Management of cranial base chondrosarcomas

A multicenter retrospective analysis of clinical outcomes of intracranial chondrosarcoma in 26 patients

Intracranial chondrosarcoma is a rare tumor with limited reports. We reviewed the clinical outcomes, imaging findings, and pathological characteristics at three centers to improve the diagnosis and treatment of intracranial chondrosarcoma. We retrospectively analyzed 26 patients with intracranial chondrosarcoma who had undergone surgical treatment at Tangdu Hospital of Air Force Military Medical University, Mianyang Central Hospital, and Nanchong Central Hospital from January 2010 to July 2022. Clinical manifestations, imaging features, surgical treatment, prognosis, and overall survival (OS) were analyzed. All 26 chondrosarcomas were located at the skull base. Gross total resection (GTR), subtotal resection (STR), and partial resection (PR) were performed in 14, 10, and 2 cases, respectively. Four cases underwent endoscopic transnasal surgery, while the remaining cases underwent craniotomy. The clinical symptoms were evaluated 1 week after surgery, and 15 cases were relieved to varying degrees. Postoperative complications included pulmonary infection, subcutaneous hydrops, dysphagia and choking, facial numbness, abducens paralysis, and intracranial infection (ICI). Fifteen cases received postoperative adjuvant radiotherapy. Seven cases showed recurrence: two with PR, four with STR, and one with GTR. Six cases received reoperation or radiotherapy after tumor progression, and one untreated patient died 5 months after tumor recurrence. The extent of tumor resection (HR 21.74, 95% CI 1.25-376.6, P = 0.03) and pathological grading (HR 131.99, 95% CI 4.05-4300.5, P = 0.006) were associated with improved OS. We presented our experience in the treatment of intracranial chondrosarcoma at three centers in the past 12 years. Intracranial chondrosarcoma lacked typical imaging features and are difficult to differentiate from other skull base lesions. Maximum extent of tumor resection with minimal injury to neurological function remains the most important treatment strategy. The extent of surgical resection and pathological grading were found to be predictors for OS.

Functional and oncological outcome of petroclival chondrosarcoma operated on through an extradural anterior petrosectomy approach. A single center experience

BACKGROUND

Management of skull base chondrosarcoma (SBC) remains challenging due to its deep location and complex growth pattern. Non-total resection and postoperative residual mass are common features, with controversy regarding the need to offer systematic postoperative radiation therapy or additional surgery.

METHODS

A single-center retrospective cohort study was conducted on 10 consecutive patients harboring petroclival chondrosarcomas that were operated on between May 2007 and March 2019. After resection, the patients were allocated to a wait-and-rescan policy.

RESULTS

Patients were operated on through an extradural anterior petrosectomy (EAP). Subtotal tumor resection was achieved in all patients. The mean duration of follow-up was 70 months (range 25-137/median 67 months). Clinical outcomes dramatically improved in three (30%) patients, while five patients retained preoperative cranial nerve (CN) disturbances after surgery (50%). Two patients reported transient postoperative worsening of their symptoms (20%). All of the postoperative CN new deficits improved within one year, except in one patient who showed permanent facial nerve palsy. The preoperative median Karnofsky Performance Scale (KPS) score was 80 (range 70-100), and then it became 90 (range 70-100) postoperatively. Patients harboring a tumor residue were included in a wait-and-rescan policy. With this regimen, tumor control was obtained in seven patients (70% of cases until the last follow-up). Three patients (30%) showed progression of the residual; two of them were treated with adjuvant therapy, while an extra cranial growth residue was observed in the third.

CONCLUSION

Optimal and reasonable surgical resection of petroclival chondrosarcomas could be achieved with good to excellent functional outcomes through an EAP. In spite of a significant percentage of regrowth, only one patient required additional salvage surgery.

Chondrosarcoma in the Parapharyngeal Space; Site of Origin an Enigma

Chondrosarcoma of the head and neck region is a rare disease, representing approximately 0.1% of all head and neck neoplasms. We present a case of a 30 year old male who presented with swelling in the right retroauricular region since 4 years. Magnetic resonance imaging and computed tomography showed lesion with its epicentre in the post styloid compartment of right parapharyngeal space with superior extent around the petrous apex. The surgical procedure considered was excision. Surgical excision was challenging in view of difficult surgical access due to close and intricate relation with neurovascular structures of head and neck and an unsual pattern of spread.

Primary Skull Base Chondrosarcomas: A Systematic Review

Simple Summary

Primary skull base chondrosarcomas (SBCs) may carry significant tumor-burden by causing severe cranial nerve neuropathies. Current treatment strategies mainly focus on surgical resection and radiotherapy protocols, with a wide range of findings in terms of efficacy and safety. The aim of our systematic review was to comprehensively analyze the current literature on primary SBCs, describing clinical and radiological characteristics, available management strategies, treatment outcomes, and prognoses. We found that most primary SBCs show benign slow-growing patterns but may cause neurological deficits by compressing critical neurovascular structures. Open surgical approaches favor maximal resection with acceptable complication rates, but only a few studies reported the use of newer endoscopic approaches. Proton-based, photon-based, and carbon-based radiotherapy protocols may also allow safe and effective local tumor control as adjuvant treatments or stand-alone strategies in patients not eligible to undergo surgery. Overall, primary SBCs’ prognoses proved to be favorable and comparable to benign skull base neoplasms.

