Outcomes following surgical management of cervical chordoma: A review of published case reports and case series

Surgical management of tumors of the cervical spine and craniovertebral junction involving the vertebral artery: A narrative review

BACKGROUND

The vertebral artery (VA) is in close proximity to bony structures, nerves and nerve sheaths of the cervical spine and craniovertebral junction (CVJ). These structures can be sources of tumors that are responsible for displacement, encasement and sometimes invasion of the VA. Removing these tumors while minimizing the risk of vascular injury requires thorough knowledge of the vascular anatomy, risk factors of vascular injury, the relationships of each tumor type with the VA, and the different surgical approaches and techniques that result in the best outcomes in terms of vascular control, tumoral exposure and resection.

OBJECTIVE

To present an overview of preoperative and anatomical considerations, differential diagnoses and various approaches to consider in cases of tumors in close relationship with the VA.

METHOD

A review of recent literature was conducted to examine the anatomy of the VA, the tumors most frequently affecting it, surgical approaches, and the necessary pre-operative preparations for ensuring safe and maximal tumor resection. This review aims to underscore the principles of treatment.

CONCLUSION

Tumors located at the CVJ and the cervical spine intimately involved with the VA, pose a surgical challenge and increase the risk of incomplete removal of the lesion. Detailed knowledge of the patient-specific anatomy and a targeted pre-operative work-up enable optimal planning of surgical approach and management of the VA, thereby reducing surgical risks and improving extent of resection.

Parasagittal resection of multilevel cervical chordoma with autograft duraplasty and unilateral vertebral artery ligation: A case report and literature review

Chordomas are rare tumors and the recommended course of treatment typically entails surgical resection, which presents significant challenges owing to the anatomical location commonly involved and the inherent resistance of these lesions to radiation and chemotherapy. This case report details the experience of a 61-year-old male who underwent a parasagittal resection spanning from C1 to C4. A durotomy was executed to enable en bloc excision of the tumor. Subsequently, a duraplasty procedure was implemented, utilizing autologous muscle fascia grafting. A comprehensive analysis of the pertinent literature was conducted to underscore the key clinical aspects and outcomes related to this topic.

A case report of Sustained triumph: 15-year recurrence-free survival following surgical resection of a cervical chordoma in a 15-year-old girl

Introduction and importance

Chordoma of the cervical spine is a rare condition associated with poor long-term outcomes. This is mainly attributed to its pathological involvement of vital structures such as the cervical roots and vertebral artery (VA). Although the most appropriate management in these cases is total en bloc excision, attaining complete resection is relatively challenging due to the vicinity of the critical anatomical structures mentioned above.

Case description

A 15-year-old female with middle cervical spine chordoma was treated by a multidisciplinary team involving neurosurgery and head and neck surgeons utilizing anterior and posterior approaches followed by high-beam X-ray radiotherapy. Histopathological examination matched the description of a chordoma. Fifteen years after the initial excision, the patient maintained her normal neurological function without local recurrence or metastasis.

Clinical discussion

The patient underwent surgery in two stages. A posterior approach for C3, C4, and C5 laminectomies was performed in the first stage, with the second stage involving head and neck surgery for complete resection of the tumor. The patient also underwent radiotherapy 3 months after surgery for a total duration of 1 month. The patient is currently 30 years old with no evidence of chordoma recurrence.

Conclusion

Patients afflicted with cervical chordomas often find themselves undergoing multiple operations due to high recurrence rates. Fortunately, the utilization of en bloc resection coupled with adjuvant radiotherapy presents a hopeful treatment modality that can serve to substantially reduce recurrence rates, increase survival rates, and ultimately enhance the quality of life.

Management of Chordoma of the Sacrum and Mobile Spine

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Chordomas account for 1% to 4% of primary tumors of the spine and sacrum.

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En bloc resection is the preferred surgical treatment for the management of chordomas.

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Proton beam radiation is increasingly being used as a postoperative radiation modality for the treatment of chordomas.

Long-term outcomes of high dose carbon-ion radiation therapy for unresectable upper cervical (C1-2) chordoma

Background

Chordoma is a rare, locally invasive neoplasm of the axial skeleton. Complete resection is often difficult, especially for the upper‐cervical (C1‐2) spine. We evaluated the efficacy and safety of carbon‐ion radiotherapy (CIRT) for unresectable C1‐2 chordoma.

