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Park H, Choi Y, Lee S, Lee SH, Kim ES, Jang SW, Park JH, Cho Y, Jang G, Ha Y, Dho YS, Yoo H, Lee SU, Seo SH, Kim KJ, Sohn S, Chung CK. The Clinical Outcomes of Cervical Spine Chordoma: A Nationwide Multicenter Retrospective Study. Neurospine 2024; 21:942-953. [PMID: 39363489 PMCID: PMC11456934 DOI: 10.14245/ns.2448448.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/26/2024] [Accepted: 07/02/2024] [Indexed: 10/05/2024] Open
Abstract
OBJECTIVE Chordoma, a rare malignant tumor originating from embryonal notochord remnants, exhibits high resistance to conventional treatments, making surgical resection imperative. However, the factors influencing prognosis specifically for cervical spine chordoma have not been clearly identified. We investigate the prognosis of cervical spine chordoma with factors influential in a nationwide multicenter retrospective study. METHODS This study included all patients diagnosed with cervical spine chordoma at 7 tertiary referral centers from January 1998 to March 2023, excluding those with clivus and thoracic spine chordomas extending into the cervical spine. Local recurrence (LR) was identified through follow-up magnetic resonance imaging, either as reappearance in completely resected tumors or regrowth in residual tumors. The study assessed LR and overall survival, analyzing factors influencing LR and death. RESULTS Forty-five patients with cervical spine chordoma had a mean age of 46.4 years. Over a median follow-up of 52 months, LR and distant metastasis were observed in 21 (46.7%) and 4 patients (8.9%), respectively, and 16 patients (36%) were confirmed dead. The 5-year and 10-year cumulative LR rates were 51.3% and 60%, respectively, while the 5-year and 10-year survival rates were 82% and 53%. Age was the only significant factor affecting mortality (hazard ratio, 1.04; 95% confidence interval, 1.04-1.07; p=0.015). Notably, the degree of resection and adjuvant therapy did not statistically significantly impact local tumor control and mortality. CONCLUSION This study, the largest multicenter retrospective analysis of cervical spine chordoma in Korea, identified age as the only factor significantly affecting patient survival.
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Affiliation(s)
- Hangeul Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Sungjoon Lee
- Department of Neurosurgery, Samsung Medical Center, Seoul, Korea
| | - Sun-Ho Lee
- Department of Neurosurgery, Samsung Medical Center, Seoul, Korea
| | - Eun-Sang Kim
- Department of Neurosurgery, Samsung Medical Center, Seoul, Korea
| | - Sun Woo Jang
- Department of Neurosurgery, Asan Medical Center, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, Seoul, Korea
| | - Yunseong Cho
- Department of Neurosurgery, Severance Hospital, Seoul, Korea
| | - Giwuk Jang
- Department of Neurosurgery, Severance Hospital, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Severance Hospital, Seoul, Korea
| | - Yun-Sik Dho
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Korea
| | - Heon Yoo
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Korea
| | - Sung Uk Lee
- Center for Proton Therapy, National Cancer Center, Goyang, Korea
| | - Seung-Ho Seo
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seil Sohn
- Department of Neurosurgery, CHA Bundang Medical Center, Seongnam, Korea
| | - Chun Kee Chung
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Noya C, D’Alessandris QG, Doglietto F, Pallini R, Rigante M, Mattogno PP, Gessi M, Montano N, Parrilla C, Galli J, Olivi A, Lauretti L. Treatment of Clival Chordomas: A 20-Year Experience and Systematic Literature Review. Cancers (Basel) 2023; 15:4493. [PMID: 37760463 PMCID: PMC10527079 DOI: 10.3390/cancers15184493] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Clival chordomas are rare but aggressive skull base tumors that pose significant treatment challenges and portend dismal prognosis. The aim of this study was to highlight the advantages and limitations of available treatments, to furnish prognostic indicators, and to shed light on novel therapeutic strategies. We conducted a retrospective study of clival chordomas that were surgically treated at our institution from 2003 to 2022; for comparison purposes, we provided a systematic review of published surgical series and, finally, we reviewed the most recent advancements in molecular research. A total of 42 patients underwent 85 surgeries; median follow-up was 15.8 years, overall survival rate was 49.9% at 10 years; meanwhile, progression-free survival was 26.6% at 10 years. A significantly improved survival was observed in younger patients (<50 years), in tumors with Ki67 ≤ 5% and when adjuvant radiotherapy was performed. To conclude, clival chordomas are aggressive tumors in which surgery and radiotherapy play a fundamental role while molecular targeted drugs still have an ancillary position. Recognizing risk factors for recurrence and performing a molecular characterization of more aggressive lesions may be the key to future effective treatment.