Abstract

Background: Primary skull base chondrosarcomas (SBCs) can severely affect patients’ quality of life. Surgical-resection and radiotherapy are feasible but may cause debilitating complications. We systematically reviewed the literature on primary SBCs. Methods: PubMed, EMBASE, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients with primary SBCs. Clinical characteristics, management strategies, and treatment outcomes were analyzed. Results: We included 33 studies comprising 1307 patients. Primary SBCs mostly involved the middle-fossa (72.7%), infiltrating the cavernous-sinus in 42.4% of patients. Cranial-neuropathies were reported in 810 patients (62%). Surgical-resection (93.3%) was preferred over biopsy (6.6%). The most frequent open surgical approaches were frontotemporal-orbitozygomatic (17.6%) and pterional (11.9%), and 111 patients (21.3%) underwent endoscopic-endonasal resection. Post-surgical cerebrospinal-fluid leaks occurred in 36 patients (6.5%). Radiotherapy was delivered in 1018 patients (77.9%): photon-based (41.4%), proton-based (64.2%), and carbon-based (13.1%). Severe post-radiotherapy complications, mostly hypopituitarism (15.4%) and hearing loss (7.1%) were experienced by 251 patients (30.7%). Post-treatment symptom-improvement (46.7%) and reduced/stable tumor volumes (85.4%) showed no differences based on radiotherapy-protocols (p = 0.165; p = 0.062). Median follow-up was 67-months (range, 0.1–376). SBCs recurrences were reported in 211 cases (16.1%). The 5-year and 10-year progression-free survival rates were 84.3% and 67.4%, and overall survival rates were 94% and 84%. Conclusion: Surgical-resection and radiotherapy are effective treatments in primary SBCs, with acceptable complication rates and favorable local tumor control.

Long-term outcomes of grade I/II skull base chondrosarcoma: an insight into the role of surgery and upfront radiotherapy

PURPOSE

To clarify the need for post-operative radiation treatment in skull base chondrosarcomas (SBCs).

METHODS

A retrospective analysis of patients with grade I or II SBC. Patients were divided according to post-surgical treatment strategies: (A) planned upfront radiotherapy and (B) watchful waiting. Tumor control and survival were compared between the treatment groups. The median follow-up after resection was 105 months (range, 9-376).

RESULTS

Thirty-two patients (Grade 1, n = 16; Grade 2, n = 16) were included. The most frequent location was petroclival (21, 64%). A gross total resection (GTR) was achieved in 11 patients (34%). Fourteen (44%) underwent upfront radiotherapy (group A) whereas 18 (56%) were followed with serial MRI alone (group B). The tumor control rate for the entire group was 77% and 69% at 10- and 15-year, respectively. Upfront radiotherapy (P = 0.25), extent of resection (P = 0.11) or tumor grade (P = 0.83) did not affect tumor control. The majority of Group B patients with recurrent tumors (5/7) obtained tumor control with repeat resection (n = 2), salvage radiotherapy (n = 2), or a combination of both (n = 1). The 10-year disease-specific survival was 95% with no difference between the group A and B (P = 0.50).

CONCLUSION

For patients with grade I/II SBC, a reasonable strategy is deferral of radiotherapy after maximum safe resection until tumor progression or recurrence. At that time, most patients can be successfully managed with salvage radiotherapy or surgery. Late recurrences may occur, and life-long follow-up is advisable.

Outcomes and Patterns of Care in Adult Skull Base Chondrosarcoma Patients in the United States

BACKGROUND

Chondrosarcomas of the skull base are rare intracranial tumors of chondroid origin. The rarity of these lesions has made it difficult to form a consensus on optimal treatment regimens. The aim of this study was to provide a comprehensive analysis of prognostic factors, treatment modalities, and survival outcomes in patients with chondrosarcoma of the skull base.

METHODS

Patients with diagnosis codes for chondrosarcoma of the skull base were queried from the National Cancer Database for the years 2004-2016. Outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization.

RESULTS

A total of 718 patients with chondrosarcoma of the skull base were identified. Mean overall survival (OS) in these patients was 10.7 years. Older age and presence of metastases were associated with worsened OS. Of patients, 83.3% received surgical intervention, and both partial resection and radical resection were associated with significantly improved OS (P < 0.001). Neither radiotherapy nor chemotherapy improved OS; however, patients who received proton-based radiation and patients who received high-dose radiation (≥6000 cGy) had significantly improved OS compared with patients who received traditional radiation.

CONCLUSIONS

In the largest study to our knowledge of skull base chondrosarcoma to date, both partial resection and radical resection significantly improved OS, thus supporting the goal of maximal safe resection to preserve vital neurovascular structures without sacrificing outcome. In patients who received radiotherapy, proton-based modalities and high-dose radiation were associated with increased OS.

