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Lemaeva A, Gulidov I, Smyk D, Agapova Y, Koryakin S, Eremina I, Gantsova E, Fatkhudinov T, Kaprin A, Gordon K. A single-center experience of the upright proton therapy for skull-base chordomas and chondrosarcomas: Updated results. Clin Transl Radiat Oncol 2024; 48:100814. [PMID: 39044782 PMCID: PMC11263508 DOI: 10.1016/j.ctro.2024.100814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/14/2024] [Accepted: 06/29/2024] [Indexed: 07/25/2024] Open
Abstract
Aim To access efficacy and safety of the upright proton therapy for the skull-base chordomas and chondrosarcomas. Materials and methods The study encompasses single-center experience of proton therapy in chordomas (CA) and chondrosarcomas (CSA) of skull-base localization. We evaluate overall survival, local control and toxicity. Tumor response was assessed in accordance with RANO criteria. Treatment-related toxicity was evaluated with the help of CTCAE v 5.0 scale. Results Proton therapy in the upright position was utilized for 51pts (patients) with CA-CSA (40 pts with chordoma and 11pts with chondrosarcoma) at the A. Tsyb Medical Radiological Research Center in 2016-2023. Median tumor volume constituted 30 cm3 (IQR (interquartile range) 15-41 cm3). Median total dose was 70 GyRBE. Median number of fractions was 35. Overall survival (OS) at 1-, 2- and 3-year rates reached 98.0 %, 88.6 % and 82.7 %, respectively. Median follow-up time was 36 months. The 1-, 2- and 3-year local control (LC) rates constituted, respectively, 98 %, 78.6 % and 66.3 %. Prior surgery showed statistically significant association with better prognosis (p = 0.023). Brainstem-to-tumor dose coverage compromise became the major pattern of LC failure (p = 0.03). The late radiation toxicity reactions included temporal lobe necrosis grade 2 in 2 pts, xerostomia grade 1 in 1pt, radiation cataract grade 2 in 1pt and persistent headache grade 2 in 4 pts. Severe late toxicity reactions were observed in 2 cases (4 %): 1 myelitis grade 3 and brainstem damage grade 5 in 1pt. Conclusion Local control was achieved in the majority of patients receiving the scanning-beam upright proton therapy for skull-base CA-CSA. The LC rates after a surgery-radiotherapy combination treatment were higher compared with irradiation alone. Pattern of failure is mostly brainstem-tumor dose compromise. The high OS and LC rates were accompanied by low toxicity incidence. Even in complex case of the skull base CA-CSA upright proton therapy shows promising clinical outcomes.
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Affiliation(s)
- Alyona Lemaeva
- A. Tsyb Medical Radiological Research Center – Branch of the National Medical Radiological Research Center, Obninsk, Russia
| | - Igor Gulidov
- A. Tsyb Medical Radiological Research Center – Branch of the National Medical Radiological Research Center, Obninsk, Russia
| | - Daniil Smyk
- A. Tsyb Medical Radiological Research Center – Branch of the National Medical Radiological Research Center, Obninsk, Russia
| | - Yuliya Agapova
- Obninsk Institute for Nuclear Power Engineering, National Research Nuclear University MEPhI, Obninsk, Russia
| | - Sergey Koryakin
- A. Tsyb Medical Radiological Research Center – Branch of the National Medical Radiological Research Center, Obninsk, Russia
| | - Irina Eremina
- Medical Institution, P. Lumumba People’s Friendship University of Russia, Moscow, Russia
| | - Elena Gantsova
- Medical Institution, P. Lumumba People’s Friendship University of Russia, Moscow, Russia
| | - Timur Fatkhudinov
- Medical Institution, P. Lumumba People’s Friendship University of Russia, Moscow, Russia
| | - Andrey Kaprin
- A. Tsyb Medical Radiological Research Center – Branch of the National Medical Radiological Research Center, Obninsk, Russia
- Medical Institution, P. Lumumba People’s Friendship University of Russia, Moscow, Russia
| | - Konstantin Gordon
- A. Tsyb Medical Radiological Research Center – Branch of the National Medical Radiological Research Center, Obninsk, Russia
- Medical Institution, P. Lumumba People’s Friendship University of Russia, Moscow, Russia
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Skotting MB, Poulsgaard L, Springborg JB, Sundbye F, Engelmann BE, Scheie D, Ciochon UM, Guldberg F, Fugleholm K. Clival chordomas and chondrosarcomas in Denmark-Outcomes in 33 patients following the national centralization of treatment in 2010. Acta Neurochir (Wien) 2024; 166:354. [PMID: 39207554 PMCID: PMC11362515 DOI: 10.1007/s00701-024-06241-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE This 13-year consecutive case series aims to provide a comprehensive overview of all patients operated for clival chordomas and clival chondrosarcomas in Denmark since the centralization of treatment in 2010, comparing outcomes to international series. METHODS This was a retrospective review of 33 patients with clival tumors, comprising 22 chordomas and 11 chondrosarcomas, who were treated at Copenhagen University Hospital between years 2010 and 2023. Data were collected from digital patient records and pathology reports. RESULTS The symptoms leading to diagnosis primarily included double vision, headaches, and dizziness. In general, patients were in good health, with a mean Charlson Comorbidity Index score of 1.6. The complication rate of the index surgery was 51.5%. Adjuvant radiotherapy was applied in 51.5% of the cases. In patients with clival chordomas, the mean age was 51.1 years, ranging from 16 to 83 years. At the time of diagnosis, the mean tumor volume was 20.9 cm3 and the five-year overall survival rates were 79.1% (95% confidence interval (CI): 62.4-100). In patients with chondrosarcomas, the mean age was 48.2 years, ranging from 15 to 76 years. At the time of diagnosis, the mean tumor volume was 22.3 cm3 and the five-year overall survival 90% (95% CI: 73.2-100). CONCLUSION The centralized treatment of clival tumors in Denmark demonstrates incidence, survival, and complication rates comparable to those found in other international series. Given the variations in treatment strategies, tumor localizations across series, and small sample sizes, the further analysis of larger compiled multicenter datasets for clival tumors could provide more solid evidence regarding the management of these rare tumors.
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Affiliation(s)
| | - Lars Poulsgaard
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Filippa Sundbye
- Department of Oncology, Hospital of Herlev and Gentofte, Herlev, Denmark
| | - Bodil Elisabeth Engelmann
- Department of Oncology, Hospital of Herlev and Gentofte, Herlev, Denmark
- Danish Particle Center, Aarhus University Hospital, Aarhus, Denmark
| | - David Scheie
- Department of Diagnostic Pathology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Urszula Maria Ciochon
- Department of Diagnostic Radiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederikke Guldberg
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kåre Fugleholm
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
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Alexander AY, Dhawan S, Venteicher AS. Role of immunotherapy in treatment refractory chordomas: review of current evidence. Front Surg 2024; 11:1375567. [PMID: 38881706 PMCID: PMC11177759 DOI: 10.3389/fsurg.2024.1375567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/14/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Chordomas are aggressive tumors that are thought to arise from remnants of the embryological notochord. They can arise along the ventromedial aspect of the sacrum, mobile spine, and clivus-with most cases occurring in the sacrum or skull base. Despite surgery and radiation, chordomas often progress and become refractory to further treatment. The high recurrence rate of chordomas has created an urgent need to develop new systemic treatment options. Recent case reports and clinical trials have highlighted the use of immunotherapy for refractory chordomas. In this review, we summarize the results of these studies and discuss the potential role of immunotherapy for chordomas. Methods The PUBMED database was queried for studies mentioning both "Chordoma" and "Immunotherapy." All case series and case reports that involved administration of an immunotherapy for chordoma were included. Additional studies that were found during literature review were added. ClinicalTrials.Gov was queried for studies mentioning both "Chordoma" and "Immunotherapy." The final cohort consisted of all clinical trials that utilized immunotherapy for chordomas of any location. Results Eight case reports and series detailing the use of immunotherapy for treatment refractory chordoma were identified. Most patients received immunotherapy targeting the PD-1/PD-L1 interaction, and two patients received therapy targeting this interaction along with the tyrosine kinase inhibitor pazopanib. One patient received a vaccine derived from autologous tumor cells, and one patient received a viral vector that downregulated the effect of TGF-beta. One clinical trial utilized a brachyury vaccine in conjunction with standard of care radiotherapy. Conclusions Immunotherapy for chordoma is a promising area of investigation with increasing, but small, numbers of case series and clinical trials. Despite challenges in patient accrual, future directions in chordoma immunotherapy may lie in vaccine-based therapies and immune checkpoint inhibitors. Understanding chordoma heterogeneity and microenvironment will likely elucidate important chordoma features that will inform future clinical trial design.
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Affiliation(s)
- A Yohan Alexander
- Department of Neurosurgery and Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Sanjay Dhawan
- Department of Neurosurgery and Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Andrew S Venteicher
- Department of Neurosurgery and Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, MN, United States
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Kotecha R, La Rosa A, Mehta MP. How proton therapy fits into the management of adult intracranial tumors. Neuro Oncol 2024; 26:S26-S45. [PMID: 38437667 PMCID: PMC10911801 DOI: 10.1093/neuonc/noad183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
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.
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
- Department of Translational Medicine, Hebert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
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5
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Perez-Vega C, Akinduro OO, Ruiz-Garcia HJ, Ghaith AKA, Almeida JP, Jentoft ME, Mahajan A, Janus JR, Bendok BR, Choby GW, Middlebrooks EH, Trifiletti DM, Chaichana KL, Laack NN, Quinones-Hinojosa A, Van Gompel JJ. Extent of Surgical Resection as a Predictor of Tumor Progression in Skull Base Chordomas: A Multicenter Volumetric Analysis. World Neurosurg 2024; 181:e620-e627. [PMID: 37898264 DOI: 10.1016/j.wneu.2023.10.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION Skull-base chordomas are aggressive tumors with a propensity for recurrence/progression. Even with standard of care (SoC), 5-year recurrence rates are variable (19%-54%). This high recurrence/progression rate correlates with increased morbidity and mortality. We sought to analyze a multicenter cohort of skull base chordomas to identify predictors of progression in patients receiving SoC. METHODS The [Blinded]-Neurosurgery data registry was queried for skull base chordomas treated from 2008-2020. Patients with the histopathologic diagnosis of chordoma were included. The cohort was composed of patients with preoperative and postoperative magnetic resonance imaging. Tumor volume and radiologic characteristics were obtained from axial T2 sequences using a Digital Imaging and Communications in Medicine viewer. Survival analysis was performed using Kaplan-Meier method, and time-to-event multivariate regression was performed to identify independent predictors of progression. RESULTS The cohort included 195 patients, of which 66 patients met inclusion criteria; median age was 44, and 28 (42%) were females. Fifty-four (82%) received SoC, 7 (11%) resection only, and 5 (8%) radiotherapy only. Median preoperative and postoperative tumor volumes were 11.55 cm3 (0.33-54.89) and 0.34 cm3 (0-42.52), respectively. Recurrence rate with SoC was 37%. Postoperative tumor volume (P = 0.010) correlated with progression. A postoperative volume of >4.9 cm3 (P = 0.044), ≤81.3% of tumor resection (P = 0.02), and lower-clivus location (P < 0.005) correlated with decreased time to progression. CONCLUSIONS Skull base chordomas can be challenging to resect. Even though maximal resection and radiotherapy improve rate of tumor progression, many of these lesions eventually recur. We have identified a postoperative tumor volume of ≥4.9 cm3 and extent of resection of ≤81.3% in this cohort as predictors of progression in patients receiving SoC.
