Chemotherapy for cranial base tumors

Oncogenic Viruses in Skull Base Chordomas

BACKGROUND

Chordomas are rare tumors assumed to derive from notochordal remnants. We believe that a molecular switch is responsible for their malignant behavior. The involvement of oncogenic viruses has not been studied, however. Thus, in the present study, we investigated the presence of oncogenic viruses in chordomas.

METHODS

DNA and RNA from snap-frozen chordoma (n = 18) and chondrosarcoma (n = 15) specimens were isolated. Real-time PCR or RT-PCR was performed to assess the presence of multiple oncogenic viruses, including herpesviridea (herpes simplex virus [HSV]-1, HSV-2, Epstein-Barr virus [EBV], cytomegalovirus, human herpesvirus [HHV]- 6, HHV-7, and Kaposi's sarcoma-associated herpesvirus), polyomaviridea (parvovirus B19 [PVB19], BK virus, JC virus, Simian virus 40, Merkel cell polyomavirus, human polyomavirus [HPyV]-6, and HPyV-7), papillomaviridae, and respiratory viruses. Immunohistochemistry (IHC) and in situ hybridization (ISH) were used to validate the positive results.

RESULTS

PVB19 DNA was detected in 4 of 18 chordomas (22%) and in 1 of 15 chondrosarcomas (7%). IHC recognizing the VP2 capsid protein of PVB19 showed a positive cytoplasmic staining in 44% of the cases (14 of 32). HHV7 DNA was present in 6 of the 18 chordomas (33%). Genomic DNA of EBV was found in 22% of the samples; however, no positive results were found on ISH. None of the chordoma cases showed any presence of DNA from the remaining viruses.

CONCLUSIONS

Viral involvement in the etiology of chordomas is likely, with PVB19 the most distinguishing.

Medical treatment of advanced chordomas

Chordoma is a very rare bone sarcoma that can arise from any site along the spine and from the skull base. En bloc resection is the gold standard for treatment while radiation therapy has been shown to provide both curative and palliative benefit. Unfortunately, local recurrences are common, even after a complete surgical resection, and up to 40% of patients suffer from distant metastases, while salvage treatments are challenging. Patients carrying an advanced disease need a systemic treatment. Unluckily, conventional chordoma are insensitive to cytotoxic chemotherapy that is considered the standard treatment option in patients with metastatic sarcoma. In the last decade, innovative therapies have been introduced, positively impacting disease control and patients' quality of life. In addition, a better understanding of the molecular characteristics of chordoma allowed to detect new potential targets. This review is focused on the pharmacological management of patients affected by an advanced disease, starting with a summary of data available on conventional chemotherapy, then moving to a deeper analysis of available data on molecular agents and immunotherapy, and finally providing an update on ongoing clinical trials and future prospective.

Systemic therapy for selected skull base sarcomas: Chondrosarcoma, chordoma, giant cell tumour and solitary fibrous tumour/hemangiopericytoma

This review highlights the data currently available on the activity of systemic therapy in chondrosarcoma, chordoma, giant cell tumour of the bone (GCTB) and solitary fibrous tumour, i.e., four rare sarcomas amongst mesenchymal malignancy arising from the skull base.

Chordoma: the entity

Chordomas are malignant tumors of the axial skeleton, characterized by their locally invasive and slow but aggressive growth. These neoplasms are presumed to be derived from notochordal remnants with a molecular alteration preceding their malignant transformation. As these tumors are most frequently observed on the skull base and sacrum, patients suffering from a chordoma present with debilitating neurological disease, and have an overall 5-year survival rate of 65%. Surgical resection with adjuvant radiotherapy is the first-choice treatment modality in these patients, since chordomas are resistant to conventional chemotherapy. Even so, management of chordomas can be challenging, as chordoma patients often present with recurrent disease. Recent advances in the understanding of the molecular events that contribute to the development of chordomas are promising; the most novel finding being the identification of brachyury in the disease process. Here we present an overview of the current paradigms and summarize relevant research findings.

