Value of MRI in the diagnosis of non-clival, non-sacral chordoma

Proton Therapy for Spinal Tumors: A Consensus Statement From the Particle Therapy Cooperative Group

PURPOSE

Proton beam therapy (PBT) plays an important role in the management of primary spine tumors. The purpose of this consensus statement was to summarize safe and optimal delivery of PBT for spinal tumors.

METHODS AND MATERIALS

The Particle Therapy Cooperative Group Skull Base/Central nervous system/Sarcoma Subcommittee consisting of radiation oncologists and medical physicists with specific expertise in spinal irradiation developed expert recommendations discussing treatment planning considerations and current approaches in the treatment of primary spinal tumors.

RESULTS

Computed tomography simulation: factors that require significant consideration include (1) patient comfort, (2) setup reproducibility and stability, and (3) accessibility of appropriate beam angles.

SPINE STABILIZATION HARDWARE

If present, hardware should be placed with cross-links well above/below the level of the primary tumor to reduce the metal burden at the level of the tumor bed. New materials that can reduce uncertainties include polyether-ether-ketone and composite polyether-ether-ketone-carbon fiber implants.

FIELD ARRANGEMENT

Appropriate beam selection is required to ensure robust target coverage and organ at risk sparing. Commonly, 2 to 4 treatment fields, typically from posterior and/or posterior-oblique directions, are used.

TREATMENT PLANNING METHODOLOGY

Robust optimization is recommended for all pencil beam scanning plans (the preferred treatment modality) and should consider setup uncertainty (between 3 and 7 mm) and range uncertainty (3%-3.5%). In the presence of metal hardware, use of an increased range uncertainty up to 5% is recommended.

CONCLUSIONS

The Particle Therapy Cooperative Group Skull Base/Central nervous system/Sarcoma Subcommittee has developed recommendations to enable centers to deliver PBT safely and effectively for the management of primary spinal tumors.

Unusual Presentation of Thoracic Chordoma with Spinal Epidural Hematoma: A Rare Case Report and PRISMA-Driven Systematic Review

A chordoma is a slow growing, locally invasive, low-grade tumor belonging to the sarcoma family. It mainly affects the sacrum and skull base. We present a case of thoracic chordoma initially presented with epidural hematoma (EDH), which is a rare clinical entity. We reported this case, and also performed a PRISMA-driven systematic review to summary the similar cases in the literature. This review includes the clinical characteristics and outcome of thoracic chordoma. Our case involves a 60-year-old male who, despite no history of trauma, presented with acute paraparesis. An epidural hematoma was identified at T6 level, leading to a surgical intervention involving T4-6 laminectomy and fixation. Six months subsequent to surgery, the patient experienced progressive lower limb weakness and spasticity. Computed tomography (CT) exhibited erosion of T6 and an associated aggressive mass. Magnetic resonance imaging (MRI) revealed a large heterogenous soft tissue mass arising from the vertebral body and right pedicle of D6, protruding in the epidural space and compressing the spinal cord focally at this level. The mass measured approximately 5 × 4 × 3.5 cm. Magnetic resonance myelography indicated a filling defect at T5-6 level, confirming the intraspinal location of the soft tissue lesion. Complete excision of the mass confirmed the diagnosis of thoracic chordoma. Postoperative follow-up demonstrated notable improvement in the lower limb spasticity and paraparesis, and the patient started adjuvant radiotherapy. This case underscores the importance of maintaining a high index of suspicion when evaluating presentations resembling EDH.

A Bibliometric Analysis of the 20 Most Cited Articles on Sacrococcygeal Chordomas

This study aims to summarize sacrococcygeal chordoma literature through bibliometric analysis and to offer insights into key studies to guide clinical practices and future research. The Web of Science database was searched using the terms "sacral chordoma", "chordomas of the sacrum", "chordomas of the sacral spine", "chordomas of the sacrococcygeal region", "coccygeal chordoma", and "coccyx chordoma". Articles were analyzed for citation count, authorship, publication date, journal, research area tags, impact factor, and evidence level. The median number of citations was 75 (range: 53-306). The primary publication venue was the International Journal of Radiation Oncology, Biology, Physics. Most works, published between 1999 and 2019, featured a median journal impact factor of 3.8 (range: 2.1-7) and predominantly fell under the research area tag, radiation, nuclear medicine, and imaging. Of these articles, 19 provided clinical data with predominantly level III evidence, and one was a literature review. This review highlights the increasing volume of sacrococcygeal chordoma publications over the past two decades, indicating evolving treatment methods and interdisciplinary patient care. Advances in radiation, particularly intensity-modulated radiation therapy (IMRT) and proton beam therapy, are believed to be propelling research growth, and the lack of level I evidence underscores the need for more rigorous studies to refine treatment protocols for sacrococcygeal chordomas.

Imaging of the Craniocervical Junction: A Pictorial Review

The craniocervical junction (CCJ) is a complex anatomical structure comprising the occiput, the atlas, and the axis. The CCJ plays an important role in maintaining stability, providing protection, and supporting neurovascular structures. The CCJ can be affected by a wide range of congenital variants and traumatic, degenerative, inflammatory, and tumoral pathologies. This pictorial review the normal anatomy of the CCJ and presents the most common anatomical variants and pathologic conditions affecting the CCJ.

Misdiagnosis of primary dumbbell chordoma of the cervical spine

AIM

This study aimed to analyze the clinical characteristics and outcomes of patients with primary dumbbell chordoma of the cervical spine and to summarize the causes of misdiagnosis.

METHODS

The clinical data of patients were retrospectively collected. The diagnostic process, surgical procedures, and outcomes were analyzed, then the difference was compared between dumbbell and non-dumbbell chordomas of the cervical spine.

RESULTS

This study included six patients with primary dumbbell chordoma (one male and five females) with a mean age of 32.2 ± 24.5 years (range: 5-61 years). Five cases with no computed tomography (CT) examination before the first operation were misdiagnosed, and on magnetic resonance imaging (MRI), primary dumbbell chordoma showed the following specific features: extensive invasion of the surrounding soft tissues with an obscure boundary (≥5 cm), intervertebral disc sparing, and hemorrhagic necrosis, furthermore, the CT features included atypical destructive vertebral lesions, minimal intralesional calcification, and neural foraminal enlargement. After comparison with non-dumbbell chordomas, it show statistical difference (p < 0.05) in terms of calcification, foramen enlargement, FNA, misdiagnosis rate but with different recurrent rate.

