cases. This included 13 sacrococcygeal, 9 mobile spine, and one clival lesions. On 18F-FDG PET/CT, chordomas demonstrated an average SUVmax of 5.8 ± 3.7, average metabolic tumor volume (MTV) of 160.2 ± 263.8 cm3, and average total lesion glycolysis (TLG) of 542.6 ± 1210 g. All demonstrated heterogeneous FDG activity. On MRI, chordomas were predominantly T2 hyperintense (22/22) and T1 isointense (18/22), contained small foci of T1 hyperintensity (17/22), and demonstrated heterogeneous enhancement (14/20). There were no statistically significant associations found between 18F-FDG PET/CT and MRI imaging features. There was no relationship of SUVmax (p = 0.53), MTV (p = 0.47), TLG (p = 0.48), maximal dimension (p = 0.92), or volume (p = 0.45) to the development of recurrent or metastatic disease which occurred in 6/22 patients over a mean follow-up duration of 4.1 ± 2.0 years. CONCLUSION On 18F-FDG PET/CT imaging, chordomas demonstrate moderate, heterogeneous FDG uptake. Predominant T2 hyperintensity and small foci of internal increased T1 signal are common on MRI. The inherent FDG avidity of chordomas suggests that 18F-FDG PET/CT may be a useful modality for staging, evaluating treatment response, and assessing for recurrent or metastatic disease.
Collapse
|
17
|
Labott JR, Brinkmann EJ, Hevesi M, Wyles CC, Couch CG, Rose PS, Houdek MT. Utility of the ACS-NSQIP surgical risk calculator in predicting postoperative complications in patients undergoing oncologic proximal femoral replacement. J Surg Oncol 2021; 124:852-857. [PMID: 34184278 DOI: 10.1002/jso.26583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/25/2021] [Accepted: 06/12/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Proximal femur replacement (PFR) in the setting of tumor resection is associated with a high rate of postoperative complication. The online American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator is approved by the Center of Medicare and Medicaid services to estimate 30-day postoperative complications. This study was to determine if the ACS-NSQIP can predict postoperative complications following PFR. METHODS We reviewed 103 (61 male and 42 female) patients undergoing PFR using the Current Procedural Terminology (CPT) codes available in the calculator: 27125 (hemiarthroplasty), 27130 (total hip), 27132 (conversion to total hip), 27134 (revision total hip), 27137 (revision acetabulum), 27138 (revision femur), and 27365 (excision tumor hip). The predicted rates of complications were compared with the observed rates. RESULTS Complications occurred in 54 (52%) of patients, with the predicted risk based on CPT codes: 27125 (21.5%); 27130 (7.8%); 27132 (16.6%), 27134 (17.8%), 27137 (14.4%), 274138 (22.7%), and 27365 (16.2%). The calculator was a poor predictor of complications (27125, area under the curve [AUC] 0.576); (27130, AUC 0.489); (27132, AUC 0.490); (27134, AUC 00.489); (27137, AUC 0.489); (27138, AUC 0.471); and (27365, AUC 0.538). CONCLUSION Oncologic PFR is known for complications. The ACS-NSQIP does not adequately predict the incidence of complications, and therefore cannot reliably be used in their shared decision-making process preoperative.