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Affiliation(s)
- Carolina Noya
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
| | - Quintino Giorgio D’Alessandris
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy;
| | - Francesco Doglietto
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy;
| | - Roberto Pallini
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
| | - Mario Rigante
- Otolaryngology, Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.R.); (C.P.)
| | - Pier Paolo Mattogno
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy;
| | - Marco Gessi
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
- Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Nicola Montano
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy;
| | - Claudio Parrilla
- Otolaryngology, Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.R.); (C.P.)
| | - Jacopo Galli
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
- Otolaryngology, Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (M.R.); (C.P.)
| | - Alessandro Olivi
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy;
| | - Liverana Lauretti
- School of Medicine, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (C.N.); (Q.G.D.); (F.D.); (R.P.); (M.G.); (N.M.); (J.G.); (A.O.)
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy;
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Gupta KK, Balai E, Darr A, Jolly K. Reconstruction and Cerebrospinal Fluid Leaks in Endoscopic Endonasal Approach for the Management of Clival Chordomas-A Systematic Review. Indian J Otolaryngol Head Neck Surg 2022; 74:4807-4815. [PMID: 36742692 PMCID: PMC9895481 DOI: 10.1007/s12070-022-03114-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/25/2022] [Indexed: 02/07/2023] Open
Abstract
The success of the endoscopic endonasal approach (EEA) to surgically manage clival chordomas (CC) relies on robust repair methods to reduce complications, such as cerebrospinal fluid (CSF) leaks. Our study aims to evaluate the existing literature to assess reconstructive techniques utilised and post-operative CSF leak rates in this cohort. A systematic review and analysis was performed of all published data related to CC patients managed with an EEA. A total of 24 articles were included, representing 363 patients and 396 procedures. A variety of reconstruction methods were used with 95.9% of studies using an intracranial repair graft, 70.8% using a nasoseptal flap (NSF), 62.5% using glue/haemostat, 58.3% using nasal packs and 75.0% employing multi-layered reconstruction. Post-operative CSF leak rate was 10.1%. The leak rate was less in subgroups where a NSF was used (9.4%) although this was not statistically significant (p = 0.273). There were no differences in leak rates when glue/haemostat (p = 0.139) or nasal packs (p = 0.550) were used. Our review is the most up-to-date synthesis of the existing literature surrounding the EEA to CCs assessing reconstruction and post-operative CSF leaks. It demonstrates most authors employ a multi-layered reconstruction method. The lack of statistical significance observed for CSF leaks in subgroups is likely due to a variety of cofounding surgeon and patient factors. Higher quality prospective randomised multi-centric studies, with reporting of specific repair techniques will enable future systematic reviews to provide a more accurate consensus regarding optimal methods of reconstruction in this field.