CONCLUSION

Primary dumbbell chordomas of the cervical spine can easily be misdiagnosed as neurogenic tumors. Preoperative CT-guided fine-needle aspiration puncture biopsy helps make an accurate diagnosis. Gross total excision with postoperative radiotherapy has been proven effective in reducing the recurrence rate.

En-bloc resection of a chordoma in L3 by a combined open posterior and less invasive retroperitoneal approach: technical description and case report

INTRODUCTION

To fulfill oncological criteria, extensive open anterior and posterior approaches are usually performed in the lumbar spine to obtain an appropriate en-bloc spondylectomy. It is commonly accepted that the price of a tumor-free margin includes such extensive incisions and soft-tissue damage, with consequent relevant blood loss and possible postoperative complications as delayed wound healing. In this article, a case of chordoma in L3 is presented, submitted to an oncologically appropriate en-bloc resection performed by an open posterior approach combined with a mini-retroperitoneal approach. The successful oncologic procedure was combined with a short and uneventful postoperative course.

MATERIALS AND METHODS

The authors present the surgical technique and the possible challenges of minimally invasive anterior oncologic surgery as a contribution to a limited literature.

RESULTS

Up to date, palliative care of single metastases has been the main setting in which anterior, minimally invasive surgery has been performed in the lumbar spine. The authors explained how, in selected cases, this approach can be performed in combination with an open posterior access for an oncologically appropriate treatment of a primary malignant tumor.

CONCLUSION

Anterior, minimally invasive surgery can have a role in selected patients with primary malignant tumors of the lumbar spine. The surgical team should have extensive training both in oncologic and minimally invasive surgery.

Mediastinal extraosseous chordoma in a teenager: Diagnosis by ultrasound-guided percutaneous biopsy

Pediatric chordomas are rarely described in the literature with most cases being managed surgically followed by adjuvant radiotherapy for local control. We present a case of an 18-year-old female with thoracic chordoma causing significant mass effect resulting in tracheal deviation, esophageal compression, and splaying of the great vessels. Ultrasound-guided anterior left transcervical percutaneous biopsy of the neck with surgical pathology immunohistochemistry confirmed the presence of chordoma. The patient underwent extensive palliative debulking followed by radiation therapy leading to clinical improvement. This case demonstrated that an ultrasound-guided percutaneous biopsy is an essential procedure in the diagnosis and treatment of chordoma, which led to successful treatment when followed by surgery and radiation.

Chordoma at the skull base, spine, and sacrum: A pictorial essay

Chordomas are rare tumors believed to be arising from the notochord remnant in the axial skeleton. Diagnosis is often difficult since they show overlapping imaging features with other more common disease including metastases. Since individualized papers are only discussing the imaging features at different locations, the aim of this pictorial review is to have a comprehensive review on the common imaging findings of chordomas along the entire neuroaxis with a series of pathological proven cases in a local tertiary hospital in Hong Kong.

An Unusual Chordoma of the Odontoid Process: A Case Report and Literature Review

The aim of this study is to present a rare case of chordoma in the odontoid process in which the tumor involved the odontoid process and compressed the spinal cord at the craniocervical junction. We report on the effectiveness and successful outcome of anterior microscopic tumor resection combined with posterior occipitocervical fixation and review the current standard treatment. A 39-year-old man presented with sudden dyspnea and quadriparesis caused by an unknown tumor compression at C2. Radiographic examination revealed a large destructive mass at C2 and heterogeneous enhancement. The patient received urgent surgical intervention by microscopic-assisted anterior tumor resection and posterior spinal fixation from the occiput to the C5 level. The pathohistologic reports for cytokeratins, epithelial membrane antigen, and S-100 protein were positive. The final diagnosis was chordoma of the odontoid process. At the 2-year follow-up, the patient's condition had improved, and a postoperative MRI showed no indication of tumor regrowth. Chordoma of the odontoid process or C2 body is very rare. The current standard management is wide tumor resection to prevent recurrence. The combined approach of anterior tumor resection with microscopic assistance and posterior stabilization of the occiput to C5 is the optimal treatment for this condition.

Thoracic dumbbell spinal chordoma mimicking a schwannoma

Background:

Epidural dumbbell-shaped chordomas are localized slow growing, and malignant/aggressive neoplasms. Here, we present a 62-year-old male with a T3-T4 dumbbell-shaped chordoma and reviewed the appropriate literature.

Case Description:

A 62-year-old male presented with a three-month history of thoracic pain. When the thoracolumbar magnetic resonance (MR) showed a T3-T4 dumbbell-shaped intracanalicular/extradural tumor, he underwent tumor removal. After the histological examination proved the lesion was a spinal chordoma, he underwent a secondary radical transthoracic tumor resection. Postoperatively, the patient was able to walk without assistance, and at 6-month follow-up, was neurologically intact with only residual paresthesias.

Conclusion:

Malignant spinal chordomas may mimic benign neurinomas on MR scans. Here, biopsy of the lesion to confirm the diagnosis of chordoma was critical and directed subsequent definitive transthoracic tumor resection.

Chordoma: 18F-FDG PET/CT and MRI imaging features

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.

Pediatric idiopathic intervertebral disc calcification (IIDC): a challenging case

Idiopathic intervertebral disc calcification is a rare condition in children with a very good prognosis. As there are no biological markers, imaging is invaluable for diagnosing this "do not touch" lesion. While the characteristic feature is nucleus pulposus calcification at one or more cervical or thoracic levels, it is important that practitioners be able to recognize atypical patterns so that biopsy can be avoided. Here we report a case of pediatric idiopathic intervertebral disc calcification with contiguous vertebral involvement and anterior longitudinal ligament ossification.

