Dermoscopy of hypopigmented macules unveiling genetic diagnosis of tuberous sclerosis complex type 2 in an infant presenting with sacral chordoma

A 2-month-old male with surgically resected sacral chordoma presented with multiple hypopigmented macules showing characteristic patchy, sharply demarcated areas of pigment network on dermoscopy. These dermoscopic findings were suggestive of the ash-leaf macules of tuberous sclerosis over other common hypopigmented macules in neonates. Chordomas presenting in early childhood in the sacral location have been reported as a rare manifestation of tuberous sclerosis complex. The combination of these findings led to a diagnosis of tuberous sclerosis, confirmed with the finding of a heterozygous TSC2 gene deletion; treatment with sirolimus resulted in regression of cardiac rhabdomyomas and hypopigmented macules.

Sacral Chordoma Presenting as Back Pain in the Chiropractic Clinic: A Case Report

Cases of lumbar and gluteal pain are commonly encountered in chiropractic clinics, with a broad differential diagnosis primarily centered on musculoskeletal conditions. This report presents the second documented case of sacral chordoma diagnosed at a chiropractic clinic and emphasizes the importance of considering alternative diagnoses and interdisciplinary collaboration in patient care. A 42-year-old man presented to a chiropractic clinic with complaints of lumbar and gluteal pain. The initial conservative management based on a presumptive musculoskeletal diagnosis was ineffective. Suspicion of an alternative etiology prompted a referral for imaging, which revealed a sacral chordoma. An interdisciplinary collaboration involving orthopedic surgeons, oncologists, radiologists, and other healthcare professionals was initiated to optimize the treatment outcomes of this rare and aggressive tumor. This case report underscores the importance of maintaining a high index of suspicion in cases of musculoskeletal presentations in chiropractic clinics and the critical role of advanced imaging in establishing a definitive diagnosis. Interdisciplinary collaboration is essential for managing complex conditions such as sacral chordomas, ensuring the delivery of the highest quality of care, and optimizing patient outcomes. Chiropractors play a crucial role in identifying, referring, and contributing to the management of patients with complex presentations as part of a comprehensive multidisciplinary treatment plan.

Sacral chordoma: an unusual cause of neurogenic bladder - a case report

Sacral chordoma is a rare tumor arising from notochord remnants. Sacral pain is the most common sign. The authors report the case of a sacral chordoma diagnosed in a urology department. It was a rare cause of erectile dysfunction and it was unusually revealed by lower urinary tract symptoms (LUTSs).

Case Presentation

A 67-year-old man had severe dysuria associated with erectile dysfunction. On digital rectal examination, we palpated a mass protruding through the posterior wall of the rectum. The gluteal region is infiltrated by a firm mass. MRI revealed an osteolytic sacral tumor. A percutaneous biopsy of the tumor was performed. A pathological examination confirmed the diagnosis of sacral chordoma. The patient had palliative radiotherapy. One year after radiotherapy, he had rectal stenosis associated with severe constipation.

Clinical Discussion

Sacral chordoma is a rare malignant tumor. Sacralgia is the most common sign. LUTS and erectile dysfunction were rarely reported in patients affected by this bone tumor. MRI is very suggestive of this pathology. Diagnostic confirmation requires pathological examination. The curative management consists of a large resection of the tumor. For inextricable tumors, palliative radiotherapy can be carried out. The prognosis of sacral chordoma is defined by a high recurrence potential and a low metastatic risk.

Conclusions

Sacral chordoma is a rare bone tumor. It is an unusual cause for LUTS and erectile dysfunction. Complete tumor excision is the only curative treatment. Recurrence after treatment is the main challenge for surgeons.

A Dosiomics Analysis Based on Linear Energy Transfer and Biological Dose Maps to Predict Local Recurrence in Sacral Chordomas after Carbon-Ion Radiotherapy

