High-energy irradiation in the management of chondrosarcoma

Chondrosarcoma of the mobile spine: a review of 21 cases treated at a single center

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To determine the effect of modern surgical and aggressive radiation techniques on outcome in patients with spinal chondrosarcoma.

SUMMARY OF BACKGROUND DATA

Chondrosarcoma of the spine presents a difficult surgical challenge. Surgical excision is considered the standard of care, yet complete excision is not always feasible, and rates of local control and survival are inferior to those reported for the extremities.

METHODS

We performed a retrospective review of cases of chondrosarcoma involving the spine above the sacrum treated surgically at our institution between 1984 and 2006. Medical charts, radiology reports, pathology reports, and operative notes were reviewed for all patients. Available imaging studies were also reviewed. The Student t test and Fisher exact test were used to compare baseline differences between groups. Survivorship analysis was performed using Kaplan-Meier methodology. Overall survival was calculated on the basis of en bloc resection, margins, local recurrence, and metastasis.

RESULTS

Twenty-one patients were treated surgically for chondrosarcoma of the mobile spine. Twenty of the 21 patients were also treated with radiation with a mean dose of 71 Gy (range, 53-83). The average overall survival for all patients in our series was 120.5 months (SE = 32.9; range, 8.5-298.9 months). The 1- and 5-year survival rates for all patients were 90% and 61%, respectively. Patients treated with en bloc resection had a better overall survival (198 months: SE = 24.5; range, 24-224.7 months) than those who underwent intralesional excision (77 months: SE = 27.3; range, 8.5-298.9 months) (P = 0.05). Five (24%) patients developed local recurrence and 9 (43%) developed metastasis. All recurrences occurred in patients who underwent intralesional resection. Metastasis, high-grade tumor, and positive surgical margins were associated with worse overall survival (P < 0.001, 0.02, and 0.04, respectively).

CONCLUSION

In this series, en bloc resection, the absence of metastasis, low-grade tumors, and negative margins were associated with improved overall survival. The aggressive use of sophisticated surgical and radiation techniques appears to confer an advantage to patients, decreasing local recurrence and increasing overall survival, even following incomplete surgical resection.

Scapular chondrosarcomas have high rates of local recurrence and metastasis

This is the first report of a large series of patients with scapular chondrosarcomas. The grade distributions, locations of the tumors in the scapula, surgical techniques, status of margins, chondrosarcoma subtypes, Enneking stages, adjuvant therapies, local recurrence rates, metastasis rates, and survival prognoses of patients with scapular chondrosarcoma were evaluated. Forty-seven patients treated between 1921 and 1999 were analyzed retrospectively. Grade 3 disease was significantly associated with a poorer survival prognosis when compared with Grades 1 or 2 disease. Patients with tumors smaller than 5 cm were treated mainly with partial scapulectomy, and patients with tumors larger than 5 cm often were treated with total scapulectomy. The survival prognoses of patients with intralesional resections at initial surgery showed a tendency toward poorer survival when compared with patients with wide resections at initial surgery. Metastasis and local recurrence (21.3% and 40.4%) were higher in scapular chondrosarcomas than rates reported for patients with general chondrosarcomas, and local recurrence or metastasis was associated with limited survival. The 5- and 15-year survival probabilities subsequent to diagnosis were 79% and 53%, respectively. The high rates of local recurrence and metastasis likely were caused by the difficult anatomic relationships encountered during scapular resections. This study shows the importance of wide margins which must be achieved to provide local disease control.

Chondrosarcoma of bone: analysis of 108 cases and evaluation for predictors of outcome

Chondrosarcoma is the second most common malignant bone tumor and is relatively unresponsive to chemotherapy and radiation regimens. In addition, the clinical course of chondrosarcoma is difficult to predict. The purpose of this study was to review the authors' experience with chondrosarcoma and ascertain any factors related to prognosis and clinical outcome. The medical records of 108 patients followed up for a minimum of 2 years were retrospectively reviewed. There were 31 low-grade and 77 high-grade chondrosarcomas. One hundred one patients underwent surgical resection. There was a statistically significant association between positive margins and local recurrence, metastasis, and death. Tumor grade was not predictive of outcome. Proliferation indices (MIB-1 expression determination through immunohistochemistry) were quantitated in 39 patients. A significant association was seen between MIB-1 expression and recurrence and death. Thus, objective quantitation of tumor proliferation was more predictive than was histologic grade of outcome in chondrosarcoma. Although histologic grade continues to be the standard grading system for chondrosarcoma, the current study contributes to ongoing research and validation of alternative techniques that may be more reliable in guiding prognosis and treatment of chondrosarcoma.

Chondrosarcoma of the mobile spine: report on 22 cases

STUDY DESIGN

A retrospective review of 22 cases of chondrosarcoma arising from the mobile spine.

OBJECTIVE

To evaluate the role of oncologic and surgical staging in correlating management and outcome of chondrosarcoma involving the spine.

SUMMARY OF BACKGROUND DATA

Approximately 10% of chondrosarcomas arise from the mobile spine, occurring mainly in adults, particularly elderly men. The course of the disease depends on the aggressiveness of the tumor, but also is influenced by the management. Intralesional surgery is followed almost constantly by local recurrence even with adjuvant therapy.

