Chordoma: an analysis of twenty cases treated over a twenty-year span

Primary maxillofacial chordoma: a rare case report and literature review

Primary maxillofacial chordoma is extremely rare. We herein report a very rare case of a recurrent maxillofacial chordate tumor that was diagnosed in a 56-year-old woman who underwent three tumor resections. After surgical treatment, the patient healed well with an Eastern Cooperative Oncology Group score of 1. She was discharged to a local hospital for adjuvant radiotherapy. Close follow-up was ongoing at the time of this writing. Radical surgery and adjuvant radiotherapy remain the main treatment strategies for chordoma. Postoperative radiotherapy is particularly important. Our experience is to administer a total dose of 50 Gy to a clearly delineated target. If appropriate comprehensive treatment is available, distant metastasis of primary chordoma is rare, and neck dissection is therefore not generally recommended. Neck lymph node dissection is generally not recommended.

The clinical outcome of recurrent sacral chordoma with further surgical treatment

To analyze the clinical results and related factors of further surgical treatment for recurrent sacral chordomas.Chordomas are rare primary malignant tumors with a high recurrence rate. The treatment of recurrent tumors is difficult and controversial. Contamination by previous operations and disturbed local anatomical structures may increase the risk of reoperation. Most previous studies have focused on the primary tumor; there are very few reports on the clinical diagnosis, treatment, and prognosis of recurrent sacral chordomas.Thirty-four patients with recurrent sacral chordomas from 1979 to 2014 were included in this study. The patients comprised 25 men and 9 women with an average age of 50.7 (24-75) years. The average time until recurrence was 19.4 (4-51) months postoperatively, and 85.3% of the recurrent tumors were located in bone. The patients had an average of 1.2 (1-3) recurrences before further operations were performed in our hospital. The mean maximum tumor diameter was 8.1 (4.6-12.0) cm. Thirty-one patients underwent further tumor resection in our hospital. The postoperative recurrence, metastasis, and survival results were followed and analyzed.The mean follow-up after surgical treatment of recurrence was 49.6 (12-144) months. Nine patients (37.5%) developed recurrence again after an average of 26.7 months. The 3-year and 5-year recurrence-free survival rate was 69.4% and 63.1%, respectively. Multivariate analysis showed that the tumor level within the sacrum (P = .001) and the surgical margin (P = .001) were significant recurrence-related factors. Four patients (16.7%) developed lung metastasis. Eighteen patients were alive at last follow-up. The 5-year and 10-year survival rate after surgical treatment of recurrence was 67.3% and 53.9%, respectively.Most recurrent tumors are located in bone, and a safe osteotomy margin is important. The surgical margin is the only controllable factor of further tumor recurrence. Some patients with recurrence achieve long survival and obtain a clinical benefit from repeated operations if complete resection is achieved.

C-Cbl and Cbl-b expression in skull base chordomas is associated with tumor progression and poor prognosis

Chordomas are rare, locally aggressive malignancies that are often difficult to eradicate. Surgery and radiotherapy are the first-line treatments, but the probability of local recurrence is high. According to our previous research, c-Cbl and Cbl-b have been linked to tumor progression and poor prognosis of glioma. However, their role in skull base chordomas is unclear. To clarify this issue, in the present study, we analyzed the expression of c-Cbl and Cbl-b in relation to the clinicopathological features and clinical outcome of skull base chordoma patients (n = 70). C-Cbl and Cbl-b expression was evaluated by immunohistochemistry, and a survival analysis was performed based on clinical data. We found that c-Cbl and Cbl-b were upregulated in 30 of 70 (42.9%) and 32 of 70 (45.7%) patients with skull base chordomas, respectively. A Kaplan-Meier analysis and log-rank test indicated that high c-Cbl and Cbl-b levels were significantly associated with overall survival (P = .003 and P = .008, respectively) and progression-free survival (P < .001 and P = .022, respectively). These data indicated that c-Cbl and Cbl-b expression in skull base chordomas can predict tumor invasion and poor prognosis and is therefore a potential therapeutic target for chordoma treatment.

Expression of programmed death-1 ligand (PD-L1) in tumor-infiltrating lymphocytes is associated with favorable spinal chordoma prognosis

Aberrant expression of programmed death-1 (PD-1) receptor/PD-1 ligand (PD-L1) proteins alters human immunoresponse and promotes tumor development and progression. We assessed the expression status of PD-1 and PD-L1 in spinal chordoma tissue specimens and their association with clinicopathological characteristics of patients. Formalin-fixed paraffin-embedded tumor samples from 54 patients with spinal chordoma were collected for immunohistochemical analysis of PD-1 and PD-L1 expression. The association of the expression levels of PD-1 and PD-L1 with clinicopathological variables and survival data were statistically analyzed. Lymphocyte infiltrates were present in all 54 patient samples. Of 54 samples, 37 (68.5%) had both positive PD-1 and PD-L1 expression in tumor cell membrane. Moreover, 38 (70.4%) and 12 (22.2%) had positive PD-1 and PD-L1 expression in tumor-infiltrating lymphocytes (TILs), respectively. Tumors with positive PD-L1 expression were significantly associated with advanced stages of chordoma (p = 0.041) and TIL infiltration (p = 0.005), and had a borderline association with tumor grade (p = 0.051). However, positive tumor PD-L1 expression was not significantly associated with local recurrence-free survival (LRFS) or overall survival (OS). PD-1 expression in TILs was associated with poor LRFS (χ(2) = 10.051, p = 0.002, log-rank test). Multivariate analysis showed that PD-L1 expression only in TILs was an independent predictor for LRFS (HR = 0.298, 95% CI: 0.098-0.907, p = 0.033), and OS (HR = 0.188, 95% CI: 0.051-0.687, p = 0.011) in spinal chordoma patients. In conclusion, PD-L1 expression in TILs was an independent predictor for both LRFS and OS in spinal chordoma patients. Our findings suggest that the PD-1/PD-L1 pathway may be a novel therapeutic target for the immunotherapy of chordoma.