Retropharyngeal chordoma extending to the spinal cord, mimicking a neurogenic tumor: a case report and literature review

Chordomas are rare, locally aggressive bone malignancies with poor prognoses. However, those with minimal or no bone involvement are more easily resectable because of their well-delineated margins and thus have better prognoses. Such extraosseous chordomas of the spine are localized both intradurally and extradurally. Only a few case reports have focused on extraosseous, extradural spinal chordomas. Radiologically, this type of chordoma has a dumbbell shape; however, dumbbell-shaped spinal tumors are traditionally thought to be neurogenic tumors (i.e., schwannomas or neurofibromas). We herein report a unique case involving a woman with a dumbbell-shaped extraosseous chordoma protruding predominantly into the retropharyngeal space. A 44-year-old woman presented for evaluation of a left submandibular mass. A T2-hyperintense, gadolinium-enhancing mass was found in her cervical spinal canal, protruding through the C2/3 neural foramen into the retropharyngeal space with minimal vertebral involvement. The initial diagnosis was a neurogenic tumor, most likely a schwannoma. After subtotal removal, the pathologic diagnosis was a chordoma. Because chordomas and schwannomas have significantly different prognoses, caution is warranted when a dumbbell-shaped tumor is identified in the spine with minimal or no vertebral deterioration on radiology. This report also provides the first thorough review of extraosseous dumbbell-shaped intraspinal–extraspinal chordomas.

An overview of the tumors affecting the spine-inside to out

Spine tumors may arise within or surrounding the spinal cord and/or vertebral column. Spinal tumors can be benign or malignant. Based on their epicenter, they may be classified as intradural-intramedullary, intradural-extramedullary, or extradural. Of these, extradural lesions are the most common, and are typically metastatic. Primary bone tumors of the spinal column comprise 5% of all primary skeletal tumors. The majority of primary spinal column tumors are benign, with malignant tumors comprising only 20%. Overall, spine metastases are the most common malignant spine tumor, and these usually arise from primaries such as lung, breast, and prostate cancers. The advent of improved systemic therapies leading to improved survival and the frequent use of imaging has positioned metastatic spine disease as the new epidemic in oncology. For spine tumors, establishing the correct diagnosis is heavily reliant on magnetic resonance imaging and histological confirmation. In this review, we will provide an overview of the epidemiology, radiological and histopathological features, and the natural history of key primary (benign and malignant) spinal cord and column tumors and metastatic spine tumors. Treatment principles for primary spinal cord or column tumors are aimed toward curative resection, whereas palliative resection forms the treatment principle for most metastatic tumors.

Exophytic Lumbar Vertebral Body Mass in an Adult with Back Pain

Chordomas are rare primary bone malignancies derived from notochord remnants. The tumors often are slow-growing and often present with indolent, nonspecific symptoms. Nevertheless, chordomas are locally aggressive and highly prone to local recurrence, necessitating precise planning before biopsy and/or surgical resection. Familiarity with the imaging features of chordomas is, therefore, essential. This case highlights the typical imaging and pathologic features of a spinal chordoma as well as the surgical approach and the patient's subsequent outcome.

Imaging of Malignant Primitive Tumors of the Spine

Primary malignant tumors of the spine are rare and mainly include chordoma, chondrosarcoma, Ewing sarcoma or primitive neuroectodermal tumor, and osteosarcoma. The final diagnosis is based on the combination of patient age, topographic and histologic features of the tumor, and lesion pattern on computed tomography (CT) and magnetic resonance (MR) imaging. Imaging evaluation includes radiography, CT, bone scintigraphy, and MR imaging. CT is more useful than radiography for evaluating location of the lesion and analyzing bone destruction and matrix, whereas MR has unmatched ability to assess soft tissue extension. This pictorial review provides an overview of the most prevalent primitive malignant tumors of spine.

Computed tomography and magnetic resonance imaging features of cervical chordoma

Computed tomography (CT) and magnetic resonance imaging (MRI) scans of 11 patients with histologically proven cervical chordoma were retrospectively evaluated. Imaging features assessed included location, morphology, association with adjacent structures, vertebral destruction, status of cortical bone, periosteal reaction, attenuation and calcification by CT, and signal intensity and enhancement pattern by MRI. Of 7 cases with CT, 6 exhibited lytic-sclerotic bone destruction. A total of 5 cases exhibited pressure erosion of outer cortex, 3 of which had spiculated periosteal reaction. Calcification was observed in 3 cases. All cases were heterogeneous and hypodense. MRI T2-weighted images (n=10) revealed heterogeneous hyperintense (n=5), intermediate (n=2) and intermediate-hyperintense signal intensity (n=3). Hypointense septa between lobules (n=5) and stripes (n=3) were observed on T2-weighted images. Post-contrast magnetic resonance images (n=6) demonstrated marked heterogeneous (n=3) and ring-like (n=3) enhancement. CT scanning is valuable in revealing the lytic-sclerotic bone destruction, pressure erosion of outer cortex and calcification. MRI is useful in demonstrating the results of soft tissue mass. The two examinations are necessary for differential diagnosis of patients with suspected cervical chordoma.

T1-Weighted Dynamic Contrast-Enhanced MR Perfusion Imaging Characterizes Tumor Response to Radiation Therapy in Chordoma

BACKGROUND AND PURPOSE

Chordomas notoriously demonstrate a paucity of changes following radiation therapy on conventional MR imaging. We hypothesized that dynamic contrast-enhanced MR perfusion imaging parameters of chordomas would change significantly following radiation therapy.

MATERIALS AND METHODS

Eleven patients with pathology-proved chordoma who completed dynamic contrast-enhanced MR perfusion imaging pre- and postradiation therapy were enrolled. Quantitative tumor measurements were obtained by 2 attending neuroradiologists. ROIs were used to calculate vascular permeability and plasma volume and generate dynamic contrast-enhancement curves. Quantitative analysis was performed to determine mean and maximum plasma volume and vascular permeability values, while semiquantitative analysis on averaged concentration curves was used to determine the area under the curve. A Mann-Whitney U test at a significance level of P < .05 was used to assess differences of the above parameters between pre- and postradiation therapy.

RESULTS

Plasma volume mean (pretreatment mean = 0.82; posttreatment mean = 0.42), plasma volume maximum (pretreatment mean = 3.56; posttreatment mean = 2.27), and vascular permeability mean (pretreatment mean = 0.046; posttreatment mean = 0.028) in the ROIs significantly decreased after radiation therapy (P < .05); this change thereby demonstrated the potential for assessing tumor response. Area under the curve values also demonstrated significant differences (P < .05).

CONCLUSIONS

Plasma volume and vascular permeability decreased after radiation therapy, suggesting that these dynamic contrast-enhanced MR perfusion parameters may be useful for monitoring chordoma growth and response to radiation therapy. Additionally, the characteristic dynamic MR signal intensity-time curve of chordoma may provide a radiographic means of distinguishing chordoma from other spinal lesions.

Osseous metastases of chordoma: imaging and clinical findings

PURPOSE

To describe the imaging and clinical characteristics of chordoma osseous metastases (COM).