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Affiliation(s)
- Carlos Perez-Vega
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | | | - Joao P Almeida
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Mark E Jentoft
- Department of Lab Medicine and Pathology, Jacksonville, Florida, USA
| | - Anita Mahajan
- Department of Radiation Oncology, Rochester, Minnesota, USA
| | | | | | - Garret W Choby
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Nadia N Laack
- Department of Radiation Oncology, Rochester, Minnesota, USA
| | | | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Brown NJ, Gendreau J, Kuo CC, Nguyen O, Yang C, Catapano JS, Lawton MT. Assessing survival outcomes and complication profiles following surgical excision and radiotherapy as interventions for skull base chordoma: a systematic review of operative margins and surgical approaches. J Neurooncol 2023; 165:41-51. [PMID: 37880419 DOI: 10.1007/s11060-023-04477-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/08/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Despite their precarious behavioral classification (benign and low grade on histopathology yet behaviorally malignant), great strides have been taken to improve prognostication and treatment paradigms for patients with skull base chordoma. With respect to surgical techniques, lateral transcranial (TC) approaches have traditionally been used, however endoscopic endonasal approaches (EEA) have been advocated for midline lesions. Nonetheless, due to the rarity of this pathology (0.2% of all intracranial neoplasms), investigations within the literature remain limited to small retrospective series. Furthermore, radiotherapeutic treatments investigated to date have proven largely ineffective. METHODS Accordingly, we performed a systematic review in order to profile surgical and survival outcomes for skull base chordoma. Fixed and random-effect meta-analyses were performed for categorical variables including GTR, STR, 5-year OS, 10-year OS, 5-year PFS, and 10-year PFS. Additionally, we pooled eligible studies for formal meta-analysis to compare outcomes by surgical approach (lateral versus midline). Statistical analyses were performed using R Studio 'metafor' package or Cochrane Review Manager. Furthermore, meta-analysis of pooled mortality rates and sub-analyses of operative margin and surgical complications were used to compare midline versus lateral approaches via the Mantel-Haenszel method. We considered all p-values < 0.05 to be statistically significant. RESULTS Following the systematic search and screen, 55 studies published between 1993 and 2022 reporting data for 2453 patients remained eligible for analysis. Sex distribution was comparable between males and females, with a slight predominance of male-identifying patients (0.5625 [95% CI: 0.5418; 0.3909]). Average age at diagnosis was 42.4 ± 12.5 years, while average age of treatment initiation was 43.0 ± 10.6 years. Overall, I2 value indicated notable heterogeneity across the 55 studies [I2 = 56.3% (95%CI: 44.0%; 65.9%)]. With respect to operative margins, the rate of GTR was 0.3323 [95% CI: 0.2824; 0.3909], I2 = 91.9% [95% CI: 90.2%; 93.4%], while the rate of STR was significantly higher at 0.5167 [95% CI: 0.4596; 0.5808], I2 = 93.1% [95% CI: 91.6%; 94.4%]. The most common complication was CSF leak (5.4%). In terms of survival outcomes, 5-year OS rate was 0.7113 [95% CI: 0.6685; 0.7568], I2 = 91.9% [95% CI: 90.0%; 93.5%]. 10-year OS rate was 0.4957 [95% CI: 0.4230; 0.5809], I2 = 92.3% [95% CI: 89.2%; 94.4%], which was comparable to the 5-year PFS rate of 0.5054 [95% CI: 0.4394; 0.5813], I2 = 84.2% [95% CI: 77.6%; 88.8%] and 10-yr PFS rate of 0.4949 [95% CI: 0.4075; 0.6010], I2 = 14.9% [95% CI: 0.0%; 87.0%]. There were 55 reported deaths for a perioperative mortality rate of 2.5%. The relative risk for mortality in the midline group versus the lateral approach group did not indicate any substantial difference in survival according to laterality of approach (-0.93 [95% CI: -1.03, -0.97], I2 = 95%, (p < 0.001). CONCLUSION Overall, these results indicate good 5-year survival outcomes for patients with skull base chordoma; however, 10-year prognosis for skull base chordoma remains poor due to its radiotherapeutic resistance and high recurrence rate. Furthermore, mortality rates among patients undergoing midline versus lateral skull base approaches appear to be equivocal.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Julian Gendreau
- Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| | - Cathleen C Kuo
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Oanh Nguyen
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Chenyi Yang
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ, 85013, USA.
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Xiao Y, Yu W, Zheng J, Cheng L, Ding X, Qiao L, Wu X, Ma J. Bibliometric Insights in Advances of Chordoma: Global Trends and Research Development in the Last Decade. Orthop Surg 2023; 15:2505-2514. [PMID: 37580859 PMCID: PMC10549828 DOI: 10.1111/os.13831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 08/16/2023] Open
Abstract
Chordoma is a rare tumor, but has a serious effect on the quality of life of patients. This study aims to assess the overall knowledge structure and trends in the development of chordoma research using a bibliometric analysis and visualization tool. Research datasets were acquired from the Web of Science. VOS viewer and CiteSpace visualization software were used to demonstrate collaborations and correlations. Annual trends in publications, distribution, H-index status, co-authorship status, and research hotspots were analyzed. A total of 1844 publications from 2012 to 2022 were included. The number of chordoma-related publications increased year by year. The United States contributed the most publications (717) and had the highest total citations (10130) and H-index (50), followed by China. The United States was also the country most frequently involved in international cooperation. The most productive organization involved in chordoma research was Massachusetts General Hospital. World Neurosurgery (114) published the most papers on chordoma. Hornicek FJ was the most productive author over the last decade (41). Initially, diagnosis and the location of onset captured the attention of the research society. Quality of life, risk factors, disability, minimally invasive surgical techniques, molecular targeted therapy, and radiotherapy technology are the research hotspots in recent years. Indeed, this study provides important insights into the overall landscape of chordoma research and also contributes to the further investigation of the international frontier of chordoma.
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Affiliation(s)
- Yu Xiao
- Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Wenlong Yu
- Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Jianhu Zheng
- The First Clinical Medical College of Shandong University of Traditional Chinese MedicineJinanChina
| | - Lin Cheng
- Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Xing Ding
- Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Liang Qiao
- Shanghai East HospitalTongji University School of MedicineShanghaiChina
| | - Xuequn Wu
- Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
| | - Junming Ma
- Longhua HospitalShanghai University of Traditional Chinese MedicineShanghaiChina
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Ioakeim-Ioannidou M, Niemierko A, Kim DW, Tejada A, Urell T, Leahy S, Adams J, Fullerton B, Nielsen GP, Hung YP, Shih AR, Patino M, Buch K, Rincon S, Kelly H, Cunnane MB, Tolia M, Widemann BC, Wedekind MF, John L, Ebb D, Shin JH, Cote G, Curry W, MacDonald SM. Surgery and proton radiation therapy for pediatric base of skull chordomas: Long-term clinical outcomes for 204 patients. Neuro Oncol 2023; 25:1686-1697. [PMID: 37029730 PMCID: PMC10484173 DOI: 10.1093/neuonc/noad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Data on clinical outcomes for base of skull (BOS) chordomas in the pediatric population is limited. We report patient outcomes after surgery and proton radiotherapy (PRT). METHODS Pediatric patients with BOS chordomas were treated with PRT or combined proton/photon approach (proton-based; for most, 80% proton/20% photon) at the Massachusetts General Hospital from 1981 to 2021. Endpoints of interest were overall survival (OS), disease-specific survival, progression-free survival (PFS), freedom from local recurrence (LC), and freedom from distant failure (DC). RESULTS Of 204 patients, median age at diagnosis was 11.1 years (range, 1-21). Chordoma location included 59% upper and/or middle clivus, 36% lower clivus, 4% craniocervical junction, and 1% nasal cavity. Fifteen (7%) received pre-RT chemotherapy. Forty-seven (23%) received PRT, and 157 (77%) received comboRT. Median total dose was 76.7 Gy (RBE) (range, 59.3-83.3). At a median follow-up of 10 years (interquartile range, 5-16 years), 56 recurred. Median OS and PFS were 26 and 25 years, with 5-, 10-, and 20-year OS and PFS rates of 84% and 74%, 78% and 69%, and 64% and 64%, respectively. Multivariable actuarial analyses showed poorly differentiated subtype, radiographical progression prior to RT, larger treatment volume, and lower clivus location to be prognostic factors for worse OS, PFS, and LC. RT was well tolerated at a median follow-up of 9 years (interquartile range, 4-16 years). Side effects included 166 patients (80%) with mild/moderate acute toxicities, 24 (12%) patients with late toxicities, and 4 (2%) who developed secondary radiation-related malignancies. CONCLUSION This is the largest cohort of BOS chordomas in the literature, pediatric and/or adult. High-dose PRT following surgical resection is effective with low rates of late toxicity.
