Clinical and pathologic review of 48 cases of chordoma

The results of treatment of 48 patients with the diagnosis of chordoma during the period 1931 to 1981 at the Massachusetts General Hospital were reviewed. Fourteen patients were treated with surgery alone: eight patients with primary tumors in the sacrococcygeal region were treated with radical surgery and four are alive with no evidence of disease (NED) with follow-up of 8 to 20 years. Recurrent tumors in six patients were treated with surgery alone resulting in long palliation (3-25 years). The actuarial survival rate at 5 years for all patients treated with surgery was 76%. Radiation therapy was used in patients after either a biopsy (15), partial excision (17), or before radical excision in 2 patients. To achieve a worthwhile level of palliation, doses greater than 4000 cGy were required. High-dose levels (greater than 6500 cGy) were achieved in nine cases by a combination of photon and 160 MeV proton beams. The results to date of this approach for lesions of the base of skull and cervical vertebral body are encouraging: high local control and low morbidity. The 5-year actuarial survival rate of all patients treated with radiation was 50%.

Psammomatoid and trabecular juvenile ossifying fibroma of the craniofacial skeleton: two distinct clinicopathologic entities

The term juvenile ossifying fibroma is used in the literature in naming 2 microscopically distinct fibro-osseous lesions of the craniofacial skeleton. One is characterized by small uniform spherical ossicles resembling psammoma bodies (psammomatoid juvenile ossifying fibroma). The other is distinguished by trabeculae of fibrillary osteoid and woven bone (trabecular juvenile ossifying fibroma). Three new cases of each type are reported, and the literature is extensively reviewed for published cases of these 2 entities.Psammomatoid juvenile ossifying fibroma is reported more commonly than trabecular juvenile ossifying fibroma. It affects patients from a wider age range (3 months to 72 years) and an older mean age range (16-33 years) as compared with 2 to 12 years and 8(1/2) to 12 years, respectively, for trabecular juvenile ossifying fibroma. In both types there is a slight male predominance and the lesions are unencapsulated and tend to infiltrate adjacent bone. A significant difference between the 2 tumors is their site of occurrence. Although psammomatoid juvenile ossifying fibroma occurs predominantly in the sinonasal and orbital bones, trabecular juvenile ossifying fibroma predominantly affects the jaws. Aggressive growth occurs in some-but not all-cases of both types. Such behavior may be related to younger patient age and the concurrent development of aneurysmal bone cysts, which is seen more frequently in psammomatoid juvenile ossifying fibroma. This study demonstrates that not only histologic but also demographic and clinical differences between psammomatoid juvenile ossifying fibroma and trabecular juvenile ossifying fibroma warrant their classification as 2 distinct clinicopathologic entities.

Low-grade adenocarcinoma of probable endolymphatic sac origin A clinicopathologic study of 20 cases

The clinical and histologic features of twenty cases of a type of papillary-cystic temporal bone neoplasm are reported. Ages of the patients ranged from 15 to 71 years. The tumors destroyed a large portion of the posterior temporal bone and included a prominent extension into the posterior cranial fossa. Patient histories indicated a slow growth rate of the lesions. Awareness of the parameters of this neoplasm, including the site of origin and probably histogenesis, may enable earlier diagnosis and more successful treatment of the tumor in the future.

From the archives of the AFIP. Paragangliomas of the head and neck: radiologic-pathologic correlation. Armed Forces Institute of Pathology

Paragangliomas of the head and neck are ubiquitous in their distribution, originating from the paraganglia or glomus cells within the carotid body, vagal nerve, middle ear, jugular foramen, and numerous other locations. The typical patient is middle-aged and presents late in the course of the disease, with a painless slow-growing mass. Clinical manifestations include hoarseness of voice, lower cranial nerve palsies, pulsatile tinnitus, and other neuro-otologic symptoms. The overall prognosis of patients with a cervical paraganglioma is favorable, whereas its temporal bone counterpart often results in recurrence, residual tumor, and neurovascular compromise when in the advanced stage. Pathologic examination reveals a characteristic biphenotypic cell line, composed of chief cells and sustentacular cells with a peripheral fibrovascular stromal layer that are organized into a whorled pattern ("zellballen"). Imaging hallmarks of paragangliomas of the head and neck include an enhancing soft-tissue mass in the carotid space, jugular foramen, or tympanic cavity at computed tomography; a salt-and-pepper appearance at standard spin-echo magnetic resonance imaging; and an intense blush at angiography. Imaging studies depict the location and extent of tumor involvement, help determine the surgical approach, and help predict operative morbidity and mortality. Surgical treatment is definitive. Radiation treatment is included as a palliative adjunct for the exceptional paraganglioma not amenable to surgery.

Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases

Generally accepted contraindications to using a transsphenoidal approach for resection of tumors that arise in or extend into the suprasellar region include a normal-sized sella turcica, normal pituitary function, and adherence of tumor to vital intracranial structures. Thus, the transsphenoidal approach has traditionally been restricted to the removal of tumors involving the pituitary fossa and, occasionally, to suprasellar extensions of such tumors if the sella is enlarged. However, conventional transcranial approaches to the suprasellar region require significant brain retraction and offer limited visualization of contralateral tumor extension and the interface between the tumor and adjacent structures, such as the hypothalamus, third ventricle, optic apparatus, and major arteries. In this paper the authors describe successful removal of suprasellar tumors by using a modified transsphenoidal approach that circumvents some of the traditional contraindications to transsphenoidal surgery, while avoiding some of the disadvantages of transcranial surgery. Four patients harbored tumors (two craniopharyngiomas and two hemangioblastomas) that arose in the suprasellar region and were located either entirely (three patients) or primarily (one patient) within the suprasellar space. All patients had a normal-sized sella turcica. Preoperatively, three of the four patients had significant endocrinological deficits signifying involvement of the hypothalamus, pituitary stalk, or pituitary gland. Two patients exhibited preoperative visual field defects. For tumor excision, a recently described modification of the traditional transsphenoidal approach was used. Using this modification, one removes the posterior portion of the planum sphenoidale, allowing access to the suprasellar region. Total resection of tumor was achieved (including absence of residual tumor on follow-up imaging) in three of the four patients. In the remaining patient, total removal was not possible because of adherence of tumor to the hypothalamus and midbrain. One postoperative cerebrospinal fluid leak occurred. Postoperative endocrinological function was worse than preoperative function in one patient. No other new postoperative endocrinological or neurological deficits were encountered. This study demonstrates the feasibility of using a modified transsphenoidal approach for resection of certain suprasellar, nonpituitary tumors.

Base of skull chordoma. A correlative study of histologic and clinical features of 62 cases

BACKGROUND

Chordomas are uncommon primary malignant tumors of bone that typically occur in the axial skeleton including the sacrum, vertebrae, and skull base. The base of skull tumors usually are not amenable to complete surgical resection, and most require postoperative radiotherapy. The natural history of skull base chordoma is typified by slow locally invasive tumor progression and eventual death, although few parameters are known that allow stratification of patients into prognostic groups.

METHODS

Sixty-two patients with skull base chordomas treated at the Massachusetts General Hospital by proton beam irradiation therapy with at least 2 years of follow-up information were reviewed in an attempt to identify clinical and pathologic parameters that predicted outcome.

RESULTS

Female sex, tumor necrosis in preradiation treatment biopsy, and tumor volume in excess of 70 ml were each independent predictors of shortened overall survival after radiation therapy for skull base chordoma.

CONCLUSIONS

Stratification of patients with skull base chordoma into poor and good outcome groups can be performed using the three parameters identified in our study. In addition, the striking difference in survival between the sexes suggests that further investigations of these tumors should include determination of their hormonal receptors status and consideration of hormonal manipulation in their management.