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Affiliation(s)
- Keshav Kumar Gupta
- Department of Surgery, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Hallam Street, West Bromwich, B71 4HJ UK
| | - Edward Balai
- Department of Surgery, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Hallam Street, West Bromwich, B71 4HJ UK
| | - Adnan Darr
- Department of Otorhinolaryngology, New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, WV10 0QP UK
| | - Karan Jolly
- Department of Otorhinolaryngology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, B15 2TH UK
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Baig Mirza A, Ravindran V, Okasha M, Boardman TM, Maratos E, Sinan B, Thomas N. Systematic Review Comparing Open versus Endoscopic Surgery in Clival Chordomas and a 10-Year Single-Center Experience. Skull Base Surg 2022; 83:e113-e125. [DOI: 10.1055/s-0041-1722933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives Chordomas are rare, slow-growing, and osteo-destructive tumors of the primitive notochord. There is still contention in the literature as to the optimal management of chordoma. We conducted a systematic review of the surgical management of chordoma along with our 10-year institutional experience.
Design A systematic search of the literature was performed in October 2020 by using MEDLINE and EMBASE for articles relating to the surgical management of clival chordomas. We also searched for all adult patients surgically treated for primary clival chordomas at our institute between 2009 and 2019.
Participants Only articles describing chordomas arising from the clivus were included in the analysis. For our institution experience, only adult primary clival chordoma cases were included.
Main Outcome Measures Patients were divided into endoscopic or open surgery. Rate of gross total resection (GTR), recurrence, and complications were measured.
Results Our literature search yielded 24 articles to include in the study. Mean GTR rate among endoscopic cases was 51.9% versus 41.7% for open surgery. Among the eight cases in our institutional experience, we found similar GTR rates between endoscopic and open surgery.
Conclusion Although there is clear evidence in the literature that endoscopic approaches provide better rates of GTR with fewer overall complications compared to open surgery. However, there are still situations where endoscopy is not viable, and thus, open surgery should still be considered if required.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Visagan Ravindran
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohamed Okasha
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Eleni Maratos
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Barazi Sinan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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Endoscopic endonasal approach for loco-regional recurrent clivus chordomas. BRAIN AND SPINE 2022; 2:100918. [PMID: 36248100 PMCID: PMC9560577 DOI: 10.1016/j.bas.2022.100918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022]
Abstract
EEA represents an ideal approach for loco-regional recurrent CCs. EEA is well tolerated, with preservation of patients QoL. EEA can be considered for patients with perspectives of adjuvant therapies. Otherwise, EEA can be considered only in selected cases with a palliative aim.
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6
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Teng C, Yang Q, Xiong Z, Ye N, Li X. Multivariate Analysis and Validation of the Prognostic Factors for Skull Base Chordoma. Front Surg 2021; 8:764329. [PMID: 34888345 PMCID: PMC8649658 DOI: 10.3389/fsurg.2021.764329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Skull base chordoma is a rare tumor with low-grade malignancy and a high recurrence rate, the factors affecting the prognosis of patients need to be further studied. For that, we investigated prognostic factors of skull base chordoma through the database of the Surveillance, Epidemiology, and End Results (SEER) program, and validated in an independent data set from the Xiangya Hospital. Methods: Six hundred and forty-three patients diagnosed with skull base chordoma were obtained from the SEER database (606 patients) and the Xiangya Hospital (37 patients). Categorical variables were selected by Chi-square test with a statistical difference. Survival curves were constructed by Kaplan–Meier analysis and compared by log-rank test. Univariate and multivariate Cox regression analyses were used to explore the prognostic factors. Propensity score matching (PSM) analysis was undertaken to reduce the substantial bias between gross total resection (GTR) and subtotal resection (STR) groups. Furthermore, clinical data of 37 patients from the Xiangya Hospital were used as validation cohorts to check the survival impacts of the extent of resection and adjuvant radiotherapy on prognosis. Results: We found that age at diagnosis, primary site, disease stage, surgical treatment, and tumor size was significantly associated with the prognosis of skull base chordoma. PSM analysis revealed that there was no significant difference in the OS between GTR and STR (p = 0.157). Independent data set from the Xiangya Hospital proved no statistical difference in OS between GTR and STR groups (p = 0.16), but the GTR group was superior to the STR group for progression-free survival (PFS) (p = 0.048). Postoperative radiotherapy does not improve OS (p = 0.28), but it can prolong PFS (p = 0.0037). Nomograms predicting 5- and 10-year OS and DSS were constructed based on statistically significant factors identified by multivariate Cox analysis. Age, primary site, tumor size, surgical treatment, and disease stage were included as prognostic predictors in the nomograms with good performance. Conclusions: We identified age, tumor size, surgery, primary site, and tumor stage as main factors affecting the prognosis of the skull base chordoma. Resection of the tumor as much as possible while ensuring safety, combined with postoperative radiotherapy may be the optimum treatment for skull base chordoma.