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Affiliation(s)
| | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel W Kim
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Athena Tejada
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tobias Urell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shannon Leahy
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Judy Adams
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Barbara Fullerton
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - G Petur Nielsen
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Yin P Hung
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Angela R Shih
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Manuel Patino
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen Buch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sandra Rincon
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hilary Kelly
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mary Beth Cunnane
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maria Tolia
- Department of Radiotherapy, School of Medicine, University of Crete, Heraklion, Greece
| | - Brigitte C Widemann
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Mary F Wedekind
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Liny John
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - David Ebb
- Department of Pediatric Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gregory Cote
- Department of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William Curry
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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9
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Yoo HD, Chung JC, Park KS, Chung SY, Park MS, Ryu S, Kim SM. Long-Term Outcomes after Multimodal Treatment for Clival Chordoma: Efficacy of the Endonasal Transclival Approach with Early Adjuvant Radiation Therapy. J Clin Med 2023; 12:4460. [PMID: 37445495 DOI: 10.3390/jcm12134460] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
This study investigates the long-term outcomes of clival chordoma patients treated with the endonasal transclival approach (ETCA) and early adjuvant radiation therapy. A retrospective review of 17 patients (2002-2013) showed a 10-year progression-free survival (PFS) rate of 67.4%, with the ETCA group showing fewer progressions and cranial neuropathies than those treated with combined approaches. The ETCA, a minimally invasive technique, provided a similar extent of resection compared to conventional skull-base approaches and enabled safe delivery of high-dose adjuvant radiotherapy. The findings suggest that ETCA is an effective treatment for centrally located clival chordomas.
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Affiliation(s)
- Hyun Dong Yoo
- Department of Neurosurgery, Eulji University Hospital, Eulji University College of Medicine, Daejeon 35233, Republic of Korea
| | - Jong Chul Chung
- Center for Neuromodulation, Department of Neurosurgery, NYU Langone Medical Center, New York, NY 11021, USA
| | - Ki Seok Park
- Department of Neurosurgery, Eulji University Hospital, Eulji University College of Medicine, Daejeon 35233, Republic of Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Eulji University College of Medicine, Daejeon 35233, Republic of Korea
| | - Moon Sun Park
- Department of Neurosurgery, Eulji University Hospital, Eulji University College of Medicine, Daejeon 35233, Republic of Korea
| | - Seungjun Ryu
- Department of Neurosurgery, Eulji University Hospital, Eulji University College of Medicine, Daejeon 35233, Republic of Korea
| | - Seong Min Kim
- Department of Neurosurgery, Eulji University Hospital, Eulji University College of Medicine, Daejeon 35233, Republic of Korea
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10
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Wolf RJ, Winkler V, Mattke M, Uhl M, Debus J. Intensity-modulated radiotherapy for the management of primary and recurrent chordomas: a retrospective long-term follow-up study. Rep Pract Oncol Radiother 2023; 28:207-216. [PMID: 37456699 PMCID: PMC10348326 DOI: 10.5603/rpor.a2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/06/2023] [Indexed: 07/18/2023] Open
Abstract
Background Chordomas have a high risk of recurrence. Radiotherapy (RT) is required as adjuvant therapy after resection. Sufficient radiation doses for local control (LC) can be achieved using either particle therapy, if this technology is available and feasible, or intensity-modulated radiotherapy. Materials and methods 57 patients (age, 11.8-81.6 years) with chordomas of the skull base, spine and pelvis who received photon radiotherapy between 1995 and 2017 were enrolled in the study. Patients were treated at the time of initial diagnosis (68.4%) or during recurrence (31.6%). 44 patients received adjuvant radiotherapy and 13 received definitive radiotherapy. The median total dose to the physical target volume was 70 Gy equivalent dose in 2 Gy fractions (EQD2) (range: 54.7-82.5) in 22-36 fractions. Results LC was 76.4%, 58.4%, 46.7% and 39.9% and overall survival (OS) was 98.3%, 89%, 76.9% and 47.9% after 1, 3, 5 and 10 years, respectively, with a median follow-up period of 6.5 years (range, 0.5-24.3 years). Age, dose and treatment concept (post-operative or definitive) were significant prognostic factors for OS. Primary treatment, macroscopic tumour at RT and size of the irradiated volume were statistically significant prognostic factors for LC. Conclusion Photon treatment is a safe and effective treatment for chordomas if no particle therapy is available. The best results can be achieved against primary tumours if the application of curative doses is possible due to organs at risk in direct proximity. We recommend high-dose radiotherapy, regardless of the resection status, as part of the initial treatment of chordoma, using the high conformal radiation technique if particle therapy is not feasible.
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Affiliation(s)
- Robert J. Wolf
- University Hospital of Heidelberg, Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
| | - Volker Winkler
- Institute of Public Health, Unit of Epidemiology and Biostatistics, University of Heidelberg, Heidelberg, Germany
| | - Matthias Mattke
- Department of Radiation Oncology, Paracelsus Medical University, SALK, Salzburg, Austria
| | - Matthias Uhl
- Department of Radiation Oncology, Ludwigshafen City Hospital, Ludwigshafen, Germany
| | - Jürgen Debus
- University Hospital of Heidelberg, Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
- German Cancer Research Center (dkfz), Heidelberg, Germany
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11
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Schnurman Z, Benjamin CG, Miceli M, Sen C. Clival Chordomas in the Endoscopic Endonasal Era: Clinical Management, Outcomes, and Complications. Neurosurgery 2023; 92:876-883. [PMID: 36700749 DOI: 10.1227/neu.0000000000002289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/03/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Surgical management of skull base chordomas has changed significantly in the past 2 decades, most notably with use of the endoscopic endonasal approach (EEA), although high quality outcome data using these modern approaches remain scarce. OBJECTIVE To evaluate outcomes in a large series of patients treated by a single surgeon, using primarily the EEA. METHODS Between 2006 and 2020, 68 patients with skull base chordoma underwent resection using mostly the EEA. Complications, outcomes, and potential contributing factors were evaluated using Kaplan-Meier survival analysis and univariable and multivariable Cox proportional hazards models. RESULTS Overall 5-year survival was 76.3% (95% CI 61.5%-86.0%), and 5-year progression-free survival was 55.9% (95% CI 40.0%-69.0%). In multivariable analysis, radical resection was associated with significant reduction in risk of death (hazard ratio [HR] 0.04, 95% CI 0.005-0.33, P = .003) and disease progression (HR 0.05, 95% CI 0.01-0.18, P < .001). Better preoperative function status reduced risk of death (HR 0.42 per 10-point increase in Karnofsky Performance Scale, 95% CI 0.28-0.63, P < .001) and progression (HR 0.60 per 10-point increase in Karnofsky Performance Scale, 95% CI 0.45-0.78, P < .001). Localization at the clivus reduced risk of death (HR 0.02, 95% CI 0.002-0.15, P < .001) and progression (HR 0.24, 95% CI 0.09-0.68, P = .007) compared with tumors at the craniovertebral junction. CONCLUSION In multivariable analysis, overall survival and progression-free survival of chordoma resection was most positively affected by radical resection, better preoperative functional status, and tumor location at the clivus rather than craniovertebral junction.
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Affiliation(s)
- Zane Schnurman
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | | | - Mary Miceli
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Chandranath Sen
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
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12
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Clinical outcomes and toxicities of 100 patients treated with proton therapy for chordoma on the proton collaborative group prospective registry. Radiother Oncol 2023; 183:109551. [PMID: 36813169 DOI: 10.1016/j.radonc.2023.109551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 01/31/2023] [Accepted: 02/05/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND We present efficacy and toxicity outcomes among patients with chordoma treated on the Proton Collaborative Group prospective registry. METHODS Consecutive chordoma patients treated between 2010-2018 were evaluated. One hundred fifty patients were identified, 100 had adequate follow-up information. Locations included base of skull (61%), spine (23%), and sacrum (16%). Patients had a performance status of ECOG 0-1 (82%) and median age of 58 years. Eighty-five percent of patients underwent surgical resection. The median proton RT dose was 74 Gy (RBE) (range 21-86 Gy (RBE)) using passive scatter proton RT (PS-PBT) (13%), uniform scanning proton RT (US-PBT) (54%) and pencil beam scanning proton RT (PBS-PBT) (33%). Rates of local control (LC), progression-free survival (PFS), overall survival (OS) and acute and late toxicities were assessed. RESULTS 2/3-year LC, PFS, and OS rates are 97%/94%, 89%/74%, and 89%/83%, respectively. LC did not differ based on surgical resection (p = 0.61), though this is likely limited by most patients having undergone a prior resection. Eight patients experienced acute grade 3 toxicities, most commonly pain (n = 3), radiation dermatitis (n = 2), fatigue (n = 1), insomnia (n = 1) and dizziness (n = 1). No grade ≥ 4 acute toxicities were reported. No grade ≥ 3 late toxicities were reported, and most common grade 2 toxicities were fatigue (n = 5), headache (n = 2), CNS necrosis (n = 1), and pain (n = 1). CONCLUSIONS In our series, PBT achieved excellent safety and efficacy outcomes with very low rates of treatment failure. CNS necrosis is exceedingly low (<1%) despite the high doses of PBT delivered. Further maturation of data and larger patient numbers are necessary to optimize therapy in chordoma.
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13
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Proton and carbon ion beam treatment with active raster scanning method in 147 patients with skull base chordoma at the Heidelberg Ion Beam Therapy Center-a single-center experience. Strahlenther Onkol 2023; 199:160-168. [PMID: 36149438 PMCID: PMC9876873 DOI: 10.1007/s00066-022-02002-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/30/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND This study aimed to compare the results of irradiation with protons versus irradiation with carbon ions in a raster scan technique in patients with skull base chordomas and to identify risk factors that may compromise treatment results. METHODS A total of 147 patients (85 men, 62 women) were irradiated with carbon ions (111 patients) or protons (36 patients) with a median dose of 66 Gy (RBE (Relative biological effectiveness); carbon ions) in 4 weeks or 74 Gy (RBE; protons) in 7 weeks at the Heidelberg Ion Beam Therapy Center (HIT) in Heidelberg, Germany. The median follow-up time was 49.3 months. All patients had gross residual disease at the beginning of RT. Compression of the brainstem was present in 38%, contact without compression in 18%, and no contact but less than 3 mm distance in 16%. Local control and overall survival were evaluated using the Kaplan-Meier Method based on scheduled treatment (protons vs. carbon ions) and compared via the log rank test. Subgroup analyses were performed to identify possible prognostic factors. RESULTS During the follow-up, 41 patients (27.9%) developed a local recurrence. The median follow-up time was 49.3 months (95% CI: 40.8-53.8; reverse Kaplan-Meier median follow-up time 56.3 months, 95% CI: 51.9-60.7). No significant differences between protons and carbon ions were observed regarding LC, OS, or overall toxicity. The 1‑year, 3‑year, and 5‑year LC rates were 97%, 80%, and 61% (protons) and 96%, 80%, and 65% (carbon ions), respectively. The corresponding OS rates were 100%, 92%, and 92% (protons) and 99%, 91%, and 83% (carbon ions). No significant prognostic factors for LC or OS could be determined regarding the whole cohort; however, a significantly improved LC could be observed if the tumor was > 3 mm distant from the brainstem in patients presenting in a primary situation. CONCLUSION Outcomes of proton and carbon ion treatment of skull base chordomas seem similar regarding tumor control, survival, and toxicity. Close proximity to the brainstem might be a negative prognostic factor, at least in patients presenting in a primary situation.
