Skull base chordomas: overview of disease, management options, and outcome

The role of chemotherapy in pediatric clival chordomas

The purpose of this retrospective study was to review the role of chemotherapy in the treatment, management and outcome of children diagnosed with clival chordomas. The medical records of six pediatric chordoma patients diagnosed at Childrens Hospital Los Angeles between 1995 and 2005 were reviewed. Of the six patients reviewed, all underwent an initial surgical resection. Following resection, three received a combination of chemotherapy and radiation therapy, two received chemotherapy alone and one patient refused both forms of therapy; this patient expired of progressive tumor. One patient developed acute monoblastic leukemia (M5a subtype) and died of intracranial hemorrhage during induction chemotherapy, 39 months after initial diagnosis. MRI of brain and spine showed disease progression shortly before his death. Two patients who received chemotherapy only after surgery, one patient who received chemotherapy at relapse following irradiation and one patient who received irradiation followed by chemotherapy are alive with stable radiographic abnormalities at a median follow-up of 9 years from diagnosis (range: 6-13 years). Chemotherapeutic agents included ifosfamide and etoposide in all four surviving patients. Chemotherapy with ifosfamide and etoposide may have a role in the treatment of pediatric clival chordomas when used alone or in combination with irradiation.

Clival chordomas: clinical management, results, and complications in 71 patients

Object

Chordomas are rare malignant neoplasms arising predominantly at the sacrum and skull base. They are uniformly lethal unless treated with aggressive resection and proton beam irradiation. The authors present results of the surgical management of a large number of patients with clivus chordomas. Factors that influence the surgeon's ability to achieve radical tumor resection are also evaluated.

Methods

Between 1991 and 2005, 71 patients with clivus chordomas underwent surgery. The average follow-up was 66 months (median 60 months, range 3–189 months). Sixty-five patients had complete records that were analyzed in the present report. Thirty-five percent of them had undergone surgery before being treated by the authors. They were evaluated with MR imaging and CT scanning and underwent surgery utilizing a variety of skull base techniques aimed at achieving radical excision. Many also underwent postoperative radiation, usually in the form of proton beam therapy. The patients were followed up with serial imaging at regular intervals as well as with neurological evaluation.

Results

Radical tumor resection was achieved in 58% of the group. The overall 5-year survival rate was 75%. Radical resection had a positive impact on survival. The ability to achieve radical resection was dependent on the preoperative tumor volume and the number of anatomical areas involved by the tumor. Cranial nerve impairment and CSF leakage were the most frequent postoperative complications.

Conclusions

Radical excision is the ideal surgical goal in the treatment of clival chordomas and can be achieved with reasonable risks. Several different surgical approaches may be necessary to accomplish this.

Vascularised fibula osteocutaneous flap for cervical spinal and posterior pharyngeal wall reconstruction

We report a case of vascularised fibula osteocutaneous flap used for composite cervical spinal and posterior pharyngeal wall reconstruction, in a patient with recurrent skull base chordoma, resected by an anterior approach via median labio-mandibular glossotomy approach. Bone stability and pharyngeal wall integrity were simultaneously restored.

A case of unilateral hypoglossus nerve palsy associated with chordoma in the region of clivus

We had a rare case of 50-year-old woman with a unilateral hypoglossus nerve palsy as a sign of clival chordoma. A computed tomography (CT) scan of the skull base showed bone destruction at the anterior part of the foramen magnum and CT scan of the neck reveals asymmetrical area at the base of the tongue. Magnetic resonance imaging showed a mass at the skull base in the region of the clivus with bone destruction in the middle and right side of the clivus. The tumor was biopsied through transnasal biopsy from the region of the clivus using a navigation system and microscopical surgical technique. Postoperatively, the patient received radiotherapy. Surgery is the most effective treatment of chordomas. An endoscopic approach provides easy, rapid and direct access to the clivus. A postoperative radiation therapy is recommended. A carbon ion radiotherapy is an effective treatment for chordomas of the skull base with minimal side effects. Close interdisciplinary collaboration between ORL, neuroradiology, pathology and oncology is desirable for effective therapy.

Skull base chordomas: efficacy of surgery followed by carbon ion radiotherapy

BACKGROUND

Skull base chordomas are challenging to treat because of their invasive nature, critical location, and aggressive recurrence. We report the effectiveness of combined radical skull base surgery with carbon ion radiotherapy for treating skull base chordomas.

METHODS

Between November 1996 and August 2007, 32 patients (12 males and 20 females; mean age at initial presentation 41.4 years, range, 10-75 years) with skull base chordomas underwent 59 operations. Sub-total resection (resection of >90% of the pre-operative tumour volume) was achieved in 24 out of 59 (40.7%) operations. After surgical excision, 9/32 (28.1%) patients underwent adjuvant carbon ion radiotherapy. The patients were followed up for a mean period of 36.3 months (range, 3-93 months) from the initial presentation.

