Spinal chordomas

Clinical characteristics and predisposing factors of lung metastasis in sacral chordoma: a cross-sectional cohort study of 221 cases

Introduction

Limited studies are available on the topic of lung metastasis in sacral chordoma. The primary objective of this study was to investigate the prevalence, characteristics, associated factors, and prognosis of lung metastasis in sacral chordoma.

Methods

A total of 221 cases with primary sacral chordoma, all of whom underwent surgical resection at our center, were included in this study. Comprehensive demographic information, imaging findings, and oncological evaluations were collected and thoroughly analyzed. The diagnosis of lung metastasis in the majority of cases was established through radiographic examinations.

Results

The prevalence of lung metastasis in the cohort was 19.5%, with the lung emerging as the predominant site of distant metastasis. Recurrent chordoma cases exhibited a significantly higher lung metastasis rate in comparison to newly diagnosed chordoma cases (33.33% and 12.76%, p=0.0005). Patients with lung metastasis had a larger tumor size, a higher proportion of previous sacral chordoma surgeries and a greater likelihood of postoperative recurrence. Associated factors of lung metastasis were tumor size, postoperative recurrence and radiotherapy. Patients with lung metastasis exhibited decreased median overall survival (91 vs. 144 months for those without lung metastasis, p<0.05) and recurrence-free survival (27 vs. 68 months, p<0.001) times.

Discussion

Lung is the most common site of distant metastasis in sacral chordoma with an incidence rate nearly 20%. Larger tumor size and postoperative recurrence are risk factors for lung metastasis while radiotherapy is a protective factor. Occurrence of lung metastasis in sacral chordoma is a negative prognostic factor.

Prognostic significance of VEGF receptors expression on the tumor cells in skull base chordoma

BACKGROUND

Chordoma is a rare refractory neoplasm that arises from the embryological remnants of the notochord, which is incurable using any multimodality therapy. Vascular endothelial growth factor (VEGF) is a potent activator of angiogenesis that is strongly associated with the tumor-immune microenvironment. These factors have not been elucidated for chordomas.

METHODS

To evaluate the characteristics of vascular and tumor cells in chordoma, we first analyzed the expression of VEGF receptor (VEGFR) 1, VEGFR2, CD34, and Brachyury in a cell line and 54 tumor tissues. Patients with primary skull base chordomas were divided into the following two groups as per the tumor growth rate: patients with slow progression (SP: < 3 mm/year) and those with rapid progression (RP: ≥ 3 mm/year). Thus, the expressions of VEGF-A, VEGFR 1, and VEGFR2 on tumor cells; tumor infiltrative immune cells, including regulatory T cells (Tregs) and tumor-associated macrophages (TAMs); and immune-checkpoint molecules (PD-1/PD-L1) were analyzed with the clinical courses, especially in a comparison between the two groups.

RESULTS

In chordomas, both VEGFR1 and VEGFR2 were strongly expressed not only on vascular endothelial cells, but also on tumor cells. The recurrent cases showed significantly higher VEGFR1 expressions on tumor cells than the primary cases. The expression of VEGF-A was significantly higher in RP than that in SP group. The numbers of CD163+ TAMs and Foxp3+ Tregs were higher in RP than that in SP group.

CONCLUSIONS

Expression of VEGFR1 and VEGFR2 on tumor cells and immunosuppressive tumor-microenvironment were related to tumor growth in patients with chordomas.

Conditional survival and changing risk profile in patients with chordoma: a population-based longitudinal cohort study

Objective

To evaluate the conditional survival of patients with chordoma to potentially help physician planning of optimal cancer surveillance and guide better clinical decisions.

Methods

In total, 1942 patients with chordoma were identified and extracted from Surveillance, Epidemiology, and End Results (SEER) databases (1973–2015). The cumulative survival estimates were used to calculate the conditional survival rate, and the Greenwood formula was used to estimate the 95% CI. In addition, multivariable Cox regression analyses were used to calculate hazard ratios, according to the duration of survival.

Results

The conditional 5-year disease-specific survival in patients with regional or localized chordoma was relatively stable over time, whereas in patients with distant chordoma, there was a gradual improvement. The conditional 5-year disease-specific survival (DSS) of patients older than 60 years old and patients with a tumor size between 5 and 10 cm improved. Interestingly, for patients with a tumor larger than 10 cm, the conditional 5-year DSS decreased over time. After surviving 5 years, the hazard ratio (HR) of patients older than 60 years old decreased from 1.33 to 1.24, that of patients with a tumor size between 5 and 10 cm decreased from 1.61 to 1.52 and that of patients with distant metastasis decreased from 3.30 to 1.09. However, after surviving 5 years, the HR of patients with a tumor size larger than 10 cm increased from 2.33 to 3.77, that of patients who underwent surgical resection increased from 0.37 to 0.58 and that of patients who received radiation therapy increased from 0.81 to 1.04.

Conclusion

Age at diagnosis, tumor size and disease stage can influence conditional survival for patients with chordoma. The HR of different factors will change over the survival time. Therefore, understanding the changing risk profile and conditional 5-year DSS of chordoma is critical for accurate clinical treatment guidance.

Tumour Volume and Dose Influence Outcome after Surgery and High-dose Photon Radiotherapy for Chordoma and Chondrosarcoma of the Skull Base and Spine

AIMS

To evaluate the long-term outcomes of patients with chordoma and low-grade chondrosarcoma after surgery and high-dose radiotherapy.

MATERIALS AND METHODS

High-dose photon radiotherapy was delivered to 28 patients at the Neuro-oncology Unit at Addenbrooke's Hospital (Cambridge, UK) between 1996 and 2016. Twenty-four patients were treated with curative intent, 17 with chordoma, seven with low-grade chondrosarcoma, with a median dose of 65 Gy (range 65-70 Gy). Local control and survival rates were calculated using the Kaplan-Meier method.

RESULTS

The median follow-up was 83 months (range 7-205 months). The 5 year disease-specific survival for chordoma patients treated with radical intent was 85%; the local control rate was 74%. The 5 year disease-specific survival for chondrosarcoma patients treated with radical intent was 100%; the local control rate was 83%. The mean planning target volume (PTV) was 274.6 ml (median 124.7 ml). A PTV of 110 ml or less was a good predictor of local control, with 100% sensitivity and 63% specificity. For patients treated with radical intent, this threshold of 110 ml or less for the PTV revealed a statistically significant difference when comparing local control with disease recurrence (P = 0.019, Fisher's exact test). Our data also suggest that the probability of disease control may be partly related to both target volume and radiotherapy dose.

CONCLUSION

Our results show that refined high-dose photon radiotherapy, following tumour resection by a specialist surgical team, is effective in the long-term control of chordoma and low-grade chondrosarcoma, even in the presence of metal reconstruction. The results presented here will provide a useful source for comparison between high-dose photon therapy and proton beam therapy in a UK setting, in order to establish best practice for the management of chordoma and low-grade chondrosarcoma.