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14
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Park M, Park I, Hong CK, Kim SH, Cha YJ. Differences in stromal component of chordoma are associated with contrast enhancement in MRI and differential gene expression in RNA sequencing. Sci Rep 2022; 12:16504. [PMID: 36192442 PMCID: PMC9529962 DOI: 10.1038/s41598-022-20787-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
Chordoma is a malignant bone neoplasm demonstrating notochordal differentiation and it frequently involves axial skeleton. Most of chordomas are conventional type with varying amount of myxoid stroma. Previously known prognostic factors for conventional chordoma are not specific for chordoma: old age, metastasis, tumor extent, and respectability. Here, we aimed to investigate the histologic, radiologic, and transcriptomic differences in conventional chordoma based on the stromal component. A total of 45 patients diagnosed with conventional chordoma were selected between May 2011 and March 2020 from a single institution. Electronic medical records, pathology slides, and pretreatment magnetic resonance imaging (MRI) scans were reviewed. Of the 45 patients, ten cases (4 stroma-rich and 6 stroma-poor tumor) were selected for RNA sequencing, and available cases in the remainder were used for measuring target gene mRNA expression with qPCR for validation. Differential gene expression and gene set analysis were performed. Based on histologic evaluation, there were 25 (55.6%) stroma-rich and 20 (44.4%) stroma-poor cases. No clinical differences were found between the two groups. Radiologically, stroma-rich chordomas showed significant signal enhancement on MRI (72.4% vs 27.6%, p = 0.002). Upregulated genes in stroma-rich chordomas were cartilage-, collagen/extracellular matrix-, and tumor metastasis/progression-associated genes. Contrarily, tumor suppressor genes were downregulated in stroma-rich chordomas. On survival analysis, Kaplan–Meier plot was separated that showed inferior outcome of stroma-rich group, although statistically insignificant. In conclusion, the abundant stromal component of conventional chordoma enhanced well on MRI and possibly contributed to the biological aggressiveness that supported by transcriptomic characteristics. Further extensive investigation regarding radiologic-pathologic-transcriptomic correlation in conventional chordoma in a larger cohort could verify additional clinical significance.
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Affiliation(s)
- Mina Park
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Inho Park
- Center for Precision Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Se Hoon Kim
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yoon Jin Cha
- Department of Pathology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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15
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Single-cell transcriptome reveals cellular hierarchies and guides p-EMT-targeted trial in skull base chordoma. Cell Discov 2022; 8:94. [PMID: 36127333 PMCID: PMC9489773 DOI: 10.1038/s41421-022-00459-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 08/19/2022] [Indexed: 11/08/2022] Open
Abstract
Skull base chordoma (SBC) is a bone cancer with a high recurrence rate, high radioresistance rate, and poorly understood mechanism. Here, we profiled the transcriptomes of 90,691 single cells, revealed the SBC cellular hierarchies, and explored novel treatment targets. We identified a cluster of stem-like SBC cells that tended to be distributed in the inferior part of the tumor. Combining radiated UM-Chor1 RNA-seq data and in vitro validation, we further found that this stem-like cell cluster is marked by cathepsin L (CTSL), a gene involved in the packaging of telomere ends, and may be responsible for radioresistance. Moreover, signatures related to partial epithelial-mesenchymal transition (p-EMT) were found to be significant in malignant cells and were related to the invasion and poor prognosis of SBC. Furthermore, YL-13027, a p-EMT inhibitor that acts through the TGF-β signaling pathway, demonstrated remarkable potency in inhibiting the invasiveness of SBC in preclinical models and was subsequently applied in a phase I clinical trial that enrolled three SBC patients. Encouragingly, YL-13027 attenuated the growth of SBC and achieved stable disease with no serious adverse events, underscoring the clinical potential for the precision treatment of SBC with this therapy. In summary, we conducted the first single-cell RNA sequencing of SBC and identified several targets that could be translated to the treatment of SBC.
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16
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Schur S, Passer JZ, Hanna EY, Su SY, Kupferman ME, DeMonte F, Raza SM. The impact of expanded endoscopic approaches on oncologic and functional outcomes for clival malignancies:a case series. J Neurooncol 2022; 159:627-635. [PMID: 35972674 DOI: 10.1007/s11060-022-04103-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Clival malignancies pose particular surgical challenges due to complex skull base anatomy and the involvement of vital neurovascular structures. While endoscopic endonasal approached are widely used, the outcomes for clival malignancies remain poorly understood. In this study we assessed the impact of endoscopic and open surgical approaches on PFS, time to initiation of radiotherapy, KPS, and GTR rates for clival malignancies. METHODS A retrospective case series for clival malignancies operated between 1993 and 2019 was conducted. Inclusion criteria were age over 18 and a follow-up of at least a 6 months. Statistical analyses were conducted using STATA version 15 statistical software package StataCorp. RESULTS For the whole cohort (113 patients), and for upper and middle lesions, open surgical approaches increased odds of disease progression, compared to EEA (HR 2.10 to HR 2.43), p < 0.05. EEA had a shorter time interval from surgery to initiation of radiotherapy. No difference in 6 and 12 month KPS was found between surgical groups. Patients undergoing open surgery were less likely to achieve GTR for upper clival lesions. CONCLUSIONS EEA was found to be associated with increased PFS, for upper and middle clival malignancies. The time to initiation of radiotherapy was shorter for patients undergoing EEA compared to open surgery for patients with middle clival involvement. GTR rates were found to be significantly better with EEA for patients with upper clival malignancies.
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Affiliation(s)
- Solon Schur
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Joel Z Passer
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Ehab Y Hanna
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Shirley Y Su
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Michael E Kupferman
- Department of Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, USA
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
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17
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Baig Mirza A, Ravindran V, Okasha M, Boardman TM, Maratos E, Sinan B, Thomas N. Systematic Review Comparing Open versus Endoscopic Surgery in Clival Chordomas and a 10-Year Single-Center Experience. Skull Base Surg 2022; 83:e113-e125. [DOI: 10.1055/s-0041-1722933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives Chordomas are rare, slow-growing, and osteo-destructive tumors of the primitive notochord. There is still contention in the literature as to the optimal management of chordoma. We conducted a systematic review of the surgical management of chordoma along with our 10-year institutional experience.
Design A systematic search of the literature was performed in October 2020 by using MEDLINE and EMBASE for articles relating to the surgical management of clival chordomas. We also searched for all adult patients surgically treated for primary clival chordomas at our institute between 2009 and 2019.
Participants Only articles describing chordomas arising from the clivus were included in the analysis. For our institution experience, only adult primary clival chordoma cases were included.
Main Outcome Measures Patients were divided into endoscopic or open surgery. Rate of gross total resection (GTR), recurrence, and complications were measured.
Results Our literature search yielded 24 articles to include in the study. Mean GTR rate among endoscopic cases was 51.9% versus 41.7% for open surgery. Among the eight cases in our institutional experience, we found similar GTR rates between endoscopic and open surgery.
Conclusion Although there is clear evidence in the literature that endoscopic approaches provide better rates of GTR with fewer overall complications compared to open surgery. However, there are still situations where endoscopy is not viable, and thus, open surgery should still be considered if required.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Visagan Ravindran
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohamed Okasha
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Eleni Maratos
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Barazi Sinan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
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18
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Pongmanee S, Sarasombath P, Rojdumrongrattana B, Liawrungrueang W. An Unusual Chordoma of the Odontoid Process: A Case Report and Literature Review. J Am Acad Orthop Surg Glob Res Rev 2022; 6:e22.00018. [PMID: 35584249 PMCID: PMC10566828 DOI: 10.5435/jaaosglobal-d-22-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/24/2022] [Indexed: 06/15/2023]
Abstract
The aim of this study is to present a rare case of chordoma in the odontoid process in which the tumor involved the odontoid process and compressed the spinal cord at the craniocervical junction. We report on the effectiveness and successful outcome of anterior microscopic tumor resection combined with posterior occipitocervical fixation and review the current standard treatment. A 39-year-old man presented with sudden dyspnea and quadriparesis caused by an unknown tumor compression at C2. Radiographic examination revealed a large destructive mass at C2 and heterogeneous enhancement. The patient received urgent surgical intervention by microscopic-assisted anterior tumor resection and posterior spinal fixation from the occiput to the C5 level. The pathohistologic reports for cytokeratins, epithelial membrane antigen, and S-100 protein were positive. The final diagnosis was chordoma of the odontoid process. At the 2-year follow-up, the patient's condition had improved, and a postoperative MRI showed no indication of tumor regrowth. Chordoma of the odontoid process or C2 body is very rare. The current standard management is wide tumor resection to prevent recurrence. The combined approach of anterior tumor resection with microscopic assistance and posterior stabilization of the occiput to C5 is the optimal treatment for this condition.
