Chordoma: radiologic evaluation of 20 cases

Cervical Paraspinal Chordoma: A Literature Review with a Novel Case Report

Chordomas are rare malignant neoplasms, accounting for 1–4% of all primary bone tumors. Most spinal chordomas occur in the sacrococcygeal region and the base of the skull; however, 6% of chordomas are observed in the cervical spine. In these cases, the lesion is mainly located in the midline. These tumors slowly grow before becoming symptomatic and encase the surrounding vascular and nerve structures. Patients with advanced chordoma have a poor prognosis due to local recurrence with infiltration and destruction of adjacent bone and tissues. Systemic chemotherapy options have not been fully effective in these tumors, especially for recurrent chordomas. Thus, new combinations of currently available targeted molecular and biological therapies with radiotherapy have been proposed as potential treatment modalities. Here, the present paper describes the case of a 41-year-old male with a C2–C4 chordoma located paravertebrally, who underwent surgical resection with a debulking procedure for a cervical chordoma. Computed tomography angiography revealed a paraspinal mass with bone remodeling and the MRI showed a paravertebral mass penetrating to the spinal canal with a widening of the intervertebral C2–C3 foramen. Initially, the tumor was diagnosed as schwannoma based on its localization and imaging features; however, the histopathology specimen confirmed the diagnosis of chordoma. This case study highlights the effectivity of radical surgical resection as a mainstay treatment for chordomas, discusses neuroimaging, diagnosis, and the use of currently available targeted therapies and forthcoming treatment strategies, as alternative treatment options for chordoma.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Endoscopic Resection of Clival Chordoma: A Tertiary Care Experience

The primary management of the rare tumor chordoma is always surgical. This study indicates the advantage of endoscopic approach for clival chordoma resection. This is a Retrospective case series of 7 endoscopically operated clival chordoma patients between May 2015 and April 2018 in our tertiary care hospital. 5 patients presented with primary disease and 2 were recurrent disease cases. Endoscopic endonasal transphenoidal approach with wide clearance of margins of tumor were performed in all 7 cases. High energy photon radiotherapy were delivered to all. All patients with primary disease as well as recurrent disease had no evidence of disease 24-32 months post surgery. Endoscopic endonasal transphenoidal approach for clival chordoma provides a safe and reliable tumor resection. This less invasive surgery can be considered as an alternative to traditional surgical technique with reduced morbidity. This approach represents a combination of various endoscopic surgical techniques which are minimally invasive and can be applied to ventral skull base surgery.

Clival chordoma with drop metastases

Chordoma is a rare midline malignant tumor arising from embryonic remnants of the primitive notochord. The base of the skull is the second most common site of disease after the sacrococcygeal region. Intracranial chordoma constitutes about 30-35% of chordoma cases. Metastasis from chordoma is uncommon but if occurs, it tends to spread to the lungs. Cerebrospinal fluid seeding or drop metastasis is very rare. Here we describe a case of a clival chordoma with drop metastases.

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.

A historical recount of chordoma

Chordoma, a rare bone tumor that occurs along the spine, has led scientists on a fascinating journey of discoveries. In this historical vignette, the authors track these discoveries in diagnosis and treatment, noting events and clinicians that played pivotal roles in our current understanding of chordoma. The study of chordoma begins in 1846 when Rudolf Virchow first observed its occurrence on a dorsum sellae; he coined the term “chordomata” 11 years later. The chordoma’s origin was greatly disputed by members of the scientific community. Eventually, Müller’s notochord hypothesis was accepted 36 years after its proposal. Chordomas were considered benign and slow growing until the early 1900s, when reported autopsy cases drew attention to their possible malignant nature. Between 1864 and 1919, the first-ever symptomatic descriptions of various forms of chordoma were reported, with the subsequent characterization of chordoma histology and the establishment of classification criteria shortly thereafter. The authors discuss the critical historical steps in diagnosis and treatment, as well as pioneering operations and treatment modalities, noting the physicians and cases responsible for advancing our understanding of chordoma.