Management of Recurrent or Progressing Skull Base Chondrosarcomas: Predictors of Long-Term Outcomes

Background  Skull base chondrosarcomas (CSA) are difficult tumors to cure and there is little data regarding salvage therapy. Objective  This study aims to identify presentation and treatment-related factors which impact the progression free survival (PFS) and disease specific survival (DSS) for recurrent CSA, and to identify salvage treatment factors associated with successful restoration to the natural history following primary treatment. Methods  This single-institution retrospective review included patients with recurrent/progressive CSA over a 25-year period. Survival analysis for factors impacting PFS and DSS was performed. Salvage treatment factors associated with achieving PFS ≥newly diagnosed median PFS were identified using univariate statistics. Analysis was performed on first recurrences and all recurrences combined. Results  A total of 47 recurrence/progression events were analyzed from 17 patients (median two events/patient, range = 1-8). The overall PFS and DSS for the initial recurrence was 32 (range = 3-267) and 79 (range = 3-285) months, respectively. Conventional grade III or mesenchymal histology significantly predicted shorter PFS and DSS ( p  < 0.0001). After stratification by histology, previous radiation predicted shorter PFS for low-grade tumors ( p  = 0.009). Gross total resection (GTR) after a first time recurrence was significantly associated with successful salvage treatment ( p  < 0.05); however, this was rare. Conclusion  In this series, high grade histology and prior radiation treatment negatively impacted salvage treatment outcomes, while GTR was associated with restoration to natural history following primary treatment. Careful consideration of histology, systemic disease status, previous treatments, and the anatomic extent of the skull base disease can optimize the outcomes of salvage intervention.

Paediatric High-Grade Intracranial Mesenchymal Chondrosarcoma: A Case Report with 6 Years of Follow-Up without Recurrence

INTRODUCTION

Intracranial mesenchymal chondrosarcoma (MSC) is an extremely rare tumour that constitutes only 0.015% of all central nervous system tumours. These tumours usually originate from skull base synchondrosis and are often observed in young adults during their second and third decades of life. Despite the absence of a consensus regarding adjuvant radiotherapy, radical excision remains crucial for the prognosis of MSC.

CASE PRESENTATION

We herein present the case of a young male patient with intracranial MSC, a malignant tumour, for which no consensus regarding its treatment has yet been established. The patient underwent radical excision followed by adjuvant radiotherapy. Histological analysis revealed a poorly differentiated tumour containing necrotic areas. Notably, no signs of recurrence had been observed after 6 years.

CONCLUSION

The absence of recurrence over a long follow-up duration suggests the importance of radical excision and adjuvant radiotherapy.

Site-Specific Considerations in the Surgical Management of Skull Base Chondrosarcomas

BACKGROUND

Numerous approaches have been reported in the management of skull base chondrosarcomas. Data are lacking for surgical outcomes by the tumor site of origin.

OBJECTIVE

To provide insight into outcomes by site of origin and factors affecting resection in order to aid in surgical approach selection.

METHODS

A retrospective review was conducted of 49 patients with chondrosarcoma treated at our institution. Charts were reviewed for tumor- and treatment-related factors. Extent of resection was the primary outcome, while neurological function and surgical complications were secondary outcomes. Statistical analyses were performed assessing variables for their impact on the primary outcome.

RESULTS

The gross total resection rate for the overall cohort was 67.3%, and 97.8% of patients were either neurologically stable or improved postoperatively. A petroclival site of origin had lower rates of resection vs all other sites (P < .05). Histology and previous surgery did not predict outcome (P > .05), while previous radiotherapy and cavernous sinus invasion correlated with a subtotal resection (P < .05). In the petroclival cohort, clival, jugular tubercle, and soft tissue involvement correlated with a subtotal resection (P < .05). An endoscopic endonasal transpterygoid approach alone or combined with a transcranial approach yielded the highest resection rates for petroclival tumors (P < .05).

CONCLUSION

Chondrosarcomas pose unique challenges based on the site of origin and pattern of extension. While current surgical strategies appear to yield adequate results at a majority of skull base sites, petroclival tumors represent a particular cohort in which improvement is needed. Based on our analysis, strategies incorporating both endoscopic and transcranial skull base approaches are likely necessary to achieve optimal outcomes.

Endoscopic Endonasal Surgery for Cranial Base Chondrosarcomas

BACKGROUND

Microsurgical resection via open approaches is considered the main treatment modality for cranial base chondrosarcomas (CBCs). The use of endoscopic endonasal approaches (EEAs) has been rarely reported.

OBJECTIVE

To present the endoscopic endonasal experience with CBCs at our institution.

METHODS

Retrospective review of the medical records of 35 consecutive patients who underwent EEA for CBC resection between January 2004 and April 2013. Surgical outcomes and variables that might affect extent of resection, complications, and recurrence were analyzed.

RESULTS

Forty-eight operations were performed (42 EEAs and 6 open approaches). Gross-total resection was achieved in 22 patients (62.9%), near total (≥90% tumor resection) in 11 (31.4%). Larger tumors were associated with incomplete resection in univariate and multivariate analysis ( P = .004, .015, respectively). In univariate analysis, tumors involving the lower clivus and cerebellopontine angle were associated with increased number of complications, especially postoperative cerebrospinal fluid leak ( P = .015) and new cranial neuropathy ( P = .037), respectively. Other major complications included 2 cases of meningitis and deep venous thrombosis, and 1 case of hydrocephalus and carotid injury. Involvement of the lower clivus, parapharyngeal space, and cervical spine required a combination of approaches to maximize tumor resection ( P = .017, .044, .017, respectively). No predictors were significantly associated with increased risk of recurrence. The average follow-up time was 44.6 ± 31 months.

CONCLUSIONS

EEAs may be considered a good option for managing CBCs without significant posterolateral extension beyond the basal foramina and can be used in conjunction with open approaches for maximal resection with acceptable morbidity.