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Affiliation(s)
- Suthipas Pongmanee
- From the Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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19
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Wang B, Li Q, Sun Y, Tong X. Surgical Strategy for Skull Base Chordomas : Transnasal Midline Approach or Transcranial Lateral Approach. J Korean Neurosurg Soc 2022; 65:457-468. [PMID: 35286801 PMCID: PMC9082126 DOI: 10.3340/jkns.2021.0187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE The clinical management paradigm of skull base chordomas is still challenging. Surgical resection plays an important role of affecting the prognosis. Endonasal endoscopic approach (EEA) has gradually become the preferred surgical approach in most cases, but traditional transcranial surgery cannot be completely replaced. This study presents a comparison of the results of the two surgical strategies and a summary of the treatment algorithms for skull base chordomas. METHODS We retrospectively analyzed the surgical outcomes and follow-up data of 48 patients with skull base chordomas diagnosed pathologically who received transnasal midline approaches (TMA) and transcranial lateral approaches (TLA) from 2010 to 2020. RESULTS Among the 48 patients, 36 cases were adopted TMA and 12 cases were performed with TLA. In terms of gross total resection (GTR) rate, 27.8% in TMA and 16.7% in TLA and with EEA alone it was increased to 38.9%, while 29.7% in primary surgery. In TMA, the cerebrospinal fluid (CSF) leak remains the most common complication (13 cases, 36.1%), other main complications included death, cranial nerve palsy, hypopituitarism, all the comparisons were no statistical significance. The Karnofsky Performance Scale scores in TMA were all better than those in TLA at different time, and the overall survival (OS) and recurrence free survival/progression free survival was just the reverse. CONCLUSION The EEA for skull base chordomas resection has improved the GTR rate, but transcranial approach is still an alternative approach. It is necessary to select an appropriate surgical approach based on the location and the pattern of tumor growth in order to obtain the best surgical outcomes.
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Affiliation(s)
- Benlin Wang
- School of Medicine, Nankai University, Tianjin, China
| | - Qi Li
- School of Medicine, Nankai University, Tianjin, China
| | - Yang Sun
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Xiaoguang Tong
- School of Medicine, Nankai University, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
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20
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Wang B, Tian F, Tong X. Clinical Grading System, Surgical Outcomes and Prognostic Analysis of Cranial Base Chordomas. J Korean Neurosurg Soc 2022; 65:469-478. [PMID: 35462525 PMCID: PMC9082115 DOI: 10.3340/jkns.2021.0240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/25/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Cranial base chordomas are rare, but their treatment is challenging. Tumor recurrence is still common despite improvements in microsurgical techniques and postoperative radiotherapy. We retrospectively analyzed the course of treatment, overall survival, and recurrence/progression of chordomas over the past 10 years.
Methods We retrospectively reviewed 50 patients who underwent surgery at Tianjin Huanhu Hospital between 2010 and 2020 and were pathologically diagnosed with chordomas. Tumor resection was performed within the maximum safe range in all patients; the extent of resection was evaluated by imaging; and the incidence of complications, recurrence or progression, and overall survival were assessed.
Results Fifty patients were divided into the low-risk group (LRG) and high-risk group (HRG) based on the cranial chordoma grading system (CCGS). The Karnofsky Performance Scale scores and gross total resection rate of the LRG were significantly higher than those of the HRG (p<0.05). The incidence of complications and mortality in the LRG were lower than those of HRG. The analysis of cumulative survival and cumulative recurrence free survival/progression free survival (RFS/PFS) showed no statistical differences in the extent of resection for survival, recurrence, or progression. Univariate and multivariate analyses showed that Ki-67 was significantly associated with tumor recurrence and was an independent hazard factor (p=0.02).
Conclusion The CCGS can help neurosurgeons anticipate surgical outcomes. Pathological results are important in evaluating the possibility of tumor recurrence, and postoperative radiotherapy improves overall survival and RFS/PFS.
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21
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Muhonen EG, Yasaka TM, Lehrich BM, Goshtasbi K, Papagiannopoulos P, Tajudeen BA, St John MA, Harris JP, Hsu FP, Kuan EC. Impact of Treatment Modalities upon Survival Outcomes in Skull Base and Clival Chordoma: An NCDB Analysis. J Neurol Surg B Skull Base 2022; 84:60-68. [PMID: 36743709 PMCID: PMC9897903 DOI: 10.1055/a-1733-9475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 01/06/2022] [Indexed: 02/07/2023] Open
Abstract
Objectives Skull base chordomas are locally aggressive malignant tumors derived from the notochord remnant. There are limited large-scale studies examining the role and extent of surgery and radiation therapy. Design Analysis of the National Cancer Database (NCDB) was performed to evaluate the survival outcomes of various treatments, and to assess for predictors of overall survival (OS). Participants This is a retrospective, population-based cohort study of patients diagnosed with a clival/skull base chordoma between 2004 and 2015 in the NCDB. Main Outcome Measures The primary outcome was overall survival (OS). Results In all, 468 cases were identified. Forty-nine percent of patients received surgery and 20.7% had positive margins. Mean age at diagnosis was 48.4 years in the surgical cohort, and 55% were males. Of the surgical cohort, 33.8% had negative margins, 20.7% had positive margins, and 45.5% had unknown margin status. Age ≥ 65 (hazard ratio [HR]: 3.07; 95% confidence interval [CI]: 1.63-5.76; p < 0.001), diagnosis between 2010 and 2015 (HR: 0.49; 95% CI: 0.26-0.90; p = 0.022), tumor size >5 cm (HR: 2.29; 95% CI: 1.26-4.15; p = 0.007), and government insurance (HR: 2.28; 95% CI: 1.24-4.2; p = 0.008) were independent predictors of OS. When comparing surgery with or without adjuvant radiation, no survival differences were found, regardless of margin status ( p = 0.66). Conclusion Surgery remains the mainstay of therapy. Advanced age (>65 years), large tumor size, and government insurance were predictors of worse OS. Whereas negative margins and the use of adjuvant radiation did not appear to impact OS, these may very well reduce local recurrences. A multidisciplinary approach is critical in achieving optimal outcomes in this challenging disease.
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Affiliation(s)
- Ethan G. Muhonen
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States
| | - Tyler M. Yasaka
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States
| | - Brandon M. Lehrich
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States
| | - Khodayar Goshtasbi
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States
| | - Peter Papagiannopoulos
- Department of Otolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Bobby A. Tajudeen
- Department of Otolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Maie A. St John
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, United States
| | - Jeremy P. Harris
- Department of Radiation Oncology, University of California, Irvine, Orange, California, United States
| | - Frank P.K. Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, California, United States
| | - Edward C. Kuan
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States,Department of Neurological Surgery, University of California, Irvine, Orange, California, United States,Address for correspondence Edward C. Kuan, MD, MBA Department of Otolaryngology–Head and Neck Surgery, University of CaliforniaIrvine, 101 The City Drive South Orange, CA 92868-3201United States
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22
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Multimodal Intraoperative Image-Driven Surgery for Skull Base Chordomas and Chondrosarcomas. Cancers (Basel) 2022; 14:cancers14040966. [PMID: 35205724 PMCID: PMC8870528 DOI: 10.3390/cancers14040966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023] Open
Abstract
Given the difficulty and importance of achieving maximal resection in chordomas and chondrosarcomas, all available tools offered by modern neurosurgery are to be deployed for planning and resection of these complex lesions. As demonstrated by the review of our series of skull base chordoma and chondrosarcoma resections in the Advanced Multimodality Image-Guided Operating (AMIGO) suite, as well as by the recently published literature, we describe the use of advanced multimodality intraoperative imaging and neuronavigation as pivotal to successful radical resection of these skull base lesions while preventing and managing eventual complications.
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23
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Chen G, Li M, Xu W, Wang X, Feng M, Wang R, Liu X. Surgical Outcomes of Clival Chordoma Through Endoscopic Endonasal Approach: A Single-Center Experience. Front Endocrinol (Lausanne) 2022; 13:800923. [PMID: 35464053 PMCID: PMC9019489 DOI: 10.3389/fendo.2022.800923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Clival chordoma is a locally aggressive tumor with low metastatic potential. In the past decade, endoscopic endonasal approach (EEA) for clival chordoma has had a higher resection rate and a lower morbidity rate than transcranial approaches. Here, we present our initial single-center experience after EEA of clival chordomas. PATIENTS AND METHODS This study retrospectively analyzed 17 consecutive patients with clival chordoma who received EEA in our department between March 2015 and September 2021. The operation was performed by a single surgeon with EEA. The clinical and pathological characteristics were analyzed along with the surgical outcomes and complications. RESULTS A total of 17 consecutive patients with clival chordoma received EEA with a median follow-up of 29.2 months (range 1-79). Gross total resection (GTR) was performed in 7 cases (41%), subtotal resection (STR) in 7 case (41%) and partially resection (PR) in 3 cases (18%). Cerebrospinal fluid leakage occurred in 2 cases (12%) and meningitis developed in 3 patients (18%) which were all successfully treated with intravenous antibiotics without any complications. There were no perioperative deaths or new focal neurological deficits postoperatively. Four in 7 patients with STR have had radiotherapy while the other three chose to be monitored. Till the last follow-up, three patients in STR group who received radiotherapy (3 in 4) had no tumor regrowth, while one in STR group with radiotherapy (1 in 4) showed tumor progression. Two patients in STR group without radiotherapy (2 in 3) showed stable tumor while the left one (1 in 3) showed tumor progression. One patient in the PR group died of tumor progression 2 years postoperation and the other one showed tumor progression and died of lung cancer 1 year postoperation. In addition, 1 in 7 patients with GTR had tumor recurrence in situ after 10 months and developed surgical pathway seeding in the spinal canal in C1 after 16 months. No recurrence occurred in the other 6 cases with GTR during the follow-up. CONCLUSION Although more cases are needed, our case series showed EEA is a safe and reliable method for clival chordoma with high resection rates and low morbidity rates. GTR without tumor residuum would improve the outcome.
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Affiliation(s)
- Ge Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Chinese Pituitary Specialists Congress, Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Chinese Pituitary Specialists Congress, Beijing, China
| | - Wenlong Xu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Chinese Pituitary Specialists Congress, Beijing, China
| | - Xu Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Chinese Pituitary Specialists Congress, Beijing, China
| | - Ming Feng
- Chinese Pituitary Specialists Congress, Beijing, China
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Chinese Pituitary Specialists Congress, Beijing, China
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Chinese Pituitary Specialists Congress, Beijing, China
- *Correspondence: Xiaohai Liu,
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24
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Napieralska A, Blamek S. Intracranial chordoma: radiosurgery, hypofractionated stereotactic radiotherapy and treatment outcomes. Rep Pract Oncol Radiother 2021; 26:764-772. [PMID: 34760311 DOI: 10.5603/rpor.a2021.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/04/2021] [Indexed: 11/25/2022] Open
Abstract
Background The aim of the study was to assess the results of stereotactic radiosurgery and hypofractionated stereotactic radiotherapy (SRS/SRT) for skull base chordomas. Materials and methods Twenty-three patients aged 12-75 were treated with SRS/SRT due to skull base chordoma. In 19 patients SRS/SRT was a part of the primary therapy, while in 4, a part of the treatment of recurrence. In 4 patients SRS/SRT was used as a boost after conventional radiotherapy and in 19 cases it was the only irradiation method applied. Patients were irradiated to total dose of 6-35 Gy and median total equivalent dose of 52 Gy. Results During median follow-up of 39 months, 4 patients died. One-, two- and five-year OS was 95%, 89% and 69%, respectively. In nine patients, progression of the disease was diagnosed during study period. One-, two- and five-year progression free survival (PFS) from the end of radiotherapy was 81%, 59% and 43%, respectively. Radiotherapy was well tolerated and only two patients in our group experienced moderate treatment-related toxicity. Conclusion SRS/SRT alone or in combination with surgery is a safe and effective method of irradiation of patients with skull base chordomas. High EQD2 is necessary to achieve satisfactory treatment results.