Upregulated human telomerase reverse transcriptase (hTERT) expression is associated with spinal chordoma growth, invasion and poor prognosis

Altered expression or activity of human telomerase reverse transcriptase (hTERT) has been associated with human carcinogenesis. This study detected hTERT expression in spinal chordoma tissues and associated the level of hTERT expression with clinicopathological data and patient survival. Tissue samples from 54 patients and 20 controls were subjected to immunohistochemical analysis of hTERT protein levels. hTERT expression levels were then analyzed for associations with patient survival rates and clinicopathological parameters (such as age, gender, tumor size, location, tumor grade, tumor stage, muscle invasion, recurrence or not, type of resection, tumor hemorrhage, tumor necrosis, levels of tumor-infiltrating lymphocytes (TILs) and Ki-67 expression). hTERT expression was detected in all 54 spinal chordomas. Expression levels were weak in 7, moderate in 17 and strong in 30 spinal chordoma tissue samples. In contrast, hTERT was rarely expressed in nucleus pulposus tissues (20 samples). hTERT expression was significantly associated with the Ki-67-staining index (t = -6.616, p < 0.001), TIL levels (F = 5.27, p = 0.008) and tumor invasion of the surrounding muscle tissue (t = -4.49, p < 0.001). Kaplan-Meier curves indicated that high hTERT expression was significantly associated with poor local recurrence-free survival of patients (χ(2) = 19.07, p < 0.001 via the log-rank test), but not associated with overall patient survival. Multivariate analysis of local recurrence-free survival demonstrated that hTERT expression was an independent prognostic factor among spinal chordoma patients (HR = 1.013, 95% CI: 1.002-1.024, p = 0.016). High hTERT expression was associated with spinal chordoma growth, invasion and poor patient prognosis. Future studies will investigate the use of hTERT as a biomarker to predict patient prognosis and disease progression or as a potential spinal chordoma therapy target.

A review of the surgical management of sacral chordoma

BACKGROUND

Sacral chordomas are rare low-to-intermediate grade malignant tumours, which arise from remnants of the embryonic notochord. This review explores prognostic factors in the management of sacral chordomas and provides guidance on the optimal treatment regimens based on the current literature.

PATIENTS AND METHODS

Electronic searches were performed using MEDLINE, Embase and the Cochrane library to identify studies on prognostic factors in the management of sacral chordomas published between January 1970 and December 2013. The literature search and review process identified 100 articles that were included in the review article. This included both surgical and non-surgical studies on the management of sacral chordomas.

RESULTS

Sacrectomy with wide resection margins forms the mainstay of treatment but is associated with high risk of disease recurrence and reduced long-term survival. Adequate resection margins may require sacrifice of adjacent nerve roots, musculature and ligaments leading to functional compromise and mechanical instability. Large tumour size (greater than 5-10 cm in diameter), dedifferentiation and greater cephalad tumour extension are associated with increased risk of disease recurrence and reduced survival. Chordomas are poorly responsive to conventional radiotherapy and chemotherapy.

CONCLUSION

Operative resection with wide resection margins offers the best long-term prognosis. Inadequate resection margins, large tumour size, dedifferentiation, and greater cephalad chordoma extension are associated with poor oncological outcomes. Routine long-term follow-up is essential to enable early detection and treatment of recurrent disease.

Sacral chordoma: can local recurrence after sacrectomy be predicted?

Surgical resection margins are reportedly the most important predictor of survival and local recurrence with sacral chordomas. We examined the relevance of invasion of the surrounding posterior pelvic musculature (piriformis and gluteus maximus) at initial diagnosis to local recurrence after sacrectomy. We retrospectively reviewed 18 patients with histologically verified sacral chordoma seen at our institution between 1998 and 2005. There were 14 men and four women with a mean age of 65.1 years (range, 31-78 years). The average overall followup was 4.4 years (range, 0.5-10 years), 5.4 years for the living patients (range, 3-10 years), and 2.8 years for the deceased (range, 0.5-5.4 years). Local recurrence occurred in 12 patients (66%) 29 months postoperatively (range, 2-84 months). Six of these patients had wide excisions at initial surgery, five had marginal excisions, and one had an intralesional excision. Ten patients had wide surgical margins, six of whom (60%) had local recurrences. Tumor invasion of adjacent muscles at presentation was present in 14 patients, 12 of whom (85%) had local recurrences. Sacroiliac joint involvement was seen in 10 patients, nine of whom (90%) had local recurrences. The findings suggest obtaining wide surgical margins posteriorly, by excising parts of the piriformis, gluteus maximus, and sacroiliac joints, may result in better local disease control in patients with sacral chordoma.