Management of Sacrococcygeal Chordoma: A Systematic Review and Meta-analysis of Observational Studies

STUDY DESIGN

Systematic review and meta-analysis of observational studies.

OBJECTIVE

The aim of the study is to evaluate different treatment modalities in the management of sacrococcygeal chordoma.

SUMMARY OF BACKGROUND DATA

Chordomas are primary malignant bone tumors associated with considerable morbidity and mortality.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central-Register of Controlled Trials, and Scopus from inception to July 2015. Eligible studies included patients with sacrococcygeal chordoma treated exclusively with surgery, radiotherapy, or both. Two reviewers independently assessed the eligibility of potential studies, risk of bias, and extracted data. Outcomes of interest were all-cause mortality, progression-free survival, and metastases. We analyzed further surgical outcomes by resection margin. All outcomes were assessed at 60 months and more than 60 months following intervention.

RESULTS

We included 33 noncomparative studies reporting on 501 patients (mean age 57 years). Overall mortality rate was (16%) after surgical resection with adjuvant radiotherapy and (28%) after surgical resection, and (43%) after radiotherapy (P = 0.28). All-cause mortality following wide surgical resection was (32%) compared to (40%) after marginal resection (P = 0.51). Overall progression-free survival rate was (58%) after surgical resection with adjuvant radiotherapy and (55%) after surgery (P = 0.92). However, at more than 60 months follow-up, progression-free survival rates were significantly higher (P = 0.024) following surgical resection with adjuvant radiotherapy (74%) in comparison to surgery (55%) and radiotherapy (36%). Overall progression-free survival rates were nonsignificantly higher after wide surgical resection (66%) than marginal resection (33%) (P = 0.16). However, at 60 months follow-up, progression-free survival rates were significantly higher following wide surgical resection (73%) than marginal resection (33%) (P = 0.047).

CONCLUSION

Sacrococcygeal chordoma is a difficult to treat disease entity. Until comparative studies become available, wide surgical resection and multidisciplinary management are the recommended approaches to improve patient outcomes.

LEVEL OF EVIDENCE

3.

Analysis of prognostic factors for survival in patients with primary spinal chordoma using the SEER Registry from 1973 to 2014

BACKGROUND

Spinal chordomas are rare primary osseous tumors that arise from the remnants of the notochord. They are commonly considered slow-growing, locally invasive neoplasms with little tendency to metastasize, but the high recurrent rate of spinal chordomas may seriously affect the survival rate and quality of life of patients. The aim of the study is to describe the epidemiological data and determine the prognostic factors for decreased survival in patients with primary spinal chordoma.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) Registry database, a US population-based cancer registry database, was used to identify all patients diagnosed with primary spinal chordoma from 1973 to 2014. We utilized Kaplan-Meier method and Cox proportional hazards regression analysis to evaluate the association between patients overall survival and relevant characteristics, including age, gender, race, disease stage, treatment methods, primary tumor site, marital status, and urban county background.

RESULTS

In the data set between 1973 and 2014, a total of 808 patients were identified with primary spinal chordoma. The overall rate of distant metastatic cases in our cohort was only 7.7%. Spinal chordoma was more common occurred in men (62.6%) than women (37.3%). Majority of neoplasms were found in the White (87.9%), while the incidence of the Black is relatively infrequent (3.3%). Three hundred fifty-seven spinal chordomas (44.2%) were located in the vertebral column, while 451 patients' tumor (55.8%) was located in the sacrum or pelvis. Age ≥ 60 years (HR = 2.72; 95%CI, 1.71 to 2.89), distant metastasis (HR = 2.16; 95%CI, 1.54 to 3.02), and non-surgical therapy (HR = 2.14; 95%CI, 1.72 to 2.69) were independent risk factors for survival reduction in analysis. Survival did not significantly differ as a factor of tumor site (vertebrae vs sacrum/pelvis) for primary spinal chordoma (HR = 0.93, P = 0.16). Race (P = 0.52), gender (P = 0.11), marital status (P = 0.94), and urban background (P = 0.72) were not main factors which affected overall survival rate.

CONCLUSION

There was no significant difference in overall survival rate between chordomas located in the sacrum and vertebral column. Spinal chordoma patients with an elderly age (age ≥ 60), performing non-surgical therapy, and distant metastasis were associated with worse overall survival. Performing surgery was an effective and reliable treatment method for patients with spinal chordoma, and public health efforts should pay more attention to the elderly patients with spinal chordoma prior to distant metastasis.

State-of-the-Art Imaging in Human Chordoma of the Skull Base

Purpose of Review

Chordoma are rare tumours of the axial skeleton which occur most often at the base of the skull and in the sacrum. Although chordoma are generally slow-growing lesions, the recurrence rate is high and the location makes it often difficult to treat. Both computed tomography (CT) and magnetic resonance imaging (MRI) are crucial in the initial diagnosis, treatment planning and post-treatment follow-up.

Recent Findings

Basic MRI and CT characteristics of chordoma were described in the late 1980s and early 1990s. Since then, imaging techniques have evolved with increased resolution and new molecular imaging tools are rapidly evolving. New imaging tools have been developed not only to study anatomy, but also physiologic changes and characterization of tissue and assessment of tumour biology. Recent studies show the uptake of multiple PET tracers in chordoma, which may become an important aspect in the diagnosis, follow-up and personalized therapy.

Summary

This review gives an overview of skull base chordoma histopathology, classic imaging characteristics, radiomics and state-of-the-art imaging techniques that are now emerging in diagnosis, treatment planning and disease monitoring of skull base chordoma.

An unusual case of oropharyngeal chordoma: A case report and literature review

RATIONALE

Chordomas are rare malignant neoplasms derived from incomplete regression of notochordal tissue along the cranio-coccygeal axis. Chordomas that develop in an atypical position are called ectopic chordomas, such as oropharyngeal chordomas (OCs). OCs are exceedingly rare; only 11 cases have been reported to date. Preoperative diagnosis is challenging, and an accurate diagnosis thus is based on postoperative pathologic examination findings and immunohistochemistry. Although surgical therapy and radiotherapy is performed in some patients, the 5-year survival rate is low. Increasingly more studies of chordomas have been based on molecular biology to increase the survival rate, and targeted therapy could be a new therapy in the future.

PATIENT CONCERNS

The patient presented with a left oropharyngeal mass that had begun slowly enlarging 1 year previously. He reported a foreign body sensation and dysphonia during this time period.

DIAGNOSES

The patient was initially diagnosed with a neurogenic tumor. Routine postoperative pathology showed that the mass was consistent with a chordoma.

INTERVENTION

Mass resection was performed.

OUTCOME

One year after the initial surgery, magnetic resonance imaging revealed block signal images at the left retropharyngeal space and clivus. The patient developed recurrence of the OC.