FINDINGS

Fifty percent of the patients had to be re-treated due to tumour regrowth during the follow-up period. Thus far, 3 patients have died from the neoplasms. The overall 7 year survival rate of 9 patients who underwent carbon ion radiotherapy was 85.7%. The rate was higher compared to that of others (76.4%). The 3 year recurrence free survival rates of carbon ion therapy treated group was 70.0%, being higher than that of the other groups treated with radiotherapy or untreated (57.1%, and 7.1% respectively). Log-rank analysis showed a significant difference in the recurrence free survival rates between the group treated with adjunctive carbon ion radiotherapy and the untreated group (P = 0.001146).

CONCLUSIONS

Surgical removal of the tumour around the brainstem and the optic nerve combined with post-operative carbon ion radiotherapy will improve the survival rate and quality of life of patients with complicated skull base chordomas.

Surgery of extra-axial tumors of the cerebral base

Because of the complex structure of the cranial base and its close proximity to cranial nerves and vessels, surgery in this area is associated with considerable risk of morbidity and mortality. Multiple approaches to each part of the cranial base have been developed over the past few decades, ranging from small modifications of more traditional approaches to complex and sophisticated new techniques. However, experience has shown that optimal outcome is achieved if the selected approach is not associated with significant approach-related morbidity. Furthermore, not all cranial base tumors can be cured by surgery. The selection of operative approach and the goal of surgery should be part of the whole treatment strategy. The attempt to achieve complete resection can, therefore, be justified only if the associated long-term morbidity is minimal. Refinements of the traditional retrosigmoid suboccipital approach have made it the most effective and safe approach, the "gold standard" for lesions in the cerebellopontine angle. On the other hand, in some basal tumors, e.g., chordomas and chondrosarcomas, the approach has to be selected individually and must always be tailored to the characteristics of the particular tumor, its location, and the patient's expectations. The expertise of the surgeon is not reflected in his or her ability to perform the most complex approaches but in the ability to select the approach that affords both removal of the tumor and preservation of patient's neurological function and quality of life.

Endonasal microscopic removal of clival chordomas

INTRODUCTION

Clival chordomas have traditionally been removed using a variety of anterior and lateral skull base approaches. Herein, we evaluate the outcomes of patients who underwent an extended endonasal transsphenoidal removal of a clival chordoma.

METHOD

All consecutive patients with a clival chordoma treated using an endonasal microscope approach were identified. In 8 cases, frameless surgical navigation was used, and in 4 cases, endoscopic assistance was used. Patients treated with prior radiotherapy were excluded.

RESULT

Over 5 years, 18 procedures were performed on 14 patients (7 females; mean age, 47 years). Patients were followed from 3 to 58 months (median, 20 months). Mean tumor diameter was 32 +/- 17 mm; 7 (50%) patients had intradural extension. Postoperative MRIs after the initial operation showed gross total, near-total (>90%), and subtotal resection in 43%, 43%, and 14% of patients, respectively. Use of the endoscope was associated with gross total or near-total tumor removal in 4 of 4 cases. Tumor regrowth occurred in 2 (14%) cases 10 and 12 months after the initial surgery and before radiotherapy. Two patients had multiple operations, in one as a planned staged operation, and in the other, 3 additional debulkings were performed despite an initial gross total removal. Nine patients, all with CS invasion, had subsequent stereotactic radiation. Of 10 patients with cranial neuropathy, 80% improved or resolved including 75% and 67% of sixth and fifth CN palsies, respectively. Complications included one each of adrenal insufficiency and chemical meningitis. There were no CSF leaks or new neurological deficits.

CONCLUSION

In this small series with relatively short follow-up, endonasal microscopic removal of clival chordomas proved safe and elfective with gross total or near-total removal in 86% of patients and improvement of cranial neuropathy in 80% of patients. Endoscopy for aiding tumor removal and assessing completeness of resection, as well as surgical navigation, are recommended for all cases.

Tumor-biology and current treatment of skull-base chordomas

Chordomas are rare, slow growing tumors of the axial skeleton, which derive from the remnants of the fetal notochord. They can be encountered anywhere along the axial skeleton, most commonly in the sacral area, skull base and less commonly in the spine. Chordomas have a benign histopathology but exhibit malignant clinical behavior with invasive, destructive and metastatic potential. Genetic and molecular pathology studies on oncogenesis of chordomas are very limited and there is little known on mechanisms governing the disease. Chordomas most commonly present with headaches and diplopia and can be readily diagnosed by current neuroradiological methods. There are 3 pathological subtypes of chordomas: classic, chondroid and dedifferentiated chordomas. Differential diagnosis from chondrosarcomas by radiology or pathology may at times be difficult. Skull base chordomas are very challenging to treat. Clinically there are at least two subsets of chordoma patients with distinct behaviors: some with a benign course and another group with an aggressive and rapidly progressive disease. There is no standard treatment for chordomas. Surgical resection and high dose radiation treatment are the mainstays of current treatment. Nevertheless, a significant percentage of skull base chordomas recur despite treatment. The outcome is dictated primarily by the intrinsic biology of the tumor and treatment seems only to have a secondary impact. To date we only have a limited understanding this biology; however better understanding is likely to improve treatment outcome. Hereby we present a review of the current knowledge and experience on the tumor biology, diagnosis and treatment of chordomas.