LEVEL OF EVIDENCE

Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Management of sacrococcygeal chordomas

A total of 16 patients in our clinic (six women, ten men; mean age 54.87 years, range 38-78 years) were diagnosed as having a sacrococcygeal chordoma. Pain was the presenting symptom in all patients. In five patients, the chordoma was inoperable. A total of 11 patients were followed-up for a mean period of 64.8 months (range 7-152 months). Five patients were lost to follow-up (3 in the operable group and two in the inoperable group). The three remaining inoperable patients received radiation therapy. The eight remaining operable patients underwent a total of 12 operations (four anterior and posterior, eight posterior only). Five of these patients received adjuvant radiotherapy and two patients received both radiotherapy and chemotherapy. In follow-up, eight patients had evidence of disease and one patient remained disease-free. Problems encountered during therapy and follow-up included urinary incontinence (72%), rectal incontinence (36%), wound infection (36%), and lower extremity muscle weakness (36%). Two patients died from metastases to the lung. Of the remaining nine patients, eight were ambulatory, with seven needing support to walk. One patient was unable to walk at all due to lower extremity muscle weakness.

Paranasal sinuses chordoma in pediatric patient: a case report and literature review

Paranasal sinuses chordoma is rare in pediatric patients. We report a case of a 15-month-old patient who presented with a nasal mass, accompanied by gradual nasal obstruction since 3 months of age. A 3.2 cmx2.2 cmx3.0 cm neoplasm was found in left maxillary sinus, ethmoid sinus and nasal cavity by CT scans. Surgery was performed through endonasal endoscopic approach under general anesthesia. Both histological examination of the biopsy and the tissue removed by surgery revealed a chordoma. No tumor has recurred during the 3-year follow-up. With total removal of the tumor, the endonasal endoscope is a safe approach with facial features remaining undestroyed.

Prognostic value of MIB-1, E-cadherin, and CD44 in pediatric chordomas

The prognosis of pediatric chordomas is difficult to predict based on histology. The objective of this study was to assess the expression of a proliferation marker and adhesion molecules in pediatric chordomas and relate the expressions to outcome. In 8 pediatric chordomas, we calculated the MIB-1 labeling index (LI) by counting the number of MIB-1-positive tumor cells in 100 tumor cells. The grade of expression of E-cadherin and CD44 was calculated by estimating the percentage of tumor cells expressing these markers. MIB-1 LI correlated with tumor recurrence (P = 0.007) and low survival rate (P = 0.007). The expression of E-cadherin correlated with disease-free survival (P = 0.009), tumor recurrence (P > 0.0007), and low survival rate (P > 0.0007). CD44 expression did not correlate with recurrence (P = 0.056) or survival rate (P = 0.056). Our results suggest that MIB-1 LI and expression of E-cadherin are helpful to predict outcome in pediatric chordomas.

Evaluation of a new concept for the management of skull base chordomas and chondrosarcomas

OBJECT

Chordomas and chondrosarcomas of the skull base are rare locally invasive tumors associated with high recurrence rates. The aim of this study was to evaluate the concept of microsurgical tumor volume reduction followed by early gamma knife surgery (GKS).

METHODS

Thirteen patients with 15 tumors were treated between October 2000 and June 2003. There were three patients (23.1%) with chordomas and 10 (76.9%) with chondrosarcomas. There were nine men and four women who ranged in age between 19 and 69 years. All patients first underwent maximal tumor resection. Within 2 to 10 months after surgery they were treated with GKS. The mean postoperative tumor volume treated with GKS was 9.7 cm3 (range 1.4-20.3 cm3). Follow-up computerized tomography and magnetic resonance imaging examinations with volumetric tumor analysis were performed every 6 months after GKS. The mean treatment dose was 17 Gy and the mean isodose was 52%. The mean follow-up duration was 17 months during which there was only one tumor recurrence at the margin of the radiation field. The mean volume reduction was 35.4%.

CONCLUSIONS

Results of this treatment strategy are encouraging but the efficacy of this multimodal treatment combining surgery and early GKS requires a longer follow up.

Evaluation of a new concept for the management of skull base chordomas and chondrosarcomas

Object. Chordomas and chondrosarcomas of the skull base are rare locally invasive tumors associated with high recurrence rates. The aim of this study was to evaluate the concept of microsurgical tumor volume reduction followed by early gamma knife surgery (GKS).

Methods. Thirteen patients with 15 tumors were treated between October 2000 and June 2003. There were three patients (23.1%) with chordomas and 10 (76.9%) with chondrosarcomas. There were nine men and four women who ranged in age between 19 and 69 years. All patients first underwent maximal tumor resection. Within 2 to 10 months after surgery they were treated with GKS. The mean postoperative tumor volume treated with GKS was 9.7 cm3 (range 1.4–20.3 cm3). Follow-up computerized tomography and magnetic resonance imaging examinations with volumetric tumor analysis were performed every 6 months after GKS.