LESSONS

Surgical resection is the mainstay of treatment for OC, and postoperative adjuvant radiotherapy is also important. An understanding of the unusual case described in this report may be helpful in diagnosing OC, and development of targeted therapy may help clinicians to provide novel treatment for patients with OC.

A Case of C5 Vertebral Chordoma in a 73-Year-Old Patient with More Than 8 Years of Follow-Up after Total Piecemeal Spondylectomy

Chordoma arising from the cervical spine is rare and the traditional long-term prognosis is typically poor. Total en bloc spondylectomy with a wide margin is generally accepted to be the most appropriate management for thoracic and lumbar malignant tumors. However, this method is still challenging for the cervical spine because of the proximity of the tumor to the vertebral arteries and neural elements. Here, we report a 73-year-old man with a C5 vertebral chordoma treated with total piecemeal spondylectomy. Histological examination revealed pathognomonic physaliphorous cells with mucus-filled cytoplasm in the tumor, and the ratio of Ki-67-positive cells within the tumor was high (19.0%), showing active proliferation rate. Local recurrences were found at 9 months, 4 years and 2 months, and 6 years after the initial surgery. All the recurrences were encapsulated and isolated and treated with an additional en bloc resection successfully at each stage. Eight years after the initial total piecemeal spondylectomy, the patient maintained his intact neurological status without local recurrence or metastasis. The prognosis of cervical chordoma depends on the patient's age, surgical procedures, and histological features. In this report, we present that piecemeal spondylectomy is an alternative management for aged patients with cervical chordoma, even for those with high MIB-1 index.

Extra-axial chordomas

INTRODUCTION

A chordoma is a slow growing malignant tumour of notochordal origin. A tumour with histological features that are identical to those of a chordoma may arise outside the axial skeleton. To date, there is little in the literature documenting their clinical course.

METHODS

Our large orthopaedic oncology database was used to document the clinical course of extra-axial chordoma.

RESULTS

Over a 30-year period, 131 patients diagnosed with a chordoma were treated at our unit. Only three (2.3%) of these cases were extra-axial chordomas: one in the femur, one in the ulna and one in the proximal fibula. All underwent surgical resection.

CONCLUSIONS

In view of the rarity of this tumour and the difficulty in confirming its diagnosis, we suggest that any suspected case is discussed with a specialist sarcoma multidisciplinary team so that the correct diagnosis can be achieved and treatment tailored accordingly.

Chordomas, malignant spinal tumors: a 15-year experience

Objective: Spinal chordomas are rare, locally invasive, malignant neoplasm, representing 5% of all malignant tumors of the skeleton. In the majority of cases the segment involved is the sacrum. This study reviews our experience during the last 15 years at The Spinal Surgery Department of “Bagdasar-Arseni” Clinical Hospital, to determine the effects of various treatment methods on the overall course of this disease process.

Methods: A retrospective study was performed, from 2000 to 2015, in which, 31 patients with spinal chordomas were evaluated at our institution.

Results: Two thirds of patients were male, with a mean age of 57 years. Patients presented with local pain, radiculopathy and bladder-bowel dysfunction at hospital admission. There were 24 patients with sacral chordomas, 4 with cervical chordomas, 2 with thoracic and one with lumbar chordoma. All patients underwent at least one surgical procedure. The main goal of surgery was to achieve total resection of the tumor.

Conclusion: Our study suggests that spinal chordomas are rare tumors with a high risk of tumor recurrence. If total resection is achieved, the risk of recurrence diminishes. If the tumor resection is subtotal, than recurrence appears in all cases. After tumor resection, the surgeon faces the problem of spinal instability that needs solving. Based on these findings, we think that, whenever possible, radical resection should be the treatment of choice for spinal chordomas.

The 100 most-cited articles in spinal oncology

OBJECTIVE The authors' objective was to identify the 100 most-cited research articles in the field of spinal oncology. METHODS The Thomson Reuters Web of Science service was queried for the years 1864-2015 without language restrictions. Articles were sorted in descending order of the number of times they were cited by other studies, and all titles and abstracts were screened to identify the research areas of the top 100 articles. Levels of evidence were assigned on the basis of the North American Spine Society criteria. RESULTS The authors identified the 100 most-cited articles in spinal oncology, which collectively had been cited 20,771 times at the time of this writing. The oldest article on this top 100 list had been published in 1931, and the most recent in 2008; the most prolific decade was the 1990s, with 34 articles on this list having been published during that period. There were 4 studies with Level I evidence, 3 with Level II evidence, 9 with Level III evidence, 70 with Level IV evidence, and 2 with Level V evidence; levels of evidence were not assigned to 12 studies because they were not on therapeutic, prognostic, or diagnostic topics. Thirty-one unique journals contributed to the 100 articles, with the Journal of Neurosurgery contributing most of the articles (n = 25). The specialties covered included neurosurgery, orthopedic surgery, neurology, radiation oncology, and pathology. Sixty-seven articles reported clinical outcomes. The most common country of article origin was the United States (n = 62), followed by Canada (n = 8) and France (n = 7). The most common topics were spinal metastases (n = 35), intramedullary tumors (n = 18), chordoma (n = 17), intradural tumors (n = 7), vertebroplasty/kyphoplasty (n = 7), primary bone tumors (n = 6), and others (n = 10). One researcher had authored 6 studies on the top 100 list, and 7 authors had 3 studies each on this list. CONCLUSIONS This study identified the 100 most-cited research articles in the area of spinal oncology. The studies highlighted the multidisciplinary and multimodal nature of spinal tumor management. Recognition of historical articles may guide future spinal oncology research.

Cervical chordoma in a domestic ferret (Mustela putorius furo) with pulmonary metastasis

A 4-year-old, male neutered domestic ferret ( Mustela putorius furo) was evaluated for a mass in the left cervical region. The owner elected humane euthanasia, and an autopsy was performed, revealing a neoplasm with infiltration into the left cranial articular fovea of the atlas and cervical vertebrae, with regional compression of the spinal cord. Histologic evaluation was consistent with cervical chordoma. At autopsy, a left cranial lung lobe nodule was observed. Additional sectioning and histologic evaluation revealed multiple foci of metastatic chordoma at this site. A small focus of micrometastasis was also detected in a section from the right lung lobes. Chordoma is the most common musculoskeletal neoplasm of ferrets, arising from remnant fetal notochord. To our knowledge, pulmonary chordoma metastasis has not been previously reported in the ferret. This case demonstrates the potential for visceral metastasis of chordoma in the ferret, as has been reported in other species.

Prognostic Factors in the Operative Management of Sacral Chordomas

OBJECTIVE

Surgical resection of sacral chordomas offers the best long-term prognosis but has high rates of local recurrence, metastases, and mortality. Most prognostic studies are limited by low patient numbers, variation in treatment, follow-up, and prognostic variables studied. The objective of this study was to identify factors associated with recurrence, metastasis, and survival.