A clinicopathologic review of 25 cases of chordoma (a pleomorphic and metastasizing neoplasm)

A clinicopathologic study of 25 cases of chordoma revealed that this tumor occurs principally in (68%), with a predominance for the sixth decade of life (seven patients--28%), and shows a predilection for the sacrococcygeal region (52%). The symptomatology was intimately related to the location of the tumor. Histologically, chordoma showed an extremely wide range in its cellular composition and pattern, not only from tumor to tumor, but also often in different portions of the same tumor. In addition to the large physaliferous cells in a lobular arrangement, large cells with apparently degenerating nuclei (ghost cells) were commonly seen; cells arranged in concentric spherical formations were observed in two cases, whereas small, round cells predominated in another case. A sarcomatous pattern was prominent in two cases. Large pink cells were frequently seen and in one case were arranged in epithelial-like columns. Whether these neoplastic components can be related to different degrees of tumor differentiation is difficult to establish. Histologic features of five cases in which metastasis occurred were compared to previously described metastasizing cases. These appear to be few reliable features helpful in suggesting the metastatic potential of this neoplasm.

Infiltration of the carotid artery by cavernous sinus meningioma

Intracranial meningiomas are known to infiltrate surrounding structures such as the calvaria and dural sinuses, and the brain itself. The issue of whether meningiomas invade major intracranial arteries is of clinical importance, particularly in the case of meningiomas of the cavernous sinus. If a meningioma has not invaded the carotid artery wall, complete tumor removal may be accomplished with careful dissection from the carotid artery; however, if the tumor has infiltrated the wall of the carotid artery, complete removal may require sacrifice of the artery. To determine whether cavernous sinus meningiomas invade the carotid artery, the authors retrospectively reviewed the histopathology of 19 consecutively treated individuals whose carotid artery was sacrificed during removal of a meningioma involving the cavernous sinus. Patients were selected for carotid artery resection based on preoperative magnetic resonance imaging studies demonstrating complete encasement of the artery. Reconstruction of the carotid artery was planned depending on the results of preoperative balloon test occlusion with blood flow determinations. None of the 19 patients had pathological evidence of malignant tumor. Eight individuals (42%) were found to have infiltration of the carotid artery by meningioma. In five cases, focal involvement of the adventitia of the carotid artery wall was noted and, in three, the vessel was infiltrated up to the tunica muscularis. In no case was the tunica muscularis invaded by tumor. Thus, meningiomas of the cavernous sinus do infiltrate the internal carotid artery and, in order to completely resect these lesions and effect a surgical cure, it may be necessary to sacrifice the carotid artery with or without reconstruction.

Chordoma and chondroid neoplasms of the spheno-occiput. An immunohistochemical study of 41 cases with prognostic and nosologic implications

BACKGROUND

Chordomas are rare neoplasms that show a proclivity for the spheno-occiput and sacral regions. A "chondroid" variant involving the spheno-occiput has been associated with improved survival. "Classic" or nonchondroid chordomas are uniformly immunoreactive for keratins. Chondroid chordomas are said to be immunonegative for epithelial markers, a feature used to support the concept that they represent chondrosarcomas.

METHODS

The authors performed immunohistochemical studies on 25 patients with chondroid chordoma (mean age, 40.0 years) and on 16 patients with classic chordomas (mean age, 44.2 years) to establish tumor subsets based upon immunophenotype, specifically reactivity for epithelial markers. Kaplan-Meier survival curves were then constructed for each group with age as an added variable.

RESULTS

All classic chordomas reacted for keratins as did 8 (32%) of the 25 chondroid chordomas. Forty-four percent of classic and 85% of chondroid chordomas were positive for S-100 protein. At 5 years, all patients younger than 40 years of age were alive in both the classic and chondroid groups. In contrast, of patients older than 40 years of age, only 22% with classic chordomas and 38% with chondroid chordomas were alive.

CONCLUSIONS

Regardless of tumor subtype, age is the single most important variable in determining survival; patients younger than 40 years of age do better than older patients. There are no significant survival differences between patients with cartilage-containing tumors that are keratin immunopositive ("true" chondroid chordoma) or negative (chondrosarcoma). Immunostaining for keratins is of no prognostic value in assessing chondroid lesions of the spheno-occiput.

Complications of craniofacial resection for tumors involving the anterior skull base

BACKGROUND

A consecutive series of 85 patients undergoing craniofacial resection for malignant tumors involving the anterior cranial base between 1974 and 1992 was reviewed.