Carbon Ion Radiotherapy (CIRT) is one of the most promising therapeutic options to reduce Local Recurrence (LR) in Sacral Chordomas (SC). The aim of this work is to compare the performances of survival models fed with dosiomics features and conventional DVH metrics extracted from relative biological effectiveness (RBE)-weighted dose (D_RBE) and dose-averaged Linear Energy Transfer (LET_d) maps, towards the identification of possible prognostic factors for LR in SC patients treated with CIRT. This retrospective study included 50 patients affected by SC with a focus on patients that presented a relapse in a high-dose region. Survival models were built to predict both LR and High-Dose Local Recurrencies (HD-LR). The models were evaluated through Harrell Concordance Index (C-index) and patients were stratified into high/low-risk groups. Local Recurrence-free Kaplan-Meier curves were estimated and evaluated through log-rank tests. The model with highest performance (median(interquartile-range) C-index of 0.86 (0.22)) was built on features extracted from LET_d maps, with D_RBE models showing promising but weaker results (C-index of 0.83 (0.21), 0.80 (0.21)). Although the study should be extended to a wider patient population, LET_d maps show potential as a prognostic factor for SC HD-LR in CIRT, and dosiomics appears to be the most promising approach against more conventional methods (e.g., DVH-based).

The Surgical Approach Combined With Minimally Invasive Surgery for Sacral Chordoma

Sacral chordomas are malignant, locally aggressive, and rare tumors. Its presentation can be diverse on the entire spine, being more frequent in the sacrococcygeal region. The main treatment is complete surgical resection, which can be performed using different approaches depending on the case. We present the case of a 44-year-old woman with a history of a complex adnexal mass, with an imaging finding of a presacral mass displacing the uterus and rectum, with a histological report of an image-guided biopsy suggestive of a soft-tissue myoepithelioma-like tumor, which was managed with a combined approach: anterior transabdominal laparoscopic and posterior approach, achieving complete tumor resection, without postoperative complications and with the benefits of minimally invasive surgery. The pathology report of the surgical piece was compatible with sacral chordoma.

Effect of hyperthermia and proton beam radiation as a novel approach in chordoma cells death and its clinical implication to treat chordoma

PURPOSE

Chordoma is a locally aggressive tumor that most commonly affects the base of the skull/clivus, cervical, and sacral spine. Conventional radiotherapy (RT), cannot be safely increased further to improve disease control due to the risk of toxicity to the surrounding critical structures. Tumor-targeted hyperthermia (HT) combined with Proton Beam Radiation Therapy (PBRT) is known to act as a potent radiosensitizer in cancer control. In this study, we investigated whether PBRT efficacy for chordoma can be enhanced in combination with HT as a radiosensitizer.

MATERIAL AND METHODS

Human chordoma cell lines, U-CH2 and Mug-chor1 were treated in vitro with HT followed by PBRT with variable doses. The colony-forming assay was performed, and dose-response was characterized by linear-quadratic model fits. HSP-70 and Brachyury (TBXT) biomarkers for chordoma aggression levels were quantified by western blot analysis. Gene microarray analysis was performed by U133 Arrays. Pathway Analysis was also performed using IPA bioinformatic software.

RESULTS

Our findings in both U-CH₂ and Mug-Chor1 cell lines demonstrate that hyperthermia followed by PBRT has an enhanced cell killing effect when compared with PBRT-alone (p < .01). Western blot analysis showed HT decreased the expression of Brachyury protein (p < .05), which is considered a biomarker for chordoma tumor aggression. HT with PBRT also exhibited an RT-dose-dependent decrease of Brachyury expression (p < .05). We also observed enhanced HSP-70 expression due to HT, RT, and HT + RT combined in both cell lines. Interestingly, genomic data showed 344 genes expressed by the treatment of HT + RT compared to HT (68 genes) or RT (112 genes) as individual treatment. We also identified activation of death receptor and apoptotic pathway in HT + RT treated cells.

CONCLUSION

We found that Hyperthermia (HT) combined with Proton Beam Radiation (PBRT) could significantly increase chordoma cell death by activating the death receptor pathway and apoptosis which has the promise to treat metastatic chordoma.

Clinical Outcome of Sacral Chordoma Patients Treated with Pencil Beam Scanning Proton Therapy

AIMS

Sacral chordomas are locally aggressive, radio-resistant tumours. Proton therapy has the potential to deliver high radiation doses, which may improve the therapeutic ratio when compared with conventional radiotherapy. We assessed tumour control and radiation-induced toxicity in a cohort of sacral chordoma patients treated with definitive or postoperative pencil beam scanning proton therapy.