Methods

Patients with C1‐2 chordoma treated with definitive CIRT (60.8 Gy [RBE] in 16 fractions) were retrospectively analyzed. We evaluated OS, LC, PFS, and toxicity.

Results

Nineteen eligible patients all completed the planned course of CIRT. With the median follow‐up 68 months (range: 29–144), median OS was 126 months (range: 36‐NA). Five‐year OS, LC, and PFS were 68.4% (95% CI, 42.8%–84.4%), 75.2% (46.1%–90.0%), and 64.1% (36.3%–82.3%), respectively. Regarding acute toxicity of grade ≥3, there was only one grade 3 mucositis. Late toxicity included radiation‐induced myelitis (grade 3 in 1 patient; 5.3%), and compression fractures (n = 5; 26.3%).

Conclusions

High‐dose CIRT is a promising treatment option for unresectable upper cervical chordoma.

Sacral Nerves Reconstruction After Surgical Resection of a Large Sacral Chordoma Restores the Urinary and Sexual Functionality and the Anal Continence

Objective

Chordomas are slow-growing tumors, with a high tendency to local relapse. En bloc resection is related to the most favorable outcome in terms of survival but is frequently associated with permanent neurological deficits involving sphincters and sexual functions. In the present article, we describe an innovative technique of en bloc resection followed by reconstruction of the sacral nerves with nerve grafts.

Methods

The chordoma was excised through a posterior approach after dividing the proximal and distal sacral nerves using the established technique. After that, a microsurgical S2-S3-S4 nerve reconstruction was performed connecting the proximal and distal stumps with sural nerve grafts withdrawn from both lower limbs.

Results

Immediately after surgery, the patient experienced complete impairment of sexual function and sphincters with urinary and fecal incontinence. After 6 months, there was a progressive recovery of sexual function and sphincter control. One year after the operation, the patient achieved an adequate sexual life (erection and ejaculation) and complete control of the bladder and anal sphincter.

Conclusion

Reconstruction of nerves sacrificed during sacral tumor removal has been shown to be effective in restoring sphincter and sexual function and is a promising technique that may significantly improve patients' quality of life.

Early Major Complications After Radical Resection of Primary C2-Involved Upper Cervical Chordoma Through the Combined Anterior Retropharyngeal-Posterior Approach: Incidence and Risk Factors

BACKGROUND

We investigated the frequency of postoperative major complications, length of stay (LOS), and associated risk factors for primary C2-involved upper cervical chordoma through the combined anterior retropharyngeal-posterior approach.

METHODS

Clinical data were collected from 102 patients with primary C2-involved upper cervical chordoma treated at our institute from January 2016 to January 2021. Additionally, the Changzheng Hospital (CZH) surgical classification system was designed to describe the different anatomic types of C2 chordomas. A multivariate logistic regression analysis was performed and a multivariate Cox proportional hazards model was used to identify the risk factors associated with the occurrence of major complications and prolonged length of stay (LOS), respectively.

RESULTS

The incidence of major complication was 29.41% (30 of 102) in our cohort. A long surgical duration (P = 0.001), increased age (P = 0.001), more preoperative comorbidities (P = 0.008) and CZH types indicating extensive tumor involvement (P < 0.001) were identified as significant predictors of the occurrence of a major complication postoperatively. The mean LOS for the entire study population was 21.50 ± 0.64 days. The patients who experienced complications required a significant longer LOS (25.50 ± 1.26 days) than those without complications (19.83 ± 0.65; P < 0.001). The independent factors affecting LOS included age (P = 0.001), Frankel grade (P = 0.001), CZH classification (P < 0.001), and surgical duration (P = 0.001).

CONCLUSIONS

Patients who are older, experience longer operative duration, or have larger tumor extension have a greater risk of postoperative major complication. The LOS can be predicted by age, preoperative neurological deficit, CZH classification, surgical approach, and surgical duration. Accordingly, patients with these risk factors should be monitored and targeted with preventative measures.

Tumours of the odontoid peg revisited

Introduction

Tumours of the odontoid peg are rare but can potentially cause significant morbidity and mortality.