RESULTS

There were two (2%) postoperative deaths. Postoperative complications occurred in 33 (39%) patients. Local major complications occurred in 26 (31%) patients, local minor in 7 (8%), and systemic in 5 (6%). More than one complication occurred in a number of patients. Bacterial contamination led to a significant proportion of local, septic complications. Repair of the skull base defect with a pedicled pericranial flap was unsatisfactory and was associated with an increased incidence of local major complications. A local major complication was associated with a dramatic lengthening of hospitalization.

CONCLUSION

Future endeavors for prevention of complications should focus on antibiotic prophylaxis and reconstruction of the cranial base defect with better vascularized flaps.

Craniocerebral epidermoids and dermoids. A review of 44 cases

We review 40 epidermoids and 4 dermoids of the skull and brain treated surgically in our Department between 1976 and 1987. Fourteen were extradural and 30 intradural. The mean duration of symptoms was 3 years for extradural and 10 years for intradural tumours. Symptoms varied with tumour site, in some sites being helpful in differential diagnosis. Skull X-rays and CT were the key diagnostic investigations in extradural and CT in intradural lesions, the latter, with few exceptions, presenting a characteristic CT scan. In 7 cases MRI supplied important details on the tumour boundaries. All the diploic and orbital lesions were removed totally, with a good outcome. Twelve of the intradural lesions were removed totally, 9 subtotally and 9 partially, with a good outcome in 21 patients and a poor outcome in 4; 5 patients died. Outcome was unrelated to degree of removal.

Tumors of the skull base: outcome and survival analysis of 77 cases

We reviewed our experience with combined approaches to lesions that transcend the bones of the skull base. Seventy-seven skull base procedures were performed on 73 patients during a 10-year period from 1982 to 1992. There were 34 patients (44%) with region lesions (anterior), seven patients (9%) with region II lesions (anterior-lateral), 25 patients (32%) with region III lesions (lateral-posterior), and 11 patients (14%) with lesions that invaded more than one anatomic site. The histopathology in this series was quite variable, with 22 patients (29%) having squamous cell carcinoma and eight patients (10%) having basal cell carcinoma. Forty-one patients had surgery by an anterior approach and 38 patients had lateral approaches, with 18 undergoing an infratemporal approach and 29 undergoing temporal bone resections. Overall, 44% of the patients had a postoperative complication. Survival of this heterogeneous group of patients is 79% at 2 years and 71% at 4 years, with those patients with region II disease having a statistically significant poorer prognosis with no survivors at 4 years.

Comparison of intensity-modulated radiotherapy with conventional conformal radiotherapy for complex-shaped tumors

PURPOSE

Conformal and intensity-modulated radiotherapy (IMRT) plans for 9 patients were compared based on characterization of plan quality and effects on the oncology department.

METHODS AND MATERIALS

These clinical cases, treated originally with conformal radiotherapy (CRT), required extraordinary effort to produce conformal treatment plans using nonmodulated, shaped noncoplanar fields with multileaf collimators (MLCs). IMRT plans created for comparison included rotational treatments with slit collimator, and fixed-field MLC treatments using equispaced coplanar, and noncoplanar fields. Plans were compared based upon target coverage, target conformality, dose homogeneity, monitor units (MU), user-interactive planning time, and treatment delivery time. The results were subjected to a statistical analysis.

RESULTS

IMRT increased target coverage an average of 36% and conformality by 10%. Where dose escalation was a goal, IMRT increased mean dose by 4-6 Gy and target coverage by 19% with the same degree of conformality. Rotational IMRT was slightly superior to fixed-field IMRT. All IMRT techniques increased integral dose and target dose heterogeneity. IMRT planning times were significantly less, whereas MU increased significantly; estimated delivery times were similar.

CONCLUSION

IMRT techniques increase dose and target coverage while continuing to spare organs-at-risk, and can be delivered in a time frame comparable to other sophisticated techniques.