MATERIALS AND METHODS

Our study was IRB approved and HIPAA compliant. A retrospective search of our pathology database for pathology-proven COM yielded 15 patients who had undergone MRI, CT, bone scan, and/or FDG-PET/CT. The imaging and clinical features of the COMs were recorded. A control group of age and gender matched chordoma patients without osseous metastasis was evaluated.

RESULTS

The COM mean maximal dimension was 6.4 ± 4.0 cm. The majority (60%) of patients had one lesion. Extra-osseous soft tissue component was present in 85% and was larger than intra-osseous component in 76%. On MRI the lesions were heterogeneous but predominantly T2 hyperintense with hypointense septae, and with variable enhancement. On CT the lesions were typically destructive or permeative; calcifications were rare. The extent of the soft tissue component was isodense to muscle on CT and therefore better evaluated on MRI. COM was in a body part contiguous to the site of the primary tumor. Compared to the controls, COM patients were more likely to have local recurrence (P = 0.0009) and positive resection margins (P = 0.002). At 1 year, 33% of COM patients were deceased and 13% had progressive metastases.

CONCLUSION

COM are associated with large extra-osseous soft tissue components, which are better visualized by MRI. They are often located in a body part contiguous to the site of the primary tumor, portend poor prognosis, and are associated with positive resection margins and local recurrence.

Morphological and dynamic contrast enhanced MR imaging features for the differentiation of chordoma and giant cell tumors in the Axial Skeleton

PURPOSE

To characterize the morphological and dynamic-contrast-enhanced (DCE) MRI features of chordoma and giant cell tumor (GCT) of bone occurring in the axial skeleton.

MATERIALS AND METHODS

A total of 13 patients with chordoma and 26 patients with GCT who received conventional T1, T2, and DCE-MRI on 3 Tesla MR scanners were retrospectively identified and analyzed. Two radiologists evaluated morphological features independently, including the lesion location, expansile bone changes, vertebral compression, presence of paraspinal soft tissue mass, fibrous septa, and the signal intensity on T1WI and T2WI. The inter-observer agreement was evaluated by kappa test. The DCE kinetics was measured to obtain the initial area under curve (IAUC) and the wash-out slope; also the two-compartmental pharmacokinetic model was applied to obtain K^trans and k_ep . The diagnostic accuracy was evaluated by CHAID decision tree and ROC analysis.

RESULTS

Chordomas were more likely to show soft tissue mass than GCTs (13/13 = 100% versus 15/26 = 58%; P = 0.007), as well as fibrous septa (9/13 = 69% versus 0; P < 0.001). In decision tree analysis, presence of fibrous septa and lesion location yield 31/39 = 79% accuracy. The DCE-MRI pharmacokinetic parameters K^trans and k_ep of GCTs were significantly higher than those of chordomas, 0.13 ± 0.65 versus 0.06 ± 0.04 (1/min) for K^trans , 0.62 ± 0.22 versus 0.17 ± 0.12 (1/min) for k_ep , P < 0.001 for both. If using kep = 0.43/min as the cut-off value, it achieved 100% sensitivity and 92% specificity to differentiate chordoma from GCT, with an overall accuracy of 37/39 = 95%. The IAUC was highly correlated with K^trans (r = 0.94), and the slope was highly correlated with k_ep (r = 0.95).

CONCLUSION

Several morphological features were significantly different between chordoma and GCT, but their diagnostic performance was inferior to that of DCE-MRI.

LEVEL OF EVIDENCE

4 J. Magn. Reson. Imaging 2017;45:1068-1075.

Is there a role for conventional MRI and MR diffusion-weighted imaging for distinction of skull base chordoma and chondrosarcoma?

BACKGROUND

Chordoma and chondrosarcoma are locally invasive skull base tumors with similar clinical symptoms and anatomic imaging features as reported in the literature.

PURPOSE

To determine differentiation of chordoma and chondrosarcoma of the skull base with conventional magnetic resonance imaging (cMRI) and diffusion-weighted MR imaging (DWI) in comparison to histopathological diagnosis.

MATERIAL AND METHODS

This retrospective study comprised 96 (chordoma, n = 64; chondrosarcoma, n = 32) patients with skull base tumors referred to the Paul Scherrer Institute (PSI) for proton therapy. cMRI signal intensities of all tumors were investigated. In addition, median apparent diffusion coefficient (ADC) values were measured in a subgroup of 19 patients (chordoma, n = 11; chondrosarcoma, n = 8).

RESULTS

The majority 81.2% (26/32) of chondrosarcomas displayed an off-midline growth pattern, 18.8% (6/32) showed clival invasion, 18.8% (6/32) were located more centrally. Only 4.7% (3/64) of chordomas revealed a lateral clival origin. Using cMRI no significant differences in MR signal intensities were observed in contrast to significantly different ADC values (subgroup of 19/96 patients examined by DWI), with the highest mean value of 2017.2 × 10(-6 )mm(2)/s (SD, 139.9( )mm(2)/s) for chondrosarcoma and significantly lower value of 1263.5 × 10(-6 )mm(2)/s (SD, 100.2 × 10(-6 )mm(2)/s) for chordoma (P = 0.001/median test).

CONCLUSION

An off-midline growth pattern can differentiate chondrosarcoma from chordoma on cMRI in a majority of patients. Additional DWI is a promising tool for the differentiation of these skull base tumors.

Aneurysmal Bone Cyst of Sphenoid Bone and Clivus Misdiagnosed as Chordoma: A Case Report

Aneurysmal bone cysts (ABCs) are benign and rapidly expanding bone destructive lesions of any bone. They are commonly localized in the metaphysis of long bones, whereas skull base ABCs are rare. We report a case of a 21-year-old man who had been misdiagnosed as chordoma and undergone surgery. However, histopathological examination revealed it to be an ABC.

Building a global consensus approach to chordoma: a position paper from the medical and patient community

Chordomas are very rare bone malignant tumours that have had a shortage of effective treatments for a long time. New treatments are now available for both the local and the metastatic phase of the disease, but the degree of uncertainty in selecting the most appropriate treatment remains high and their adoption remains inconsistent across the world, resulting in suboptimum outcomes for many patients. In December, 2013, the European Society for Medical Oncology (ESMO) convened a consensus meeting to update its clinical practice guidelines on sarcomas. ESMO also hosted a parallel consensus meeting on chordoma that included more than 40 chordoma experts from several disciplines and from both sides of the Atlantic, with the contribution and sponsorship of the Chordoma Foundation, a global patient advocacy group. The consensus reached at that meeting is shown in this position paper.