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Affiliation(s)
- Aleksandra Napieralska
- Radiotherapy Department, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Sławomir Blamek
- Radiotherapy Department, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
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25
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Roy A, Warade A, Jha AK, Misra BK. Skull Base Chordoma: Long-Term Observation and Evaluation of Prognostic Factors after Surgical Resection. Neurol India 2021; 69:1608-1612. [PMID: 34979650 DOI: 10.4103/0028-3886.333474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Skull base chordoma (SBC) is relatively rare and data on its clinical outcome after surgical resection and adjuvant radiotherapy are still limited. OBJECTIVE Analyzing the clinical postoperative outcome of SBC patients and defining prognostic factors regarding current treatment modalities. METHODS AND MATERIAL In this study, 41 SBC patients from 2001 to 2017 were retrospectively analyzed in this single-center study. RESULTS The most common clinical symptoms were headache (63%) and problems concerning vision (54%) like diplopia. The follow-up controls took place from 1 to 192 months. The mean survival time for the patients was 123.37 months (95% CI 90.89-155.86). The 5- and 10-year survival rates were 73.3 and 49%, respectively. Regarding the Karnofsky-Performance Scale (KPS), Cox regression showed a significant relationship between the survival rates in the overall study population and pre-surgery KPS (P = 0.004). This was further supported with a positive significant correlation between the pre-surgery KPS and the KPS at the last follow-up (P = 0.039). CONCLUSION Statistical analysis showed that repeat surgical resection and radiotherapy could be prognostic factors. Furthermore, we were able to show that mortality decreased by 4.5% with each 10 points increase of pre-surgery KPS. This could be a major prognostic factor when deciding treatment modalities. Nevertheless, further standardized clinical studies with a larger patient population should be carried out to extrapolate prognostic factors and improve treatment modalities.
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Affiliation(s)
- Amrit Roy
- Department of Neurosurgery, HELIOS-Klinikum Berlin-Buch, Berlin, Germany
| | - Anshu Warade
- Department of Neurosurgery, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Ashish K Jha
- Department of Neurosurgery, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Basant K Misra
- Department of Neurosurgery, PD Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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26
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Cavallo LM, Mazzatenta D, d'Avella E, Catapano D, Fontanella MM, Locatelli D, Luglietto D, Milani D, Solari D, Vindigni M, Zenga F, Zona G, Cappabianca P. The management of clival chordomas: an Italian multicentric study. J Neurosurg 2021; 135:93-102. [PMID: 32886913 DOI: 10.3171/2020.5.jns20925] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the last 2 decades, the endoscopic endonasal approach in the treatment of clival chordomas has evolved to be a viable strategy to achieve maximal safe resection of this tumor. Here, the authors present a multicentric national study, intending to analyze the evolution of this approach over a 20-year time frame and its contribution in the treatment of clival chordomas. METHODS Clival chordoma cases surgically treated between 1999 and 2018 at 10 Italian neurosurgical departments were included in this retrospective study. Clinical, radiological, and surgical findings, adjuvant therapy, and outcomes were evaluated and compared according to classification in the treatment eras from 1999 to 2008 and from 2009 to 2018. RESULTS One hundred eighty-two surgical procedures were reviewed, with an increase in case load since 2009. The endoscopic endonasal transclival approach (EETA) was performed in 151 of 182 cases (83.0%) and other approaches were performed in 31 cases (17%). There was an increment in the use of EETA, neuronavigation, and Doppler ultrasound after 2008. The overall postoperative complication rate was 14.3% (26 of 182 cases) consisting of 9 CSF leaks (4.9%), 7 intracranial hemorrhages (3.8%), 5 cases of meningitis (2.7%), and 5 cerebral ischemic injuries (2.7%). Gross-total resection (GTR) was achieved in 93 of 182 cases (51.1%). Extent of resection (EOR) improved in the second era of the study. Signs and/or symptoms at presentation worsened in 27 cases (14.8%), and the Katz Index worsened in 10 cases (5.5%). Previous treatment, dural involvement, EETA, and intraoperative Doppler ultrasound correlated with GTR. Patients received adjuvant proton beam radiation in 115 of 182 cases (63.2%), which was administered more in the latter era. Five-year progression-free survival (PFS) and overall survival (OS) were 62.3% and 73.5%, respectively. GTR, EETA, proton beam therapy, and the chondroid subtype correlated with a better survival rate. The mean follow-up was 62 months. CONCLUSIONS Through multicentric data collection, this study encompasses the largest series in the literature of clival chordomas surgically treated through an EETA. An increase in the use of this approach was found among Italian neurosurgical departments together with an improved extent of resection over time. The satisfactory rate of GTR was marked by low surgical morbidity and the preservation of patient quality of life. Surgical outcome was reinforced, in terms of PFS and OS, by the use of proton beam therapy, which was increasingly performed along the period of study.
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Affiliation(s)
- Luigi Maria Cavallo
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples
| | - Diego Mazzatenta
- 2Department of Biomedical and Neuromotor Sciences, University of Bologna, IRCCS Institute of Neurological Sciences of Bologna, "Bellaria" Hospital, Bologna
| | - Elena d'Avella
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples
| | - Domenico Catapano
- 3Division of Neurosurgery, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo
| | | | - Davide Locatelli
- 5Division of Neurosurgery, Università degli Studi dell'Insubria, Ospedale di Circolo e Fondazione Macchi, Varese
| | | | - Davide Milani
- 7Division of Neurosurgery, Humanitas Research Hospital, Rozzano
| | - Domenico Solari
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples
| | - Marco Vindigni
- 8Neurosurgery Unit, Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine
| | - Francesco Zenga
- 9Department of Neuroscience, "Rita Levi Montalcini", Neurosurgery Unit, University of Turin; and
| | - Gianluigi Zona
- 10Neurosurgery and Neurotraumatology, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Paolo Cappabianca
- 1Department of Neurosciences and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, University of Napoli "Federico II", Naples
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27
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Munari S, Colangeli R, Ramacciotti G, Zanoletti E. Clivus Chordoma: Case Report and Current Considerations on Treatment Strategies. J Int Adv Otol 2021; 16:286-290. [PMID: 32784169 DOI: 10.5152/iao.2020.7494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chordomas are the rare malignant bone lesions derived from the embryonic notochord. They are slow-growing tumors with a locally aggressive behavior. The clival chordomas are extradural, exophytic, and lytic lesions centered on the clivus, and are managed differently from those arising elsewhere because of the emphasis on preserving the neurological function. The gold standard for therapy is the complete resection followed by radiation therapy for a better local control of the tumor. This case report concerns a 20-year old girl with an incidental diagnosis of the clival chordoma, which was first treated via an endoscopic anterior approach to remove the exophytic portion of the tumor. The adjuvant radiation therapy was not feasible because of the macroscopic intradural residual tumor being at the level of jugular foramen. The girl was referred to our institute for the removal of the intradural residual tumor via a petro-occipital trans-sigmoid (POTS) approach followed by adjuvant proton beam therapy. The choice of the surgical approach depends on the size of the tumor, its location, and its anatomical distribution, but should also be balanced against the morbidity, considering the patient's age, and the feasibility of postoperative rehabilitation.
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Affiliation(s)
- Sara Munari
- Division of Otolaryngology, Department of Neurosciences DNS, Padova University, Padova, Italy
| | - Roberta Colangeli
- Division of Otolaryngology, Department of Neurosciences DNS, Padova University, Padova, Italy
| | - Giulia Ramacciotti
- Division of Otolaryngology, Department of Neurosciences DNS, Padova University, Padova, Italy
| | - Elisabetta Zanoletti
- Division of Otolaryngology, Department of Neurosciences DNS, Padova University, Padova, Italy
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Numerical Simulation of Nasal Airflow Aerodynamics, and Warming and Humidification in Models of Clival Chordoma Pre and Post-Endoscopic Endonasal Surgery. Respir Physiol Neurobiol 2021; 291:103693. [PMID: 34020066 DOI: 10.1016/j.resp.2021.103693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/16/2021] [Accepted: 05/15/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To study the effect of endoscopic endonasal surgery on nasal function for the treatment of clival chordoma. METHODS Pre and post-operative computed tomography (CT) scans of a case of chordoma treated with an endoscopic endonasal approach (EEA) were collected retrospectively, and models of the nasal cavity were reconstructed so that a subsequent numerical simulation of nasal airflow characteristics, warming, and humidification could be conducted. RESULTS Middle turbinectomy resulted in redistribution of airflow within the nasal cavity, and the most significant changes occurred in the middle section. Consistent with the results of airflow evaluation, it was found that the change in nasal anatomical structure significantly reduced warming and humidification. Nasal humidification decreased substantially when postoperative loss of mucosa was taken into consideration. The H2O mass fraction of pharynx in inspiration phase were significantly correlated with airway surface-to-volume ratio (SVR). CONCLUSIONS The EEA for chordoma significantly affected nasal function. Attention should be paid to the protection of nasal structure and the associated mucosa.
