Three-stage excision of recurrent cervical chondrosarcoma. A case report

Primary mobile vertebral column sarcomas: Prognostic factors vary by histologic subtypes

BACKGROUND

Primary sarcomas originating from the mobile spine portends a particularly sinister outcome. Rarity of the disease process has resulted in inconsistent data due to small sample size and heterogeneity in patient selection and analytics.

METHODS

Surveillance, Epidemiology and End Result (SEER) database from 1975 to 2017 was queried to report incidence and survival data in 712 patients in the United States. Kaplan-Meier and Cox Regression were used to determine the prognostic factors affecting survival.

RESULTS

Incidence of spinal sarcoma was 0.019 per 100,000 persons in 2017 and has not significantly changed since 2000 (p > 0.05). Disease-specific 5-year survival for the entire cohort was 57%. Osteosarcoma has the worst 5-year survival (39%) and chondrosarcoma has the best 5-year survival (69%). Independent predictors of survival for the entire cohort included age, grade, and stage. Stage was an independent predictor of survival for every histologic subtype. Additional predictors of survival for spinal osteosarcoma, Ewing sarcoma, and chondrosarcoma included age, size, and grade, respectively.

CONCLUSIONS

The current study is an analysis of a population-based registry reporting incidence survival data for patients with sarcoma of mobile vertebral column. Survival and prognostic factors vary by histologic subtypes. There is lack of improvement in survival over the last three decades.

Challenges of local recurrence and cure in low grade malignant tumors of the spine

STUDY DESIGN

Systematic review and ambispective multicenter cohort study.

OBJECTIVE

1. To compare the effects of wide/marginal (en bloc) resection with intralesional resection on local recurrence and survival for chordomas and chondrosarcomas of the spine. 2. To determine the influence of radiation therapy in the management of chordomas and chondrosarcomas.

SUMMARY OF BACKGROUND DATA

Chordomas and chondrosarcomas of the spine are prone to local recurrence and death despite being low-grade malignant tumors. No study to date has enough numbers or adequate scientific rigor to determine the influence of resection or radiation therapy on outcome.

METHODS

A systematic review was performed to evaluate the 2 objectives. In addition an ambispective multicenter cohort analysis of chordomas and chondrosarcomas was performed. The GRADE system of analysis integrating the results of the systematic review, the multicenter cohort study and the expert opinion of the Spine Oncology Study Group (SOSG) was used to arrive at treatment recommendations.

RESULTS

A total of 63 articles were included in the systematic reviews. Evidence was low quality. En bloc resection appeared to improve both local recurrence and disease free survival in Chordoma and Chondrosarcoma. Radiation therapy had a positive impact on the management of Chordoma and Chondrosarcoma with predictably low side effects. The cohort analysis showed significantly decreased local recurrence for Chordoma (P < 0.0001) and Chondrosarcoma (P < 0.0001) with en bloc resection, and significantly decreased death for both Chordoma (P = 0.0001) and Chondrosarcoma (P = 0.0015) with en bloc resection.

CONCLUSION

When wide or marginal margins (en bloc) are achieved in surgical resection of chordomas and chondrosarcomas of the spine there is a decrease in local recurrence and mortality. Therefore, en bloc resection should be undertaken for the treatment of chordomas and chondrosarcomas of the spine. Strong Recommendation, Moderate Quality Evidence.Radiation therapy of at least 60 to 65 Gy equivalents is indicated as an adjuvant treatment for chordoma and chondrosarcoma of the spine when there has been incomplete resection or an intralesional margin. Weak Recommendation, Low Quality Evidence.

Surgical management of primary and metastatic sarcoma of the mobile spine

Object

Sarcomas of the spine are a challenging problem due to their frequent and extensive involvement of multiple spinal segments and high recurrence rates. Gross-total resection to negative margins, with preservation of neurological function and palliation of pain, is the surgical goal and may be achieved using either intralesional resection or en bloc excision. The authors report outcomes of surgery for primary and metastatic sarcomas of the mobile spine in a large patient series.

Methods

A retrospective review of patients undergoing resection for sarcomas of the mobile spine between 1993 and 2005 was undertaken. Sarcomas were classified by histology study results and as either primary or metastatic. Details of the surgical approach, levels of involvement, and operative complications were recorded. Outcome measures included neurological function, palliation of pain, local recurrence, and overall survival.

Results

Eighty patients underwent 110 resections of either primary or metastatic sarcomas of the mobile spine. Twenty-nine lesions were primary sarcomas (36%) and 51 were metastatic sarcomas (64%). Intralesional resections were performed in 98 surgeries (89%) and en bloc resections were performed in 12 (11%). Median survival from surgery for all patients was 20.6 months. Median survival for patients with a primary sarcoma of the spine was 40.2 months and was 17.3 months for patients with a metastatic sarcoma. Predictors of improved survival included a chondrosarcoma histological type and a better preoperative functional status, whereas osteosarcoma and a high-grade tumor were negative influences on survival. Multivariate analysis showed that only a high-grade tumor was an independent predictor of shorter overall survival. American Spinal Injury Association scale grades were maintained or improved in 97% of patients postoperatively, and there was a significant decrease in pain scores postoperatively. No significant differences in survival or local recurrence rates between intralesional or en bloc resections for either primary or metastatic spine sarcomas were found.

Conclusions

Surgery for primary or metastatic sarcoma of the spine is associated with an improvement in neurological function and palliation of pain. The results of this study show a significant difference in patient survival for primary versus metastatic spine sarcomas. The results do not show a statistically significant benefit in survival or local recurrence rates for en bloc versus intralesional resections for either metastatic or primary sarcomas of the spine, but this may be due to the small number of patients undergoing en bloc resections.

Intralesional resection of primary and metastatic sarcoma involving the spine: outcome analysis of 59 patients

OBJECTIVE

Surgery plays an important role in achieving local tumor control and cure for primary and metastatic tumors of the spine. As has been established with regard to sarcomas at extraspinal sites, these goals may best be achieved by en bloc resection with negative histological margins. Unfortunately, sarcomas of the spine often present with tumor patterns that are amenable only to intralesional resection, if neurological preservation is a priority. This study is a retrospective analysis of the long-term outcomes of patients who had operations for sarcomas of the spine using modern surgical approaches, intralesional resections, and spinal instrumentation.

METHODS

Between 1985 and 1997, 59 patients had spinal operations for sarcoma involving the extrasacral spine. Data regarding tumor histology, grade, surgical indications, patterns of spinal tumor involvement, and neurological and functional outcomes were reviewed at presentation and at tumor recurrence.

RESULTS

Thirty-five patients underwent a single operation, and 24 patients required reoperation for locally recurrent tumors. At presentation, only nine patients (15%) had tumors that were amenable to marginal or wide resections. Functional outcomes after initial spinal surgery and after operations performed at first tumor recurrence showed that 95% of patients had maintained or regained ambulation. Intradural extension of tumor was seen in 5 of 12 patients who had three or more operations for locally recurrent disease. The median survival from first spine operation was 18 months, and the median event-free interval between the first and second spine operations was 13 months.

CONCLUSION

Surgery for sarcoma of the spine is useful for maintaining or improving neurological and functional outcomes, but local tumor recurrences are common. Because of the anatomy of the tumor at presentation and concern for neurological preservation, few patients are candidates for marginal or wide resections.