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Affiliation(s)
- Chubei Teng
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China.,Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China.,Department of Neurosurgery, The First Affiliated Hospital, University of South China, Hengyang, China
| | - Qi Yang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China.,Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China
| | - Zujian Xiong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China.,Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China
| | - Ningrong Ye
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China.,Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China
| | - Xuejun Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China.,Hunan International Scientific and Technological Cooperation Base of Brain Tumor Research, Xiangya Hospital, Central South University, Changsha, China
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7
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Bai J, Li M, Xiong Y, Shen Y, Liu C, Zhao P, Cao L, Gui S, Li C, Zhang Y. Endoscopic Endonasal Surgical Strategy for Skull Base Chordomas Based on Tumor Growth Directions: Surgical Outcomes of 167 Patients During 3 Years. Front Oncol 2021; 11:724972. [PMID: 34631554 PMCID: PMC8493096 DOI: 10.3389/fonc.2021.724972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/02/2021] [Indexed: 11/25/2022] Open
Abstract
Background Skull base chordomas (SBCs) are rare malignant bone tumors with dismal long-term local control. Endoscopic endonasal surgeries (EESs) are increasingly adopted to resect SBCs recently. Gross total resection (GTR) favors good outcomes. However, the SBCs often invade the skull base extensively and hide behind vital neurovascular structures; the tumors were challenging to remove entirely. To improve the GTR, we established a surgical strategy for EES according to the tumor growth directions. Methods A total of 112 patients with SBCs from 2018 to 2019 were classified into the derivation group. We retrospectively analyzed their radiologic images and operation videos to find the accurate tumor locations. By doing so, we confirmed the tumor growth directions and established a surgical strategy. Fifty-five patients who were operated on in 2020 were regarded as the validation group, and we performed their operations following the surgical strategy to verify its value. Results In the derivation group, 78.6% of SBCs invade the dorsum sellae and posterior clinoid process region. 62.5% and 69.6% of tumors extend to the left and right posterior spaces of cavernous ICA, respectively. 59.8% and 61.6% of tumors extend to the left and right posterior spaces of paraclival and lacerum ICA (pc-la ICA), respectively. 30.4% and 28.6% of tumors extended along the left and right petroclival fissures that extend toward the jugular foramen, respectively. 30.4% of tumors involved the foramen magnum and craniocervical junction region. The GTR was achieved in 60.8% of patients with primary SBCs in the derivation group. Based on the tumors’ growth pattern, pituitary transposition and posterior clinoidectomy techniques were adopted to resect tumors that hid behind cavernous ICA. Paraclival ICA transposition was used when the tumor invaded the posterior spaces of pc-la ICA. Lacerum fibrocartilage resection and eustachian tube transposition may be warranted to resect the tumors that extended to the jugular foramen. GTR was achieved in 75.0% of patients with primary SBCs in the validation group. Conclusion Besides the midline clival region, the SBCs frequently grow into the eight spaces mentioned above. The surgical strategy based on the growth pattern contributes to increasing the GTR rate.