Endoscopic endonasal transpterygoid transnasopharyngeal management of petroclival chondrosarcomas without medial extension

Chondrosarcomas of the skull base are malignant tumors for which surgery is the primary therapeutic option. Gross-total resection has been demonstrated to improve survival in patients with these tumors. Chondrosarcomas arising from the petroclival synchondrosis harbor particularly unique anatomical considerations that have long been a barrier to achieving such a resection. Endoscopic endonasal transpterygoid approaches have been recently used to gain improved access to such lesions; however, these approaches have classically relied on a medial to lateral transclival trajectory, which provides limited exposure for complete resection of lateral disease. In this paper the authors describe an endoscopic endonasal transpterygoid transnasopharyngeal approach that provides comprehensive access to the petroclival region through dissection of the eustachian tube with resection of the cartilaginous torus tubarius. Of note, the authors have previously demonstrated the superior outcomes and validity of this approach relative to other cranial base techniques for petroclival chondrosarcomas. Surgical outcomes in 5 cases of chondrosarcoma without medial extension are detailed. Gross-total resection was achieved in 4 of 5 patients. Postoperative complications included transient palatal numbness in all patients and eustachian tube dysfunction due to the approach. With tympanostomy tube placement, no patient had persistent hearing loss. Overall, this approach appears to be a safe and effective technique for resection of petroclival chondrosarcomas.

The Differences Between Intracranial Mesenchymal Chondrosarcoma and Conventional Chondrosarcoma in Clinical Features and Outcomes

OBJECTIVE

To report differences in clinical features and outcomes between intracranial mesenchymal chondrosarcoma (MCS) and conventional chondrosarcoma (CCS).

METHODS

Clinical data of patients with primary intracranial MCS and CCS were retrospectively extracted and analyzed to compare differences between MCS and CCS.

RESULTS

Seventy-four patients with intracranial chondrosarcoma (61 cases with MCS and 13 cases with CCS) were included. Compared with patients with CCS, patients with MCS presented at a younger mean age (21.1 years vs. 34.5 years, P < 0.001) and had a poor mean preoperative Karnofsky performance scale score (64.6 vs. 77.8, P = 0.014). Compared with CCS, MCS was less often located in the skull base (38.5% vs. 96.7%, P < 0.001) and had a larger tumor volume (87.8 cm³ vs. 26.7 cm³, P < 0.001). Rates of gross total resection in MCS and CCS subgroups were 41.1% (n = 25) and 46.2% (n = 6), respectively; rates of adjuvant radiotherapy postoperatively were 44.2% (n = 27) and 46.2% (n = 6), respectively. After mean follow-up of 41.7 months, 1-year, 3-year, and 5-year overall survival and progression-free survival of MCS were significantly shorter than overall survival and progression-free survival of CCS. Multivariate analysis revealed that tumor pathology and extent of surgery were independent predictors for tumor recurrence.

CONCLUSIONS

Clinical features of MCS are quite different from CCS. Treatment strategies used for CCS do not yield satisfactory outcomes for MCS. Treatment of MCS should be aggressive and individualized.

Proposed Treatment Paradigm for Intracranial Chondrosarcomas Based on Multidisciplinary Coordination

OBJECTIVES

There was no consensus regarding the treatment of intracranial chondrosarcoma (CSA). The study aimed to evaluate the adverse factors for progression-free survival (PFS) and overall survival (OS) and to propose a treatment strategy for CSA.

METHODS

The clinical chart and radiographic data of 106 consecutive cases (mesenchymal and conventional CSA in 18 and 88 patients, respectively) of surgically treated CSAs were retrospectively reviewed.

RESULTS

Gross total resection was achieved in 43 patients (40.6%), and adjuvant radiotherapy was administered in 45 patients. After a mean follow-up duration of 47.8 months, 38 patients (37.3%) experienced recurrence. PFS and disease-specific OS at 5 years was 57.7% and 74.4%. Independent adverse factors for PFS were previous surgery (hazard ratio [HR] 2.261; P = 0.028), increased lesion size (HR, 1.298; P = 0.026), extent of surgical resection (HR, 3.226; P < 0.001), malignant pathology (HR, 2.018; P = 0.003), and postoperative radiotherapy (HR, 3.246; P = 0.001). The stereotactic radiosurgery subgroup presented best 5-year PFS of 88.9%, and a linear accelerator prolonged the mean PFS time (57.0 months) compared with no radiation (38.1 months). In the incomplete resection subgroup (n = 63), radiotherapy significantly benefited tumor control (HR, 2.101; P = 0.016). Extent of surgical resection (HR, 1.797; P = 0.026) and malignant disease (HR, 1.717; P = 0.030) were associated with OS.

CONCLUSIONS

Intracranial CSAs were not completely amendable by surgery alone. Gross total resection as far as possible plus radiation were necessary for mesenchymal CSA and conventional CSA with active growth or residual tumor. Stereotactic radiosurgery was an alternative if proton therapy was unavailable. A future study with a large cohort is required to verify our findings.

Tracheal Chondrosarcoma: Systematic Review of Tumor Characteristics, Diagnosis, and Treatment Outcomes with Case Report

To our knowledge this is the first systematic review of tracheal chondrosarcoma treatment outcomes. Management insights are thoroughly discussed. Men constitute 93.8% of cases, and most of these occur in the distal trachea. The most common symptom, dyspnea, occurs in virtually all patients. Extratracheal extension had occurred in 78.6% of patients. Definitive treatment with tracheal resection showed no recurrences in 10 patients with mean follow-up of 3.1 years. Adjuvant radiotherapy may be utilized for improving local control when open complete resection cannot be performed, but only after endoscopic excision of gross tumor.