Immunophenotypic features of dedifferentiated skull base chordoma: An insight into the intratumoural heterogeneity

Chordomas are rare and low-grade malignant solid tumours, despite their histologically benign appearance, that arise in the bone from embryonic notochordal vestiges of the axial skeleton, a mesoderm-derived structure that is involved in the process of neurulation and embryonic development. Chordomas occurring in the skull base tend to arise in the basiocciput along the clivus. Three major morphological variants have been described (classical, chondroid, and atypical/dedifferentiated). The pathogenesis and molecular mechanisms involved in chordoma development remain uncertain. From a pathological standpoint, the microenvironment of a chordoma is heterogeneous, showing a dual epithelial-mesenchymal differentiation. These tumours are characterised by slow modality of biologic growth, local recurrence, low incidence of metastasis rates, and cancer stem cell (CSC) phenotype. The main molecular findings are connected with brachyury immunoexpression and activation of the downstream Akt and mTOR signalling pathways. The differentiation between typical and atypical chordomas is relevant because the tumoural microenvironment and prognosis are partially different. This review provides an insight into the recent and relevant concepts and histochemical markers expressed in chordomas, with special emphasis on dedifferentiated chordomas and their prognostic implications.

Presentation, Treatment, and Long-Term Outcome of Intrasellar Chordoma: A Pooled Analysis of Institutional, SEER (Surveillance Epidemiology and End Results), and Published Data

BACKGROUND

Chordoma that occurs primarily in the sella turcica is rare and presents unique treatment challenges.

OBJECTIVE

The purpose of this study was to determine common features, treatment approaches, and survival characteristics of intrasellar chordoma.

METHODS

Institutional databases, the SEER (Surveillance Epidemiology and End Results) database, and PubMed/EMBASE were queried for chordoma with a primarily intrasellar component. The SEER database was also queried for adult skull base chordoma. Patient-level data were extracted where available. Kaplan-Meier survival analyses were conducted.

RESULTS

Among 80 cases, the mean age at presentation was 55.6 (standard deviation, 15.9), with a female predominance (1.16:1.00). Patients experienced symptoms for a mean duration of 19.0 months, including cranial nerve deficits, hypopituitarism, and hyperprolactinemia. Among patients receiving treatment, 77.5% underwent surgery. In addition, less than half of the patients (n = 34, 47.3%) received adjuvant radiation therapy. The 5-year overall survival (OS) of intrasellar chordoma was 60.0% (standard error [SE], 6.9). Patients aged 40 years and younger had a 5-year OS of 80.8% (SE, 12.2), compared with patients older than 40 years, who had an OS of 55.4% (SE, 7.7) (Mantel-Cox, P = 0.044). Males experienced a lower 5-year OS (44.0; SE, 9.7) than did females (76.8; SE, 8.5), (Mantel-Cox, P = 0.003). Median OS was greater in patients with skull base chordoma than in patients with intrasellar chordoma (Mantel-Cox, P = 0.046).

CONCLUSIONS

Intrasellar chordoma presents frequently with visual disturbances and hyperprolactinemia and has a slightly higher incidence in females. Young age predicts a better prognosis. Intrasellar chordoma has a lower overall survival than has skull base chordoma.

Endoscopic Resection of Clival Malignancies

Surgical management of clival lesions presents numerous therapeutic challenges because of the close proximity of surrounding critical structures. With a detailed understanding of the endoscopic endonasal approach and relevant considerations, appropriate lesions can be removed in a safe and minimally invasive manner. Use of this technique as a primary approach represents the standard of care for many lesions at leading skull base centers, although adjunct techniques may be necessary in extensive lesions and those with significant lateral extension.