[Chordoma]

PURPOSES

To review in the literature, all the epidemiological, clinical, radiological, histological and therapeutic data regarding chordomas as well as various notochordal entities: ecchordosis physaliphora, intradural and intraparenchymatous chordomas, benign notochordal cell tumors, parachordomas and extra-axial chordomas. To identify different types of chordomas, including familial forms, associations with tuberous sclerosis, Ollier's disease and Maffucci's syndrome, forms with metastasis and seeding. To assess the recent data regarding molecular biology and progress in targeted therapy. To compare the different types of radiotherapy, especially protontherapy and their therapeutic effects. To review the largest series of chordomas in their different localizations (skull base, sacrum and mobile spine) from the literature.

MATERIALS

The series of 136 chordomas treated and followed up over 20 years (1972-2012) in the department of neurosurgery at Lariboisière hospital is reviewed. It includes: 58 chordomas of the skull base, 47 of the craniocervical junction, 23 of the cervical spine and 8 from the lombosacral region. Similarly, 31 chordomas in children (less than 18 years of age), observed in the departments of neurosurgery of les Enfants-Malades and Lariboisière hospitals, are presented. They were observed between 1976 and 2010 and were located intracranially (n=22 including 13 with cervical extension), 4 at the craniocervical junction level and 5 in the cervical spine.

METHODS

In the entire Lariboisière series and in the different groups of localization, different parameters were analyzed: the delay of diagnosis, of follow-up, of occurrence of metastasis, recurrence and death, the number of primary patients and patients referred to us after progression or recurrence and the number of deaths, recurrences and metastases. The influence of the quality of resection (total, subtotal and partial) on the prognosis is also presented. Kaplan-Meier actuarial curves of overall survival and disease free survival were performed in the entire series, including the different groups of localization based on the following 4 parameters: age, primary and secondary patients, quality of resection and protontherapy. In the pediatric series, a similar analysis was carried-out but was limited by the small number of patients in the subgroups.

RESULTS

In the Lariboisière series, the mean delay of diagnosis is 10 months and the mean follow-up is 80 months in each group. The delay before recurrence, metastasis and death is always better for the skull base chordomas and worse for those of the craniocervical junction, which have similar results to those of the cervical spine. Similar figures were observed as regards the number of deaths, metastases and recurrences. Quality of resection is the major factor of prognosis with 20.5 % of deaths and 28 % of recurrences after total resection as compared to 52.5 % and 47.5 % after subtotal resection. This is still more obvious in the group of skull base chordomas. Adding protontherapy to a total resection can still improve the results but there is no change after subtotal resection. The actuarial curve of overall survival shows a clear cut in the slope with some chordomas having a fast evolution towards recurrence and death in less than 4 years and others having a long survival of sometimes more than 20 years. Also, age has no influence on the prognosis. In primary patients, disease free survival is better than in secondary patients but not in overall survival. Protontherapy only improves the overall survival in the entire series and in the skull base group. Total resection improves both the overall and disease free survival in each group. Finally, the adjunct of protontherapy after total resection is clearly demonstrated. In the pediatric series, the median follow-up is 5.7 years. Overall survival and disease free survival are respectively 63 % and 54.3 %. Factors of prognosis are the histological type (atypical forms), localization (worse for the cervical spine and better for the clivus) and again it will depend on the quality of resection.

CONCLUSIONS

Many different pathologies derived from the notochord can be observed: some are remnants, some may be precursors of chordomas and some have similar features but are probably not genuine chordomas. To-day, immuno-histological studies should permit to differentiate them from real chordomas. Improving knowledge of molecular biology raises hopes for complementary treatments but to date the quality of surgical resection is still the main factor of prognosis. Complementary protontherapy seems useful, especially in skull base chordomas, which have better overall results than those of the craniocervical junction and of the cervical spine. However, we are still lacking an intrinsic marker of evolution to differentiate the slow growing chordomas with an indolent evolution from aggressive types leading rapidly to recurrence and death on which more aggressive treatments should be applied.

Acute cauda equina syndrome secondary to lumbar chordoma: case report and literature review

BACKGROUND CONTEXT

Chordomas are rare tumors in the craniospinal axis arising from persistent notochordal rests commonly seen in the skull base, including the clivus and the sacrum. Chordomas in the mobile spine occur less commonly. To the best of our knowledge, the clinical presentation of acute cauda equina syndrome (CES) due to chordoma of the lumbar vertebra is not published in the English literature.

PURPOSE

To describe an unusual cause of acute CES resulting from chordoma of the lumbar vertebra and discuss management dilemmas in this clinical context.

STUDY DESIGN

Case report with review and discussion.

METHODS

We report the case of a 75-year-old man who presented with acute CES that was clinically considered a metastasis from his previously documented carcinoma of the urinary bladder treated a year ago. Clinical, radiological, and histopathological features of the case and a review of chordomas in the lumbar vertebrae in adults in the published English literature are presented.

RESULTS

He underwent urgent surgical decompression with laminectomy of L3/L4 and L4/L5 with debulking and open biopsy of the tissue mass. Histopathological examination of the tissue mass confirmed the unsuspected diagnosis of chordoma. The salient features of chordomas in the lumbar vertebrae published in the English literature over the last 22 years are summarized. The origin, classification, clinical presentation, and management protocols for lumbar chordomas are also reviewed.

CONCLUSIONS

The clinical presentation of acute CES as the first symptom of chordoma in the lumbar vertebrae is extremely rare. Preoperative tissue diagnosis of this uncommon pathology is usually unavailable. In the face of acute CES, surgical decompression remains the primary goal of management with a planned definitive second-stage curative surgical resection for chordoma.

Stereotactic radiosurgery of intracranial chordomas, chondrosarcomas, and glomus tumors

Chordomas and chondrosarcomas are rare, slow-glowing, locally aggressive tumors with high recurrence rates. Stereotactic radiosurgery (SRS) is an important management option for patients with recurrent or residual chordomas and chondrosarcomas. Glomus jugulare tumor are rare highly vascularized tumors that arise from the paraganglionic structures of the glossopharyngeal and vagal nerves. Because of their highly vascular nature and surgically formidable anatomic location, curative resection often proves challenging. SRS can be used as an up-front treatment or as an additional treatment for patients with recurrent or residual glomus jugulare tumor after surgical resection.