A retrospective clinicopathological study of 37 patients with chordoma: a danish national series

Purpose. There are, in general, few published series on chordoma. It is a rare disease and further data are still needed.

Patients/methods. The data of 37 patients with chordoma were retrospectively analyzed. Treatment was surgical excision in 11, radical radiotherapy in 9 and a combination of the two in 16 cases. The male to female ratio was 2.7 : 1. Median age was 59 years (range 1–89 years).

Results. The most common symptoms at diagnosis were pain (98%), neurological disturbances (42%) and incontinence (33%). The tumours were located in the sacro-coccygeal region in 68%, the spheno-occipital region in 16% and the vertebrae in 16% of the patients. Median tumour.size was 7 cm (range 1–30 cm). Local recurrence occurred in 21/36 treated cases and distant metastases developed in eight patients (23%). The median time to recurrence/progression after primary treatment was 2 years (range 1–10 years). The actuarial 5-year rates of overall, progression-free and symptom-free survival were 40%, 31% and 20%, respectively. The corresponding 10-year rates were 26%, 21% and 14%, respectively. At the time of analysis, seven patients were alive, six without evidence of disease. Four of the six patients without active disease were symptom free. A univariate analysis showed that age, sex, tumour size, histopathology, surgical safety margin, treatment modality and radiation dose did not significantly affect overall, progression-free or symptom-free survival. Only turnout site had a prognostic value with turnouts in the spheno-occipital region carrying the worst prognosis.

Discussion. We conclude that effective treatment against chordomas is still lacking and a prospective multi-institutional registration study may provide more information on the optimal work-up and treatment of this rare disease.

Steroid hormone receptor and COX-2 expression in chordoma

Reports of sex steroid receptor expression in chordoma suggest that these tumors may be responsive to hormone manipulation therapy. Immunohistochemical stains for estrogen receptor (ER)-alpha, ER-beta, progesterone receptor (PR), androgen receptor (AR), and cyclooxygenase 2 (COX-2), were performed on a tissue microarray containing 21 samples of chordoma. Most chordomas expressed COX-2, ER-beta, and AR, whereas ER-alpha and PR stains were negative in all cases. ER-beta expression did not correlate with AR expression (P = .4142; McNemar test). There were no statistically significant correlations between the expression of any of these markers and anatomic location of tumor, patient sex, patient age, or disease-free survival. Chordomas commonly express COX-2, AR, and ER-beta. These findings may have therapeutic implications concerning the use of agents that inhibit or modulate these signaling molecules.

Infantile clivus chordoma without clivus involvement: case report and review of the literature

BACKGROUND

We present a giant clival chordoma with disseminated disease but without involvement of the clivus. To our knowledge, this is the youngest child and only the second case, presenting without base of skull involvement, in paediatric literature and the fourth reported case of a chordoma in a patient with tuberous sclerosis.

DISCUSSION

We discuss the subtle presentation, difficulties in diagnosis and management and also review the literature.

Recurrent and metastatic clivus chordoma: systemic palliative therapy retards disease progression

We report on a male patient with progressive and metastatic clivus chordoma treated over a period of 9 years by a multidisciplinary approach. Within the first 4 years, the patient underwent surgery four times. Thereafter, he received radiotherapy and subsequent chemotherapy. Stabilization of disease was achieved repeatedly for variable periods under local radiotherapy, systemic chemotherapy, immunomodulatory and anti-angiogenic therapy with isotretinoin and interferon-alpha, followed by thalidomide. Due to the occurrence of brain and lung metastases 8 years after initial diagnosis, liposomal doxorubicin was added to thalidomide. At the last follow-up control the patient had stable disease, with no progression of the intracranial tumor and regression of pulmonary metastases. He is in a good physical, psychological and neurological condition with a Karnofsky score of 80. Our observations show that multimodal therapy including a systemic palliative approach is associated with long quiescent intervals in recurrent chordoma and with regression of its metastases. Use of substances with high efficacy on tumor tissue and low toxicity, allowing long-term administration, seems promising in similar situations.