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Affiliation(s)
- Jiwei Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Mingxuan Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yujia Xiong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yutao Shen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Chunhui Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lei Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Beijing Institute for Brain Disorders Brain Tumor Center, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Key Laboratory of Central Nervous System Injury Research, Capital Medical University, Beijing, China
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Bai J, Li M, Shi J, Jing L, Zhai Y, Zhang S, Wang J, Zhao P, Li C, Gui S, Zhang Y. Mid-term follow-up surgical results in 284 cases of clival chordomas: the risk factors for outcome and tumor recurrence. Neurosurg Rev 2021; 45:1451-1462. [PMID: 34623525 PMCID: PMC8976789 DOI: 10.1007/s10143-021-01576-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/12/2021] [Accepted: 05/26/2021] [Indexed: 12/03/2022]
Abstract
Objective Skull base chordoma (SBC) is rare and one of the most challenging diseases to treat. We aimed to assess the optimal timing of adjuvant radiation therapy (RT) and to evaluate the factors that influence resection and long-term outcomes. Methods In total, 284 patients with 382 surgeries were enrolled in this retrospective study. Postsurgically, 64 patients underwent RT before recurrence (pre-recurrence RT), and 47 patients underwent RT after recurrence. During the first attempt to achieve gross-total resection (GTR), when the entire tumor was resected, 268 patients were treated with an endoscopic midline approach, and 16 patients were treated with microscopic lateral approaches. Factors associated with the success of GTR were identified using χ2 and logistic regression analyses. Risk factors associated with chordoma-specific survival (CSS) and progression-free survival (PFS) were evaluated with the Cox proportional hazards model. Results In total, 74.6% of tumors were marginally resected [GTR (40.1%), near-total resection (34.5%)]. History of surgery, large tumor volumes, and tumor locations in the lower clivus were associated with a lower GTR rate. The mean follow-up period was 43.9 months. At the last follow-up, 181 (63.7%) patients were alive. RT history, histologic subtype (dedifferentiated and sarcomatoid), non-GTR, no postsurgical RT, and the presence of metastasis were associated with poorer CSS. Patients with pre-recurrence RT had the longest PFS and CSS, while patients without postsurgical RT had the worst outcome. Conclusion GTR is the goal of initial surgical treatment. Pre-recurrence RT would improve outcome regardless of GTR. Supplementary Information The online version contains supplementary material available at 10.1007/s10143-021-01576-4.
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Affiliation(s)
- Jiwei Bai
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Mingxuan Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jianxin Shi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD, USA
| | - Liwei Jing
- Department of Health Statistics, Shanxi Medical University, Taiyuan, China
| | - Yixuan Zhai
- Department of Neurosurgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Shuheng Zhang
- Department of Neurosurgery, Anshan Central Hospital, Anshan, China
| | - Junmei Wang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China. .,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
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Mattavelli D, Fiorentino A, Tengattini F, Colpani A, Agnelli S, Buffoli B, Ravanelli M, Ferrari M, Schreiber A, Rampinelli V, Taboni S, Verzeletti V, Deganello A, Rodella LF, Maroldi R, Ceretti E, Sartore L, Piazza C, Fontanella MM, Nicolai P, Doglietto F. Additive Manufacturing for Personalized Skull Base Reconstruction in Endoscopic Transclival Surgery: A Proof-of-Concept Study. World Neurosurg 2021; 155:e439-e452. [PMID: 34450324 DOI: 10.1016/j.wneu.2021.08.080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic transnasal transclival intradural surgery is limited by a high postoperative cerebrospinal fluid leak rate. The aim of this study was to investigate the role of three-dimensional printing to create a personalized, rigid scaffold for clival reconstruction. METHODS Two different types of clivectomy were performed in 5 specimens with the aid of neuronavigation, and 11 clival reconstructions were simulated. They were repaired with polylactide, three-dimensional-printed scaffolds that were manually designed in a computer-aided environment based either on the real or on the predicted defect. Scaffolds were printed with a fused filament fabrication technique and different offsets. They were positioned and fixed either following the gasket seal technique or with screws. Postdissection radiological evaluation of scaffold position was performed in all cases. In 3 specimens, the cerebrospinal fluid leak pressure point was measured immediately after reconstruction. RESULTS The production process took approximately 30 hours. The designed scaffolds were satisfactory when no offset was added. Wings were added during the design to allow for screw positioning, but broke in 30% of cases. Radiological assessment documented maximal accuracy of scaffold positioning when the scaffold was created on the real defect; accuracy was satisfactory when the predicted clivectomy was performed under neuronavigation guidance. The cerebrospinal fluid leak pressure point was significantly higher when the scaffold was fixed with screws compared with the gasket technique. CONCLUSIONS In this preclinical setting, additive manufacturing allows the creation of customized scaffolds that are effective in reconstructing even large and geometrically complex clival defects.