Chordomas of the skull base: surgical management and outcome

OBJECT

The goal of this study was to report on the surgical management of skull base chordomas and to evaluate both the short- and long-term treatment outcomes.

METHODS

The authors retrospectively studied data from 49 patients who had undergone consecutive surgeries at a single institution. They also analyzed patterns of chordoma extension. Complications and surgery-related morbidity were recorded. A Kaplan-Meier analysis was performed to determine survival rates in patients 5 and 10 years after their first surgery. Operative approaches were selected on the basis of the predominant tumor extension.

RESULTS

The approach used most frequently was the transethmoidal in 36.3%, followed by the pterional in 23.4% and the retrosigmoid in 23.4%. The tumor was totally removed in 49.4% and subtotally in 50.6%. The rate of total removal was highest at initial surgery (78%) and progressively declined thereafter. In 11.8% of cases a new neurological deficit developed, while the preoperative deficit remained unchanged. In 20% of cases the preoperative deficits improved, but new deficits also appeared. The 5- and 10-year survival rates are 65 and 39%, respectively.

CONCLUSIONS

With an individually tailored surgical approach, total tumor removal in 78% of the cases was achieved at the initial surgery. Radical surgery appears to increase slightly the surgical morbidity, but at the same time prolongs the recurrence-free interval. Chordomas cannot be regarded as surgically curable tumors given the 5- and 10-year survival rates in patients harboring such lesions.

Infratentorielle Tumoren

This article gives an overview concerning the typical infratentorial tumors of adults.

Non-meningeal tumours of the cavernous sinus: a surgical analysis

The popularisation of cavernous sinus approaches and subsequent experience has shaped our treatment paradigms for cavernous sinus meningiomas. However, pathologies in this region are diverse and each one requires individual consideration. The purpose of this study was first to analyse, define and summarise the individual characteristics of different non-meningeal tumours of the cavernous sinus and, secondly, to stress that their surgery can be accomplished with acceptable morbidity and rewarding results when those characteristics are considered. A retrospective analysis of 42 cases of benign non-meningeal tumours of the cavernous sinus operated on at Marmara University between April 1992 and April 2003 is presented. The patients were 15 males and 27 females aged 24-72 years. The study cohort consisted of 13 pituitary adenomas, 11 trigeminal schwannomas, seven chordomas, three chondrosarcomas, two juvenile angiofibromas, two epidermoid tumours, one plasmacytoma, one cavernous haemangioma and one internal carotid plexus schwannoma. The 42 patients underwent 46 operations aimed at radical surgical excision. Total resection was achieved in 50% and subtotal resection in 50% of cases. The majority of incompletely resected tumours were pituitary adenomas and chordomas, and 95% required further treatment. Twenty-nine percent of patients developed complications, namely cerebrospinal fluid fistula, haematoma, hydrocephalus, diabetes insipidus, cerebral infarction and cranial nerve palsies. Recurrence was seen in 7.1% of patients. At final follow up at an average of 48.2 months after surgery, the mean Karnofsky performance scale had risen from 83.4 to 87.4. Non-meningeal tumours of the cavernous sinus can be surgically resected with acceptable morbidity and mortality. In selected tumours the results are better than those for cavernous sinus meningiomas. The best surgical results are achieved with interdural tumours of the lateral sinus wall and the worst surgical results are seen in invasive tumours such as chordomas and pituitary adenomas. Individual tumour characteristics are presented in the text.

Analysis of radiological features relative to histopathology in 42 skull-base chordomas and chondrosarcomas

Chordomas and chondrosarcomas are malignant tumors that are reported to have similar clinical presentations and radiological features but different behaviors and outcomes. The aim of this retrospective study was to determine whether specific radiological features of skull-base chordomas or chondrosarcomas are correlated with histopathology, and thus allow preoperative diagnosis. The study involved 32 classic chordomas, 6 chondroid chordomas and 4 chondrosarcomas (42 tumors total). For each case, tumor size and extent, the detailed anatomy involved, and magnetic resonance imaging and computed tomography findings were analyzed. Tumor extent was assessed using a novel method that assessed presence/absence in 18 defined skull-base zones. The chondrosarcomas presented significantly earlier in life than the chordomas (means, 20.5 years versus 36 years, respectively). At time of diagnosis, the median tumor volume was 23 cm(3) (range, 1.2-78.8 cm(3)) and the mean tumor extent was 6.7+/-2.9 zones. There were no differences between chordomas and chondrosarcomas, or between the two chordoma subgroups, with respect to lesion volume or extent. Comparison of other imaging findings revealed no features that were diagnostic for either chordoma or chondrosarcoma. The data support previous claims that chondrosarcomas present earlier in life than chordomas, but this finding is not diagnostic. There is wide variation in the extent of skull-base chordomas and chondrosarcomas, and in the specific anatomical structures these tumors involve. None of the MRI or CT features of these tumors appear to be useful for differentiating chordomas from chondrosarcomas preoperatively. For surgical planning, specific, area-oriented definition of tumor extent might provide more useful information than tumor-type classification schemes.