Multimodality Treatment of Skull Base Chondrosarcomas: The Role of Histology Specific Treatment Protocols

BACKGROUND: Limited data exist to guide the multimodality management of chondrosarcomas (CSAs) arising in the skull base.

OBJECTIVE: To determine the impact of histological subtype/grade on progression-free survival (PFS) and the indications for surgery, radiation, and chemotherapy based on histology.

METHODS: A retrospective review was performed of 37 patients (conventional type: 81%, mesenchymal: 16.2%, dedifferentiated: 2.7%) treated at The University of Texas M.D. Anderson Cancer Center. Of the conventional subtype, 23% were grade 1, 63% were grade 2, and 14% were grade 3. In addition to surgery, mesenchymal/dedifferentiated CSAs (18% of the cohort) underwent neoadjuvant chemotherapy and 48.6% of the overall cohort received adjuvant radiotherapy. Histological grade/subtype and treatment factors were assessed for impact on median PFS (primary outcome).

RESULTS: Conventional subtype vs mesenchymal/dedifferentiated was positively associated with median PFS (166 vs 24 months, P &lt; .05). Increasing conventional grade inversely correlated with median PFS (P &lt; .05). Gross total resection positively impacted PFS in conventional CSAs (111.8 vs 42.9 months, P = .201) and mesenchymal/dedifferentiated CSAs (58.2 vs 1.0 month, P &lt; .05). Adjuvant radiotherapy significantly impacted PFS in conventional grades 2 and 3 (182 vs 79 months, P &lt; .05) and a positive trend with mesenchymal/dedifferentiated CSAs (43.5 vs 22.0 months). Chemotherapy improved PFS for mesenchymal/dedifferentiated CSAs (50 vs 9 months, P = .089).

CONCLUSION: There is a potential need for histological subtype/grade specific treatment protocols. For conventional CSAs, surgery alone provides optimal results grade 1 CSAs, while resection with adjuvant radiotherapy yields the best outcome for grade 2 and 3 CSAs. Improvements in PFS seen with neoadjuvant therapy in mesenchymal/dedifferentiated CSAs indicate a potential role for systemic therapies. Larger studies are necessary to confirm the proposed treatment protocols.

Classical intracranial chondrosarcoma: A case report

Intracranial chondrosarcoma is a rare malignant cartilage-forming tumor, with only a small number of cases in the posterior cranial fossa reported previously. The present study reports the case of a 40-year-old male patient who was admitted to Tianjin Huanhu Hospital with a progressive headache and dizziness that had lasted for 2 years. Physical and neurological examinations were normal. Radiography of the skull identified an opaque lesion in the left frontal region of the brain. Cranial computed tomography and magnetic resonance imaging revealed a lesion with calcification and homogenous contrast enhancement in the left frontal region. Subsequently, the patient underwent bicoronal craniotomy and gross total resection of the tumor. Pathological examination confirmed the diagnosis of classical intracranial chondrosarcoma. The patient was discharged 10 days after surgery, with no neurological deficit. One month after initial discharge, the patient underwent γ-knife treatment. A follow-up examination 9 months after surgery revealed that the patient was still alive and had returned to work, with no obvious symptoms or evidence of recurrence.

Postsurgical management strategies in patients with skull base chondrosarcomas

Chondrosarcomas of the skull base are rare, slow-growing tumors that are often lethal and remain a management quandary. A systematic review was performed to understand postsurgical management options for patients with these tumors. The current standard of care includes surgical resection followed by either adjuvant radiation therapy and/or early radiosurgery. The role of chemotherapy has been limited, but remains under investigation. Overall survival and progression-free survival range between 70 and 100% at 5 years when multimodality approaches are used. Overall survival may be greater for patients who have a shorter interval (<6 months) between diagnosis and radiosurgery, an older age, and either a single or no prior resection. Progression-free survival may be increased for patients older than 40 years of age, who have not had prior radiation therapy, and for those with smaller tumors that do not compress the brainstem.

Bilateral chondrosarcoma of the jugular foramen: literature review and personal experience

Chondrosarcomas (CS) are slow-growing malignant cartilaginous tumors with locally invasive behavior. They account for only 0.15% head and neck neoplasia. There have been no reports in the management of bilateral skull base CS in the literature to date. The synchronous presentation of bilateral CS of the jugular foramen (JF) was diagnosed in a 22-year-old woman with right abducens nerve palsy. Once evaluated the collateral intracranial venous discharge, the lesions were removed in two surgical stages through a bilateral petro-occipital trans-sigmoid (POTS) approach performing a bilateral closure of sigmoid sinus. The patient is disease free 15 years after surgery. No complications occurred. Diplopia improved after excision of the tumor on the right side. A review of relevant English literature was performed. The POTS approach to the JF proved to be safe and effective. Staged radical surgery alone, assessing intracranial venous flow at all stages of surgery, was a valid strategy for bilateral CS, achieving long-term disease control, avoiding early adjuvant radiotherapy, and carrying no complications.

Endoscopic endonasal resection of skull base chondrosarcomas: technique and early results

OBJECT

The authors of this study sought to report the technique and early clinical outcomes of a purely endonasal endoscopic approach for resection of petroclival chondrosarcomas.