Methods

A retrospective review of oncology and radiology database of tertiary orthopaedic oncology centre for all lesions affecting the odontoid peg over the last 12 years was performed.

Results

We identified a total of 15 tumours involving the odontoid peg, majority being malignant. Myeloma was the most common tumour.

Conclusion

Tumours of the odontoid peg are rare. Spinal surgeons and Radiologists need to be aware of them.

Prognostic significance of human telomerase reverse transcriptase promoter region mutations C228T and C250T for overall survival in spinal chordomas

BACKGROUND

Spinal chordomas, a subtype of primary spinal column malignancies (PSCM), are rare tumors with poor prognosis, and we have limited understanding of the molecular drivers of neoplasia.

METHODS

Study design was a retrospective review of prospectively collected data with cross-sectional survival. Archived paraffin embedded pathologic specimens were collected for 133 patients from 6 centers within Europe and North America between 1987 and 2012. Tumor DNA was extracted and the human telomerase reverse transcriptase (hTERT) promoter was sequenced. The hTERT mutational status was correlated with overall survival (OS) and time to first local recurrence.

RESULTS

Ninety-two chordomas, 26 chondrosarcomas, 7 osteosarcomas, 3 Ewing's sarcomas, and 5 other malignant spinal tumors were analyzed. Median OS following surgery was 5.8 years (95% CI: 4.6 to 6.9) and median time to first local recurrence was 3.9 years (95% CI: 2.5 to 6.7). Eight chordomas, 2 chondrosarcomas, 1 Ewing's sarcoma, and 1 other malignant spinal tumor harbored either a C228T or C250T mutation in the hTERT promoter. In the overall cohort, all patients with hTERT mutation were alive at 10 years postoperative with a median OS of 5.1 years (95% CI: 4.5 to 6.6) (P = 0.03). hTERT promoter mutation was observed in 8.7% of spinal chordomas, and 100% of chordoma patients harboring the mutation were alive at 10 years postoperative compared with 67% patients without the mutation (P = 0.05).

CONCLUSIONS

We report for the first time that hTERT promoter mutations C228T and C250T are present in approximately 8.7% of spinal chordomas. The presence of hTERT mutations conferred a survival benefit and could potentially be a valuable positive prognostic molecular marker in spinal chordomas.

Chordoma of the mobile spine and sacrum: clinical management and prognosis

Background

Chordomas are rare malignant tumors of the spinal column often afflicting the upper cervical spine and sacrum. There are few large single center series on chordomas due to its rarity. The purpose of this study is to report a single center's experience with the operative and non-operative management of chordomas.

Methods

We evaluated our institution's pathology database from 1994 to 2016 to identify patients diagnosed with chordomas. Inclusion criteria were chordomas of the mobile spine and sacrum. Exclusion criteria were chordomas of the clivus and resection performed at another institution. We collected patient demographics as well as the type of resection performed, intra-operative complications, wound complications and recurrence/prognosis.

Results

We identified 18 patients diagnosed with chordomas at our institution, and 12 met our inclusion criteria. There were four females and eight males with an average age of 64 [32-87] years. All patients were Caucasian and 10 of the 12 had surgery. Of the two patients with sacral chordomas that did not have surgery, one received chemotherapy and the other did not elect for any treatment. One is alive 161 months following diagnosis and the second died 96 months following diagnosis. Five of the lesions were in the mobile spine (one cervical, two thoracic, two lumbar) and seven were in the sacrum. Six patients underwent an en bloc resection [two via total en bloc spondylectomy (TES)]. Average length of follow up is 60 [3-161] months and eight of 12 patients are alive at latest follow up. Intraoperative complications included cardiac arrest, pleural tear, and excessive blood loss (8 L). Two patients, with sacral chordomas, had wound complications. Recurrence occurred in one patient with piecemeal resection and one patient with incomplete resection had post-operative metastatic lesions to the liver and lung.

Conclusions

We found less recurrence in patients managed with an en bloc resection as opposed to piece meal or intralesional resections. Sacral chordoma patients had higher wound complication rates as compared to chordomas of the mobile spine. The long life expectancy of non-surgically managed patients underscores the indolent nature of chordomas.