METHODS AND MATERIALS

Sixty patients with histologically proven sacral chordoma treated between November 1997 and October 2018 at the Paul Scherrer Institute with postoperative (n = 50) or definitive proton therapy (n = 10) were retrospectively analysed. Only 10 (17%) patients received combined photon radiotherapy and proton therapy. Survival rates were calculated using the Kaplan-Meier actuarial method. The Log-rank test was used to compare different functions for local control, freedom from distant recurrence and overall survival. Acute and late toxicity were assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

RESULTS

The median follow-up was 48 months (range 4-186). Local recurrence occurred in 20 (33%) patients. The 4-year local control, freedom from distant recurrence and overall survival rates were 77%, 89% and 85%, respectively. On univariate analysis, subtotal resection/biopsy (P = 0.02), tumour extension restricted to bone (P = 0.01) and gross tumour volume >130 ml (P = 0.04) were significant predictors for local recurrence. On multivariate analysis, tumour extension restricted to bone (P = 0.004) and gross total resection (P = 0.02) remained independent favourable prognostic factors for local recurrence. Twenty-four (40%), 28 (47%) and eight (11%) patients experienced acute grade 1, 2 and 3 toxicities, respectively. The 4-year late toxicity-free survival was 91%. Two patients developed secondary malignancies to the bladder 3-7 years after proton therapy.

CONCLUSIONS

Our data indicate that pencil beam scanning proton therapy for sacral chordomas is both safe and effective. Gross total resection, tumour volume <130 ml and tumour restricted to the bone are favourable prognostic factors for local tumour control.

Rectal dose-sparing effect with bioabsorbable spacer placement in carbon ion radiotherapy for sacral chordoma: dosimetric comparison of a simulation study

It is difficult to treat patients with an inoperable sarcoma adjacent to the gastrointestinal (GI) tract using carbon ion radiotherapy (C-ion RT), owing to the possible development of serious GI toxicities. In such cases, spacer placement may be useful in physically separating the tumor and the GI tract. We aimed to evaluate the usefulness of spacer placement by conducting a simulation study of dosimetric comparison in a patient with sacral chordoma adjacent to the rectum treated with C-ion RT. The sacral chordoma was located in the third to fourth sacral spinal segments, in extensive contact with and compressing the rectum. Conventional C-ion RT was not indicated because the rectal dose would exceed the tolerance dose. Because we chose spacer placement surgery to physically separate the tumor and the rectum before C-ion RT, bioabsorbable spacer sheets were inserted by open surgery. After spacer placement, 67.2 Gy [relative biological effectiveness (RBE)] of C-ion RT was administered. The thickness of the spacer was stable at 13-14 mm during C-ion RT. Comparing the dose-volume histogram (DVH) parameters, Dmax for the rectum was reduced from 67 Gy (RBE) in the no spacer plan (simulation plan) to 45 Gy (RBE) in the spacer placement plan (actual plan) when a prescribed dose was administered to the tumor. Spacer placement was advantageous for irradiating the tumor and the rectum, demonstrated using the DVH parameter analysis.

High-dose proton therapy and tomotherapy for the treatment of sacral chordoma: a retrospective monocentric study

OBJECTIVE

Radiation therapy (RT) is used for the treatment of sacral chordoma, in combination with surgery or alone for unresected tumours, to improve local control (LC) and potentially overall survival (OS). The purpose of the present study was to evaluate efficacy and toxicity of proton therapy (PT), and/or intensity modulated radiation therapy (IMRT), particularly Tomotherapy, for sacral chordoma treatment. Material: Between November 2005 and June 2018, 41 consecutive patients who were not included in clinical trials, received sacral chordoma radiation treatment in Institut Curie with Tomotherapy alone in 13 patients, and combined PT and Tomotherapy boost (Proton - Tomo) in 28 patients. RT was delivered as the exclusive local treatment in 11 patients, and as a post-operative complementary treatment in 30 patients.

RESULTS

After a median follow-up of 46 months (range, 0-125 months), eight local relapses were observed, and seven patients developed distant metastasis (particularly bone and lung). The 2- and 5- year local relapse rates were 11.4% CI (0.65-22.2%) and 29% (10.5-47.4%), respectively. Over the follow-up period, ten patients died (24.4%). The estimated 2- and 5-year OS rates were 91.4% CI (82.5-100%) and 74.5% (59.4-93.5%), respectively. Fibrosis, cauda equina syndrome, and pain were the most common late toxicities. The comparison between Tomotherapy alone and Proton - Tomo revealed that acute and late cystitis were significantly more frequent in the Tomotherapy group: SHR = 0.12 IC95% (0.01-0.90 [p = .04]), as well as late proctitis. A dosimetric comparison confirmed the interest of PT to spare rectum and bladder in this context.