Coming together is a beginning: the making of an intervertebral disc

The intervertebral disc (IVD) is a complex fibrocartilaginous structure located between the vertebral bodies that allows for movement and acts as a shock absorber in our spine for daily activities. It is composed of three components: the nucleus pulposus (NP), annulus fibrosus, and cartilaginous endplate. The characteristics of these cells are different, as they produce specific extracellular matrix (ECM) for tissue function and the niche in supporting the differentiation status of the cells in the IVD. Furthermore, cell heterogeneities exist in each compartment. The cells and the supporting ECM change as we age, leading to degenerative outcomes that often lead to pathological symptoms such as back pain and sciatica. There are speculations as to the potential of cell therapy or the use of tissue engineering as treatments. However, the nature of the cells present in the IVD that support tissue function is not clear. This review looks at the origin of cells in the making of an IVD, from the earliest stages of embryogenesis in the formation of the notochord, and its role as a signaling center, guiding the formation of spine, and in its journey to become the NP at the center of the IVD. While our current understanding of the molecular signatures of IVD cells is still limited, the field is moving fast and the potential is enormous as we begin to understand the progenitor and differentiated cells present, their molecular signatures, and signals that we could harness in directing the appropriate in vitro and in vivo cellular responses in our quest to regain or maintain a healthy IVD as we age.

Primary chordomas of the cervical spine: a consecutive series of 14 surgically managed cases

OBJECT

Cervical chordomas are rare lesions and usually bring about challenges in treatment planning because of their wide extension and complicated adjacent anatomy. There are few large published series at present focusing on cervical chordomas. The authors studied a consecutive series of 14 patients with primary cervical chordomas who underwent surgical treatment and were observed between 1989 and 2008. By reviewing the clinical patterns and follow-up data, they sought to investigate the clinical characters, tailor the appropriate surgical techniques, and establish prognosis factors for cervical chordomas.

METHODS

Hospitalization and follow-up data in the 14 patients were collected. All patients underwent piecemeal tumor excision and reconstruction for stability; total spondylectomy was achieved in 5 cases. Postoperative radiotherapy was administered in all patients. Kaplan-Meier plots were used to represent tumor recurrence and patient survival, and log-rank testing was used to determine the risk factors of local recurrence.

RESULTS

Follow-up ranged from 8 to 120 months (mean 58.6 months). Symptom and neural status in most patients improved after surgery. The 1- and 5-year disease-free survival rates were 78.6% and 50%, respectively, and the 1- and 5-year survival rates were 92.9% and 85.7%, respectively. Log-rank tests revealed that the following variables were significantly associated with a high rate of tumor recurrence: age less than 40 years or greater than 70 years (p = 0.006) and an upper cervical tumor location (p = 0.019).

CONCLUSIONS

Chordomas in the cervical spine are usually neoplasms that exhibit insidious growth and a wide extension by the time of diagnosis. Radical intralesional debulking surgery and postoperative radiotherapy have been effective treatment. A limited application of en bloc tumor resection and the highly likely intraoperative intralesional tumor seeding may partially explain the high local recurrence rate, whereas the chance of distant metastases, fortunately, is very low. Most recurrence were documented within 3 years. Some specific surgical techniques should be emphasized to minimize tumor seeding. Patients with upper cervical chordomas, younger adults, and elderly adults have worse prognosis. For patients with chordoma extending to both the anterior and posterior spinal columns, total spondylectomy combined with piecemeal excision is recommended for a better prognosis.

A comprehensive analysis of intracranial chordoma and survival: a systematic review

OBJECTIVE

Despite the published information on cranial chordoma, most of the data regarding survival in these patients has come from a single institution. Here, we perform a systematic review of the literature to evaluate across multiple institutions the overall survival after treatment for intracranial chordoma.

MATERIALS AND METHODS

We systematically analysed every study published in English and found a total of over 2000 patients being treated for intracranial chordoma. The overall 5-year and 10-year survivals in these patients were stratified according to the age (<5 years vs. >5 years and  <40 years vs. >40 years), treatment (surgery and radiation vs. surgery alone) and histological findings (chondroid vs. typical). Data were analysed via Pearson chi-square test and student t-test when appropriate.