METHODS

Between 2010 and 2014, 8 patients (4 men and 4 women) underwent endonasal endoscopic operations to resect petroclival chondrosarcomas at 2 institutions. The patients' mean age was 44.8 years (range 30-64 years). One of the patients had previously undergone radiation therapy and another a staged craniotomy. Using volumetric software, an independent neuroradiologist assessed the extent of the resections on MRI scans taken immediately after surgery and at the 3-month follow-up. Immediate complications and control of symptoms were also recorded. In addition, the authors reviewed the current literature on surgical treatment of chondrosarcoma.

RESULTS

The mean preoperative tumor diameter and volume were 3.4 cm and 9.8 cm(3), respectively. Six patients presented with cranial neuropathies. Endonasal endoscopic surgery achieved > 95% resection in 5 of the 8 patients and < 95% resection in the remaining 3 patients. One of the 6 neuropathies resolved, and the remaining 5 partially improved. One instance of postoperative CSF leakage required a reoperation for repair; no other complications associated with these operations were observed. All of the patients underwent adjuvant radiotherapy.

CONCLUSIONS

According to the authors' experience, the endoscopic endonasal route is a safe and effective approach for the resection of appropriately selected petroclival chondrosarcomas.

Diagnosis and microsurgical treatment of chondromas and chondrosarcomas of the cranial base

Chondromas and chondrosarcomas of the cranial base are rare neoplastic diseases. The aim of the present study was to evaluate the diagnosis and microsurgical treatment of these difficult cranial base tumors. A total of 19 patients who underwent microsurgery were pathologically diagnosed with cranial base chondromas or chondrosarcomas and their clinical data was reviewed. The chondromas and chondrosarcomas of the cranial base in the present study commonly originated in the sphenopetrosal, sphenoclival or petroclival junctions, and the majority were located in the parasellar region of the middle cranial base extradurally. The most frequent symptoms were headaches and cranial nerve palsy, and the Karnofsky performance score (KPS), assessed pre-operatively, averaged at 87.1. A frontotemporal or preauricular subtemporal-infratemporal approach was used in 11 cases, a tempo-occipital transtentorial or presigmoid supratentorial-infratentorial approach was employed in six further cases, and the far-lateral or retrosigmoid approach was applied in the remaining two cases. A total or near-total tumor removal was secured in 13 cases, while a subtotal removal was obtained in another five and a partial removal was achieved in one case. The most common post-operative complications included cranial nerve palsy and cerebrospinal fluid leakage, but there were no post-operative fatalities. A total of 15 patients were followed up for a mean of 67.2 months (range, 5–140 months), and 13 (76.5%) of these patients were living normal lives (KPS, 80–90). There were two patients with recurrent tumors. The neuroradiological examinations and the presenting symptoms and signs allow the pre-operative diagnosis to be presumed for the majority of cranial base chondromas or chondrosarcomas. Surgical resection is the key treatment for these tumors, and this treatment is known to improve the survival rates.

Chondrosarcomas of the head and neck

Chondrosarcoma represents approximately 11% of all primary malignant bone tumors. It is the second most common sarcoma arising in bone after osteosarcoma. Chondrosarcomas of the head and neck are rare and may involve the sinonasal tract, jaws, larynx or skull base. Depending on the anatomical location, the tumor can produce a variety of symptoms. Computed tomography and magnetic resonance imaging are the preferred imaging modalities. The histology of conventional chondrosarcoma is relatively straightforward; major challenges are the distinction between grade I chondrosarcomas and chondromas, and the differential diagnosis with chondroblastic osteosarcoma and chondroid chordoma. Surgery alone or followed by adjuvant radiotherapy is the treatment of choice. Radiotherapy alone has also been reported to be effective and can be considered if mutilating radical surgery is the only curative alternative. The 5-year survival for chondrosarcoma reaches 80%; distant metastases and/or local recurrences significantly worsen prognosis. The present review aims to summarize the current state of information about the biology, diagnosis and management of these rare tumors.

Skull base chondrosarcoma: evidence-based treatment paradigms

Chondrosarcomas are indolent but invasive chondroid malignancies that can form in the skull base. Standard management of chondrosarcoma involves surgical resection and adjuvant radiation therapy. This review evaluates evidence from the literature to assess the importance of the surgical approach and extent of resection on outcomes for patients with skull base chondrosarcoma. Also evaluated is the ability of the multiple modalities of radiation therapy, such as conventional fractionated radiotherapy, proton beam, and stereotactic radiosurgery, to control tumor growth. Finally, emerging therapies for the treatment of skull-base chondrosarcoma are discussed.

Cranial chondrosarcoma and recurrence

The literature regarding recurrences in patients with cranial chondrosarcoma is limited to small series performed at single institutions, raising the question if these data precisely reflect the true recurrence of this tumor for guiding the clinician in the management of these patients. An extensive systematic review of the English literature was performed. The patients were stratified according to treatment modality, treatment history, histological subtype, and histological grade, and the recurrence rates were analyzed. A total of 560 patients treated for cranial chondrosarcoma were included. Five-year recurrence rate among all patients was 22% with median follow-up of 60 months and median disease-free interval of 16 months. Tumor recurrence was more common in patients who only received surgery or had mesenchymal subtype tumors. Our systematic review closely reflects the actuarial recurrence rate and provides predictive factors in the recurrence of cranial chondrosarcoma.