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29
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Cahill J, Ibrahim R, Mezey G, Yianni J, Bhattacharyya D, Walton L, Grainger A, Radatz MWR. Gamma Knife Stereotactic Radiosurgery for the treatment of chordomas and chondrosarcomas. Acta Neurochir (Wien) 2021; 163:1003-1011. [PMID: 33608764 DOI: 10.1007/s00701-021-04768-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 02/10/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Primary chordomas and chondrosarcomas of the skull base are difficult tumours to treat successfully. Despite advances in surgical techniques, a gross total resection is often impossible to achieve. In addition, some patients may be deemed unsuitable or not wish to undergo extensive surgery for these conditions. This study examines the role of Gamma Knife Stereotactic Radiosurgery (GKRS) in the treatment of these difficult cases. METHODS All patients harbouring either a chordoma or chondrosarcoma treated at the National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK, between 1985 and 2018, were reviewed with regard to their clinical presentations, pre- and post-treatment imaging, GKRS prescriptions and outcomes. RESULTS In total, 24 patients with a mean tumour volume of 13 cm3 in the chordoma group (n=15) and 12 cm3 in the chondrosarcoma group (n=9) underwent GKRS. The 5- and 10-year overall survival rates for the chordoma group were 67% and 53% respectively, while for the chondrosarcoma group, they were 78% at both time points. The tumour control rates at 5 and 10 years in the chordoma group were 67% and 49% and for the chondrosarcoma group 78% at both time points. Patients with tumour volumes of less than 7 cm3 before GKRS treatment demonstrated a statistically significant longer overall survival rate (p=0.03). CONCLUSIONS GKRS offers a comparable option to proton beam therapy for the treatment of these tumours. Early intervention for tumour volumes of less than 7 cm3 gives the best long-term survival rates.
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30
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Metcalfe C, Muzaffar J, Kulendra K, Sanghera P, Shaw S, Shad A, Saravanappa N, Paluzzi A, Ahmed S. Chordomas and chondrosarcomas of the skull base: treatment and outcome analysis in a consecutive case series of 24 patients. World J Surg Oncol 2021; 19:68. [PMID: 33750413 PMCID: PMC7945343 DOI: 10.1186/s12957-021-02178-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background We present our 9-year consecutive case series of skull base chordomas and chondrosarcomas from a UK tertiary referral centre, discussing treatments offered and outcomes. This was carried out to improve understanding around current treatment and to better inform the management of future patients. Methods Consecutive case series over a 9-year period (2007–2016). Retrospective data analysis from the electronic skull base multidisciplinary team database and the digital patient records at a UK tertiary referral centre Results Twenty-four patients were identified (11 chordomas, 13 chondrosarcomas, mean age 52). Nineteen had proton beam therapy (PBT) postoperatively; two had intensity-modulated radiotherapy; two had no further treatment. One patient was lost to follow-up. All chordomas were resected via a transnasal endoscopic approach. Of the 19 patients undergoing resection with PBT, 13 were disease free at latest follow-up, and six patients had local recurrence, of which two died (mean follow up 7.4 years). Of the three patients treated with surgery then IMRT/TomoTherapy, one died 4 years post-treatment, and the other two are alive after 4 and 5 years of follow-up respectively. Of the two patients treated with surgery alone, one was lost to follow-up, and the other is alive after more than 8 years. Chondrosarcoma 5-year survival was 91.6%, and chordoma 4-year survival was 75%. Conclusion Skull base chordomas and chondrosarcomas can be challenging to resect, and most cases require adjuvant therapy to achieve control. Where complete resection is not possible, it is critical to undertake sufficient resection to permit high-dose radiation.
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Affiliation(s)
- Christopher Metcalfe
- Regional Skull-Base Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Jameel Muzaffar
- Regional Skull-Base Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Kevin Kulendra
- Regional Skull-Base Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Paul Sanghera
- Regional Skull-Base Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Simon Shaw
- Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Amjad Shad
- University Hospital Coventry & Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | | | - Alessandro Paluzzi
- Regional Skull-Base Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Shahzada Ahmed
- Regional Skull-Base Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK.
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Barber SM, Sadrameli SS, Lee JJ, Fridley JS, Teh BS, Oyelese AA, Telfeian AE, Gokaslan ZL. Chordoma-Current Understanding and Modern Treatment Paradigms. J Clin Med 2021; 10:jcm10051054. [PMID: 33806339 PMCID: PMC7961966 DOI: 10.3390/jcm10051054] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 01/29/2021] [Accepted: 01/31/2021] [Indexed: 12/23/2022] Open
Abstract
Chordoma is a low-grade notochordal tumor of the skull base, mobile spine and sacrum which behaves malignantly and confers a poor prognosis despite indolent growth patterns. These tumors often present late in the disease course, tend to encapsulate adjacent neurovascular anatomy, seed resection cavities, recur locally and respond poorly to radiotherapy and conventional chemotherapy, all of which make chordomas challenging to treat. Extent of surgical resection and adequacy of surgical margins are the most important prognostic factors and thus patients with chordoma should be cared for by a highly experienced, multi-disciplinary surgical team in a quaternary center. Ongoing research into the molecular pathophysiology of chordoma has led to the discovery of several pathways that may serve as potential targets for molecular therapy, including a multitude of receptor tyrosine kinases (e.g., platelet-derived growth factor receptor [PDGFR], epidermal growth factor receptor [EGFR]), downstream cascades (e.g., phosphoinositide 3-kinase [PI3K]/protein kinase B [Akt]/mechanistic target of rapamycin [mTOR]), brachyury—a transcription factor expressed ubiquitously in chordoma but not in other tissues—and the fibroblast growth factor [FGF]/mitogen-activated protein kinase kinase [MEK]/extracellular signal-regulated kinase [ERK] pathway. In this review article, the pathophysiology, diagnosis and modern treatment paradigms of chordoma will be discussed with an emphasis on the ongoing research and advances in the field that may lead to improved outcomes for patients with this challenging disease.
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Affiliation(s)
- Sean M. Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, TX 77030, USA; (S.M.B.); (S.S.S.); (J.J.L.)
| | - Saeed S. Sadrameli
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, TX 77030, USA; (S.M.B.); (S.S.S.); (J.J.L.)
| | - Jonathan J. Lee
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, TX 77030, USA; (S.M.B.); (S.S.S.); (J.J.L.)
| | - Jared S. Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI 02903, USA; (J.S.F.); (A.A.O.); (A.E.T.)
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, TX 77030, USA;
| | - Adetokunbo A. Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI 02903, USA; (J.S.F.); (A.A.O.); (A.E.T.)
| | - Albert E. Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI 02903, USA; (J.S.F.); (A.A.O.); (A.E.T.)
| | - Ziya L. Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI 02903, USA; (J.S.F.); (A.A.O.); (A.E.T.)
- Correspondence: ; Tel.: +1-(401)-793-9132
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Apparent diffusion coefficient as a prognostic factor in clival chordoma. Sci Rep 2021; 11:486. [PMID: 33436803 PMCID: PMC7804259 DOI: 10.1038/s41598-020-79894-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022] Open
Abstract
Clival chordoma is a rare disease with high recurrence rates even after a combination of surgical resection and radiotherapy. Apparent diffusion coefficient (ADC) has been used to evaluate aggressive features of chordoma, but its utility for clival chordoma has not been explored specifically. In this study, the utility of preoperative ADC values was analyzed for predicting tumor progression and recurrence in patients with clival chordoma. Between 2012 and 2019, a total of 30 operated cases were analyzed with available preoperative ADC data. Receiver operating characteristic (ROC) analysis was used to obtain ADC cutoff values for predicting tumor aggressiveness. The mean and minimum ADC values were significantly lower in the aggressive tumor group than in the stable tumor group (both P < 0.001). ROC analysis showed that a mean cutoff ADC value of 1198 × 10−6 mm2/s and minimum ADC value of 895.5 × 10–6 mm2/s could be used to predict aggressive features of clival chordoma. Subtotal resection, partial resection, and mean and minimum ADC values that were lower than cutoff values were negative predictors of overall survival and progression-free survival. In conclusion, mean and minimum ADC values could be useful in predicting aggressiveness of clival chordoma.
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33
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Haubner F, Rachinger W. [Multidisciplinary management of clival chordoma]. Laryngorhinootologie 2020; 100:357-363. [PMID: 33348381 DOI: 10.1055/a-1332-2002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Chordoma of the clivus belong to the rare tumors of the skull base. Due to their aggresive behaviour including intradural infiltration of neurovascular structures an interdisciplinary treatment is mandatory. This article gives an overview on current surgical concepts including the endoscopic approach as well as the postoperative radiotherapy. Novel diagnostic tools and molecular targets to optimize individual tumor therapy are discussed.
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Affiliation(s)
- Frank Haubner
- HNO-Klinik, LMU Faculty of Medicine, München, Germany
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Zweckberger K, Giese H, Haenig B, Federspil PA, Baumann I, Albrecht T, Uhl M, Unterberg A. Clivus chordomas: Heterogeneous tumor extension requires adapted surgical approaches. Clin Neurol Neurosurg 2020; 199:106305. [PMID: 33091655 DOI: 10.1016/j.clineuro.2020.106305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/01/2020] [Accepted: 10/11/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Clivus chordomas are semi-malignant, but infiltratively growing tumors. Currently, a widely-accepted treatment concept encompasses maximal, but safe, surgical resection and radiotherapy. Caused by the size and the tumor extension, different surgical approaches, especially in recurrent cases, might be necessary. METHODS Retrospective review of 50 patients on whom 70 surgeries were performed: 29 in primary and 41 in recurrent cases. Based on MRI images, all cases were asserted according to the size and the extension of the tumor. Used surgical approaches were evaluated. Postoperative complications, neurological function prior to and after the surgery, the extent of tumor resection on postoperative MR images were assessed and progression-free survival was calculated. RESULTS Tumor size was estimated as small (< 5 cm3) in 8, as medium (5-20 cm3) in 21, as large (20-100 cm3) in 17, and as giant (> 100 cm3) in 4 patients. Most frequently used surgical approaches in primary cases were the transsphenoidal one and midfacial degloving (51.7 % and 17.2 %, respectively). In recurrent cases, dependent on the tumor extension, transsphenoidal (21.9 %), retrosigmoidal (29.3 %), and pterional (19.5 %) approaches, as well as midfacial degloving (17.1 %) were used. Due to the vast tumor extension and infiltration, gross total or near total resection could be achieved in 12 patients (24 %), only. There was no mortality and no major complications in primary cases. In recurrences, however, postoperative hemorrhages and strokes emerged in 4.9 % and 7.1 %. Minor complications occurred in 17.1 % and were dominated by CSF leaks (12.2 %), both in primary in recurrent cases. While most cranial nerve impairments were caused by tumor infiltration of the cavernous sinus, and hence have not improved by treatment, the sixth nerve palsy as a consequence of tumor mass compression, could significantly be improved by surgery. Following surgery, patients were subjected to radiotherapy (68.9 % for primary cases, and 36.6 % for recurrences) mainly with carbon ions. Overall, 5-year progression-free survival was 44.7 %. CONCLUSION Caused by the heterogenous pattern of growth of clivus chordomas, surgical approaches should be chosen individually. Vast and infiltrative tumor extension constitute major limitations of surgical resection, and hence result in poor progression-frees survival.