RESULTS

A total of 560 non-duplicated patients treated for cranial chordoma met inclusion criteria for this systematic analysis. The survival rate among these patients was 63% (299 patients) and 16% (176 patients) for 5-year and 10-year survivals, respectively. There was no difference in overall survival between the two groups when a cut-off age of 40 years was used (<40 years = 50% vs.  >40 years = 51% at 5-year survival; p = 0.1), but when 5 years was used as the cut-off age, then survival was better for patients in the group older than 5 years of age (<5 years = 14% vs.  >5 years = 66%; p = 0.001). There was no difference between 5-year survival in patients with chordoma with histological chondroid features and those with chordoma possessing typical histology (45% vs. 67%; p = 0.06). When patients who only received surgery were compared to those patients who were treated with surgical intervention in combination with adjuvant radiation treatment, no difference in survival rate was found (54% vs. 56% at 5 years; p = 0.8).

CONCLUSION

The results of our systematic study provide data to predict the survival of intracranial chordoma patients across multiple institutions. Our data suggest that patients younger than 5 years of age may be associated with a worse prognosis, and adjuvant radiation therapy and histological type were not associated with the improvement of survival rates.

Adjuvant radiation therapy and chondroid chordoma subtype are associated with a lower tumor recurrence rate of cranial chordoma

Cranial chordomas are rare tumors that have been difficult to study given their low prevalence. Individual case series with decades of data collection provide some insight into the pathobiology of this tumor and its responses to treatment. This meta-analysis is an attempt to aggregate the sum experiences and present a comprehensive review of their findings. We performed a comprehensive review of studies published in English language literature and found a total of over 2,000 patients treated for cranial chordoma. Patient information was then extracted from each paper and aggregated into a comprehensive database. The tumor recurrences in these patients were then stratified according to age (<21 vs. >21 years), histological findings (chondroid vs. typical) and treatment (surgery and radiation vs. surgery only). Data was analyzed via Pearson chi-square and t-test. A total of 464 non-duplicated patients from 121 articles treated for cranial chordoma met the inclusion criteria. The recurrence rate among all patients was 68% (314 patients) with an average disease-free interval of 45 months (median, 23 months). The mean follow-up time was 39 months (median, 27 months). The patients in younger group, patients with chordoma with chondroid histologic type, and patients who received surgery and adjuvant radiotherapy had significantly lower recurrence rate than their respective counterparts. The results of our systematic analysis provide useful data for practitioners in objectively summarizing the tumor recurrence in patients with cranial chordomas. Our data suggests that younger patients with chondroid type cranial chordoma treated with both surgery and radiation may have improved rates of tumor recurrence in the treatment of these tumors.

Primary chordoma in the nasal cavity and nasopharynx: CT and MR imaging findings

BACKGROUND AND PURPOSE

Primary chordoma in the nasal cavity and nasopharynx is an extremely rare tumor in the extraosseous axial skeleton. Unlike intracranial chordomas, lesions in these sites primarily present as a soft tissue mass without involvement of the skull base bone (clivus), so the preoperative diagnosis of the tumor is possibly difficult. Here, we reviewed the imaging features of 5 cases of chordomas in the nasal cavity and nasopharynx that resulted in successful diagnosis and differential diagnosis of this rare tumor.

MATERIALS AND METHODS

We retrospectively studied 5 patients with histologically proven chordomas in the nasal cavity and nasopharynx. The lesion features of CT and MR imaging were reviewed, with emphasis on the size, shape, location, margin, calcification, CT attenuation characteristics, signal intensity, and degree of MR imaging enhancement.

RESULTS

Expansible and lobular soft tissue masses were mainly present, with irregular intratumor calcification in all 5 cases on CT examination. MR imaging revealed a well-defined tumor with heterogeneous signal intensity in 4 patients, whereas homogeneous signal intensity in 1 patient was present on all pulse sequences. Four cases of nasopharyngeal mass showed mild to moderate heterogenous enhancement. Intratumor septa could be seen in 2 cases.

CONCLUSIONS

Although no imaging features are pathognomonic, primary chordomas without skull base (clivus) bony changes in the nasal cavity and nasopharynx have some CT and MR imaging findings that are suggestive of diagnosis. The differential diagnosis of the soft tissue mass should be limited to these sites.