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Affiliation(s)
- Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Fiorentino
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Francesco Tengattini
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessandro Colpani
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Silvia Agnelli
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Stefano Taboni
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Vincenzo Verzeletti
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alberto Deganello
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Fabrizio Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Elisabetta Ceretti
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Luciana Sartore
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Cesare Piazza
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
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10
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Cavallo LM, Mazzatenta D, d'Avella E, Catapano D, Fontanella MM, Locatelli D, Luglietto D, Milani D, Solari D, Vindigni M, Zenga F, Zona G, Cappabianca P. The management of clival chordomas: an Italian multicentric study. J Neurosurg 2021; 135:93-102. [PMID: 32886913 DOI: 10.3171/2020.5.jns20925] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the last 2 decades, the endoscopic endonasal approach in the treatment of clival chordomas has evolved to be a viable strategy to achieve maximal safe resection of this tumor. Here, the authors present a multicentric national study, intending to analyze the evolution of this approach over a 20-year time frame and its contribution in the treatment of clival chordomas. METHODS Clival chordoma cases surgically treated between 1999 and 2018 at 10 Italian neurosurgical departments were included in this retrospective study. Clinical, radiological, and surgical findings, adjuvant therapy, and outcomes were evaluated and compared according to classification in the treatment eras from 1999 to 2008 and from 2009 to 2018. RESULTS One hundred eighty-two surgical procedures were reviewed, with an increase in case load since 2009. The endoscopic endonasal transclival approach (EETA) was performed in 151 of 182 cases (83.0%) and other approaches were performed in 31 cases (17%). There was an increment in the use of EETA, neuronavigation, and Doppler ultrasound after 2008. The overall postoperative complication rate was 14.3% (26 of 182 cases) consisting of 9 CSF leaks (4.9%), 7 intracranial hemorrhages (3.8%), 5 cases of meningitis (2.7%), and 5 cerebral ischemic injuries (2.7%). Gross-total resection (GTR) was achieved in 93 of 182 cases (51.1%). Extent of resection (EOR) improved in the second era of the study. Signs and/or symptoms at presentation worsened in 27 cases (14.8%), and the Katz Index worsened in 10 cases (5.5%). Previous treatment, dural involvement, EETA, and intraoperative Doppler ultrasound correlated with GTR. Patients received adjuvant proton beam radiation in 115 of 182 cases (63.2%), which was administered more in the latter era. Five-year progression-free survival (PFS) and overall survival (OS) were 62.3% and 73.5%, respectively. GTR, EETA, proton beam therapy, and the chondroid subtype correlated with a better survival rate. The mean follow-up was 62 months. CONCLUSIONS Through multicentric data collection, this study encompasses the largest series in the literature of clival chordomas surgically treated through an EETA. An increase in the use of this approach was found among Italian neurosurgical departments together with an improved extent of resection over time. The satisfactory rate of GTR was marked by low surgical morbidity and the preservation of patient quality of life. Surgical outcome was reinforced, in terms of PFS and OS, by the use of proton beam therapy, which was increasingly performed along the period of study.