METHODS

Retrospective review of 58 patients undergoing sacrectomy for chordoma with a mean age of 63 years (range: 41-80 years) and a mean follow-up of 45.3 months (range: 2-144 months). Data on prognostic variables and outcomes were collected. Forty-two patients underwent a combined anterior and posterior approach and 16 underwent a posterior-only approach.

RESULTS

Twenty-six patients (44.8%) died during follow-up. Kaplan-Meier estimates for 5- and 10-year survival were 62% and 26%, respectively. Local recurrence occurred in 32 patients (51.7%) and metastases in 19 (32.7%). Adequacy of resection margins was the most important predictor of disease recurrence, metastases, and survival. Tumors >8 cm were associated with significantly increased risk of metastases and reduced survival (P < 0.05). Dedifferentiated disease and infiltration of the sacroiliac joints and/or adjacent musculature were also associated with reduced survival. Median survival was 23 months for patients with gluteus maximus invasion, 66 months for gluteus maximus and piriformis invasion, 67 months for piriformis invasion, and 90 months for patients with no muscle invasion.

CONCLUSIONS

Patients with inadequate resection margins, tumors >8 cm, sacroiliac joint and/or musculature infiltration, and dedifferentiated disease have significantly worse oncologic outcomes. Involvement of gluteus maximus alone confers a higher risk of metastases and local recurrence than involvement of piriformis and gluteus maximus, or piriformis alone.

Epidemiologic, functional, and oncologic outcome analysis of spinal sarcomas treated surgically at a single institution over 10 years

BACKGROUND CONTEXT

Spinal sarcomas are aggressive tumors that originate from the cells of mesechymal origin, specifically fat, cartilage, bone, and muscle. They are high-grade lesions, and treatment of spinal sarcomas can involve chemotherapy, radiation therapy, and surgery. In the appendicular skeleton, sarcomas are often treated with amputation, however, in the spinal column, surgical resection poses a unique set of challenges.

PURPOSE

To better understand the optimal treatment regimens and the impact of en bloc or intralesional resection on patient outcome.

STUDY DESIGN

A cohort of 25 sarcoma patients treated at a single medical institution between 2002 and 2012 was reviewed.

PATIENT SAMPLE AND OUTCOME MEASURES

Patients were classified by tumor type for subgroup analysis, including chondrosarcoma, osteosarcoma, and other malignant spinal sarcomas. Demographic data for review included patient age, tumor type, tumor location, surgery type, exposure to chemotherapy, and radiation therapy.

METHODS

Survival statistics and Kaplan-Meier curves were calculated using GraphPad Prism 5.0. The threshold for statistical significance was set at p<.05. Unpaired, two-tailed, equal variance t tests were performed for statistical analyses in Microsoft Excel 2010.

RESULTS

Twenty-five patients with spinal sarcomas were treated over the 10-year period. Diagnosis included chondrosarcoma (n=9), osteosarcoma (n=4), and other sarcomas (n=12). Mean age at the time of diagnosis was 42 years. Pain was present at the time of diagnosis in 92% patients. Median survival after surgery was 59.5 months for chondrosarcoma, undefined for other sarcomas, and 16.8 months for osteosarcoma. Median survival after en bloc resection was undefined. Median survival after intralesional resection was 17.8 months. The difference in median survival between en bloc and intralesional resection was statistically significant (p=.049).

CONCLUSIONS

The authors report the largest cohort of patients with spinal sarcoma. Median survival in this cohort was the longest for patients with sarcomas of varying pathologies. Median survival was longer for chondrosarcoma. En bloc resection demonstrated a survival advantage over intralesional resection. Long-term follow-up is needed for patients with spinal sarcoma to establish definitive survival data.

A new type of reconstruction of the hemipelvis after Type 3 amputative sacrectomy using pedicled fibula

This is a technical note of pelvic reconstruction performed by an advanced multidisciplinary team. The authors report a new 3-stage reconstruction of the hemipelvis after Type 3 sacrectomy involving instrumented spinoiliac arthrodesis and pedicled fibula grafting in 2 patients.

The anterior stage of the procedure begins with a transabdominal approach to mobilize the viscera and to free up the tumor from the vessels. The posterior divisions of internal iliac vessels, the middle sacral vessels, and the lateral sacral vessels are then ligated. An anterior vertebrectomy is done at the appropriate level, followed by an anterior osteotomy through the lateral planed surgical margin of the sacrum close to the salvaged sacroiliac joint. The second stage includes a major sacral resection with lower-extremity amputation from the pubic symphysis through the intact side of the sacrum, ipsilateral pedicled fibula harvesting, and closure with an ipsilateral pedicled quadriceps flap. The final stage involves reconstruction with lumboiliac instrumentation. The pedicled fibular graft left from the second stage is then placed distally within the previously created iliopectineal docking site and proximally within the L-5 docking site.

The authors believe that this is a feasible and reproducible technique with theoretical advantages that have to be proved in the long-term follow-up.

Prognostic Factors in the Operative Management of Dedifferentiated Sacral Chordomas

BACKGROUND:

Dedifferentiated chordomas are rare high-grade malignant spinal tumors for which there is minimal information to help guide treatment.

OBJECTIVE:

To identify prognostic factors associated with increased risk of local recurrence, metastases, and reduced survival in a cohort of patients undergoing sacrectomy for de novo dedifferentiated sacral chordoma.

METHODS:

Ten patients undergoing sacrectomy for histologically confirmed dedifferentiated chordoma at a specialist center were reviewed. There were 6 male and 4 female patients with a mean age of 66.7 years (range, 57-80 years) and mean follow-up of 36.7 months (range, 3-98 months). Data on prognostic factors were collected.

RESULTS:

The commonest presenting symptom was lumbar/gluteal pain. Mean duration of preoperative symptoms was 3.6 months (range, 2-7 months). Local recurrence was seen in 7 patients; metastases occurred in 5 patients. After sacrectomy, 7 patients died at a mean of 41 months (range, 3-98 months). Tumor size &gt;10 cm in diameter, amount of dedifferentiation within the conventional chordoma, sacroiliac joint infiltration, and inadequate resection margins were associated with increased risk of recurrence and reduced survival. Surgical approach, cephalad extent of primary tumor, and adjuvant radiotherapy did not affect oncological outcomes.

CONCLUSION:

Dedifferentiated chordomas are aggressive malignant tumors with a higher risk of local recurrence, metastases, and early mortality than conventional chordomas. Tumor diameter &gt;10 cm, marginal resection, and sacroiliac joint infiltration may be associated with increased risk of local recurrence and mortality. Those with a smaller burden of dedifferentiated disease (&lt;1 cm2) within the primary chordoma have a better prognosis. Patients should be counseled about these risks before surgery and should have regular follow-up for the detection of local recurrence and metastases.

[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.

A review of the surgical management of sacral chordoma

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Particle therapy using carbon ions or protons as a definitive therapy for patients with primary sacral chordoma

OBJECTIVE

This study retrospectively evaluated the efficacy and toxicity of particle therapy using carbon ions or protons for primary sacral chordomas.