Endolymphatic sac tumors: histopathologic confirmation, clinical characterization, and implication in von Hippel-Lindau disease

The term "endolymphatic sac tumor" (ELST) was coined to identify the likely origin of aggressive papillary tumors of the temporal bone. To evaluate the validity of this designation, the temporal bone collection at the Massachusetts Eye and Ear Infirmary was accessed in an effort to determine the pathologic relationship between these tumors and the endolymphatic sac. The search resulted in the identification of a de-novo papillary epithelial lesion arising within the confines of the endolymphatic sac in a patient with von Hippel-Lindau (VHL) disease who harbored a large, destructive ELST in the opposite temporal bone. This finding provides the most substantial evidence to date regarding the origin of the ELST and the accuracy of its nomenclature. Seven additional clinical cases of ELST were identified and analyzed in order to define the natural history of these tumors. All patients had a history of sensorineural hearing loss diagnosed an average of 10.6 years prior to tumor discovery. The presence of a polypoid external auditory canal mass, facial paralysis, and evidence of a destructive mass arising on the posterior fossa surface of the temporal bone were common physical and radiographic findings. The management of these patients, as well as those who are probably prone to such tumors (i.e., VHL patients), is discussed.

The potential impact of CT-MRI matching on tumor volume delineation in advanced head and neck cancer

PURPOSE

To study the potential impact of the combined use of CT and MRI scans on the Gross Tumor Volume (GTV) estimation and interobserver variation.

METHODS AND MATERIALS

Four observers outlined the GTV in six patients with advanced head and neck cancer on CT, axial MRI, and coronal or sagittal MRI. The MRI scans were subsequently matched to the CT scan. The interobserver and interscan set variation were assessed in three dimensions.

RESULTS

The mean CT derived volume was a factor of 1.3 larger than the mean axial MRI volume. The range in volumes was larger for the CT than for the axial MRI volumes in five of the six cases. The ratio of the scan set common (i.e., the volume common to all GTVs) and the scan set encompassing volume (i.e., the smallest volume encompassing all GTVs) was closer to one in MRI (0.3-0.6) than in CT (0.1-0.5). The rest volumes (i.e., the volume defined by one observer as GTV in one data set but not in the other data set) were never zero for CT vs. MRI nor for MRI vs. CT. In two cases the craniocaudal border was poorly recognized on the axial MRI but could be delineated with a good agreement between the observers in the coronal/sagittal MRI.

CONCLUSIONS

MRI-derived GTVs are smaller and have less interobserver variation than CT-derived GTVs. CT and MRI are complementary in delineating the GTV. A coronal or sagittal MRI adds to a better GTV definition in the craniocaudal direction.

Chondroid chordoma--a variant of chordoma. A morphologic and immunohistochemical study

In 1973, Heffelfinger and coworkers described a variant of chordoma that contained cartilaginous areas indistinguishable from hyaline type chondrosarcoma. They designated these tumors chondroid chordomas and found that they had a better prognosis than classic (nonchondroid) chordomas. Since that time, there has been an ongoing debate over whether chondroid chordoma is best considered a distinct clinicopathologic entity separable from chondrosarcoma or a misdiagnosed chondrosarcoma whose concept developed from the erroneous interpretation of morphology. In an attempt to clarify the issue, the authors used light microscopy and immunohistochemistry to study 12 chondroid chordomas, 38 classic chordomas, and 28 chondrosarcomas that arose in the base of the skull or spine. As a reference, they also analyzed the immunohistochemical profile of fetal notochord, ecchordosis physaliphora, and fetal hyaline cartilage. They found that all chondroid and nonchondroid chordomas were positive for cytokeratin, and the majority were also positive for epithelial membrane antigen (EMA) and carcinoembryonic antigen (CEA). In contrast, none of the chondrosarcomas stained for cytokeratin, EMA or CEA. Vimentin and S-100 were positive in more than 95% of both classic and chondroid chordomas and chondrosarcomas. The immunohistochemical profile of these tumors was similar to the pattern of immunoreactivity of their nonneoplastic counterparts. The authors conclude that chondroid chordomas is a variant of chordoma and should not be confused with chondrosarcoma. Because chondroid chordomas have been reported to have a better prognosis, they felt that this nosologic term should be preserved and that chondroid chordoma should continue to be a focus of clinical and pathologic study.