A systematic review of proton therapy in the treatment of chondrosarcoma of the skull base

Chondrosarcoma (CSA) of the skull base (SB) is an uncommon, slowly growing, neoplasm comprising approximately 0.1% of all intracranial tumors and 6% of SB lesions. Even though its growth is slow, CSA is a potentially lethal tumor. The therapeutic approach to CSA of the SB is still controversial and clinical experience is limited because of the relative rarity of this tumor. The use of proton therapy (PT) after maximal surgery is widely accepted, but there are no controlled studies demonstrating the need of PT and its superiority in comparison to radiotherapy with photons. We conducted a systematic review of the scientific literature published during the period between January 1980 and June 2008 on data regarding irradiation of CSA of the SB with PT and a series of inclusion criteria. During August 2008, two independent reviewers (M.A. and D.A.), by applying the key words "skull base", "chondrosarcoma", and "proton therapy" selected those studies from the PubMed database in which a minimum of ten patients received palliative, radical, or postoperative irradiation with protons and which furnished a minimum of 24 months of follow-up. Forty nine reports were retrieved. There were no prospective trials (randomized or nonrandomized) but just nine uncontrolled single-arm studies for PT mainly related to advanced and frequently incompletely resected tumors. According to the inclusion criteria, only four articles, reporting the most recent updated results of the publishing institution, were included in the analysis providing clinical outcomes for 254 patients in total. Therapeutic approach to CSA of the SB has traditionally relied on surgical control. Radiation therapy has demonstrated to be a valuable modality for local control in the postoperative setting or in advanced/inoperable cases treated with definitive intent. The use of PT following maximal surgical resection shows a very high probability of medium- and long-term cure with a relatively low risk of significant complications.

[Surgical treatment of head and neck chondrosarcomas]

INTRODUCTION

Head and neck chondrosarcomas may adopt different locations and biological behaviour.

MATERIAL AND METHOD

We present a retrospective clinical series of 17 chondrosarcomas surgically treated in our Department from 1977 until 2006.

RESULTS

Chondrosarcomas were located in the nasosinusal area (n=6), larynx (n=5), petrous bone (n=3), atlas (n=1), parapharyngeal space (n=1) and trachea (n=1). All patients except for one underwent surgery with radical intention. The mean follow-up period was 84 months (median, 71 months). Six patients developed recurrent disease with a mean latency of 10 months. Two patients died due to the disease and two remained alive with evidence of tumour. Patients with grade I chondrosarcomas presented less recurrent disease than those with grade II or III chondrosarcomas (17% versus 80%, P=0.029). The estimated 5-year survival was 88% with the better survival of patients with grade I chondrosarcomas reaching statistical significance (P=0.023). In 2 patients with cricoid chondrosarcomas, the reconstruction was carried out using the Rethi-Ward technique, and they were without evidence of disease at 71 months (with no cannula) and 145 months (with cannula). Chondrosarcomas of the jugular foramen were treated using a modified infratemporal type A approach.

CONCLUSION

Low grade head and neck chondrosarcomas have a good prognosis while high grade chondrosarcomas tend to recur, despite radical surgical treatment.

A systematic review of intracranial chondrosarcoma and survival

Most data regarding survival in patients with chondrosarcoma are limited to case studies and small series performed at single institutions. A systematic review was performed to study the relationship between potential prognostic factors and survival. The survival rates were analyzed according to modality of treatment, treatment history, histological subtype, and histological grade. A total of 560 patients with intracranial chondrosarcoma were analyzed. Median follow-up time was 60 months. The 5-year mortality among all patients was 11.5% with median survival of 24 months. Mortality at 5 years was significantly greater for patients with tumors of higher grade, or of the mesenchymal subtype, or who had received surgical resection alone. The results of our systematic review provide useful data in predicting survival among intracranial chondrosarcoma patients.

Primary falcine chondrosarcoma

Non-skull-base intracranial chondrosarcomas are extremely rare. We present a patient with a classic falcine chondrosarcoma and review the radiological features that may aid in a pre-operative diagnosis, as well as the adjuvant treatment options. A 32-year-old woman presented with a 5-year history of progressive weakness in her right leg. MRI scan demonstrated a 4.9 x 4.3 x 2.7 cm irregular parasaggital mass in the left frontoparietal region that was in contact with the falx. A left fronto-parietal craniotomy was performed and gross total excision was achieved. Intracranial chondrosarcomas that occur above the skull base tend to be of the mesenchymal variety. Classic chondrosarcomas of the falx are rare. The management of these tumours is surgery, with adjuvant radiotherapy for incompletely excised lesions.

Radiosurgery for chordomas and chondrosarcomas of the skull base

OBJECT

Chordomas and chondrosarcomas of the skull base are aggressive and locally destructive tumors with a high tendency for local progression despite treatment. The authors evaluated the effect of stereotactic radiosurgery (SRS) on local tumor control and survival.

METHODS

Twenty-eight patients with histologically confirmed chordomas (18) or chondrosarcomas (10) underwent Gamma Knife SRS either as primary or adjuvant treatment. Their ages ranged from 17 to 72 years (median 44 years). The most common presenting symptom was diplopia (26 patients, 93%). In two patients, SRS was the sole treatment. Twenty-six patients underwent between one and five additional surgical procedures. Two underwent an initial transsphenoidal biopsy. The average tumor volume was 9.8 cm3. The median dose to the tumor margin was 16 Gy.

RESULTS

No patient was lost to follow-up. Transient symptomatic adverse radiation effects developed in only one patient. The actuarial local tumor control for chondrosarcomas at 5 years was 80 +/- 10.1%. For chordomas both the actuarial tumor control and survival was 62.9 +/- 10.4%.