Primary tumors of the osseous spine

Primary tumors of the spine are less frequent than metastatic disease, multiple myeloma, and lymphoma. MR imaging is commonly used to evaluate the spine in patients presenting with pain and can further characterize lesions that may be encountered on other imaging studies, such as radiographs, bone scintigraphy, or CT. This article guides radiologists in identifying these lesions and referring physicians to the appropriate patient evaluation. It also offers directions for avoiding all-encompassing broad differential diagnosis lists in situations where the clinical scenario or specific imaging features can significantly limit the diagnostic possibilities.

Review of spinal epidural cavernous hemangioma

The characteristics of spinal epidural cavernous hemangioma without primary origin in the vertebral bone were evaluated in 54 patients including our new case. The 36 male and 18 female patients were aged 5 to 78 years (mean 47 years). Most lesions were in the thoracic spine (80%) and on the dorsal side of the spinal cord (93%). The clinical course was mostly slowly progressive, with myelopathy in 33% at onset and 83% at admission. The lesion appeared isointense to the spinal cord on T1-weighted imaging, and isointense or slightly hypointense to the cerebrospinal fluid on T2-weighted imaging. Lesion without hemorrhage showed prominent homogeneous enhancement after administration of gadolinium-diethylenetriaminepenta-acetic acid because of the sinusoidal channel structure. Heterogeneous enhancement was caused by hematoma and/or post-hemorrhagic degeneration. The differential diagnosis of this disease includes metastatic tumor, Ewing's sarcoma, chordoma, eosinophilic granuloma, sarcoidosis, lipoma, hypertrophy of the posterior longitudinal ligament or the ligamentum flavum, meningioma, and neurinoma. The relationships between clinical course and surgery or outcome suggest that early diagnosis and total removal of the lesion before massive lesional bleeding occurs are necessary for a good outcome.

Giant vertebral notochordal rest: a lesion distinct from chordoma: discussion of an evolving concept

A 14-year-old boy with severe back pain for several years is described. Roentgenograms, bone scans, and computed tomographic scans of the spine were normal, but magnetic resonance imaging studies showed a lumbar vertebral body lesion, confined to the bone, with low T1- and high T2-weighted signal intensities. Histologically, the lesion consisted of sheet-like notochordal-type tissue, containing physaliphorous cells but lacking the usual features of chordoma. A diagnosis of giant notochordal rest was made. A review of prior possible examples of this recently described and controversial entity is made with a discussion of its embryologic foundations and distinction from chordoma.

Vertebral tumors and pseudotumors

This article discusses lesions that may present as vertebral tumors at radiologic examination. Conditions are discussed in order of decreasing frequency: pseudotumoral lesions, vertebral metastases, bone marrow diseases, and primary vertebral tumors, which are relatively uncommon. The differential diagnosis between nontraumatic benign and malignant vertebral collapses is also discussed.

Low cervical chordoma: case report

We report a case of a 32-year old woman with radicular symptoms associated with a low cervical chordoma. According to our knowledge this is the 10th case of low cervical chordoma reported in the literature.

Epidural dumbbell-shaped chordoma mimicking a neurinoma

The authors present a case of cervical chordoma which manifested in a 5-year-old boy as a dumbbell-shaped epidural tumor without bone destruction. Both CT and MRI demonstrated tumor features suggesting this diagnosis, which was confirmed by histology.

Clival chordomas

Three cases of clival chordomas are reviewed and the findings are compared to those in the recent literature. In the first case the tumour arose from the basion, spreading downwards to invade the upper cervical canal and the paravertebral fascial planes. The second case is a rare case since it affects a 12 year old pre-adolescent boy. The third case showed the characteristic features of petro-clival erosion and a large extracranial component in the nasopharynx. In all three cases, computed tomography was an excellent modality for demonstrating bone destruction, sequestra and calcification but inferior to magnetic resonance imaging (MRI) in demonstrating the soft tissue extent of the tumour. The multiplanar capability of MRI was found to be particularly useful for planning treatment. Vertebral angiography can demonstrate the tumours by vessel displacement, encasement and vascular staining. Two cases had angiography and demonstrated tumour blush. Pre-operative embolization was helpful in one case.