CONCLUSION

RT remains essential to improve local control in sacral chordoma. The combination of proton and photon seems to improve organ at risk sparing, resulting in a decreased rate of reported late toxicities.

Carbon Ion Radiotherapy for sacral chordoma: a systematic review of the literature

The aim of the present study is to describe the clinical outcomes and the incidence of complications related to Carbon Ion Radiotherapy (CIRT) in the treatment of sacral chordoma. Through a systematic review of published investigations on CIRT, we collected the local control rates (LC), the overall survival rates (OS) and the post-CIRT adverse effects. Afterwards, we calculated their weighted average, to have a broader perspective. PubMed/Medline and Google Scholar databases were searched to identify studies on Carbon Ion Radiotherapy as a treatment for sacral chordoma. We used Medical Subject Heading (MeSh) terms and keywords. We based our systematic review on the PRISMA guidelines. No data limitations were applied in the search on Pubmed/ Medline database; data limitation (from 2000 to 2019) was applied in the search on Google Scholar. Six studies were included in our review. Local control proportions reported in individual studies ranged between 77% and 96% (95% confidence interval), with respect to a 5-years follow-up. Overall survival rates ranged from 52% to 86% (95% confidence interval), with respect to a 5-years follow-up. Adverse CIRT-related events involving bone occurred in 7% of patients. Neurological and skin toxicities affected 20% and 5% of patients, respectively. Nowadays the gold standard of treatment for sacral chordoma is the surgical resection with wide margins. Whenever adequate oncological margins could not be achieved or could be achieved only by sacrificing neurological structures with consequent functional impairment, CIRT is an effective alternative which has been demonstrated to reach optimal local control and overall survival rate. The caregiver, anyway, should be aware of the potential adverse events and complications related to this kind of treatment.

Fingolimod inhibits proliferation and epithelial-mesenchymal transition in sacral chordoma by inactivating IL-6/STAT3 signalling

Purpose: To explore the sensitivity of the immunosuppressive agent fingolimod (FTY720) in chordoma and determine whether it can serve as an appropriate alternate treatment for unresectable tumours in patients after incomplete surgery.

Methods: Cell viability assays, colony formation assays and EdU assays were performed to evaluate the sensitivity of chordoma cell lines to FTY720. Transwell invasion assays, wound healing assays, flow cytometry, cell cycle analysis, immunofluorescence analysis, Western blotting analysis and enzyme-linked immunosorbent assays (ELISAs) were performed to evaluate cell invasion, epithelial–mesenchymal transition (EMT) and activation of related pathways after treatment with FTY720. The effect of FTY720 was also evaluated in vivo in a xenograft model.

Results: We found that FTY720 inhibited the proliferation, invasion and metastasis of sacral chordoma cells (P < 0.01). FTY720 also inhibited the proliferation of tumour cells in a xenograft model using sacral chordoma cell lines (P < 0.01). The mechanism was related to the EMT and apoptosis of chordoma cells and inactivation of IL-6/STAT3 signalling in vitro and in vivo.

Conclusions: Our findings indicate that FTY720 may be an effective therapeutic agent against chordoma. These findings suggest that FTY720 is a novel agent that can treat locally advanced and metastatic chordoma.

Association between patient age and the risk of mortality following local recurrence of a sacral chordoma

BACKGROUND

Local recurrence (LR) of sacral chordoma is a difficult problem and the mortality risk associated with LR remains poorly described. The purpose of this study was to evaluate the risk of mortality in patients with LR and determine if patient age is associated with mortality.

METHODS

A total of 218 patients (144 male, 69 female; mean age 59 ± 15 years) with sacrococcygeal chordomas were reviewed. Cumulative incidence functions and competing risks for death due to disease and nondisease mortality were employed to analyze mortality trends following LR.

RESULTS

The 10-year overall survival (OS) was 55%. Patients with LR had 44% 10-year OS, similar to patients without (59%; P = .38). The 10-year OS between those less than 55 compared with ≥55 years were similar (69% vs 48%; P = .52). The 10-year death due to disease was worse in patients with LR compared with those without (44% vs 84%; P < .001). In patients without LR, patients ≥55 years were 1.6-fold more likely to experience death due to other causes.

CONCLUSIONS

Patients with an LR are more likely to die due to disease. Advanced patient age was associated with higher all-cause mortality following resection of sacral chordoma. LR of chordoma was associated with increased disease-specific mortality, regardless of age.