Paravertebral high cervical chordoma. A case report

Spinal chordomas are more often located on the midline and are associated with marked destruction of the vertebral bodies. We report a rare case of large cervical (C2-C3) right lateral paravertebral chordoma extending into the spinal canal through a very enlarged intervertebral foramen. The tumor was initially diagnosed as a mucous adenocarcinoma on a percutaneous needle biopsy. However, the neuroradiological features, including the well-defined tumor margins, the regular and sclerosing lytic bone changes with regular enlargement of the intervertebral C2-C3 foramen, were in favor of a more slowly growing lesion, such as schwannoma or neurofibroma. At surgery a well-demarcated capsulated tumor involving the nerve root was partially resected. Histology was in favor of a low-grade chordoma (Ki-67/MIB-1<1%). Postoperative proton beam therapy was also performed. The differential neuroradiological diagnosis is discussed.

The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials

OBJECT

Advocates of minimally invasive discectomy (MID) have promoted this operation as an alternative to open discectomy (OD), arguing that there may be less injury to the paraspinal muscles, decreased postoperative pain, and a faster recovery time. However, a recently published large randomized controlled trial (RCT) comparing these approaches reported inferior relief of leg pain in patients undergoing MID. The authors conducted a meta-analysis to evaluate complications and improvement in leg pain in patients with radiculopathy enrolled in RCTs comparing OD to MID.

METHODS

The authors performed a literature search using Medline and EMBASE of studies indexed between January 1990 and January 2011. Predetermined RCT eligibility included the usage of tubular retractors during MID, a minimum follow-up duration of 1 year, and quantification of pain with the visual analog scale (VAS). Trials that only evaluated patients with recurrent disc herniation were excluded. Data on operative parameters, complications, and VAS scores of leg pain were extracted by 2 investigators. A meta-analysis was performed assuming random effects to determine the difference in mean change for continuous outcomes and the risk ratio for binary outcomes.

RESULTS

Six trials comprising 837 patients (of whom 388 were randomized to MID and 449 were randomized to OD) were included. The mean operative time was 49 minutes during MID and 44 minutes during OD; this difference was not statistically significant. Incidental durotomies occurred significantly more frequently during MID (5.67% compared with 2.90% for OD; RR 2.05, 95% CI 1.05-3.98). Intraoperative complications (incidental durotomies and nerve root injuries) were also significantly more common in patients undergoing MID (RR 2.01, 95% CI 1.07-3.77). The mean preoperative VAS score for leg pain was 6.9 in patients randomized to MID and 7.2 in those randomized to OD. With long-term follow-up (1-2 years postoperatively), the mean VAS score improved to 1.6 in both the MID and OD cohorts. There was no significant difference in relief of leg pain between the 2 approaches with either short-term follow-up (2-3 months postoperatively, 0.81 points on the VAS, 95% CI -4.71 to 6.32) or long-term follow-up (2.64 on the VAS, 95% CI -2.15 to 7.43). Reoperation for recurrent herniation was more common in patients randomized to the MID group (8.50% compared with 5.35% in patients randomized to the OD group), but this difference was not statistically significant (RR 1.56, 95% CI 0.92-2.66). Total complications did not differ significantly between the operations (RR 1.50, 95% CI 0.97-2.33).

CONCLUSIONS

The current evidence suggests that both OD and MID lead to a substantial and equivalent long-term improvement in leg pain. Adequate decompression, regardless of the operative approach used, may be the primary determinant of pain relief-the major complaint of many patients with radiculopathy. Incidental durotomies occurred significantly more frequently during MID, but total complications did not differ between the techniques.

Chordoma of the thoracic spine in an 89-year-old

STUDY DESIGN

Case report and literature review.

OBJECTIVE

Report the highly unusual presentation of thoracic spine chordoma in an 89-year-old and review existing literature as it impacts treatment in the elderly. Chordomas are infrequent tumors of the spine that commonly present during mid-adulthood at the spheno-occipital or sacrococcygeal junctions. The mobile spine is affected in 10-15% of cases but chordomas are extremely rare in the thoracic spine. Chordoma rarely enters the differential diagnosis of spinal tumors in elderly patients, for whom metastases and multiple myeloma are by far the most common.

METHODS

A case report is detailed of an 89-year-old male presenting with incapacitating pain and early signs of thoracic myelopathy. A lytic, expanding lesion of the T10 vertebral body with epidural spinal cord compression was identified. In the absence of evidence of other primary tumor, a CT-guided needle biopsy revealed chordoma. A literature review of reported thoracic spine chordomas was also performed.

RESULTS

An intralesional posterolateral resection and reconstruction was performed with good results and no recurrence at 13 months' follow-up. 30 reports of thoracic spine chordomas were identified in the literature since 1902. Mean age of presentation at 35.7 years is earlier than for most chordomas. The oldest previously reported patient was 68-year-old. Neurological impairment at presentation is rare with the usual presenting symptom being pain. Response to radiation and chemotherapy is limited. 5-year survival rates range from 50 to 60%.

CONCLUSION

Chordoma is a highly uncommon epidural neoplasm of the thoracic spine and is vanishingly rare in elderly patients. This report documents the oldest reported patient with thoracic spine chordoma at 89-year-old. Their locally aggressive behavior typically prompts consideration of aggressive surgical resection. When tailored to the individual patient, such procedures are feasible without excessive morbidity even in elderly patients.

Stereotactic Radiosurgery for Chordoma

BACKGROUND:

Although considered slow-growing, low-grade malignancies, chordomas are locally aggressive and destructive tumors with high recurrence rates.

OBJECTIVE:

To assess patient survival, tumor control, complications, and selected variables that predict outcome in patients who underwent Gamma Knife stereotactic radiosurgery (SRS) as primary, adjuvant, or salvage management for chordomas of the skull base.

METHODS:

Six participating centers of the North American Gamma Knife Consortium identified 71 patients who underwent SRS for chordoma. The median patient age was 45 years (range, 7-80 years). The median SRS target volume was 7.1 cm3 (range, 0.9-109 cm3), and median margin dose was 15.0 Gy (range, 9-25 Gy).