Tumors of the skull base in children: review of tumor types and management strategies

Although many treatment strategies for skull base tumors in adults have been reported, relatively little has been reported regarding such therapies in the pediatric population. Skull base tumors in children present a therapeutic challenge because of their unique pathological composition, the constraints of the maturing skull and brain, and the small size of the patients. In this review, the authors examine the pediatric skull base lesions that occur in the anterior, middle, and posterior cranial base, focusing on unique pediatric tumors such as encepahalocele, fibrous dysplasia, esthesioneuroblastoma, craniopharyngioma, juvenile nasopharyngeal angiofibroma, cholesteatoma, chordoma, chondrosarcoma, and Ewing sarcoma. They review management strategies that include radio- and chemotherapy, as well as surgical approaches with emphasis on the modifications and complications associated with the procedures as they apply in children. Evidence for the advantages and limitations of radiotherapy, chemotherapy, and surgery as it pertains to the pediatric population will be examined. With a working knowledge of skull base anatomy and special considerations of the developing craniofacial skeleton, neurosurgeons can treat skull base lesions in children with acceptable morbidity and mortality rates. Outcomes in this population may be better than those in adults, in part because of the benign histopathology that frequently affects the pediatric skull base, as well as the plasticity of the maturing nervous system.

Chordoma

Optimal therapy of chordoma is a combined approach of surgical resection followed by proton beam irradiation for residual disease. The goals of surgery are to establish a definitive diagnosis, obtain total or maximal resection, and "shape" any residual disease so that it is favorable for radiation. Given the difficult locations and large sizes of these tumors, potential morbidity from these surgeries is high. Chordomas respond best to high doses of radiation, but nearby neurologic structures limit doses that can be delivered. Proton beam radiation appears to have a distinct advantage over conventional external beam radiation in this disease because of the rapid fall-off of radiation beyond the target. Unfortunately, the data on efficacy and safety of treatments for chordoma is limited because of the rarity of disease. Current reports in the literature are exclusively case series and reports, limiting the strength of the conclusions that can be drawn.

Esthesioneuroblastoma--what is the optimal treatment?

A retrospective review was conducted on 13 patients with esthesioneuroblastoma (ENB), treated at our institution from 1977 to 1997. According to the Kadish classification, one patient was in stage A, 5 patients were classified as stage B and 7 patients were in stage C. Five-year disease-specific survival was found to be 51%. Forty-six percent of the patients experienced relapse and despite intensive salvage therapy, median survival after recurrences was only 12 months. This indicates the need for good primary control in local as well as distant disease. The role of pre- versus postoperative radiotherapy to secure good local control is discussed and compared with the literature, and treatment guidelines are proposed. The tumours were graded according to the Hyams' classification and its importance as a prognostic factor is briefly discussed.

Cutaneous metastasis of chordoma

BACKGROUND

Chordomas are rare neoplasms that arise from the notochord remnant. They develop in the sacrococcygeal (50%) or cervical (15%) region and are generally regarded as a locally aggressive tumor with a slow progressive growth rate and a metastatic incidence ranging from 3 to 48%. Skin involvement by chordoma is rare, but can occur by direct extension, by local recurrence and by metastases.

OBJECTIVE

To illustrate by a case report the clinical presentation and management of this disease.

METHODS

We present a case of sacral chordoma with metastases over a 10-year period to the lungs, the soft tissue of the chest wall, the triceps tendon, and distant cutaneous metastases to the back and the nose.

RESULTS

The cutaneous metastases were treated by excision.

CONCLUSION

Chordoma is a slow growing tumor of the notochord remnant that may metastasize to the skin. Physicians and pathologists should be aware of this entity.