ADAM10 Is a Potential Novel Prognostic Biomarker for Sacral Chordoma

The ADAM (A Disintegrin and Metalloprotease) is a zinc-dependent family of transmembrane proteins upregulated in cancers. As the most frequent member, ADAM10's potential prognostic role in chordoma is unknown.

OBJECTIVE

We investigated the expression of ADAM10 protein and its prognostic value in sacral chordoma.

DESIGN

Clinical information of patients with sacral chordoma diagnosis during a 7-year period and their archived pathology were retrieved. Immunohistochemistry study of the expression of ADAM10 protein in sacral chordoma and control samples was conducted. The ADAM10 expression was correlated with the patients' clinicopathological information and analyzed by statistical methods.

RESULTS

The average age of 64 patients was 57.6 years (range, 35-83 years). Follow-up ranged from 12 to 141 months (mean, 72 months). The histological type included 47 classic, 6 chondroid, and 11 dedifferentiated chordomas. The expression level of ADAM10 was significantly correlated with the histological type (χ ²=11.345, P=0.003), metastasis (χ ²=10.149, P=0.001), overall survival (log-rank test: χ ²=8.177, P=0.004) and disease free survival (log-rank test: χ ²=6.805, P=0.009). The average survival time of patients with weak expression of ADAM10 was longer than that of strong expression.

CONCLUSION

The expression of ADAM10 protein is related to the histologic type and the prognosis of sacral chordoma.

Rectotumoral fistula formation occurring more than 5 years after carbon ion radiotherapy for sacral chordoma: A case report

Chordoma is a rare tumor that originates from the notochord. Half of chordomas involve the sacral region. Surgery is considered to be the standard treatment for sacral chordoma. However, carbon ion radiotherapy (CIRT) has recently emerged as a promising treatment for unresectable sacral chordoma. Little is known about the long-term complications of CIRT. We present two cases of rectotumoral fistula formation that occurred >5 years after CIRT for sacral chordoma. We considered two possible explanations for fistula formation: radiation enterocolitis after CIRT might cause formation of the fistula long-term, and tumor regrowth might compress the rectum and cause fistula formation. A biopsy in Case 1 showed that regrowth tumor was post-CIRT. It is important to be aware of the possibility of rectal complications after CIRT, and if found, resection of the rectum should be considered. This is a first report of rectotumoral fistula formation that occurred >5 years after CIRT for sacral chordoma.

Local and Distant Recurrence in Resected Sacral Chordomas: A Systematic Review and Pooled Cohort Analysis

STUDY DESIGN

Systematic review.

OBJECTIVES

Sacral chordomas are rare, primary tumors of the spine, best treated with en bloc resection. The purpose of this study was to assess the literature for resected sacral chordoma and to quantify the prevalence of, risk factors for, and treatment outcomes of local and distant recurrence therein.

METHODS

We searched 5 online databases from January 1980 to May 2016 to find articles that report survival, recurrence outcomes, and/or prognostic factors for the resected sacral chordoma patient population. Characteristics and clinical outcomes of the pooled cohort are reported. Fisher exact tests, unpaired t tests, and one-way analysis of variance were used to investigate patient- and treatment-associated prognostic factors for local and distant recurrence. Survival analyses were performed for time to local recurrence and death. The protocol's PROSPERO ID is CRD42015024384.

RESULTS

Fifty-seven studies, with 1235 unique sacral chordoma patients, were included in this review. Local and distant recurrence occurred in 42.6% and 22.4% of patients with adequate follow-up, respectively. Kaplan-Meier overall median survival for patients with and without recurrence were 98 and 209 months after surgery, respectively. Wide surgical margin was associated with a lower rate of local recurrence; and wide surgical margin, female sex, and patient age ≥65 years were associated with lower rates of distant recurrence.

CONCLUSIONS

While surgical margin remains the most significant prognostic factor for local and distant recurrence, combined surgical approach may be associated with local recurrence. Male sex and age <65 years may be associated with distant recurrence. Patients with risk factors for recurrence should undergo close monitoring to maximize survival.

[Complications of surgical treatment of sacral tumors]

Sacral tumors are a group of neoplasms heterogeneous in the histological type, malignancy, and growth pattern, but with common localization. Surgical treatment of these tumors is associated with the risk of major and minor complications, both during and after surgery. Usually, any surgery aimed at removing tumors in the sacrum or sacral region is associated with the need for reconstruction of bones and/or soft tissues to provide conditions for normal wound healing and the possibility of activating the patient.