Collapse
Affiliation(s)
- Joshua R Labott
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elyse J Brinkmann
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cody C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Cory G Couch
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
18
|
Pennington Z, Ehresman J, Elsamadicy AA, Shin JH, Goodwin CR, Schwab JH, Sciubba DM. Systematic review of charged-particle therapy for chordomas and sarcomas of the mobile spine and sacrum. Neurosurg Focus 2021; 50:E17. [PMID: 33932924 DOI: 10.3171/2021.2.focus201059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Long-term local control in patients with primary chordoma and sarcoma of the spine and sacrum is increasingly reliant upon en bloc resection with negative margins. At many institutions, adjuvant radiation is recommended; definitive radiation is also recommended for the treatment of unresectable tumors. Because of the high off-target radiation toxicities associated with conventional radiotherapy, there has been growing interest in the use of proton and heavy-ion therapies. The aim of this study was to systematically review the literature regarding these therapies. METHODS The PubMed, OVID, Embase, and Web of Science databases were queried for articles describing the use of proton, combined proton/photon, or heavy-ion therapies for adjuvant or definitive radiotherapy in patients with primary sarcoma or chordoma of the mobile spine and sacrum. A qualitative synthesis of the results was performed, focusing on overall survival (OS), progression-free survival (PFS), disease-free survival (DFS), and disease-specific survival (DSS); local control; and postradiation toxicities. RESULTS Of 595 unique articles, 64 underwent full-text screening and 38 were included in the final synthesis. All studies were level III or IV evidence with a high risk of bias; there was also significant overlap in the reported populations, with six centers accounting for roughly three-fourths of all reports. Five-year therapy outcomes were as follows: proton-only therapies, OS 67%-82%, PFS 31%-57%, and DFS 52%-62%; metastases occurred in 17%-18% and acute toxicities in 3%-100% of cases; combined proton/photon therapy, local control 62%-85%, OS 78%-87%, PFS 90%, and DFS 61%-72%; metastases occurred in 12%-14% and acute toxicities in 84%-100% of cases; and carbon ion therapy, local control 53%-100%, OS 52%-86%, PFS (only reported for 3 years) 48%-76%, and DFS 50%-53%; metastases occurred in 2%-39% and acute toxicities in 26%-48%. There were no studies directly comparing outcomes between photon and charged-particle therapies or comparing outcomes between radiation and surgical groups. CONCLUSIONS The current evidence for charged-particle therapies in the management of sarcomas of the spine and sacrum is limited. Preliminary evidence suggests that with these therapies local control and OS at 5 years are comparable among various charged-particle options and may be similar between those treated with definitive charged-particle therapy and historical surgical cohorts. Further research directly comparing charged-particle and photon-based therapies is necessary.
Collapse
Affiliation(s)
- Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aladine A Elsamadicy
- 2Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - John H Shin
- 3Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - C Rory Goodwin
- 4Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Joseph H Schwab
- 5Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
19
|
Konieczkowski DJ, DeLaney TF, Yamada YJ. Radiation Strategies for Spine Chordoma: Proton Beam, Carbon Ions, and Stereotactic Body Radiation Therapy. Neurosurg Clin N Am 2020; 31:263-288. [PMID: 32147017 DOI: 10.1016/j.nec.2019.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgery alone provides suboptimal local control of spine and sacral chordomas. Radiotherapy (RT) may improve local control in patients undergoing surgery and be used as definitive-intent treatment in patients not undergoing surgery. Although conventional-dose RT is inadequate for these radioresistant tumors, newer techniques allow treatment of the tumor to higher, more effective doses while limiting spinal cord dose to safe levels. The best local control is achieved when RT is delivered in the primary setting; RT dose is a critical determinant of local control. RT should be considered for all spine and sacral chordoma patients.
Collapse
Affiliation(s)
- David J Konieczkowski
- Harvard Radiation Oncology Program, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Yoshiya Josh Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| |
Collapse
|
20
|