METHODS

We evaluated 23 patients with primary sacral chordoma treated with carbon ion therapy (CIT) or proton therapy (PT) between July 2005 and June 2011 at the Hyogo Ion Beam Medical Center, Hyogo, Japan. The median patient age was 72 years. 14 patients were treated with 70.4 Gy equivalents (GyE) in 16 fractions and 9 were treated with 70.4 GyE in 32 fractions. CIT was used for 16 patients, and PT was used for 7 patients.

RESULTS

The median follow-up period was 38 months. At 3 years, local control (LC), overall survival (OS) and progression-free survival (PFS) for all patients were 94%, 83% and 68%, respectively. The log-rank test revealed that male sex was significantly related to better PFS (p=0.029). No other factors, including dose fractionation and ion type, were significant for LC, OS or PFS. In nine patients, ≥ Grade 3 acute dermatitis was observed, and ≥ Grade 3 late toxicities were observed in nine patients. The 32-fraction protocol reduced severe toxicities in both the acute and late phases compared with the 16-fraction protocol.

CONCLUSION

Particle therapy for patients with sacral chordoma showed favourable LC and OS. Severe toxicities were successfully reduced by modifying the dose fractionation and treatment planning in the later treatment era. Thus, this therapeutic modality should be considered useful and safe.

ADVANCES IN KNOWLEDGE

This is the first study including both CIT and PT for sacral chordomas.

[Tumours of the upper cervical spine]

OBJECTIVE

Vertebral tumours arising in the upper cervical spine are rare. We present our experience in managing these neoplasms.

MATERIAL AND METHODS

We retrospectively reviewed the case histories of patients treated at our institution between January 2000 and June 2011.

RESULTS

There were 9 patients with tumours in C1-C2-C3: 2metastases, 3chordomas, 2plasmocytomas, 1chondrosarcoma and 1osteochondroma. All patients complained of neck pain at the time of diagnosis. Three patients underwent an anterior and posterior approach, 3 an exclusively posterior approach and 3 an exclusively anterior surgical approach. Tumour resection was intralesional in 7 cases. Chemo-radiotherapy was used as adjuvant therapy in patients with malignant tumours.

CONCLUSIONS

Vertebral tumours in the upper cervical spine are usually malignant. Achieving en bloc resection is particularly challenging and is technically unfeasible in many cases. This worsens the prognosis and makes adjuvant treatment very important.

High expression of survivin in sacral chordoma

Chordoma is a rare and invasive malignant tumor which primarily relies on surgical treatments. Anticipation of its recurrence and patient survival longevity has been a critical issue of the treatments. This retrospective study examined the survivin expression of sacral chordoma in 30 patients undergoing surgery in our hospital from January 2000 to July 2010, and compared it with chordoma recurrence. Survivin expression was 70 % positive in 30 patients. The positive expression of survivin with recurrence was significantly higher than that without recurrence (p = 0.017) and was inversely related to the continuous disease-free survival time (p < 0.001). Survivin expression was associated with recurrence. The correlation suggested that the survivin expression could be used as an independent predictor of recurrence and could be a potential bio-target gene of angiogenesis in sacral chordoma.

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.

Expression of ezrin, MMP-9, and COX-2 in 50 chordoma specimens: a clinical and immunohistochemical analysis

STUDY DESIGN

Retrospective study.

OBJECTIVE

To investigate the immunohistochemical expression profile of ezrin, matrix metalloproteinase-9 (MMP-9), and cyclooxygenase-2 (COX)-2 in chordomas.

SUMMARY OF BACKGROUND DATA

Ezrin, MMP-9, and COX-2 are expressed in different solid tumors, including chordomas. This study investigates the immunohistochemical expression of the aforementioned biomarkers and the clinical outcome in regard to immunohistochemistry, tumor volume, and localization.

METHODS

Fifty brachyury-verified chordoma specimens of 34 primary and 16 recurrent tumors of 44 patients were tested for ezrin, MMP-9, and COX-2 as possible therapeutical targets by immunohistochemistry. The clinical evaluation concentrated on tumor location, volume, and age-related data.

RESULTS

Ezrin expression was detected in 33 of 34 primary chordomas and in 16 of 16 recurrent cases. The primary chordomas located in the sacrum and the spine demonstrated a significantly higher percentage of positively stained tumor cells (P = 0.034) than the skull-based chordomas. An expression of MMP-9 and COX-2 was observed in 33 of 34 primary chordomas and in 16 of 16 recurrences, and in 13 of 34 primary chordomas and in 11 of 16 recurrences, respectively. Patients' survival was significantly influenced by age (P = 0.01), tumor location (P = 0.029), and tumor volume (P = 0.002). A significant positive correlation between tumor volume and the anatomic distance of the chordoma from the skull was calculated (P = 0.00002).

CONCLUSION

En bloc resection with tumor-free margins is seldom feasible, particularly in the sacrum. Intralesional excisions mostly end in early local recurrence; therefore, the demand for further treatment options is frequently posed. The marked trend of the investigated biomarkers of this study may build a starting point for further investigations as molecular targets for future adjuvant therapies in chordomas. Future multicenter studies on larger patients' series are necessary to elucidate these preliminary data and to test new treatment options for patients with chordomas.

Chordoma of the lumbar spine - a potential diagnosis not to be forgotten

Chordoma is a rare, malignant neoplasm thought to develop from the notochord. It most commonly occurs in the base of the cranium or the sacro-coccygeal region but around 15-20% affect the vertebral body. Extra-lesional resection with or without adjuvant radiotherapy is generally accepted as the mainstay of treatment for this slow-growing tumour. We present a case whereby a patient with a solitary L3 vertebral body lesion causing caudal compression was treated with spinal decompression and posterior stabilisation. Pre-operative biopsy was not performed as the lesion was presumed to be a metastatic deposit from a co-existing renal mass. Intra-operative biopsy, however, identified the tumour to be chordoma of the L3 vertebral body which would have been more appropriately treated with ‘en-bloc’ excision. This case highlights the importance of pre-operative tissue diagnosis, and that, although rare (0.8 per 100,000), chordoma should always be considered.

In vitro characterization of cells derived from chordoma cell line U-CH1 following treatment with X-rays, heavy ions and chemotherapeutic drugs

Background

Chordoma, a rare cancer, is usually treated with surgery and/or radiation. However, very limited characterizations of chordoma cells are available due to a minimal availability (only two lines validated by now) and the extremely long doubling time. In order to overcome this situation, we successfully derived a cell line with a shorter doubling time from the first validated chordoma line U-CH1 and obtained invaluable cell biological data.

Method

After isolating a subpopulation of U-CH1 cells with a short doubling time (U-CH1-N), cell growth, cell cycle distribution, DNA content, chromosome number, p53 status, and cell survival were examined after exposure to X-rays, heavy ions, camptothecin, mitomycin C, cisplatin and bleocin. These data were compared with those of HeLa (cervical cancer) and U87-MG (glioblastoma) cells.