The mean treatment dose was 17 Gy and the mean isodose was 52%. The mean follow-up duration was 17 months during which there was only one tumor recurrence at the margin of the radiation field. The mean volume reduction was 35.4%.

Conclusions. Results of this treatment strategy are encouraging but the efficacy of this multimodal treatment combining surgery and early GKS requires a longer follow up.

Tumors of the skull base in children: review of tumor types and management strategies

Although many treatment strategies for skull base tumors in adults have been reported, relatively little has been reported regarding such therapies in the pediatric population. Skull base tumors in children present a therapeutic challenge because of their unique pathological composition, the constraints of the maturing skull and brain, and the small size of the patients. In this review, the authors examine the pediatric skull base lesions that occur in the anterior, middle, and posterior cranial base, focusing on unique pediatric tumors such as encepahalocele, fibrous dysplasia, esthesioneuroblastoma, craniopharyngioma, juvenile nasopharyngeal angiofibroma, cholesteatoma, chordoma, chondrosarcoma, and Ewing sarcoma. They review management strategies that include radio- and chemotherapy, as well as surgical approaches with emphasis on the modifications and complications associated with the procedures as they apply in children. Evidence for the advantages and limitations of radiotherapy, chemotherapy, and surgery as it pertains to the pediatric population will be examined. With a working knowledge of skull base anatomy and special considerations of the developing craniofacial skeleton, neurosurgeons can treat skull base lesions in children with acceptable morbidity and mortality rates. Outcomes in this population may be better than those in adults, in part because of the benign histopathology that frequently affects the pediatric skull base, as well as the plasticity of the maturing nervous system.

Surgical seeding of chordomas

OBJECT

Chordomas have a high propensity for local recurrence and progression, as well as for systemic and cerebrospinal fluid metastasis. The authors identified and analyzed a series of patients with chordomas, focusing on an underrecognized pathological entity-surgical seeding of tumor cells.

METHODS

In a retrospective analysis of 82 patients with chordomas treated over a 10-year period (1990-2000), the authors found six patients (7.3%) in whom surgical seeding had occurred. In five (83%) of these patients the primary tumor was located at the clivus. In one (17%), the tumor was present at the cervical spine. There were two male (33%) and four female patients (67%) whose mean age was 34 years. The seeding sites, which were separate from the primary tumor, were located along the operative route or in the abdomen where fat was removed. The seeding was diagnosed 5 to 15 months (mean 12 months) after surgery. One seeding site was present in five patients, and 17 seeding sites were present in one patient. The involved tissues included mucosa, bone, dura, muscle, and fat. After resection, all seedings were confirmed histologically.

CONCLUSIONS

Seeding of chordomas occurs along the operative route and at distant locations where tissue is harvested. Early diagnosis and aggressive surgery are recommended. Based on the results of this study, the authors suggest that surgical techniques, postoperative radiotherapy, neuroradiological follow-up protocol, and even research on chordomas should be reevaluated.

Chordoma: review of clinicoradiological features and factors affecting survival

This study reviews the clinicoradiological features of cranial and sacrospinal chordomas and identifies factors affecting survival. Nineteen patients seen between January 1980 and December 2000 with histopathological diagnosis of chordomas were retrospectively reviewed with reference to clinical presentation, imaging features, treatment modalities and post-therapy status. Eight had tumours in the skull base while 11 patients had spinal and sacrococcygeal lesions. Surgical resection was performed in 16 patients whose subsequent natural history was used to identify clinical indicators that may influence survival. Completeness of resection, age, gender and postoperative irradiation were subjected to analysis using the Cox proportional hazard models. Kaplan-Meir survival curves illustrate the survival distributions. Diplopia and facial pain are prime clinical presentations in cranial lesions, while extremity weakness and a sacrogluteal mass are common complaints in the sacrospinal group. Lesional calcifications are present in 40% while an osteolytic soft tissue mass is detectable by CT in all cases. Heterogeneous signals and internal septations on T2-weighted MRI are predominant features. In sacrospinal tumours, complete excision with adjuvant radiotherapy achieves the best results with a disease-free survival of more than 5 years. The clinical and imaging findings in this study are in accordance with those of other series. Except for complete surgical excision followed by radiotherapy in the subset of patients with sacrospinal tumours, none of the other clinical indicators show a statistical significant influence on survival.

Surgical seeding of chordomas

Object

Chordomas have a high propensity for local recurrence and progression, as well as for systemic and cerebrospinal fluid metastasis. The authors identified and analyzed a series of patients with chordomas, focusing on an underrecognized entity—surgical seeding.