Houdek MT, Wellings EP, Moran SL, Bakri K, Dozois EJ, Mathis KL, Yaszemski MJ, Sim FH, Rose PS. Outcome of Sacropelvic Resection and Reconstruction Based on a Novel Classification System. J Bone Joint Surg Am 2020; 102:1956-1965. [PMID: 32941308 DOI: 10.2106/jbjs.20.00135] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Sacral tumor resections require a multidisciplinary approach to achieve a cure and a functional outcome. Currently, there is no accepted classification system that provides a means to communicate among the multidisciplinary teams in terms of approach, osseous resection, reconstruction, and acceptable functional outcome. The purpose of this study was to report the outcome of sacral tumor resection based on our classification system. METHODS In this study, 196 patients (71 female and 125 male) undergoing an oncologic en bloc sacrectomy were reviewed. The mean age (and standard deviation) was 49 ± 16 years, and the mean body mass index was 27.2 ± 6.4 kg/m. The resections included 130 sarcomas (66%). The mean follow-up was 7 ± 5 years. RESULTS Resections included total sacrectomy (Type 1A: 20 patients [10%]) requiring reconstruction, subtotal sacrectomy (Type 1B: 5 patients [3%]) requiring reconstruction, subtotal sacrectomy (Type 1C: 104 patients [53%]) not requiring reconstruction, hemisacrectomy (Type 2: 29 patients [15%]), external hemipelvectomy and hemisacrectomy (Type 3: 32 patients [16%]), total sacrectomy and external hemipelvectomy (Type 4: 5 patients [3%]), and hemicorporectomy (Type 5: 1 patient [1%]). The disease-specific survival was 66% at 5 years and 52% at 10 years. Based on the classification, the 5-year disease-specific survival was 34% for Type 1A, 100% for Type 1B, 71% for Type 1C, 65% for Type 2, 57% for Type 3, 100% for Type 4, and 100% for Type 5 (p < 0.001). Tumor recurrence occurred in 67 patients, including isolated local recurrence (14 patients), isolated metastatic disease (31 patients), and combined local and metastatic disease (22 patients). At 5 years, the local recurrence-free survival was 77% and the metastasis-free survival was 68%. Complications occurred in 153 patients (78%), most commonly wound complications (95 patients [48%]). Following the procedure, 154 patients (79%) were ambulatory, and the mean Musculoskeletal Tumor Society (MSTS93) score was 60% ± 23%. CONCLUSIONS Although resections of sacral malignancies are associated with complications, they can be curative in a majority of patients, with a majority of patients ambulatory with an acceptable functional outcome considering the extent of the resection. At our institution, this classification allows for communication between surgical teams and implies a surgical approach, staging, reconstruction, and potential functional outcomes. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Matthew T Houdek
- Divisions of Plastic and Reconstructive Surgery (S.L.M. and K.B.) and Colorectal Surgery (E.J.D. and K.L.M.) and Department of Orthopedic Surgery (M.T.H., E.P.W., M.J.Y., F.H.S., and P.S.R.), Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Wei R, Dean DC, Thanindratarn P, Hornicek FJ, Guo W, Duan Z. Prognostic Significance of Cyclin E1 Expression in Patients With Chordoma: A Clinicopathological and Immunohistochemical Study. Front Oncol 2020; 10:596330. [PMID: 33282745 PMCID: PMC7705258 DOI: 10.3389/fonc.2020.596330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/19/2020] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Chordomas are rare, slow-growing sarcomas without any accepted prognostic biomarkers. Owing to their proximity to critical neurovascular structures, discovering predictive biomarkers in chordoma has been a significant research effort because it may potentially reduce risky therapies in patients with less aggressive tumors. In response, because cyclin E1 overexpression correlates with patient prognosis in several malignancies, we investigated its expression in chordoma and whether it informs patient prognosis. METHODS Seventy-five chordoma patient specimens were enrolled in a tissue microarray (TMA) to evaluate cyclin E1 expression via immunohistochemical staining. Western blot was used to assess cyclin E1 expression in chordoma cell lines and fresh tissues. We then correlated cyclin E1 staining intensity in the TMA to clinicopathological features and chordoma patient outcomes. RESULTS Sixty-three percent of the chordoma patient specimens in the TMA, fifty-six percent of the fresh chordoma tissues, and all chordoma cell lines showed high cyclin E1 expression. In TMA analysis, cyclin E1 expression positively correlated to chordoma patient disease status. By survival analysis, high cyclin E1 expression was an independent prognostic risk factor for chordoma patients along with advanced disease status and positive surgical margin. CONCLUSION Cyclin E1 is a promising biomarker predicting chordoma patient prognosis.
Collapse
Affiliation(s)
- Ran Wei
- Musculoskeletal Tumor Center, Beijing Key Laboratory of Musculoskeletal Tumor, Peking University People’s Hospital, Beijing, China
- Sarcoma Biology Laboratory, Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Dylan C. Dean
- Sarcoma Biology Laboratory, Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Pichaya Thanindratarn
- Sarcoma Biology Laboratory, Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- Department of Orthopedic Surgery, Chulabhorn Hospital, HRH Princess Chulabhorn College of Medical Science, Bangkok, Thailand
| | - Francis J. Hornicek
- Sarcoma Biology Laboratory, Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Wei Guo
- Musculoskeletal Tumor Center, Beijing Key Laboratory of Musculoskeletal Tumor, Peking University People’s Hospital, Beijing, China
| | - Zhenfeng Duan
- Sarcoma Biology Laboratory, Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| |
Collapse
|
22
|
Abstract
Oncologic sacrectomy is used in the curative treatment of patients with primary sacral malignancies or select locally invasive visceral malignancies.
A systematic surgical approach involves preoperative imaging, diagnosis, and multidisciplinary surgical execution. Close collaboration with pediatric, medical, and radiation oncology colleagues is often necessary to individualize treatment plans.