Cranial chordoma in the first decade

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

Intracranial chordoma in a preadolescent. Case report

Chordomas are rare tumors derived from notochord remnants occurring primarily in the sacrum, clivus, and cervical regions. Exceptionally, these tumors occur in children, though usually in the sacrum. Eight cases of clivus chordoma have been described in preteenagers. In this report, a clival chordoma with unusual radiologic features is described in an 11-year-old boy. The literature regarding this entity is reviewed.

The foramen ovale. MR and CT correlation

Six patients with lesions involving the foramen ovale are presented and analyzed. Anatomy, pathology and imaging of diseases occurring in the vicinity of the foramen ovale are reviewed. Computerized tomography (CT) and magnetic resonance imaging (MRI) are complimentary in the evaluation of pathology in this region. CT is better able to evaluate bony detail while MR imaging is useful in detailing the anatomical extent and tissue characteristics.

Imaging of cranial chordomas

The clinical, pathologic, and imaging characteristics of clival chordomas in 14 patients who underwent magnetic resonance examinations were evaluated. Magnetic resonance imaging (MRI) was compared with skull series, tomography, computed tomography (CT), and magnification angiography in the diagnosis of clival chordomas. Although all examinations were highly sensitive for the detection of clival chordomas, MRI was the best single study because of its ability to image in orthogonal planes, its excellent soft-tissue contrast, and its demonstration of the relationship between the neoplasm and regional vital structures, particularly the brainstem, cavernous sinus, cranial nerves, and neighboring vessels. The deficiencies of MRI are poor visualization of tumoral calcification and osseous destruction--findings that are better identified on CT. In all 14 cases, MRI revealed the neoplasms to be black on inversion-recovery, gray on partial-saturation, and white on T2-weighted pulse sequences. Three chordomas had a speckled signal void pattern, typical of tumor calcification.

Thoracic chordoma with unusual radiographic features

A case of chordoma involving the thoracic spine (T12) is reported. The plain film findings included lytic obstruction and partial collapse of a single vertebral body. Noncontrast CT and CT following Metrizamide myelography revealed vertebral body destruction with paravertebral and intraspinal soft tissue masses. Unusual findings in the case included a photon deficient area on nuclear medicine corresponding to the lesion and normal vascularity on spinal angiography. We know of no previous report describing chordoma as a "cold" defect on bone scanning.

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

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

Metastasizing chordoma in early childhood: a pathological and immunohistochemical study with review of the literature

A 2 1/2-year-old female with a sphenooccipital-vertebral chordoma presented with neck pain, torticollis, fever, a lytic lesion of C2 vertebra, and bilateral nodular infiltrates in the lung. The lung biopsy revealed multiple tumor emboli by an enigmatic epithelioid-appearing neoplasm with immunohistochemical staining for vimentin, cytokeratin, and epithelial membrane antigen. A thorough roentgenographic evaluation disclosed a destructive, prepontine mass in the region of the clivus, erosion of the odontoid process, and compression of the cervical spinal cord. The patient died after a clinical course of 3 months. We identified 16 additional cases of metastasizing chordomas in the pediatric-age population; this case is the first to our knowledge with pathologically documented pulmonary metastasis at presentation.

Craniocervical chordomas in the Mersey Region (a ten-year experience)

The clinical presentation and management of craniocervical chordomas in the Mersey Region between 1974 and 1984 are presented, and compared to those in previously published series. A review of the current modalities of treatment is also discussed.

Computed tomography of spinal chordomas

Computed tomography of 16 spinal chordomas revealed lytic lesions, or lytic and blastic lesions, of 2 or more adjacent vertebrae and a fairly well-delineated soft tissue mass in 16 patients. Intravenous contrast enhancement revealed multiple zones of hypodensity in 5 tumors pathologically proved to contain areas of cystic degeneration. Invasion of the epidural space was noted on computed tomography in 2 vertebral and 7 sacral lesions, and on myelography in 7 vertebral lesions. Computed tomography is ideal for delineation of the soft tissue component of these lesions, detection of sacral lesions at an early stage, planning of surgical excision or irradiation treatment, and detection of recurrence.