AIM

The study aim was to analyze complications associated with surgery for sacral tumors.

MATERIAL AND METHODS

The study is based on the experience of surgical treatment of 57 patients with the diagnosis of sacral tumor. The patients underwent 60 surgical interventions related to treatment of the underlying pathology and complications of surgical treatment. Major and minor complications developed in 37 (68%) operated patients. A total of 47 different complications were recorded. In 6 patients, complications in the early postoperative period required additional surgery.

CONCLUSION

Surgical treatment of sacral tumors is associated with a high risk of complications. Despite the potential risk of major complications, sacrectomy for primary, or potentially aggressive, or malignant neurogenic tumors of the sacrum is necessary to improve local control and survival of patients.

Pediatric extraosseous sacral chordoma: case report and literature review of embryonic derivation and clinical implications

An extraosseous intradural presentation for a sacral chordoma in the pediatric age group has not been reported to date. This is a report on an 11-year-old boy who presented with an extraosseous, intradural sacral chordoma. He underwent gross-total resection and received adjuvant proton beam therapy. Neoplastic transformation of the notochord is reviewed to illustrate the developmental basis for the surgical anatomy and pathogenesis of the classic chordoma variant. Clinical and pathological features are reviewed to differentiate this chordoma presentation from classic osseous chordomas and ecchordosis physaliphora, a related benign developmental notochordal lesion. Finally, the role of developmental signaling in the pathogenesis of chordomas from postembryonic notochordal tissue is discussed.

Use of image-guided bone scalpel for resection of spine tumors: technical note

In the literature, the use of navigation for spine tumor surgery has largely centered on implant placement. We describe the cases of two patients with spinal tumors on whom we utilized our resection technique of registering an ultrasonic bone scalpel (UBS) to a navigation system. In both cases, we achieved a satisfactory tumor resection with negative margins and excellent neurologic outcomes. We feel that using the navigation-registered UBS is a valuable tool to increase the operator's ability to achieve desired resections while minimizing the neurologic deficits and operative morbidity associated with these challenging surgical cases.

The Current Understanding of MicroRNA's Therapeutic, Diagnostic, and Prognostic Role in Chordomas: A Review of the Literature

Chordomas are primary low-grade bone tumors derived from the embryonic notochord that make up less than 5% of all osseous malignancies and commonly affect the spine at its vertebral body and at its two ends i.e., skull base and the sacrum. Although histologically defined to be low-grade, chordoma is locally destructive, metastatic, and has a serious recurrence rate, which all contribute to the dismal median survival rate of six years. Its locally destructive nature places the adjacent vital neurovascular structures at risk, making an en-bloc resection a challenge. This tumor is also known to show high resistance to currently available chemoradiotherapy, although the benefit of proton beam therapy for skull base chordoma has been demonstrated. There is an additional need to focus our attention on investigating the molecular biology of this chemoradiotherapy-resistant tumor to develop a more targeted therapy, which has additional diagnostic and prognostic values. In this paper, we discuss the therapeutic, diagnostic, and prognostic role of microRNAs (miRNAs) in chordomas.

Ketamine as Part of a Multimodal Approach to Postoperative Pain Management

Some surgeries present increased challenges for adequate perioperative pain management, which require innovative methods to prevent development of chronic postsurgical pain (CPSP). Ketamine is an adjunct to traditional pain management methods and is an effective analgesic. The potent antihyperalgesic effects of ketamine represent an interesting option for those searching for multimodal approaches. This case report describes pain management for a 73-year old man scheduled for surgical excision of a sacral chordoma who was at high risk of development of CPSP. The intraoperative pain management plan consisted of T9-10 epidural anesthesia with continuous infusion of ropivacaine and hydromorphone, intravenous low-dose ketamine infusion, and intermittent intravenous hydromorphone boluses for breakthrough pain. Post-operatively the epidural infusion was continued for 4 days. The ketamine infusion rate was decreased on transfer to the intensive care unit and titrated to off by postoperative day 3. An intravenous hydromorphone patient-controlled analgesia pump was available to the patient for breakthrough pain postoperatively. This multimodal approach controlled the patient's pain postoperatively without reported complications. At his 1-year postsurgical follow-up visit, the patient reported some generalized "dull aching pain" that was well controlled with oral ibuprofen. Overall, the patient was satisfied with his pain control, and CPSP did not develop.