Collapse
Affiliation(s)
- Peter S Rose
- 1Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
23
|
Claxton MR, Shirley MB, Johnson JD, Perry KI, Rose PS, Houdek MT. Hip Arthroplasty Following Subtotal Sacrectomy for Chordoma. In Vivo 2020; 34:2517-2520. [PMID: 32871780 DOI: 10.21873/invivo.12068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Chordomas often affect the sacrum with a high predilection for local-regional recurrence. Patients typically retain their ability to ambulate, and the development of metastatic disease in the periacetabular region can have significant morbidity and pain with ambulation. The purpose of the study was to describe the outcome of patients undergoing a hip arthroplasty following resection of a sacral chordoma. PATIENTS AND METHODS From 1990 to 2015, 84 patients underwent sacrectomy for chordoma, while four of these (5%) patients underwent hip arthroplasty. The most common level of nerve root sacrifice was S2-5 (n=2). The mean time between sacrectomy and hip arthroplasty was 7 years. Indications for arthroplasty included metastatic disease (n=3) and coxarthrosis (n=1). RESULTS Postoperatively two patients ambulated with a gait aid, and no patient had a Trendelenburg gait. The mean Harris Hip Score significantly improved from 49 to 80 postoperatively (p=0.02). CONCLUSION The results of this study indicate that hip arthroplasty is a durable treatment option for patients with metastatic disease or coxarthrosis following subtotal sacrectomy for chordoma.
Collapse
Affiliation(s)
| | | | - Joshua D Johnson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, U.S.A
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, U.S.A
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, U.S.A
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, U.S.A.
| |
Collapse
|
24
|
Houdek MT, Hevesi M, Griffin AM, Yaszemski MJ, Sim FH, Ferguson PC, Rose PS, Wunder JS. Can the ACS-NSQIP surgical risk calculator predict postoperative complications in patients undergoing sacral tumor resection for chordoma? J Surg Oncol 2020; 121:1036-1041. [PMID: 32034772 DOI: 10.1002/jso.25865] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The ACS-NSQIP surgical risk calculator is an online tool that estimates the risk of postoperative complications. Sacrectomies for chordoma are associated with a high rate of complications. This study was to determine if the ACS-NSQIP calculator can predict postoperative complications following sacrectomy. METHODS Sixty-five (42 male, 23 female) patients who underwent sacrectomy were analyzed using the Current Procedural Terminology (CPT) codes: 49215 (excision of presacral/sacral tumor), 63001 (laminectomy of sacral vertebrae), 63728 (laminectomy for biopsy/excision of sacral neoplasm) and 63307 (sacral vertebral corpectomy for intraspinal lesion). The predicted rates of complications were compared to the observed rates. RESULTS Complications were noted in 44 (68%) patients. Of the risk factors available to input to the ACS-NSQIP calculator, tobacco use (OR, 20.4; P < .001) was predictive of complications. The predicted risk of complications based off the CPT codes were: 49215 (16%); 63011 (6%); 63278 (11%) and 63307 (15%). Based on ROC curves, the use of the ACS-NSQIP score were poor predictors of complications (49215, AUC 0.65); (63011, AUC 0.66); (63307, AUC 0.67); (63278, AUC 0.64). CONCLUSION The ACS-NSQIP calculator was a poor predictor of complications and was marginally better than a coin flip in its ability to predict complications following sacrectomy for chordoma.
Collapse
Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | | | - Franklin H Sim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| |
Collapse
|
25
|
Houdek MT, Hevesi M, Schwab JH, Yaszemski MJ, Griffin AM, Healey JH, Ferguson PC, Hornicek FJ, Boland PJ, Sim FH, Rose PS, Wunder JS. Association between patient age and the risk of mortality following local recurrence of a sacral chordoma. J Surg Oncol 2020; 121:267-271. [PMID: 31758570 PMCID: PMC7242148 DOI: 10.1002/jso.25774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/08/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Local recurrence (LR) of sacral chordoma is a difficult problem and the mortality risk associated with LR remains poorly described. The purpose of this study was to evaluate the risk of mortality in patients with LR and determine if patient age is associated with mortality. METHODS A total of 218 patients (144 male, 69 female; mean age 59 ± 15 years) with sacrococcygeal chordomas were reviewed. Cumulative incidence functions and competing risks for death due to disease and nondisease mortality were employed to analyze mortality trends following LR. RESULTS The 10-year overall survival (OS) was 55%. Patients with LR had 44% 10-year OS, similar to patients without (59%; P = .38). The 10-year OS between those less than 55 compared with ≥55 years were similar (69% vs 48%; P = .52). The 10-year death due to disease was worse in patients with LR compared with those without (44% vs 84%; P < .001). In patients without LR, patients ≥55 years were 1.6-fold more likely to experience death due to other causes. CONCLUSIONS Patients with an LR are more likely to die due to disease. Advanced patient age was associated with higher all-cause mortality following resection of sacral chordoma. LR of chordoma was associated with increased disease-specific mortality, regardless of age.