Intracranial tumors arising from the floor of the middle fossa

Tumors involving or arising from the floor of the middle fossa in cases seen at the Neurological Institute C. Besta were reviewed, and the radiological findings of plain films, angiographic and CT studies are described. Meningiomas, metastases, trigeminal neurinomas, epidermoids, chordomas and chondromas were included in the study.

Intradural chordoma without bone involvement: nuclear magnetic resonance (NMR) appearance. Case report

This paper presents a rare case of intradural chordoma which involved the pons but had no radiological or surgical evidence of bone involvement. The appearance of this tumor on nuclear magnetic resonance imaging is presented.

Sacrococcygeal chordoma in young adults

Sacrococcygeal chordoma in young adults is rare. Two patients, aged 29 and 34 years, are presented. Computed tomography plays an important role in delineating the extent of bony destruction and soft-tissue involvement. This information is necessary for treatment which may include surgery, radiotherapy and/or chemotherapy. A review of sacrococcygeal chordomas is presented.

Scintigraphic photopenia in sacrococcygeal chordoma

A case with a photon deficient or cold lesion on bone scintigraphy due to sacrococcygeal chordoma is presented. The proposed mechanism is also explained.

Definitive radiation therapy for chordoma and chondrosarcoma of base of skull and cervical spine

Proton-beam radiation therapy has been developed for the treatment of chordomas or sarcomas of bone or soft tissue that abut the central nervous system. The authors report the results of treatment of 10 patients, six with chordoma, three with chondrosarcoma, and one with a neurofibrosarcoma. Local control has been achieved for all patients (with, however, one marginal failure) with a follow-up period ranging from 2 months to 6 years. High doses of radiation, up to 76 Cobalt Gray Equivalents (CGE), have been delivered without significant morbidity. In particular, no neurological sequelae have been observed.

Hemispherical spondylosclerosis--a polyetiologic syndrome

Radiologic examination of 43 patients revealed 47 lesions of a type which we have termed hemispherical spondylosclerosis (HSS). This term describes and includes the following essential and possible radiologic findings of the disease: 1) Hemispherical (or "dome-" or "helmet-shaped") sclerosis of the vertebra above the intervertebral disk. Thus it is a supradiscal HSS. 2) One or more small erosions of the inferior end plate of the vertebra involved. 3) Periosteal apposition on the anterior border of the vertebra along the length of the sclerosis. 4) New bone formation on the inferior end plate. 5) Anterior vertebral osteophytes. 6) Narrowing of the disk space below the affected vertebra. HSS occurs not only as a sequel of degenerative disk disease, but also in bacterial (tuberculous and non-tuberculous) spondylitis, ankylosing spondylitis, osteoid osteoma, and metastases of neoplasms. The differential diagnosis between inflammatory and noninflammatory pathogenesis and etiology of HSS is described. The characteristic shape of HSS, its sites of predilection (14 greater than L5 greater than L3), and the preponderance of female sufferers from this painful condition are due to factors which, as yet, remain unknown.

Sacral chordoma: a case study and review

Chordomas are a low grade, tenacious, but eventually lethal neoplasm for which little improvement in outcome has been reported. A current review of the literature and a case report are provided to support his position. The reported sacral chordoma did respond temporarily to chemotherapy. Its rare occurrence precludes controlled studies of chordoma; therefore, any response merits reporting. The authors observed that hyperthermic chemotherapy was feasible for treating some chordomas but has not yet been reported. It was evaluated for the patient in this report.

Chondroid chordoma. Case report and literature review

A case of the chondroid variant of chordoma is presented. The differentiating features of this entity are discussed on a clinical and histopathologic basis. A review of the topic of chordoma is also provided.