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Affiliation(s)
- Luigi Maria Cavallo
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples
| | - Diego Mazzatenta
- 2Department of Biomedical and Neuromotor Sciences, University of Bologna, IRCCS Institute of Neurological Sciences of Bologna, "Bellaria" Hospital, Bologna
| | - Elena d'Avella
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples
| | - Domenico Catapano
- 3Division of Neurosurgery, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo
| | | | - Davide Locatelli
- 5Division of Neurosurgery, Università degli Studi dell'Insubria, Ospedale di Circolo e Fondazione Macchi, Varese
| | | | - Davide Milani
- 7Division of Neurosurgery, Humanitas Research Hospital, Rozzano
| | - Domenico Solari
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples
| | - Marco Vindigni
- 8Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine
| | - Francesco Zenga
- 9Department of Neuroscience, "Rita Levi Montalcini", Neurosurgery Unit, University of Turin; and
| | - Gianluigi Zona
- 10Neurosurgery and Neurotraumatology, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Paolo Cappabianca
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples
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11
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Hug EB, Pelak M, Frank SJ, Fossati P. A Review of Particle Therapy for Skull Base Tumors: Modern Considerations and Future Directions. Int J Part Ther 2021; 8:168-178. [PMID: 34285944 PMCID: PMC8270106 DOI: 10.14338/ijpt-20-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/24/2021] [Indexed: 11/23/2022] Open
Abstract
Skull base tumors constitute one of the established indications for particle therapy, specifically proton therapy. However, a number of prognostic factors, practical clinical management issues, and the emerging role of carbon ion therapy remain subjects of active clinical investigation. This review summarizes these topics, assesses the present status, and reflects on future research directions focusing on the management of chordomas, one of the most aggressive skull base tumors. In addition, the role of particle therapy for benign tumors of the skull base, including pituitary adenoma and acoustic neuroma, is reviewed.
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Affiliation(s)
- Eugen B Hug
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Maciej Pelak
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Steven J Frank
- MD Anderson Cancer Center, Division of Radiation Oncology, Houston, TX, USA
| | - Piero Fossati
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
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12
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Passer JZ, Alvarez-Breckenridge C, Rhines L, DeMonte F, Tatsui C, Raza SM. Surgical Management of Skull Base and Spine Chordomas. Curr Treat Options Oncol 2021; 22:40. [PMID: 33743089 DOI: 10.1007/s11864-021-00838-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 12/22/2022]
Abstract
OPINION STATEMENT Management of chordoma along the cranial-spinal axis is a major challenge for both skull base and spinal surgeons. Although chordoma remains a rare tumor, occurring in approximately 1 per 1 million individuals, its treatment poses several challenges. These tumors are generally poorly responsive to radiation and chemotherapy, leading to surgical resection as the mainstay of treatment. Due to anatomic constraints and unique challenges associated with each primary site of disease, gross total resection is often not feasible and is associated with high rates of morbidity. Additionally, chordoma is associated with high rates of recurrence due to the tumor's aggressive biologic features, and postoperative radiation is increasingly incorporated as a treatment option for these patients. Despite these challenges, modern-day surgical techniques in both skull base and spinal surgery have facilitated improved patient outcomes. For example, endoscopic endonasal techniques have become the mainstay in resection of skull base chordomas, improving the ability to achieve gross total resection, while reducing associated morbidity of open transfacial techniques. Resection of spinal chordomas has been facilitated by emerging techniques in preoperative imaging, intraoperative navigation, spinal reconstruction, and radiotherapy. Taken collectively, the treatment of chordoma affecting the skull base and spinal requires a multidisciplinary team of surgeons, radiation oncologists, and medical oncologists who specialize in the treatment of this challenging disease.
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Affiliation(s)
- Joel Z Passer
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Christopher Alvarez-Breckenridge
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Laurence Rhines
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Claudio Tatsui
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA.