METHODS

All charts, radiographs, and images were reviewed. The composite information provided by this review allowed for oncologic and surgical staging of the reviewed cases. According to Enneking criteria, the surgical procedures were defined as curettage (piecemeal excision) or en blocexcision. The margins were submitted to histologic study and reported as intralesional, marginal, or wide. - As primary management, 10 intralesional curettages (follow-up period, 2-119 months; average, 61 months) and 12 en bloc excisions (follow-up period, 39-207 months; average, 97 months) were performed. A total of 33 procedures were performed, including the management of the recurrences (18 curettages and 15 en bloc excisions: one for soft tissue recurrence). A clinical and radiographic follow-up period of of 2 to 236 months (average, 81 months; minimal follow-up period for survivors, 30 months; average follow-up period for survivors, 115 months) was available for all the patients.

RESULTS

Three recurrences occurred in 14 patients treated by en bloc excision at onset or for recurrence, two in cases of histologically proven contaminated or intralesional margins. All but one patient were alive at final follow-up evaluation. Conversely, all the patients treated by one or more curettages (with or without adjuvant radiation therapy) had at least one recurrence, and 8 of 10 of these patients died of the disease. At final follow-up evaluation, nine patients had died of the disease; nine were continuously disease free (but one had died of another unrelated malignancy); and four were symptom free after management for recurrences (one was found alive 155 months after a soft-tissue metastasis en-bloc excision).

CONCLUSIONS

En bloc excision, with wide or marginal histologic margins, is the suggested management for chondrosarcomas of the spine. Early diagnosis and careful surgical staging and planning are necessary for conducting adequate management. However, tumor contamination of the specimen margins, even in a small area, or spreading of the tumor myxoid content can worsen the prognosis.

Chondrosarcoma of the spine: 1954 to 1997

OBJECT

Primary chondrosarcoma of the spine is extremely rare. During the last 43 years only 21 patients with this disease were registered at The University of Texas M. D. Anderson Cancer Center. The purpose of this study was to examine the demographic characteristics, treatments, and outcomes of this set of patients.

METHODS

Medical records for 21 patients were reviewed. Age, sex, race, clinical presentation, tumor histology, tumor location in the spinal column, treatments, surgical details, and response to treatment were recorded. Surgical procedures were categorized as either gross-total resection or subtotal excision of tumor. Neurological function was assessed using Frankel's functional classification. Time to recurrence and survival analyses were performed using the Kaplan-Meier method. The median age of patients was 51 years, with fairly equal gender representation. Eighteen patients underwent at least one surgical procedure for a total of 28 surgical procedures: seven radical resections and 21 subtotal excisions. Radiation therapy was used in conjunction with 10 of the 28 surgical procedures. The median Kaplan-Meier estimate of overall survival for the entire group was 6 years (range 6 months-17 years). Tumors recurred after 18 of the 28 procedures. Kaplan-Meier analysis revealed a statistically significant difference in the per-procedure disease-free interval after gross-total resection relative to subtotal excision (exact log rank 3.39; p = 0.04). The addition of radiation therapy prolonged the median disease-free interval from 16 to 44 months, although this was not statistically significant (exact log rank 2.63; p = 0.16).

CONCLUSIONS

Our results suggest that gross-total resection of the chondrosarcoma provides the best chance for prolonging the disease-free interval in patients. Subtotal excision should be avoided whenever possible. Addition of radiation therapy does not appear to lengthen significantly the disease-free interval in this patient population.

The use of gold foil wrapping for radiation protection of the spinal cord for recurrent tumor therapy

PURPOSE

The development of a technique to provide sufficient radiation protection to previously irradiated spinal cord in such a manner that interstitial brachytherapy can be conducted after resection of a recurrent tumor and decompression of the cord.

METHODS AND MATERIALS

A technique was developed that uses multiple layers of gold foil that are applied around the thecal sac and nerve root sleeves to produce an enveloping radiation shield after resection of recurrent tumor. Once the layers of gold foil are in place, interstitial I125 seeds are permanently placed in the bed of the tumor resection to prevent any recurrence from microcellular disease. The technique is described and its application in the case of a 28-year-old with a third recurrence of chondrosarcoma after external fractionated radiation therapy at the second to the fourth thoracic segments is reviewed.

RESULTS

This technique has been used in this first patient. An additional tumor dose of 120.0 Gy was delivered to the tumor bed while the spinal cord was calculated to receive only 1% of the dose over the life span of the implant. To date, this dose of radiation has prevented tumor recurrence for more than 18 months of follow-up.

CONCLUSION

This technique of multiple layers of gold foil shielding over the spinal cord and nerve roots has the potential to be a useful tool for the shielding of a previously irradiated spinal cord in the setting of resection of recurrent tumor. It may also have a wider application to a number of other radiosensitive tumors where interstitial brachytherapy may be useful to provide additional treatment after external fractionated radiation therapy.

Chondrosarcoma. I. A selected literature review

More than 200 articles and texts relating to chondrosarcoma in the general skeleton, in the head and neck area, and in extraskeletal soft tissues, were reviewed and summarized. In the interest of space conservation and avoidance, to the extent possible, of distracting referential interjections in the text, the entire list of materials reviewed has not been referenced. For example, articles that contribute essentially nothing more than single case reports are not included in the list of references. Effort has been made, however, to include articles of historical significance, articles reporting series of cases, and articles exploring ideas and concepts. The authors believe this review to be a comprehensive summary of the chondrosarcoma literature. An analysis of 37 cases of chondrosarcoma of the jaws will be published as Part II.

Chondrosarcoma arising in the nasal septum: a case report

A rare case of chondrosarcoma arising in the nasal septum, which appeared in an eighty-year-old female, was reported. The tumor extended bilaterally in the nasal cavity and to the skull base. Radiation therapy was performed for the patient, considering of her age. Histological findings including electron micrograph were shown, and pertinent literatures were reviewed to discuss clinicopathological features of the tumor.