Results

The cell doubling times for HeLa, U87-MG and U-CH1-N were approximately 18 h, 24 h and 3 days respectively. Heavy ion irradiation resulted in more efficient cell killing than x-rays in all three cell lines. Relative biological effectiveness (RBE) at 10% survival for U-CH1-N was about 2.45 for 70 keV/μm carbon and 3.86 for 200 keV/μm iron ions. Of the four chemicals, bleocin showed the most marked cytotoxic effect on U-CH1-N.

Conclusion

Our data provide the first comprehensive cellular characterization using cells of chordoma origin and furnish the biological basis for successful clinical results of chordoma treatment by heavy ions.

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.

Long-term results: adjuvant radiotherapy in en bloc resection of sacrococcygeal chordoma is advisable

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

The purpose of this report is to define the role of postoperative radiotherapy in the prevention of local recurrence (LR).

SUMMARY OF BACKGROUND DATA

Sacrococcygeal chordoma is a slow growing, malignant tumor with a clinical poor outcome due to a high LR rate. Several studies emphasize that margin-free tumor resection is the most important predictor of LR. However, even after extralesional resection a high LR up to 80% remains.

METHODS

A retrospective series of 15 patients who underwent surgical treatment for sacrococcygeal chordoma in one center between 1981 and 2003 was reviewed. Overall survival and continuous disease-free survival rates were compared between patients with intralesional resection with standard radiotherapy and patients with extralesional resection and no standard radiotherapy.

RESULTS

The median age at surgery was 53 years. The mean follow-up was 7 years or until death. Mean duration of preoperative complaints was 3 years. In 10 patients, an en bloc resection was (histologic resection margins were free) performed and in 5 patients, an intralesional resection was achieved. All but one patients with intralesional resection received radiotherapy (>50 Gy) and patients with extralesional resection only received radiotherapy in case of LR (6 of 10 patients). After extralesional resection (no initial radiotherapy), all 10 patients had LR of the tumor with a mean time to recurrence of 2 years. Six of these ten patients received radiotherapy after LR and had mean survival duration of 7 years. Only one (of five patients) in the group with intralesional resection and postoperative radiotherapy had LR after 11 years. The time to recurrence was significantly longer and we found a trend toward a longer overall survival in the group that received immediate radiotherapy after surgery.

CONCLUSION

The results support the strategy to add radiotherapy as standard adjuvant therapy to sacrococcygeal chordoma tumor resection.

Surgical management of primary bone tumors of the spine: validation of an approach to enhance cure and reduce local recurrence

STUDY DESIGN

Multicenter ambispective cohort analysis.

OBJECTIVE

The purpose of this study is to determine whether applying Enneking's principles to surgical management of primary bone tumors of the spine significant decreases local recurrence and/or mortality.

SUMMARY OF BACKGROUND DATA

Oncologic management of primary tumors of spine has historically been inconsistent, controversial, and open to individual interpretation.

METHODS

A multicenter ambispective cohort analysis from 4 tertiary care spine referral centers was done. Patients were analyzed in 2 cohorts, "Enneking Appropriate" (EA), surgical margin as recommended by Enneking, and "Enneking Inappropriate" (EI), surgical margin not recommended by Enneking. Benign tumors were not included in mortality analysis.

RESULTS

Two cohorts represented an analytic dataset with 147 patients, 86 male, average age 46 years (range: 10-83). Median follow-up was 4 (2-7) years in the EA and 6 (5.5-15.5) years in the EI. Seventy-one patients suffered at least 1 local recurrence during the study, 57 of 77 in the EI group and 14 of 70 in the EA group. EI surgical approach caused higher risk of first local recurrence (P < 0.0001). There were 48 deaths in total; 29 in the EI group and 19 in the EA. There was a strong correlation between the first local recurrence and mortality with an odds ratio of 4.69, (P < 0.0001). EI surgical approach resulted in a higher risk of mortality with a hazard ratio of 3.10, (P = 0.0485) compared to EA approach.

CONCLUSION

Surgery results in a significant reduction in local recurrence when primary bone tumors of the spine are resected with EA margins. Local recurrence has a high concordance with mortality in resection of these tumors. A significant decrease in mortality occurs when EA surgery is used.

Lumbar chordoma mimicking a neurogenic tumour

Chordomas are rare tumours arising from the primitive notochord along the axial skeleton, typically from the sacrococcygeal region, spheno-occipital region and less commonly, the mobile spine. Midline location associated with bony involvement with extension to the surrounding tissues is the norm. Chordomas presenting laterally, centred within the neural exit foramen and extending to the paraspinal muscles without significant vertebral involvement is rare. We present a 60-year-old woman with lower back pain and radiculopathy. Imaging revealed a unilateral lesion at L4/5 extending through the left neural exit foramen into the paraspinal region. There was only minimal apparent bony involvement. Though these features were highly suggestive of a neurogenic tumour, histopathology revealed the lesion to be a chordoma. Excision of the tumour was performed under neurophysiological monitoring.

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.

Effect of carbon ion radiotherapy for sacral chordoma: results of Phase I-II and Phase II clinical trials

PURPOSE

To summarize the results of treatment for sacral chordoma in Phase I-II and Phase II carbon ion radiotherapy trials for bone and soft-tissue sarcomas.

PATIENTS AND METHODS

We performed a retrospective analysis of 38 patients with medically unresectable sacral chordomas treated with the Heavy Ion Medical Accelerator in Chiba, Japan between 1996 and 2003. Of the 38 patients, 30 had not received previous treatment and 8 had locally recurrent tumor after previous resection. The applied carbon ion dose was 52.8-73.6 Gray equivalents (median, 70.4) in a total of 16 fixed fractions within 4 weeks.

RESULTS

The median patient age was 66 years. The cranial tumor extension was S2 or greater in 31 patients. The median clinical target volume was 523 cm(3). The median follow-up period was 80 months. The 5-year overall survival rate was 86%, and the 5-year local control rate was 89%. After treatment, 27 of 30 patients with primary tumor remained ambulatory with or without supportive devices. Two patients experienced severe skin or soft-tissue complications requiring skin grafts.

CONCLUSION

Carbon ion radiotherapy appears effective and safe in the treatment of patients with sacral chordoma and offers a promising alternative to surgery.

Chordoma of the lumbar spine presenting as sciatica and treated with vertebroplasty

The lumbar spine is a less common location for chordoma. Here we describe a 44-year-old woman presenting with pain due to a L4 vertebral expansile lesion that caused significant canal stenosis and neural foraminal compromise. Vertebroplasty was performed and resulted in immediate pain relief. For patients with painful lumbar chordoma who are unwilling to undergo surgery, vertebroplasty can play a palliative role as in patients with other vertebral lesions. Treating pain and stabilizing vertebra by way of vertebroplasty in a case of chordoma has not yet been reported.