RESULTS:

At a median follow-up of 5 years (range, 0.6-14 years) after SRS, 23 patients died of tumor progression. The 5-year actuarial overall survival after SRS was 80% for the entire group, 93% for the no prior fractionated radiation therapy (RT) group (n = 50), and 43% for the prior RT group (n = 21). Younger age, longer interval between initial diagnosis and SRS, no prior RT, &lt; 2 cranial nerve deficits, and smaller total tumor volume were significantly associated with longer patient survival. The 5-year treated tumor control rate after SRS was 66% for the entire group, 69% for the no prior RT group, and 62% for the prior RT group. Older age, recurrent group, prior RT, and larger tumor volume were significantly associated with worse tumor control.

CONCLUSION:

Stereotactic radiosurgery is a potent treatment option for small sized chordomas, especially in younger patients and as part of a multipronged attack that includes surgical resection when possible.

Pediatric cervical chordoma: report of two cases and a review of the current literature

INTRODUCTION

The majority of chordomas occur between the fifth and seventh decades of life and are thus extremely rare in children, which account for less than 5% of all spinal chordoma cases.

CASE REPORT

We report on the development of this rare condition in two boys aged 7 and 10 years. One patient presented with a palpable neck mass and dysphagia, while the other presented with posterior neck pain. Radiological studies revealed an extensive mass in the cervical vertebrae and paravertebral soft tissue of both patients. The tumors were subtotally removed in an attempt to improve the success of adjuvant proton beam radiotherapy. Pathological examination, which included immunohistochemical staining, revealed chordoma of the cervical spine in both patients.

CONCLUSION

Although en bloc resection is the ideal modality for treatment of chordoma, such a procedure is often associated with a significant risk of surgical morbidity due to the tumor location. Therefore, piecemeal resection followed by postoperative adjuvant radiotherapy, including proton radiotherapy or radiosurgery, should be considered in such cases.

Neoplastic disease of the vertebral column: radiologic-pathologic correlation

Spine imaging is frequently performed in daily practice. Due to the high frequency of spine examinations and the multiple modalities (ie, radiography, computed tomography, magnetic resonance imaging, positron emission tomography/computed tomography, single-photon emission computed tomography/computed tomography) used for imaging, neoplastic disease of the vertebral column will occasionally be encountered by practicing radiologists. When a lesion in the spine is encountered, it is helpful to have an understanding of the general types of pathology and key differentiating features that may aid in guiding appropriate workup (eg, no follow-up required, short-term follow-up, or directed biopsy). This article aims to provide a framework for characterizing neoplastic disease in the spine and allows the practicing radiologist an opportunity to develop a more concise and accurate differential diagnosis with which to guide clinical management.

Surgery significantly improves survival in patients with chordoma

STUDY DESIGN

Retrospective database review using Surveillance, Epidemiology, and End Results database, National Cancer Institute.

OBJECTIVE

To determine current treatment outcomes and demographic characteristics and to define the prognostic factors and impact of surgery on survival.

SUMMARY OF THE BACKGROUND DATA

Rarity of the disease has limited the number of population-based studies addressing the issues of prognostic factors and the current treatment outcomes.

METHODS

A total of 962 patients with chordoma, diagnosed between 1973 and 2005, were identified in the Surveillance, Epidemiology, and End Results database. Patient demographics and clinical characteristics, incidence, year of diagnosis, location, size and stage at diagnosis, treatment(s), and survival were extracted. Kaplan-Meier, log-rank, and Cox regression were used to analyze the significance of prognostic factors.

RESULTS

Race specific incidence per 100,000 persons in 2005 shows whites to have the highest (0.473) incidence, followed by Asians/Pacific Islanders (0.091), and Afro-Americans (zero), respectively. The incidence difference between whites and Afro-Americans over time is statistically significant (P < 0.001). The age adjusted incidence reveals a peak in eighth decade of life. Survival was not impacted by race. Age category <59, Hispanic ethnicity, size <8 cm, and surgical resection were all independent predictors of better overall survival. Analysis revealed that survival outcomes were very similar in patients with "in-operable disease" and those in which "surgery was recommended but not performed" suggesting that benefits of resection cannot be solely attributed to selection bias.

CONCLUSION

With high local recurrence rates and the significant functional morbidity associated with surgical resections, clinicians are left wondering if surgery constitutes an appropriate treatment option. Our study clearly demonstrates that surgery significantly improves the overall survival for patients with chordoma. We have further identified age <59 and size of primary tumor <8 cm as important prognostic factors determining the outcome with substantial statistical significance.

Imaging appearance of primary bony tumors and pseudo-tumors of the spine

We aim to review the imaging appearance of primary bony tumors of the spine and simulating lesions. Benign bone tumors commonly appear as well-circumscribed, slow-growing lesions with a calcified or sclerotic matrix. Malignancy is often aggressive permeative lesions with bone destruction, cortical invasion and associated soft-tissue mass. CT is an excellent imaging modality for characterization of the tumor matrix, exact location, extension and osseous changes, while MR imaging is superior for evaluation of the associated soft-tissue mass, bone marrow infiltration and intraspinal extension. There is a spectrum of pseudotumors that may also involve the spine. The imaging appearance of primary spinal bone tumor in conjunction with the patient's age, gender and lesion location allows a high percentage of correct diagnosis. Imaging plays an important role in diagnosis, characterization and extension of bone tumors of the spine which will help guide therapy.

Cervical chordoma in childhood without typical vertebral bony destruction: case report and review of the literature

STUDY DESIGN

Case report.

OBJECTIVE

We present a giant cervical chordoma without typical vertebral bony destruction in an 11-year-old girl.

SUMMARY OF BACKGROUND DATA

Chordomas are rare malignant bone tumors that arise at both the cranial and the caudal ends of the axial skeleton, characteristically destroying the bone. Cervical chordomas comprise only 3% to 7% of all chordomas. To our knowledge, there is no case of cervical chordoma in a child, presenting without vertebral body involvement, in English literature.

METHODS

Discussion on the patient's clinical, radiologic history, and histopathologic diagnosis of the resected tumor, with a review of the relevant background literature.

RESULTS

We report the first case of cervical chordoma in a child without typical vertebral bony destruction, the diagnosis of which was difficult to confirm before and after operation.

CONCLUSION

Giant notochordal rest and benign notochordal cell tumors (BNCTs) need to be recognized for differential diagnosis of this atypical chordoma. A long-term follow-up might be necessary for the diagnosis of this nontypical patient.

