Surgery and proton radiation therapy for pediatric base of skull chordomas: Long-term clinical outcomes for 204 patients

Characteristics and survival outcomes in pediatric patients with spinal chordomas: insights from the National Cancer Database and review of the literature

PURPOSE

Spinal chordomas are aggressive tumors that rarely occur in the pediatric population. Demographics and post-treatment outcomes in this select group of patients is poorly studied. We hence aimed to analyze the clinical characteristics, demographics, and survival outcomes of pediatric patients with spinal chordomas, in contrast to the adult population. To address this, the literature was reviewed to evaluate the coverage on spinal chordomas of the pediatric population, and the National Cancer Database (NCDB) was analyzed to provide insights into the US experience over the past two decades.

METHODS

A search of the literature was performed leveraging the MEDLINE and Web of Science electronic databases from inception until March 2024, using the keywords "spinal," "chordoma," and "pediatric". Additionally, the NCDB was queried for pediatric patients (≤ 21 years) with chordoma treated between 2004 and 2017. Baseline characteristics, tumor specifics, treatment details, and survival outcomes were collected and analyzed.

RESULTS

From the literature, 45 pediatric chordoma patients were identified, with a median age of 7 years. Most chordomas were in the cervical spine (40%), and 93% of the patients received surgical treatment. Gross total resection was achieved in 59% of cases, and 49% received adjuvant radiotherapy. Recurrence, metastasis, and mortality rates were 7%, 18%, and 24%, respectively at a median follow-up of 12 months. In the NCDB cohort, 53 pediatric patients (≤ 21 years) and 980 adults (> 21 years) were compared. Despite having smaller tumors in size, pediatric patients presented with more advanced tumors with a higher proportion of stage 4 tumors. They had more mobile spine chordomas (83% vs. 51%) and traveled further for treatment (57 vs. 27 miles). Pediatric patients also received higher radiation doses (5420 vs. 5049 cGy). Surgical resection and adjuvant radiotherapy were common treatments in both groups. After matching, outcomes, including survival rates and early mortality, were similar between age groups. Kaplan-Meier analysis showed no difference in overall survival probabilities between the age groups both prior to and after matching.

CONCLUSION

While pediatric patients with spinal chordomas present with more advanced stage tumors, they demonstrate similar overall survival outcomes when compared to adults. The current literature is mainly composed of single cases and other reports of low evidence levels.

The efficacy and safety of tyrosine kinase inhibitors in the treatment of advanced or metastatic chordoma: a single-arm meta-analysis

Chordoma is a rare malignant tumor with a higher incidence in males than in females. There is an increasing number of clinical studies related to tyrosine kinase inhibitors (TKIs), yet the efficacy and safety of different drugs vary. In this single-arm meta-analysis evaluating the efficacy and safety of TKIs for chordoma treatment, 12 studies involving 365 patients were analyzed. The findings suggest that TKIs can improve outcomes, with an objective response rate of 1.7% and 29% based on RECIST and Choi criteria, a median progression-free survival (mPFS) of 8.41 months and a median overall survival (mOS) of 36.6 months. Imatinib, in particular, showed a longer mOS of 39.3 months compared to 25.0 months for other TKIs. However, high toxicity was noted, with a 95% overall incidence of adverse events (AEs), including hypertension, nausea and vomiting, and edema. Serious AEs occurred at a rate of 55%. In subgroup analysis, Imatinib showed a lower incidence of AEs compared to other TKIs. Combination therapy reduced the risk of severe adverse events compared to monotherapy. The study underscores the potential of TKIs to extend survival in chordoma patients but also highlights the need for careful management of treatment-related toxicity. Combining TKIs, especially imatinib, with other treatments may avoid serious adverse events. Further high-quality clinical trials are needed to confirm these findings and optimize treatment protocols.

Proton beam therapy for clival chordoma: Optimising rare cancer treatments in Australia

With the anticipated launch of the Australian Bragg Centre for Proton Therapy and Research (ABCPTR) in Adelaide, Australia, proton therapy will become a significant addition to existing cancer treatment options for Australians. The anticipated benefits will be particularly evident in rare cancers such as clival chordomas, a challenging tumour entity due to the anatomical relationship with critical structures, and proven radio-resistance to conventional radiation therapy. The article synthesises key findings from major studies and evaluates the current evidence supporting various management strategies for clival chordomas. It also considers the influence of institutional volume and multidisciplinary team management on patient outcomes and outlines how high-quality care can be effectively delivered within the Australian healthcare system, emphasising the potential impact of proton therapy on the treatment paradigm of clival chordomas in Australia.

The Use of Proton and Carbon Ion Radiation Therapy for Sarcomas

The unique physical and biological characteristics of proton and carbon ions allow for improved sparing of normal tissues, decreased integral dose to the body, and increased biological effect through high linear energy transfer. These properties are particularly useful for sarcomas given their histology, wide array of locations, and age of diagnosis. This review summarizes the literature and describes the clinical situations in which these heavy particles have advantages for treating sarcomas.

How proton therapy fits into the management of adult intracranial tumors

Intracranial tumors include a challenging array of primary and secondary parenchymal and extra-axial tumors which cause neurologic morbidity consequential to location, disease extent, and proximity to critical neurologic structures. Radiotherapy can be used in the definitive, adjuvant, or salvage setting either with curative or palliative intent. Proton therapy (PT) is a promising advance due to dosimetric advantages compared to conventional photon radiotherapy with regards to normal tissue sparing, as well as distinct physical properties, which yield radiobiologic benefits. In this review, the principles of efficacy and safety of PT for a variety of intracranial tumors are discussed, drawing upon case series, retrospective and prospective cohort studies, and randomized clinical trials. This manuscript explores the potential advantages of PT, including reduced acute and late treatment-related side effects and improved quality of life. The objective is to provide a comprehensive review of the current evidence and clinical outcomes of PT. Given the lack of consensus and directives for its utilization in patients with intracranial tumors, we aim to provide a guide for its judicious use in clinical practice.