Combined anterior and posterior en bloc vertebrectomy for lumbar chordoma

Chordoma is a rare bone tumor derived from remnants of the notochord. The majority of chordomas involve the sacrum or skull base. We report a rare case of a L4 vertebral body chordoma treated with anterior en bloc vertebrectomy and posterior stabilization. No tumor recurrence was observed at the 5 year follow-up examination.

Bone sarcoma of the spine

Primary malignant bone tumors of the vertebral column, i.e., bone sarcomas of the spine, are inherently rare entities. Vertebral osteosarcomas and chordomas represent the largest groups, followed by the incidence of chondro-, fibro-, and Ewing's sarcomas. Detailed clinical and neurological examination, complete radiographic imaging [radiographs, computed tomography (CT), magnetic resonance imaging (MRI)], and biopsy are the decisive diagnostic steps. Oncosurgical staging for spinal tumors can serve as a decision-guidance system for an individual's oncological and surgical treatment. Subsequent treatment decisions are part of an integrated, multimodal oncological concept. Surgical options comprise minimally invasive surgery, palliative stabilization procedures, and curative, wide excisions with complex reconstructions to attain wide or at least marginal resections. The most aggressive mode of surgical resection for primary vertebral column tumors is the total en bloc vertebrectomy, i.e., single- or multilevel en bloc spondylectomy. En bloc spondylectomy involves a posterior or combined anterior/posterior approach, followed by en bloc laminectomy, circumferential (360 degrees) vertebral dissection, and blunt ventral release of the large vessels, intervertebral discectomy and rotation/ en bloc removal of the vertebra along its longitudinal axis. Due to the complex interdisciplinary approach and the challenging surgical resection techniques involved, management of vertebral bone sarcomas is recommended to be performed in specific musculoskeletal tumor centers.

A Case of Coccygeal Chondroid Chordoma in a Cat: Morphological and Immunohistochemical Features

In August 2007, a 4-year-old, intact, female Domestic Shorthair cat was examined for a mass on the tip of the tail. Histological examination performed after apical caudectomy revealed a neoplasm affecting the distal part of the last coccygeal vertebra. The neoplasm consisted of lobules of physaliferous cells surrounding cartilaginous tissue and a central core of trabecular bone. A diagnosis of chondroid chordoma was made based on histomorphological features and immunohistochemical results. Chondroid chordoma has been previously reported in humans, rats, ferrets, and mink. To the authors' knowledge, chondroid chordoma has not been reported in cats. Neither recurrence nor metastasis was reported 7 months after surgery.

Chordoma and chondrosarcoma gene profile: implications for immunotherapy

Chordoma and chondrosarcoma are malignant bone tumors characterized by the abundant production of extracellular matrix. The resistance of these tumors to conventional therapeutic modalities has prompted us to delineate the gene expression profile of these two tumor types, with the expectation to identify potential molecular therapeutic targets. Furthermore the transcriptional profile of chordomas and chrondrosarcomas was compared to a wide variety of sarcomas as well as to that of normal tissues of similar lineage, to determine whether they express unique gene signatures among other tumors of mesenchymal origin, and to identify changes associated with malignant transformation. A HG-U133A Affymetrix Chip platform was used to determine the gene expression signature in 6 chordoma and 14 chondrosarcoma lesions. Validation of selected genes was performed by qPCR and immunohistochemistry (IHC) on an extended subset of tumors. By unsupervised clustering, chordoma and chondrosarcoma tumors grouped together in a genomic cluster distinct from that of other sarcoma types. They shared overexpression of many extracellular matrix genes including aggrecan, type II & X collagen, fibronectin, matrillin 3, high molecular weight-melanoma associated antigen (HMW-MAA), matrix metalloproteinase MMP-9, and MMP-19. In contrast, T Brachyury and CD24 were selectively expressed in chordomas, as were Keratin 8,13,15,18 and 19. Chondrosarcomas are distinguished by high expression of type IX and XI collagen. Because of its potential usefulness as a target for immunotherapy, the expression of HMW-MAA was analyzed by IHC and was detected in 62% of chordomas and 48% of chondrosarcomas, respectively. Furthermore, western blotting analysis showed that HMW-MAA synthesized by chordoma cell lines has a structure similar to that of the antigen synthesized by melanoma cells. In conclusion, chordomas and chondrosarcomas share a similar gene expression profile of up-regulated extracellular matrix genes. HMW-MAA represents a potential useful target to apply immunotherapy to these tumors.

Extranotochordal extralaryngeal chordoma: a case report

Chordomas are rare, malignant, slowly growing neoplasms which develop from vestigial remnants of the fetal notochord. Most chordomas arise in the sacrococcygeal and spheno-occipital region. Extranotochordal chordomas are extremely unusual. A case of extranotochordal chordoma with extralaryngeal localization is described. A 73-year-old male presented with swallowing difficulties and hoarseness. Contrast-enhanced magnetic resonance imaging of the neck revealed a well-encapsulated tumor mass that was well enhanced and located in the left retrolaryngeal space at the level of C4, dislocating the larynx to the right. Left radical neck dissection and tumor extirpation were performed. The tumor had not invaded cervical vertebra and the surrounding soft tissue but superficial erosions of the ossificated thyroid and cricoid cartilage were found. High-power pathologic examination and immunohistochemistry defined the lesion as a dedifferentiated type of chordoma. The patient received adjuvant radiotherapy. Four years after the surgery, the patient has been free from tumor recurrence.

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.

Dedifferentiated chordoma of the thoracic spine with rhabdomyosarcomatous differentiation. Report of a case and review of the literature

A case of spinal thoracic chordoma involving the T9 vertebra in a 70-year-old male patient, destroying the vertebral body and invading the vertebral canal with compression of the spinal cord, is presented. The patient was referred to our neurosurgical unit with a history of an irradiated metastatic adenocarcinoma to the thoracic vertebra, a diagnosis that was rendered 3 years earlier at another hospital on presentation. This misdiagnosis was likely due to the absolute rarity of thoracic vertebral chordomas (2%-3% of all chordomas), the higher frequency of metastatic deposits to the vertebrae from visceral cancers in the elderly, the limited amount of biopsy material available for histologic examination, and the epithelial phenotype of the tumor (keratin/EMA positive). The patient underwent second palliative surgery with subtotal piecemeal removal of the tumor bringing relief of the neurologic symptoms. The bulk of the tumor was represented by a high-grade pleomorphic sarcoma with adjacent areas of atypical chordoma. Small foci of conventional chordoma were also found. The previous histologic slides were also reviewed, which were consistent with the areas of atypical chordoma. Small targeted tissue fragments from areas of (atypical) chordoma and from sarcomatous areas were recovered for electron microscopy. The fine features of chordoma and focal rhabdomyoblastic differentiation were found with the latter retrospectively supported by immunohistochemical detection of striated muscle markers. A final diagnosis of dedifferentiated chordoma with rhabdomyoblastic differentiation was finally established. Rhabdomyoblastic metaplasia is a novelty in dedifferentiated chordoma. The patient died after 5 months. Autopsy was not requested.