Methods

In a retrospective analysis of 82 patients with chordomas treated over a 10-year period (1990–2000) the authors found six patients (7.3%) in whom surgical seeding had occurred. In five (83%) of these patients the primary tumor was located at the clivus. In one (17%) the tumor was present in the cervical region. There were two male (33%) and four female patients (67%) with a mean age of 34 years. The seeding sites, which were separate from the primary tumor, were located along the operative route or in the abdomen where fat was removed. The seeding was diagnosed 5 to 15 months after surgery (mean 12 months). One seeding site was present in five patients and 17 seeding sites were present in one patient. The involved tissues included mucosa, bone, dura, muscle, and fat. After resection, all seedings were documented histologically.

Conclusions

Seeding of chordomas occurs along the operative route and at distant locations where fat is harvested. Early diagnosis and aggressive surgical treatment are recommended. Based on the results of this study, it is suggested that surgical techniques, postoperative irradiation, the neuroradiological follow-up protocol, and even research on chordomas should be reevaluated.

Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients

BACKGROUND

The prognosis of patients with chordoma of the sacrum and mobile spine has been reported to be dismal and attributable in the majority of cases to intralesional surgery. The purpose of this study was to evaluate the clinical outcome of these patients using modern surgical principles aimed at complete resection and to identify prognostic factors.

METHODS

The clinical and morphologic features, type of surgery, and follow-up of 39 consecutive patients with chordoma were reviewed and analyzed statistically.

RESULTS

Thirty sacral and 9 mobile spine chordomas (size range, 3-20 cm; mean, 8 cm) occurring in 22 women and 17 men (median age, 55 years) were analyzed. The preoperative morphologic diagnosis was based on fine-needle aspiration (FNA) biopsy, core needle biopsy, or incisional biopsy. The final surgical margins were wide in 23 patients and marginal or intralesional in 16. The mean follow-up was 8.1 years (range, 0.1-23 years). Seventeen patients (44%) developed local recurrences and 11 patients (28%) developed metastases. The estimated 5-, 10-, 15-, and 20-year survival rates were 84%, 64%, 52%, and 52%, respectively. Local recurrence was associated significantly with an increased risk of metastasis and tumor-related death (P < 0.001).

CONCLUSIONS

New surgical techniques have improved local control and survival of patients with sacral or spinal chordoma significantly and have decreased progressive neurologic deterioration. Larger tumor size, performance of an invasive morphologic diagnostic procedure outside of the tumor center, inadequate surgical margins, microscopic tumor necrosis, Ki-67 > 5%, and local recurrence were found to be adverse prognostic factors. FNA is the preferred method for establishing the preoperative morphologic diagnosis of chordoma.

Sacral chordoma: 40-year experience at a major cancer center

OBJECTIVE

Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Despite surgical resection, adjuvant radiation therapy, and chemotherapy, recurrence is common. This study reviews our experience during the last 40 years at The University of Texas M.D. Anderson Cancer Center, to determine the effects of various treatment methods on the overall course of this disease process.

METHODS

A retrospective study was performed. From 1954 to 1994, 27 patients with sacral chordomas were evaluated at our institution.

RESULTS

There were 19 male and 8 female patients, with a mean age of 56 years (range, 27-80 yr). All except one of the patients presented with pain, and 17 of 27 showed evidence of autonomic dysfunction at initial presentation. Based on microscopic examination of surgical specimen margins, surgical procedures were categorized as either radical resection or subtotal excision. All patients underwent at least one surgical procedure, for a total of 67 procedures (28 radical resections and 39 subtotal excisions). Twelve patients underwent one operation, whereas nine underwent two procedures and six underwent more than two operations (range, 3-16 operations). Radiation therapy was used in conjunction with 13 of the 67 surgical procedures. The median Kaplan-Meier estimate of the overall survival time for the entire group was 7.38 years (range, 4 mo to 34 yr). Tumors recurred after 47 of the 67 procedures. The overall disease-free interval for patients undergoing radical resection was 2.27 years for each procedure, compared with 8 months for each procedure for patients treated with subtotal excision (log-rank test for the inequality between the two curves, 19.58; P<0.0001). The addition of radiation therapy prolonged the disease-free interval for patients undergoing subtotal resection (2.12 yr versus 8 mo; log-rank test for the inequality between the two curves, 5.82; P<0.02).

CONCLUSION

Our results suggest frequent recurrences in the majority of patients with chordomas. Radical resection is associated with a significantly longer disease-free interval, compared with subtotal removal of the tumor. Addition of radiation after subtotal resection improves the disease-free interval, although radiation therapy can generally be used only once. Based on these findings, we think that, whenever possible, radical resection should be the treatment of choice for sacral chordomas.