Lateral approaches to the petroclival region

The microsurgical anatomy that provides the basis for dealing with lesions arising in the petroclival region was reviewed in 15 adult cadaver heads and 25 dry skulls. The eight surgical approaches studied were the retrosigmoid, extreme lateral transcondylar, translabyrinthine, transcochlear, combined supra and infratentorial presigmoid, subtemporal anterior transpetrosal, subtemporal preauricular infratemporal, and the postauricular transtemporal approach. Considerations important in the selection of these approaches are discussed. Special attention was directed to the course of the facial nerve and internal carotid artery in the temporal bone and the major venous pathways draining the region.

Cranial chordomas in children and young adults

A series of 12 surgically treated and pathologically proven cranial chordomas presenting in children and young adults is reviewed. These rare tumors occur in relation to the path of the primitive notochord; four were parasellar, six were mid-clival, and two were inferior clival in location. Pathological evaluation revealed five of the tumors to have a significant chondroid component. Follow-up studies ranging from 1 month to 21 years revealed that eight patients were alive, all of whom had received radiation therapy following surgery.

Isolated sphenoid sinus disease: an analysis of 132 cases

Solitary involvement of the sphenoid sinus is a relatively uncommon entity. A series of 132 patients with isolated sphenoid disease accumulated over a 22-year period is reported. A retrospective chart review was performed with special attention to the patients' presenting signs, symptoms, and radiographic findings. There were 80 patients with inflammatory disease, 38 with neoplasms, four with fibroosseous disorders, and 10 with traumatic and developmental lesions. The most common presenting symptom was headache, followed by visual changes and cranial nerve palsies. Cranial nerve abnormalities were encountered in 12% of the inflammatory cases, 60% of the benign tumors, and 57% of the malignant tumors. Radiographically, bone remodeling was associated with chronic inflammatory disease, especially mucoceles. Bone erosion was found principally with neoplastic disease, occurring rarely with mucoceles. Extension was associated with malignant tumors.

An unusual intraosseous lesion with fibroblastic, osteoclastic, osteoblastic, aneurysmal and fibromyxoid elements. "Solid" variant of aneurysmal bone cyst

Four examples are reported of an unusual noncystic intraosseous lesion which does not conform to any hitherto recognized entity and which can be mistaken, not only by the general histopathologist but by the osteoarticular pathologist, for a variety of other conditions, including sarcoma and giant-cell tumor. They were in patients aged 5 to 13 years; three in the spine, one in the ethmoid. Local excision, supplemented by low-dose radiotherapy in cases with cord compression, produced a satisfactory outcome in all cases. At presentation the radiologic findings were nonspecific but, following treatment, an eggshell rim of bone developed in those lesions which had been incompletely excised. Histologically, they are characterised by florid fibroblastic or fibrohistiocytic proliferation, osteoblastic differentiation with osteoid production, areas rich in osteoclast-type giant cells, aneurysmal sinusoids, and occasional foci of degenerate calcifying fibromyxoid tissue. Because this combination of histologic features can be found in the solid parts of aneurysmal bone cyst and in no other condition, at this centre we have regarded this lesion as a variant of aneurysmal bone cyst devoid of any cystic component.

Evidence of meningioma infiltration into cranial nerves: clinical implications for cavernous sinus meningiomas

Anatomical and biological studies of cavernous sinus meningiomas help us understand the biological heterogeneity of these tumors. The question of whether cavernous sinus meningiomas infiltrate cranial nerves is clinically important because of the effect on treatment planning. In the authors' experience of treating 36 patients with cavernous sinus meningiomas, tumor invasion into a cranial nerve was documented in two patients in whom a cranial nerve was resected during the cavernous sinus dissection. In both patients, histological examination using hematoxylin and eosin and bodian stains showed infiltration of the cranial nerves by a benign meningioma which, to the best of the authors' knowledge, is a condition previously unreported. This histological finding of meningioma invasion into a cranial nerve demonstrates the biological heterogeneity of cavernous sinus meningiomas and raises concern about the invasive character of meningioma. Because not all tumor cells can be identified radiologically or by direct visualization at surgery, occult tumor infiltration predisposes a patient to recurrence despite the best neurosurgical efforts. Evidence of cranial nerve infiltration by meningioma suggests that, in some circumstances, cavernous sinus dissection in the hope of total removal of a meningioma may be futile and, in the long term, may provide no advantage over treatment options with lower morbidity.