CONCLUSIONS

Stereotactic radiosurgery is an important option for skull base chordomas and chondrosarcomas either as primary or adjunctive treatment. Multimodal management appears crucial to improve tumor control in most patients.

Update on chondrosarcomas

PURPOSE OF REVIEW

This paper reviews recent molecular, biologic, developmental therapeutic, and clinical findings in conventional and variant chondrosarcomas.

RECENT FINDINGS

The prognosis of chondrosarcomas traditionally correlates with histologic grade and adequacy of surgery. Newer markers of cell differentiation, activation, genetics, and cell signaling may offer important prognostic information. Translational research has validated platelet-derived growth factor receptor, estrogen signaling, matrix metalloproteinase-1, histone deacetylase, methylthioadenosine phosphorylase, and vascular endothelial growth factor-A as potential therapeutic targets. Bisphosphonates may also possess important antitumoral effects. Molecular studies have established that extraskeletal myxoid chondrosarcoma is a unique entity defined by the presence of a fusion gene between the orphan nuclear receptor, CHN/NOR1, and a promiscuous partner, most commonly EWSR1. Clinical studies have shown that development of second malignancies is an uncommon but real risk for chondrosarcoma survivors; the benefit of chemotherapy for dedifferentiated chondrosarcomas remains questionable; and late recurrences of clear cell chondrosarcomas emphasize the need for long-term follow up.

SUMMARY

Chondrosarcomas are a heterogeneous group of bone and soft tissue tumors. Recent advances in molecular diagnostics, pathobiology, and developmental therapeutics will aid both scientists and clinicians in improving the classification and therapy of this diverse family of cartilaginous tumors.

Chordomas and chondrosarcomas of the skull base: comparative analysis of clinical results in 30 patients

Chordomas and chondrosarcomas occur rarely in the skull base and have been often considered commonly with respect to the management. The aim of this study was to investigate the clinical results in each series of these tumors and analyze comparative outcome. Between 1991 and 2005, 30 consecutive patients with pathological diagnosis of chordoma (n=19) or chondrosarcoma (n=11) of the skull base were managed by multimodal treatment combining surgical resection with conventional photon radiotherapy and/or gamma knife radiosurgery. A retrospective analysis was conducted on these patients (aged 3 to 69 years; mean age of 37.3 years; 17 females and 13 males; mean follow-up of 56.1 months). Four deaths occurred among the patients with chordoma. The progression-free survival rate at 3 and 5 years was 61.5 and 40.0% in chordoma. In contrast, no mortalities were observed, and there was only one recurrence among the patients with chondrosarcoma. The progression-free survival rate at 3 and 5 years was 88.9 and 80.0% in chondrosarcoma. Among 15 survivors with chordoma, four patients were suffering from severe disability with progressive disease. On the other hand, most patients with chondrosarcoma harbored stable disease and less disabling symptoms except one instance of recurrence. As the biological behavior of chordoma is much more aggressive than that of chondrosarcoma in the skull base, one should make a distinction between these entities to plan an optimal treatment strategy.

Maffucci' s syndrome complicated by intracranial chondrosarcoma: two new illustrative cases

Maffucci's syndrome is a rare congenital condition, sometimes misdiagnosed as Ollier's disease, characterized by multiple enchondromas combined with hemangiomas and phlebectasia. Coexisting primary malignancies have been described sporadically. We report two cases of Maffucci's syndrome associated with cranial base chondrosarcoma, emphasizing pathophysiological features and the challenging management of intracranial chondrosarcomas. To the best of our knowledge, only twelve similar cases have been reported in the literature.

Chordoma and chondrosarcoma: Similar, but quite different, skull base tumors

BACKGROUND

Chordoma and chondrosarcoma of the skull base are frequently amalgamated because of similar anatomic location, clinical presentation, and radiologic findings. The chondroid chordoma variant has been reported to carry a better prognosis. The objective of the current study was to investigate the distinctions between these 3 entities.

METHODS

The data concerning 109 patients with chordoma, chondroid chordoma, and chondrosarcoma who were treated by a single surgeon with maximum surgical resection and frequently by adjunct proton beam radiotherapy between 1990 and 2006 were analyzed retrospectively. Pathologic distinction was established by cytokeratin and epithelial membrane antigen staining. Clinical, radiologic, pathologic, and cytogenetic studies were analyzed in relation to disease recurrence and death.

RESULTS

The average follow-up was 48+/-37.5 months (range, 1-191 months). There were no reliable distinguishing clinical or radiologic features noted between the groups. Chondrosarcoma patients had a significantly better outcome compared with chordoma patients with regard to survival and recurrence-free survival (P=.028 and P<.001, respectively), whereas patients with chondroid chordoma had a poor outcome similar to chordoma patients with regard to survival and recurrence-free survival (P=.337 and P=.906, respectively).

CONCLUSIONS

Chordoma and chondrosarcoma differ with regard to their origin and histology, and differ markedly with regard to outcome. Chondroid chordomas behave in a manner that is clinically similar to chordomas, with the same prognosis. Both chordoma types demonstrate an aggressive clinical course and poor outcome after disease recurrence. The optimal treatment for all groups of patients involves radical surgical resection followed by high-dose radiotherapy in patients with chordomas. Radiotherapy may not be necessary in patients with low-grade chondrosarcoma.