Chordomas and chondrosarcomas of the cranial base: results and follow-up of 60 patients

The management of chordomas and chondrosarcomas involving the cranial base remains controversial. The options for therapy include biopsy, partial resection, radical resection, and various forms of radiotherapy. In this article, we analyze the outcome of 60 patients with cranial base chordoma or chondrosarcoma treated with extensive surgical resection between 1984 and 1993. Forty-six patients had chordomas, and 14 had low-grade chondrosarcomas; 50% of these patients had been treated previously. Preoperative studies included computed tomography, magnetic resonance imaging, cerebral angiography, and balloon occlusion test of the internal carotid artery, as indicated. Magnetic resonance imaging was performed on all patients during follow-up. The surgical approaches used for tumor resection were predominantly the following: subtemporal, transzygomatic, transcavernous, and transpetrous apex; subtemporal and infratemporal; extended frontal; and extreme lateral transcondylar. Staged operations with a combination of approaches were used when necessary (52% of cases) to remove a tumor more completely. Statistical analysis was done by the chi 2 test and correlation matrix. Sixty-seven percent of the patients had total or near-total resection. Twenty percent of the patients received postoperative radiotherapy. Eleven patients died during the postoperative follow-up period, nine with chordomas and two with chondrosarcomas. Three patients died because of systemic complications within 3 months after surgery, five died because of tumor recurrence, one died from unrelated causes, and two died from late complications of radiotherapy. The recurrence-free survival rate for all tumors was 80% at 3 years and 76% at 5 years. Chondrosarcomas had a better prognosis than chordomas (recurrence-free survival rates, 90% at 5 years and 65% at 5 years, respectively; P = 0.09). Patients who had undergone previous surgery had a greater risk of recurrence (5-year recurrence-free survival rate, 64%) than did patients who had not undergone previous surgery (5-year recurrence-free survival rate, 93%; P < 0.05). Patients with total or near-total resection had a better 5-year recurrence-free survival rate (84%) than did patients with partial or subtotal resection (64%) (P < 0.05). Postoperative leakage of cerebrospinal fluid was the most frequent complication (30% of patients) and was found to increase the risk of permanent disability. Patients who had undergone previous radiotherapy had a greater risk of death in the postoperative period (within 3 months of their operations) and during follow-up. However, total or near-total resection did not increase the rate of postoperative disability.(ABSTRACT TRUNCATED AT 400 WORDS)

Base of skull and cervical spine chordomas in children treated by high-dose irradiation

PURPOSE

To evaluate the outcome of children with base of skull or cervical spine chordomas treated by high dose irradiation.

METHODS AND MATERIALS

Eighteen children, 4 to 18 years of age, with base of skull or cervical spine chordomas, received fractionated high-dose postoperative radiation using mixed photon and 160 MeV proton beams. The median tumor dose was 69 Cobalt Gray-equivalent (CGE) with a 1.8 CGE daily fraction.

RESULTS

The median follow-up was 72 months. The 5-year actuarial survival was 68% and the 5-year disease-free survival (DFS) was 63%. The only significant prognostic factor was the location: patients with cervical spine chordomas had a worse survival than those with base of skull lesions (p = 0.008). The incidence of treatment-related morbidity was acceptable: two patients developed a growth hormone deficit corrected by hormone replacement, one temporal lobe necrosis, and one fibrosis of the temporalis muscle, improved by surgery.

CONCLUSION

Chordomas in children behave similarly to those in adults: children can receive the same high-dose irradiation as adults with acceptable morbidity.

Experience in charged particle irradiation of tumors of the skull base: 1977-1992

PURPOSE

To review the experience at University of California Lawrence Berkeley Laboratory in using charged particles to irradiate primary neoplasms of the skull base and those extending to the skull base from the nasopharynx and paranasal sinuses.

METHODS AND MATERIALS

During the period from 1977 to 1992, 223 patients were irradiated with charged particles at the Lawrence Berkeley Laboratory for tumors either arising in or extending to the skull base, of whom 48 (22%) had recurrent lesions, either post previous surgery or radiotherapy. One hundred twenty-six patients had lesions arising in the cranial base, mostly chordoma (53), chondrosarcoma (27), paraclival meningioma (27) with 19 patients having other histologies such as osteosarcoma or neurofibrosarcoma. There were also 31 patients with primary or recurrent squamous carcinoma of the nasopharynx extending to the skull base, 44 patients with major or minor salivary gland tumors, mostly adenocarcinoma, and 22 patients with squamous carcinoma of the paranasal sinuses, all with cranial base extension.

RESULTS

Local control and survival appeared improved in tumors arising in the skull base, following the ability with charged particles to deliver high doses (mean of 65 Gy-equivalent) with relative sparing of the adjacent normal tissues. The Kaplan-Meier 5-year local control was 85% for meningioma, 78% for chondrosarcoma, 63% for chordoma and 58% for other sarcoma. Follow-up ranged from 4-191 months with a median of 51 months.

CONCLUSION

Charged particle radiotherapy is highly effective in controlling cranial base lesions which have have been partially resected. Better tumor localization with CT and MRI, improved 3-D treatment planning and beam delivery techniques have continued to reduce the level of serious complications and increase local control and survival.

Chemotherapy for cranial base tumors

The tumors I will discuss in this chapter on chemotherapy will be ethesioneuroblastoma, salivary gland tumors, chordoma and nasopharyngeal carcinoma. Due basically to the rarity of these lesions, with the exception of nasopharyngeal carcinoma, there have been no multi-institutional studies of chemotherapy use reported in the literature. As a result, there is no clear-cut consensus on the standard of care as it relates to chemotherapy for these tumors. As with most authors who have previously reviewed these tumor types, I believe it is important for us to propose protocols of therapy and test these in arenas where we can accumulate enough patients for meaningful results. In this way, we can test the apparently active agents and combinations in relapsed or extensive disease. We might also begin to explore concurrent therapy (i.e., concurrent radiation and chemotherapy after the surgical procedure, for example).

