Novel use of a threadwire saw for high sacral amputation

Outcomes of Surgery for Sacral Chordoma and Impact of Complications: A Report of 50 Consecutive Patients With Long-Term Follow-Up

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To determine predictive factors of overall survival (OS) and local recurrence (LR), report complications, and assess the impact of complications on survival, recurrence, and function in patients undergoing en bloc resection of sacral chordoma.

METHODS

This retrospective case series was obtained from a prospective database (1995-2016). All patients underwent en bloc resection of sacral chordoma. Demographic, perioperative, and complication data were collected. Outcomes included: overall survival(OS), local recurrence(LR), and complications. Survival analysis with multivariable cox regression was performed.

RESULTS

Among 50 patients, median follow-up was 5.3 years (range = 1.3-17.2). The majority (82%) underwent a negative margin resection. Survival: 17 patients died (34%) with a median OS of 10.0 years (range = 1.3-17.2). Multivariable cox regression revealed that a negative margin resection was not significantly associated with improved survival (HR = 3.35, 95%CI 0.87-12.80, P = .078). Recurrence: 20 patients (40%) experienced LR with a median time of 6.2 years (range = 0-16.9). Multivariable cox regression revealed that a negative margin resection was associated with a significant decreased risk of LR (HR = 4.96, 95%CI 1.84-13.34, P = 0.002,). A 62% overall complication rate was seen (42% major), with 26% reoperation rate. Of the reoperations, 54% were delayed (>6 weeks after the index surgery). Multivariable cox regression demonstrated that neither major complication nor reoperation significantly impacted OS (HR = 0.62, 95%CI 0.22-1.79, P = 0.380), LR (HR = 1.28, 95%CI 0.49-3.36, P = 0.611), or functional outcomes (OR = 2.94, 95%CI 0.25-34.8, P = 0.393).

CONCLUSIONS

Negative margin resection was associated with decreased LR. Neither major complication nor reoperation significantly impacted OS, LR, or functional outcome. Though additional studies are needed, it appears that despite the morbidity associated with sacral chordoma resection, the long-term clinical outcomes are favorable.

Long-term outcome following surgical treatment of sacral chordoma

BACKGROUND

Sixteen sacral chordoma surgeries performed at a single institution during the 1983-2008 period were retrospectively studied. Our aim is to assess surgical treatment and long-term outcomes.

METHODS

Fifteen patients underwent primary wide excision, and one intralesional excision using ethanol for local control and radiation therapy (RT). A combined anteroposterior approach for large tumors above S2, and wide excision was performed with the modified threadwire-saw (MT-saw) after 1997.

RESULTS

Fourteen of the 15 patients had wide margins, one a wide margin with contamination. The MT-saw was facilitated sacral excision with wide margins. Eleven patients are alive for 5-28 years. Five patients died before 10 years, two patients experienced sepsis, and one of another disease. Two patients died of local recurrence (LR) and another of multiple metastases after intralesional excision and wide excision with contamination, respectively. LR and complications occurred 4 each of 11 patients with tumors ≥ 10 cm, neither with tumors < 10 cm. The overall 5- and 10-year survival rate with wide surgical margins was 13/16 (81.3%) and 8/13 (61.5%).

CONCLUSIONS

A combined anteroposterior approach for large tumors, and the MT-saw facilitates sacral excision with wide margins. Wide excision is recommended for younger patients.

En bloc resection of sacral chordomas aided by frameless stereotactic image guidance: a technical note

BACKGROUND

The most important predictor of survival for patients with sacral chordomas is an initial en bloc resection with negative margins. However, obtaining negative margins can be technically challenging. Intraoperative navigation may be helpful in attempting an excision with negative margins.

OBJECTIVE

This is the first report of partial sacrectomy guided by frameless stereotactic navigation.

METHODS

Three patients with a mean age of 58.7 years underwent en bloc resection of sacral chordomas aided by image guidance. Intraoperatively, the reference arc was clamped to the spinous process of L5 and the bony landmarks of S1 were used for registration. Subsequently, the drill was registered, allowing the osteotomy trajectory to be visualized in real time with reference to the patients' anatomy and tumor location.

RESULTS

None of the patients had any intraoperative or postoperative complications. Two patients with smaller tumors (5 cm) had negative margins, whereas the third patient with an 11.5 cm tumor had marginal margins. With an average follow-up of 44 months, none of the patients have had a recurrence of the tumor.

CONCLUSION

The use of frameless stereotaxy during the en bloc resection of sacral tumors is safe and feasible. Frameless stereotactic navigation was a useful adjunct to preoperative imaging and to the surgeon's anatomic knowledge. Image guidance was used during the osteotomies to decrease the likelihood of injury to vital adjacent structures or violation of the tumor capsule and to increase the likelihood that the appropriate surrounding tissue was resected to attempt a wide or marginal resection.