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13
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Wierzbicka M, Szyfter W, Greczka G, Gawęcki W. Otosurgery with the High-Definition Three-Dimensional (3D) Exoscope: Advantages and Disadvantages. J Clin Med 2021; 10:jcm10040777. [PMID: 33669166 PMCID: PMC7919662 DOI: 10.3390/jcm10040777] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/27/2021] [Accepted: 02/12/2021] [Indexed: 12/18/2022] Open
Abstract
Background: The aim of the study was to describe our initial experience with the high-definition three-dimensional (3D) exoscope for middle ear surgery versus the operating microscope. Methods: The study included 60 randomly chosen patients diagnosed with otosclerosis (n = 30) or chronic otitis media (n = 30) with a clinical indication for surgery. The primary measurement was the subjective estimation of quality of the visibility of the operating field provided by the 3D exoscope—VITOM-3D (Karl Storz, Tuttlingen, Germany) in comparison to the operating microscope. Results: All procedures, except for two (3.3%) converted to the microscope, were successfully completed using a 3D exoscope. In both stapedotomy and tympanoplasty, the exoscope was superior to the microscope during more superficial portions of the procedures. By contrast, in deeper areas of the middle ear, the exoscope provided significantly worse visibility, but usually not suboptimal. Both intraoperative bleeding and the narrow surgical field substantially reduced the visibility with the 3D exoscope in comparison to the microscope. Conclusions: Overall, our study shows that the 3D exoscope offers excellent, highly magnified, and well-illuminated high-definition images of the surgical field. However, our experience revealed several important limitations of this system, including decreased depth perception in deep areas of the tympanic cavity and reduced visibility in a difficult surgical field, with subsequent need to switch to an operating microscope in select cases.
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14
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Li H, Zhang H, Hu L, Wang H, Wang D. Endoscopic endonasal resection and radiotherapy as treatment for skull base chordomas. Acta Otolaryngol 2020; 140:789-794. [PMID: 32804560 DOI: 10.1080/00016489.2020.1748225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of endonasal endoscopic surgery and radiotherapy in the treatment of skull base chordomas remains unclear. OBJECTIVE We investigated the effect of endonasal endoscopic surgery and radiotherapy as treatment for skull base chordomas. METHOD We investigated 46 patients (2006-2018) treated at the Affiliated Eye Ear Nose and Throat Hospital, Fudan University. We documented demographics, clinical presentation, operative resection, complications, postoperative radiotherapy, follow-up time, and survival in all patients. RESULT Complete tumour resection was performed in 18 (39.1%), subtotal tumour resection in 16 (34.8%), and partial tumour resection in 12 (26.1%) patients. Most common clinical manifestations included nasal obstruction (41%), headaches (30%), and visual impairment (20%). The median duration of progression-free survival (PFS) and overall survival (OS) was 21.5 and 33.5 months, respectively. Primary vs. recurrent disease (p = .043), partial resection (PR) vs. subtotal resection (STR) (p = .006), STR vs. gross total resection (GTR) (p = .020), GTR vs. PR (p = .001), and complicated vs. uncomplicated status (p = .002) were significantly associated with PFS. Primary vs. recurrent disease (p = .002), PR vs. STR (p = .001), GTR vs. PR (p = .001), surgery alone vs. surgery concomitant with radiotherapy (p = .048), and complicated vs. uncomplicated status (p = .017) were significantly associated with OS. CONCLUSION Surgery is the primary treatment for chordoma; higher tumour resection rates are associated with higher OS and PFS. Surgeons should aim to resect as much tumour as is safely possible. Postoperative radiotherapy is useful adjuvant treatment to improve OS, and IMRT serves as an effective alternative to PBRT.The optimal radiotherapeutic technique is determined by cost, accessibility, availability of the modality, and tumour volume.
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Affiliation(s)
- Hongbing Li
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
| | - Huankang Zhang
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
| | - Li Hu
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
- Department of Research Centre, Eye and ENT Hospital of Fudan University, Shanghai, China
| | - Huan Wang
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
| | - Dehui Wang
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
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