Collapse
Affiliation(s)
- Matthew T. Houdek
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN,Corresponding Author: , 200 First St. SW, Rochester, MN 55905, (507) 284-2511
| | - Mario Hevesi
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, MA
| | | | - Anthony M. Griffin
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - John H. Healey
- Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center and Weill College of Medicine, Cornell University, New York, NY
| | - Peter C. Ferguson
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Francis J. Hornicek
- Department of Orthopedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Patrick J. Boland
- Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center and Weill College of Medicine, Cornell University, New York, NY
| | - Franklin H. Sim
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN
| | - Peter S. Rose
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN
| | - Jay S. Wunder
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| |
Collapse
|
26
|
[From bench to bedside for new treatment paradigms in chordomas: An update]. Bull Cancer 2019; 107:129-135. [PMID: 31882268 DOI: 10.1016/j.bulcan.2019.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 11/23/2022]
Abstract
Chordomas are rare malignant tumours, which typically occur in the axial skeleton and skull base. They arise from embryonic remnants of the notochord. They constitute less than 5 % of primary bone tumours. They are characterised by their locally aggressive potential with high frequency of recurrences and a median overall survival of 6 years. The initial therapeutic strategy must be discussed in an expert centre and may involve surgery, preoperative radiotherapy, exclusive radiotherapy or therapeutic abstention. Despite this, more than 50 % of patients will be facing recurrences with few therapeutic options available at this advanced stage. This review aims to outline current treatment options available in chordomas, as well as discussing potentiality of new therapeutic approaches through their molecular characterization and the comprehension of their immunological environment.
Collapse
|
27
|
Fujiwara T, Tsuda Y, Stevenson J, Parry M, Jeys L. Sacral chordoma: do the width of surgical margin and the use of photon/proton radiotherapy affect local disease control? INTERNATIONAL ORTHOPAEDICS 2019; 44:381-389. [PMID: 31863159 DOI: 10.1007/s00264-019-04460-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Chordoma is a rare but highly aggressive primary bone sarcoma that arises commonly from the sacrum. While en bloc resection has been the mainstay of the treatment, the role of resection margin in millimetres with/without adjuvant radiotherapy (RT) has been unknown. We investigated the prognostic impact of surgical margin width, adjuvant RT, and their combined factor for sacral chordoma. METHODS Forty-eight patients who underwent surgical treatment between 1996 and 2016 were studied. Of these, 11 patients (23%) received adjuvant RT; photon RT in 7 (15%) and proton RT in 4 (8%). Margins were microscopically measured in millimetres from the resection surface to the closest tumour on histologic slides. RESULTS The five year and ten year disease-specific survival was 88% and 58%, respectively, and the local recurrence (LR) rate was 48%. The LR rate with 0-mm, < 1.5-mm, and ≥ 1.5-mm margin was 50% (group 1), 50% (group 2: RT-, 61%; group 3: RT+, 14%), and 0% (group 4), respectively. We observed a significantly lower LR rate in patients with adjuvant photon/proton RT (18%) than without it (57%; p = 0.026), and no LR was observed after post-operative proton RT. The combined factor of margin with RT clearly stratified the LR risk: patients of group 1 (positive margin) and 2 (< 1.5-mm margin, RT-) had approximately 7.5× LR risk (p = 0.049) compared with those of group 3 (< 1.5-mm margin, RT+) and 4 (≥ 1.5-mm margin). CONCLUSION This study identified the lowest risk of local failure in tumour resection with ≥ 1.5-mm margin or negative but < 1.5-mm margin with the use of adjuvant photon/proton radiotherapy for sacral chordoma. Early results of adjuvant proton RT demonstrated excellent local control.
Collapse
Affiliation(s)
- Tomohiro Fujiwara
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK. .,Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Yusuke Tsuda
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Jonathan Stevenson
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Michael Parry
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Lee Jeys
- Oncology Service, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
28
|
Affiliation(s)
- Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|