Complete removal of an intraspinal and extraspinal cervical chordoma in one stage using the lateral approach. Technical note

The authors describe a precise surgical technique in which a large intraspinal and extraspinal, multivertebral, cervical chordoma was completely removed in one stage using the lateral approach. The patient in this case was a 29-year-old woman who presented with signs of radicular pain in the left C-3 area. Computed tomography and magnetic resonance imaging demonstrated a large intra- and extraspinal multivertebral tumor from C-2 to C-5, a finding that suggested a cervical chordoma. The tumor was completely removed in one stage using the lateral approach while controlling the vertebral artery (VA), and a partial corporectomy of C2-5 was also performed. Results from a postoperative histopathological examination confirmed that the tumor was a typical chordoma. The patient's postoperative course was uneventful. Cervical chordomas are typically excised using a posterior-anterior surgical approach with partial resection of the tumor. The lateral approach was appropriate in this patient for complete resection in one stage, because it enabled the surgeons to control the VA and access both extraspinal and intraspinal components of the chordoma.

Cutaneous metastatic chordoma with concomitant tuberous sclerosis

BACKGROUND

Chordomas are rare malignant tumors of notochord origin and are locally aggressive with a metastatic potential. Of noted interest, the skin rarely is seen as a metastatic site.

METHODS AND OBSERVATIONS

We describe a 20-month-old infant whose primary presentation of a clivus-based chordoma was multiple asymptomatic cutaneous nodules. A skin biopsy showed large vacuolated cells embedded in a myxoid stroma. Immunohistochemical staining was positive for S-100, keratin, and epithelial membrane antigen markers consistent with malignant chordoma. Magnetic resonance imaging revealed a clivus-based chordoma with scattered metastases within the neuraxis and multiple visceral sites. Further examination also revealed a diagnosis of tuberous sclerosis.

LIMITATIONS

An observed association between chordoma and tuberous sclerosis cannot be established firmly on the basis of a case report.

CONCLUSIONS

This case illustrates a diagnostic challenge because of the unusual presentation of an already rare tumor. By reporting our case, we hope to assist in the recognition of this rare dermal condition and highlight the speculated coexistence of tuberous sclerosis with chordoma tumors.

Sacral chordomas: Impact of high-dose proton/photon-beam radiation therapy combined with or without surgery for primary versus recurrent tumor

PURPOSE

To assess the efficacy of definitive treatment of sacral chordoma by high-dose proton/photon-beam radiation therapy alone or combined with surgery.

METHODS AND MATERIALS

The records of 16 primary and 11 recurrent sacral chordoma patients treated from November 1982 to November 2002 by proton/photon radiation therapy alone (6 patients) or combined with surgery (21 patients) have been analyzed for local control, survival, and treatment-related morbidity. The outcome analysis is based on follow-up information as of 2005.

RESULTS

Outcome results show a large difference in local failure rate between patients treated for primary and recurrent chordomas. Local control results by surgery and radiation were 12/14 vs. 1/7 for primary and recurrent lesions. For margin-positive patients, local control results were 10 of 11 and 0 of 5 in the primary and recurrent groups, respectively; the mean follow-up on these locally controlled patients was 8.8 years (4 at 10.3, 12.8, 17, and 21 years). Radiation alone was used in 6 patients, 4 of whom received > or =73.0 Gy (E); local control was observed in 3 of these 4 patients for 2.9, 4.9, and 7.6 years.

CONCLUSION

These data indicate a high local control rate for surgical and radiation treatment of primary (12 of 14) as distinct from recurrent (1 of 7) sacral chordomas. Three of 4 chordomas treated by > or =73.0 Gy (E) of radiation alone had local control; 1 is at 91 months. This indicates that high-dose proton/photon therapy offers an effective treatment option.

Chordoma: 6 years' experience at a tertiary centre

Nine patients with a histologically proven diagnosis of chordoma seen at the Department of Radiation Oncology, Maulana Azad Medical College and Lok Nayak Hospital between January 1999 and December 2004 were retrospectively reviewed with respect to age, sex, presentation, location of tumour, treatment, response, recurrence, metastasis and follow up. Chordoma constituted 0.07% of total cancer cases registered over 6 years. Out of nine patients, eight were males and one was female with median age at time of diagnosis 52 years (range 34-68 years). All had sacrococcygeal lesions except one who had a spheno-occipital lesion. Seven patients had undergone either subtotal or gross total resection whereas only biopsy had been carried out in two of them. All patients received radiation therapy, seven in a postoperative setting and two for palliation. Follow-up period ranged from 2 to 50 months. Four patients died--the first after fourth fraction of radiation, second after 10 days of treatment, third of progressive lesion in sphenoidal region despite resection and radiation and fourth of local recurrence in the sacrococcyx. One patient developed distant metastases in the lungs and subcutaneous tissue over the scalp along with local recurrence; he is still alive. Two patients are locally free of disease whereas the other two were lost to follow up. The present analysis was undertaken to review our institutional experience with an aim to provide a practical approach to these tumours. In this report, these cases are discussed and the published works have been reviewed for the optimal management of patients with chordoma.

Management of sacrococcygeal chordomas

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

Chordoma of the lumbar spine: a case report

Chordomas are rare tumors and they may arise anywhere along the spinal column and clival bone. The vast majority of tumors are found at skull base and sacrum. Chordomas involving the lumbar spine are rare. Approximately 6% of spinal chordomas originate in the lumbar vertebrae. We report a case of this chordoma arising from the lumbar vertebra.

Reconstruction after total sacrectomy: early experience with a new surgical technique

Nine patients had sacrectomy with ilio-lumbar arthrodesis for treatment of sacral malignancies at our institution between 2000 and 2004. Five patients had total sacrectomy, three had a sagittal hemisacrectomy, and one had an extended internal hemipelvectomy Type I-S. The average patient age was 39 years. Tumors were Stage IIB in seven patients and Stage IB in two patients. A combined anteroposterior approach was used and a wide surgical margin was attained in all seven patients. A new form of reconstruction using structural fibular grafts and pedicle screw-rod instrumentation was used to create a triangular construct along the anatomic force transmission vectors from the femoral heads to the lumbar spine. The average followup was 18 months. At latest followup, seven patients were alive with no evidence of disease, and two had died from disease. One patient suffered postoperative infection. Independent ambulation was noted in seven patients at last followup. Eight patients had stable reconstructions at latest followup (one patient, who died in December 2004, had a stable reconstruction and was walking with braces and a walker before her death). One patient had instrumentation failure twice and had additional revision instrumentation and bone grafting procedures. She eventually obtained a solid lumbopelvic fusion and walks with Canadian crutches and ankle-foot orthoses. The technique of reconstruction reported here offers promise in dealing with the challenges of reestablishing spinopelvic stability in this difficult anatomic location.

LEVEL OF EVIDENCE

Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.