Diagnostic imaging of solitary tumors of the spine: what to do and say

Metastatic disease, myeloma, and lymphoma are the most common malignant spinal tumors. Hemangioma is the most common benign tumor of the spine. Other primary osseous lesions of the spine are more unusual but may exhibit characteristic imaging features that can help the radiologist develop a differential diagnosis. Radiologic evaluation of a patient who presents with osseous vertebral lesions often includes radiography, computed tomography (CT), and magnetic resonance (MR) imaging. Because of the complex anatomy of the vertebrae, CT is more useful than conventional radiography for evaluating lesion location and analyzing bone destruction and condensation. The diagnosis of spinal tumors is based on patient age, topographic features of the tumor, and lesion pattern as seen at CT and MR imaging. A systematic approach is useful for recognizing tumors of the spine with characteristic features such as bone island, osteoid osteoma, osteochondroma, chondrosarcoma, vertebral angioma, and aneurysmal bone cyst. In the remaining cases, the differential diagnosis may include other primary spinal tumors, vertebral metastases and major nontumoral lesions simulating a vertebral tumor, Paget disease, spondylitis, echinococcal infection, and aseptic osteitis. In many cases, vertebral biopsy is warranted to guide treatment.

Chordoma: the nonsarcoma primary bone tumor

Chordomas are rare, slowly growing, locally aggressive neoplasms of bone that arise from embryonic remnants of the notochord. These tumors typically occur in the axial skeleton and have a proclivity for the spheno-occipital region of the skull base and sacral regions. In adults, 50% of chordomas involve the sacrococcygeal region, 35% occur at the base of the skull near the spheno-occipital area, and 15% are found in the vertebral column. Craniocervical chordomas most often involve the dorsum sella, clivus, and nasopharynx. Chordomas are divided into conventional, chondroid, and dedifferentiated types. Conventional chordomas are the most common. They are characterized by the absence of cartilaginous or additional mesenchymal components. Chondroid chordomas contain both chordomatous and chondromatous features, and have a predilection for the spheno-occipital region of the skull base. This variant accounts for 5%-15% of all chordomas and up to 33% of cranial chordomas. Dedifferentiation or sarcomatous transformation occurs in 2%-8% of chordomas. This can develop at the onset of the disease or later. Aggressive initial therapy improves overall outcome. Patients who relapse locally have a poor prognosis but both radiation and surgery can be used as salvage therapy. Subtotal resection can result in a stable or improved status in as many as 50% of patients who relapse after primary therapy. Radiation therapy may also salvage some patients with local recurrence. One series reported a 2-year actuarial local control rate of 33% for patients treated with proton beam irradiation.

En bloc resection of a C4 chordoma: surgical technique

The prognosis of aggressive benign and low-grade malignant tumors in the spine as in the limbs, seems to be mostly related to the feasibility of en bloc resection, while in the treatment of high-grade malignant tumors the protocols of treatment include the combination of chemotherapy, radiation and surgery. Indications, criteria of feasibility and surgical technique are extensively reported for the thoracic and lumbar spine. In the cervical spine few cases are reported of resection, due not only to anatomical constraint, but also to the rarity of finding a tumor accomplishing the criteria of feasibility. A case of double-approach vertebrectomy finalized to remove en bloc the body of C4 for a stage IA chordoma is reported. The first stage was posterior, aiming to remove the posterior healthy elements by piecemeal technique. The anterior approach consisted of contemporary right and left prevascular presternocleidomastoid approaches The specimen was submitted for the histological study of the margins, which resulted tumor-free. This technical note is finalized to confirm that en bloc resection of the vertebral body through total vertebrectomy is feasible in the midcervical spine by double approaches, provided the tumor involves only layers B and C, maximum extension sectors 5-8.

Imaging features of posterior mediastinal chordoma in a child

A 5 1/2-year-old boy presented with repeated episodes of stridor and cough. Chest radiography demonstrated a widened mediastinum. Evaluation by CT revealed a low-density posterior mediastinal mass initially diagnosed as benign tumor. Histopathological analysis of the resected mass disclosed a malignant chordoma. Our radiological results are described with an analysis of the imaging findings in the medical literature. We present our suggestions for preoperative evaluation of posterior mediastinal tumors.

Les chordomes

Chordoma is a rare bone tumor, believed to derive from notochordal rests, which generally arises at the two extremities of axial skeleton. We present a literature review on chordomas. Diagnosis has been greatly improved by MRI and immunohistochemistry. Conversely, complementary immunohistochemistry, cytometry and cytogenetic techniques have failed to improve prognosis evaluation. Radical surgery with free surgical margins is the most accurate curative treatment. Progress in radiotherapy should offer new therapeutic perspectives in the future. The recognition of new entities such as giant notochordal rest or hamartoma, and notochordal cells benign tumor, can lead to confusion since there is no consensus regarding their nature and whether or not they correspond to chordoma precursors. Prudence should be the rule in order to avoid overtreatment.

Analysis of radiological features relative to histopathology in 42 skull-base chordomas and chondrosarcomas

Chordomas and chondrosarcomas are malignant tumors that are reported to have similar clinical presentations and radiological features but different behaviors and outcomes. The aim of this retrospective study was to determine whether specific radiological features of skull-base chordomas or chondrosarcomas are correlated with histopathology, and thus allow preoperative diagnosis. The study involved 32 classic chordomas, 6 chondroid chordomas and 4 chondrosarcomas (42 tumors total). For each case, tumor size and extent, the detailed anatomy involved, and magnetic resonance imaging and computed tomography findings were analyzed. Tumor extent was assessed using a novel method that assessed presence/absence in 18 defined skull-base zones. The chondrosarcomas presented significantly earlier in life than the chordomas (means, 20.5 years versus 36 years, respectively). At time of diagnosis, the median tumor volume was 23 cm(3) (range, 1.2-78.8 cm(3)) and the mean tumor extent was 6.7+/-2.9 zones. There were no differences between chordomas and chondrosarcomas, or between the two chordoma subgroups, with respect to lesion volume or extent. Comparison of other imaging findings revealed no features that were diagnostic for either chordoma or chondrosarcoma. The data support previous claims that chondrosarcomas present earlier in life than chordomas, but this finding is not diagnostic. There is wide variation in the extent of skull-base chordomas and chondrosarcomas, and in the specific anatomical structures these tumors involve. None of the MRI or CT features of these tumors appear to be useful for differentiating chordomas from chondrosarcomas preoperatively. For surgical planning, specific, area-oriented definition of tumor extent might provide more useful information than tumor-type classification schemes.