Chordomas and chondrosarcomas involving the cavernous sinus: review of surgical treatment and outcome in 31 patients

During the last 9 years, 31 patients with chordomas (20 cases) and chondrosarcomas (11 cases) involving the cavernous sinus have been treated using an aggressive surgical approach. On the basis of postoperative magnetic resonance imaging (MRI), 17 patients were considered to have undergone total removal, whereas in the remaining 14 cases the tumor was either subtotally or partially removed. Surgical complications were most commonly encountered among patients who had undergone previous operations. One patient died 3 months after the operation as a result of pulmonary embolism. Significant disability occurred in one patient because of thalamic perforator occlusion and hemorrhage. Recovery of extraocular muscle function was gratifying, and correlated to the preoperative functional level. After a median follow-up of 24 months, three recurrences (21%) occurred among the 14 patients who had undergone incomplete removal. No recurrence was observed among the 17 patients with total resection. This experience shows that gross radical removal of chordomas and chondrosarcomas involving the cavernous sinus can be accomplished with an acceptable surgical morbidity. However, much longer follow-up will be required to determine whether such aggressive surgical treatment results in cure or long-term control of these neoplasms.

Extranotochordal chordoma presenting as multiple neck masses: report of a case

Chordomas are rare tumours which arise from notochordal remnants. A primary cervical chordoma of extranotochordal origin, sparing osseous structures, was excised by a bilateral neck dissection. The patient was disease-free two and a half years later.

Chordoma cutis: a report of nineteen patients with cutaneous involvement of chordoma

BACKGROUND

Chordoma, an uncommon tumor originating from remnants of the notochord, with cutaneous involvement has rarely been reported.

OBJECTIVE

Our purpose was to document clinical manifestations, histopathologic features, immunohistochemical findings, treatment, and course of chordoma with cutaneous involvement.

METHODS

Pathologically proven cases of chordoma were reviewed retrospectively for cutaneous involvement. Detailed clinical data and histopathologic changes were studied. Skin biopsy specimens were stained for immunohistochemical phenotyping.

RESULTS

Of 207 cases of chordoma, 19 had skin involvement: as local recurrences or metastasis in 12, as direct extension of primary tumor in 6, and as a result of distant metastasis from sacrococcygeal chordoma in 1. Local recurrences were frequent, but distant metastasis to various organs, including skin, occurred.

CONCLUSION

We propose the term chordoma cutis to describe this condition. In seven patients, cutaneous lesions were detected when the diagnosis of primary chordoma was made.

Chordoma presenting as a posterior mediastinal mass in a pediatric patient

Chordomas are slow-growing malignant tumors that arise from fetal notochord cells. They are commonly found at the cranial or caudal ends of the spinal cord, but can be seen infrequently in other areas of the cord. Thoracic chordomas can present as either a posterior mediastinal mass or with cord compression symptoms. The tumors present most frequently in the 4th to 5th decade of life. It is extremely rare to see thoracic chordoma in a child. The treatment of choice for chordomas is surgery. The tumors should be totally excised when possible. If the tumor is large or invasive, debulking is indicated. Adjuvant therapy is controversial. Chordomas are very resistant to radiotherapy but there have been several reports of increased survival with high-dose radiotherapy (7,500 rad). Chemotherapy is unproven in the treatment of chordomas. Chordomas tend to recur locally quite frequently and occasionally with distant metastases. Survival ranges from 10% to 30% at 5 years.

Chordoma involving the skin: an immunohistochemical study of 11 cases

Immunohistochemical properties were studied in 16 lesions from 11 patients with chordoma involving the skin. There were nine men and two women ranging from 21 to 62 years old (mean, 42.6). The initial tumor was sacrococcygeal in 10 cases and nasopharyngeal in 1 case. Three lesions represented a direct extension from the primary tumor to the skin, and 13 lesions were examples of local recurrences in the skin. Immunohistochemically, all lesions showed positivity for keratin, whereas 14 lesions were positive for vimentin and 12 for protein S-100. Epithelial membrane antigen was positive in four instances and carcinoembryonic antigen was negative in all studies. No significant difference was observed between the immunoprofile of cases of direct extension and those of local recurrences. Overall, the remarkable triple positivity for keratin, vimentin, and protein S-100 was observed in 11 lesions from eight different cases (73%). This study confirmed the utility of immunohistochemistry in the differential diagnosis of chordoma from tumors with similar histologic characteristics encountered in the skin.