High expression of Sam68 in sacral chordomas is associated with worse clinical outcomes

Src-associated in mitosis of 68 kDa (Sam68), also known as KHDRBS1 (KH domain-containing, RNA-binding, signal transduction-associated 1), is a member of the signal transduction and activation of RNA family. Previous studies have demonstrated that the aberrant expression of Sam68 is associated with the progression and prognosis of a variety of cancers, but little is known about its expression and role in chordomas, which are rare and aggressive bone neoplasms. In this study, we analyzed 40 tumor tissues and 20 distant normal tissues obtained from 40 patients with sacral chordoma using immunohistochemistry, and observed the expression of Sam68 was significantly upregulated in sacral chordomas compared with normal tissues (P=0.001). A positive correlation between the expression of Sam68 and the cell proliferation index Ki-67 was determined using Spearman’s rank correlation test (γ =0.599, P<0.001). In addition, high expression of Sam68 was significantly associated with surrounding muscle invasion (P<0.001). Moreover, Kaplan–Meier curves showed that patients with overexpressed Sam68 had shorter local recurrence-free survival time (P<0.001). Lastly, multivariate analysis indicated that Sam68 is an independent prognostic factor for the local recurrence-free survival of sacral chordomas (hazard ratio =5.929, 95% CI: 1.092–32.188, P=0.039). Our findings suggest the use of Sam68 as a predictor for the recurrence of sacral chordomas.

Dramatic Response of a Large Sacral Chordoma to Intensity Modulated Proton Beam Therapy

Sacral chordomas are slow-growing, indolent, and locally invasive tumors that typically present with pain and neurologic dysfunction. Wide en-bloc surgical excision is the primary treatment, but achieving adequate margins is difficult and surgery is often associated with significant morbidity. Adjuvant radiation therapy (RT) is utilized to decrease the risk of local recurrence or as definitive treatment for nonsurgical candidates. Although chordomas are considered to be relatively radioresistant tumors, several studies have demonstrated tumor response to high-dose proton therapy. Here, we present a patient with a large sacral chordoma who underwent definitive treatment with intensity-modulated proton therapy (IMPT).

Surgical Management of Sacral Chordomas: Illustrative Cases and Current Management Paradigms

Sacral chordomas represent more than 50% of all sacral tumors. These slow-growing, malignant lesions present insidiously and are often large and intimately involved with sacral neurovascular and pelvic structures. En bloc resection is the only well-established predictor of progression-free survival. Optimal surgical management requires a complex multi-disciplinary approach. Here, we describe two cases of sacral chordoma and review current management paradigms.

Overexpression of Raf-1 and ERK1/2 in sacral chordoma and association with tumor recurrence

Chordoma is a rare and low-malignant neoplasm which is considered to arise from notochord remnants. Due to its large resistance to chemotherapy and radiotherapy, surgical resection so far is the prior treatment for chordoma. However, the recurrence rate is high even after complete surgical resection. Recently, targeted cancer therapy has been demonstrated to be effective in several other tumors, while the related research on chordoma is rare. Mitogen-activated protein kinase signaling pathway is acknowledged to participate in tumor development, in which Raf-1 and extracellular regulated protein kinase 1/2 (ERK1/2) play vital roles. In this study, we evaluated the expression of Raf-1 and ERK1/2 by immunohistochemical staining in 42 chordoma tissue and 16 distant normal tissue. Moreover, we also investigated the correlations of Raf-1 and ERK1/2 expression with clinical features in sacral chordoma. Expression of Raf-1 and ERK1/2 was both significantly higher in sacral chordoma tissue than distant normal tissue (P = 0.008, P = 0.019). Raf-1 positive expression was related to surrounding muscle invasion (P = 0.032) and chordoma recurrence (P = 0.002), but the results did not indicate any association with patients' age, gender, tumor size and location. ERK1/2 was associated with tumor size (P = 0.044) instead of other clinical factors (P > 0.05). Spearman correlation test showed close relation between ERK1/2 and Raf-1 (P = 0.001, r = 0.518). Kaplan-Meier survival Curve and log-rank test showed that Raf-1 positive expression was associated with shorter continuous disease-free survival time (CDFS) (P = 0.001), while ERK1/2 had no relation to CDFS (P = 0.961). Conclusively, Raf-1 may be an important biomarker in predicting the prognosis of chordoma patients.

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.