Surgical debulking is associated with improved survival in stage I-II diffuse large cell lymphoma

Tumor burden is an important predictor of survival in patients with diffuse large cell lymphoma (DLCL). The authors reviewed the charts of 147 patients with early stage presentation (Stage I-IE and II-IIE) seen from 1974 through 1984. The 10-year survival for the 85 patients with bulky disease was 54% compared with 76% for those who did not have bulky disease. Of the 62 with nonbulky disease, 14 had been rendered so by removal of greater than 80% of the initial tumor mass (surgical debulking). The authors compared these 14 patients with a matched control group of 14 patients selected from the 85 with bulky disease who had equivalent stage, therapy, site, size of initial mass, performance status, and sex and age. All had received similar therapy with cyclophosphamide, Adriamycin (doxorubicin), vincristine, prednisone, bleomycin, and radiotherapy to the involved field. At a 7-year follow-up, the 14 debulked patients had a better survival when compared with the matched controls (93% versus 35%, P = 0.003). The authors also analyzed the initial serum lactate dehydrogenase (LDH) levels. Preoperative LDH values were available in six of 14 debulked patients. In the three with elevated LDH levels at presentation, surgical debulking was associated with subsequent decreased LDH levels, which is known to be associated with better prognosis. The other three presented with normal values that remained normal after surgery. These data suggest a potentially important role for surgery as front-line therapy in patients with Stage I-IE and II-IIE bulky DLCL whose disease is deemed resectable. More studies are needed in order to better define this role as well as to determine how frequently and safely surgical debulking can be performed.

Secondary chordoma of the mandible

The first case of primary sacrococcygeal chordoma metastasising to the mandible and presenting with obstructed labour is described. The pathological features of this tumour, its clinical presentation and management are discussed.

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.

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.

Clinical and pathologic review of 48 cases of chordoma

The results of treatment of 48 patients with the diagnosis of chordoma during the period 1931 to 1981 at the Massachusetts General Hospital were reviewed. Fourteen patients were treated with surgery alone: eight patients with primary tumors in the sacrococcygeal region were treated with radical surgery and four are alive with no evidence of disease (NED) with follow-up of 8 to 20 years. Recurrent tumors in six patients were treated with surgery alone resulting in long palliation (3-25 years). The actuarial survival rate at 5 years for all patients treated with surgery was 76%. Radiation therapy was used in patients after either a biopsy (15), partial excision (17), or before radical excision in 2 patients. To achieve a worthwhile level of palliation, doses greater than 4000 cGy were required. High-dose levels (greater than 6500 cGy) were achieved in nine cases by a combination of photon and 160 MeV proton beams. The results to date of this approach for lesions of the base of skull and cervical vertebral body are encouraging: high local control and low morbidity. The 5-year actuarial survival rate of all patients treated with radiation was 50%.

Dundee chordomas

All patients with chordomas that have been treated in the Dundee neurosurgical unit are reviewed. Five intracranial and two sacral chordomas have presented since the unit opened in 1966. Survival has ranged from one to fifteen years following treatment. The difficulties in diagnosis and in assessing treatment of these rare slow growing neoplasms are discussed.

Chordoma: results of treatment

Sixty-nine patients with chordoma were seen at the Christie Hospital, Manchester, between 1932 and 1980. Fifty-three per cent of the tumours were located in the sacrococcygeal region and 24% in the clivus region. Forty-eight patients were treated with radiotherapy, and the 10-year survival for the whole group was 23%. There was no difference in survival between the two major sites. Patients who had radical surgery and radical radiotherapy achieved better palliation and longer survival. Sixteen per cent of the patients developed metastases.

Chordoma: the results of megavoltage radiation therapy

Twenty-four patients with chordoma who received one or more courses of megavoltage radiation therapy following biopsy or incomplete resection were reviewed. The uncorrected survival rate at five years was 62%, and at 10 years was 28%, but most patients had clinically detectable residual chordoma present at the time of death or last follow-up. The duration of symptomatic improvement following irradiation ranged from a few months to 18 years, median 3.5 years. Detailed dose-time and symptomatic response data for 56 patients from this series and from the literature who were treated by conventional daily fractionated megavoltage irradiation show no convincing evidence that symptomatic relief is more likely after high doses than after total doses of only 4000 to 5500 cGy. Patients are rarely cured of chordoma by partial tumor resection and conventional radiation. Four patients received multiple fractions of 100 cGy each day either as retreatment for recurrence, or as initial treatment. Symptomatic responses, and decreases in the size of tumor masses, were seen following total doses ranging from 2000 cGy/20 fractions/5 days/4 X 3 hourly fractions each day to 4000 cGy/40 fractions/12 days/4 X 3 hourly fractions each day. The short duration of follow-up in these patients prevents comparison with conventional fractionation. However, this technique presents one possible new approach for the treatment of chordoma.

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

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

The radiologic findings in posterior mediastinal chordoma

A 14-year-old girl with a posterior mediastinal chordoma is described. Computed tomography is helpful in defining the extent of the soft tissue mass. Osseous changes related to the presence of the chordoma are described. A review of the pertinent literature is presented.

Low cervical chordoma: report of two cases with documentation by computed tomography and review of the literature

Chordoma is a slow-growing neoplasm of the axial skeleton. Two cases of lower cervical chordoma are reported, along with a review. Despite combined high voltage radiation therapy and radical surgery chordoma invariably recurs, producing bone erosion and destruction of vital contiguous structures with resulting high morbidity and mortality rates. Computed tomography appears very useful in detecting the early soft tissue involvement and assessing the adequacy of therapy of this spinal malignancy.