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Affiliation(s)
| | - Henrik Giese
- Department of Neurosurgery, University of Heidelberg, Germany
| | - Benjamin Haenig
- Department of Neurosurgery, University of Heidelberg, Germany
| | - Philippe A Federspil
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Heidelberg, Germany
| | - Ingo Baumann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Heidelberg, Germany
| | - Tobias Albrecht
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Heidelberg, Germany
| | - Matthias Uhl
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
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Champagne PO, Passeri T, Jabre R, Bernat AL, Voormolen EH, Froelich S. Vertebrobasilar Artery Encasement by Skull Base Chordomas: Surgical Outcome and Management Strategies. Oper Neurosurg (Hagerstown) 2020; 19:375-383. [PMID: 32324880 DOI: 10.1093/ons/opaa091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/10/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Vascular encasement by skull base chordomas can increase surgical risk and hinder completeness of resection. However, the evidence behind this remains anecdotic. OBJECTIVE To give a better portrayal of chordomas encasing vertebrobasilar arteries mainly in regard of surgical vascular risk and its impact on extent of resection. METHODS A retrospective cohort study comparing skull base chordomas with encasement (≥180o encirclement) of the vertebrobasilar arteries to a control group of skull base chordomas with intradural extension. Data gathered involved pre- and postoperative volumetric analysis of the tumor, degree of encasement of involved vessel, occurrence of complication, and survival data including progression-free survival (PFS) and overall survival (OS). RESULTS A total of 24 patients with vertebrobasilar encasement were included in the study and an equal number of control cases were randomly selected from the same time period, totalizing 48 patients. Lower clival tumors with condyle involvement were more likely to have encasement. Gross total resection (GTR) rate was significantly lower in the encasement group (13% vs 42%, P = .023). Rates of postoperative new neurological deficit, CFS leak and 30 d postoperative mortality were not statistically different between groups. There was no statistically significant difference in mean PFS (P = .608) and OS (P = .958). CONCLUSION Skull base chordomas encasing vertebrobasilar arteries are highly challenging tumors. This study demonstrates that although safe resection is possible, GTR is hindered by the presence of encasement. We advocate letting the tumor's adherence to vessels lead the resection, leaving a small piece of tumor behind if adherent to the vessels.
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Affiliation(s)
| | - Thibault Passeri
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
| | - Roland Jabre
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
- Neurosurgery Service, Department of Surgery, Centre hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Canada
| | - Anne-Laure Bernat
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
| | - Eduard H Voormolen
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
| | - Sébastien Froelich
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
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Li H, Zhang H, Hu L, Wang H, Wang D. Endoscopic endonasal resection and radiotherapy as treatment for skull base chordomas. Acta Otolaryngol 2020; 140:789-794. [PMID: 32804560 DOI: 10.1080/00016489.2020.1748225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of endonasal endoscopic surgery and radiotherapy in the treatment of skull base chordomas remains unclear. OBJECTIVE We investigated the effect of endonasal endoscopic surgery and radiotherapy as treatment for skull base chordomas. METHOD We investigated 46 patients (2006-2018) treated at the Affiliated Eye Ear Nose and Throat Hospital, Fudan University. We documented demographics, clinical presentation, operative resection, complications, postoperative radiotherapy, follow-up time, and survival in all patients. RESULT Complete tumour resection was performed in 18 (39.1%), subtotal tumour resection in 16 (34.8%), and partial tumour resection in 12 (26.1%) patients. Most common clinical manifestations included nasal obstruction (41%), headaches (30%), and visual impairment (20%). The median duration of progression-free survival (PFS) and overall survival (OS) was 21.5 and 33.5 months, respectively. Primary vs. recurrent disease (p = .043), partial resection (PR) vs. subtotal resection (STR) (p = .006), STR vs. gross total resection (GTR) (p = .020), GTR vs. PR (p = .001), and complicated vs. uncomplicated status (p = .002) were significantly associated with PFS. Primary vs. recurrent disease (p = .002), PR vs. STR (p = .001), GTR vs. PR (p = .001), surgery alone vs. surgery concomitant with radiotherapy (p = .048), and complicated vs. uncomplicated status (p = .017) were significantly associated with OS. CONCLUSION Surgery is the primary treatment for chordoma; higher tumour resection rates are associated with higher OS and PFS. Surgeons should aim to resect as much tumour as is safely possible. Postoperative radiotherapy is useful adjuvant treatment to improve OS, and IMRT serves as an effective alternative to PBRT.The optimal radiotherapeutic technique is determined by cost, accessibility, availability of the modality, and tumour volume.
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Affiliation(s)
- Hongbing Li
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
| | - Huankang Zhang
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
| | - Li Hu
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
- Department of Research Centre, Eye and ENT Hospital of Fudan University, Shanghai, China
| | - Huan Wang
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
| | - Dehui Wang
- Department of Otolaryngology, Eye and ENT Hospital of Fudan University, Shanghai, China
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Detchou DK, Dimentberg R, Vaughan KA, Kolster R, Braslow BM, Malhotra NR. Navigated Ultrasonic Osteotomy to Aid in En Bloc Chordoma Resection via Spondylectomy. World Neurosurg 2020; 143:319-324. [PMID: 32791231 DOI: 10.1016/j.wneu.2020.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chordomas are rare, locally malignant tumors derived from remnants of the notochord that can manifest anywhere in the spine or base of the skull. Surgical treatment for chordomas of the lumbar spine often fails to achieve successful en bloc resection, which is critical to minimizing recurrence risk. CASE DESCRIPTION In this case report, the authors describe total en bloc resection of a lumbar vertebral body chordoma via the first documented approach of navigated ultrasonic osteotomy for spondylectomy. The patient is a 43-year-old man with end-stage renal disease, requiring dialysis, secondary to diabetes mellitus. The lesion in question was incidentally discovered in the L5 vertebral body during full body scanning for evaluation for a renal transplant. The lesion was diagnosed as a chordoma via percutaneous coaxial needle biopsy. Allogeneic renal transplant was canceled pending treatment of this newly discovered lesion. A combined, staged approach of L3-pelvis posterior instrumented fusion, L5 laminectomy and spondylectomy, and anterior L5 cage reconstruction with L4-S1 fusion was planned. Intraoperative computed tomography scan was performed and stereotactic osteotomies were planned. Ultrasonic osteotome (SONOPET Ultrasonic Aspirator) was registered as a navigation tool and employed, after verification, to complete the posterior stereotactic osteotomies, with postoperative computed tomography, magnetic resonance imaging, and pathology demonstrating successful en bloc resection. The navigated osteotome provided a critical combination of surgical precision and efficiency intraoperatively. CONCLUSIONS This approach offers a promising technological adjunct for the treatment of complex spine tumors requiring precise resection and reconstruction.
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Affiliation(s)
- Donald K Detchou
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Dimentberg
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kerry A Vaughan
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel Kolster
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin M Braslow
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Translational Spine Research Lab, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Surgical Outcomes with Midline versus Lateral Approaches for Cranial Base Chordomas: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 140:378-388.e2. [DOI: 10.1016/j.wneu.2020.03.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 12/15/2022]
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Connors SW, Aoun SG, Shi C, Peinado-Reyes V, Hall K, Bagley CA. Recent advances in understanding and managing chordomas: an update. F1000Res 2020; 9. [PMID: 32724558 PMCID: PMC7366033 DOI: 10.12688/f1000research.22440.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 12/20/2022] Open
Abstract
Chordomas are rare and difficult-to-treat tumors arising from the embryonic notochord. While surgery is the mainstay of treatment, and despite new techniques aimed at maximizing total tumoral resection, recurrence remains high and the probability of disease-free survival low. New breakthroughs in genetics, targeted molecular therapy, and heavy-particle beam therapy offer some promise as adjuvant treatments in addition to surgical resection. A multidisciplinary approach encompassing genetics, immunotherapy, radiation therapy, and surgery, at a facility experienced in the management of this complex disease, offers the best chance of survival and quality of life to patients while limiting the intrinsic morbidity of these treatments.
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Affiliation(s)
- Scott W Connors
- Department of Neurological Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA.,UT Southwestern Spine Center, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Chen Shi
- Department of Neurological Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Valery Peinado-Reyes
- Department of Neurological Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA.,UT Southwestern Spine Center, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Kristen Hall
- Department of Neurological Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA.,UT Southwestern Spine Center, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Carlos A Bagley
- Department of Neurological Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA.,UT Southwestern Spine Center, University of Texas Southwestern School of Medicine, Dallas, TX, USA.,Department of Orthopedic Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA
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Cytotoxic T lymphocyte antigen-4 (CTLA-4) expression in chordoma and tumor-infiltrating lymphocytes (TILs) predicts prognosis of spinal chordoma. Clin Transl Oncol 2020; 22:2324-2332. [DOI: 10.1007/s12094-020-02387-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/10/2020] [Indexed: 12/26/2022]
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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De Virgilio A, Costantino A, Ebm C, Conti V, Mondello T, Di Bari M, Cugini G, Mercante G, Spriano G. High definition three-dimensional exoscope (VITOM 3D) for microsurgery training: a preliminary experience. Eur Arch Otorhinolaryngol 2020; 277:2589-2595. [DOI: 10.1007/s00405-020-06014-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023]
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Hottinger AL, Bojaxhiu B, Ahlhelm F, Walser M, Bachtiary B, Zepter S, Lomax T, Pica A, Weber DC. Prognostic impact of the "Sekhar grading system for cranial Chordomas" in patients treated with pencil beam scanning proton therapy: an institutional analysis. Radiat Oncol 2020; 15:96. [PMID: 32375820 PMCID: PMC7201750 DOI: 10.1186/s13014-020-01547-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/22/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Skull base chordomas are rare and heterogeneously behaving tumors. Though still classified as benign they can grow rapidly, are locally aggressive, and have the potential to metastasize. To adapt the treatment to the specific needs of patients at higher risk of recurrence, a pre-proton therapy prognostic grading system would be useful. The aim of this retrospective analysis is to assess prognostic factors and the "Sekhar Grading System for Cranial Chordomas" (SGSCC) by evaluating the larger cohort of patients treated at our institution as to determine its reproducibility and ultimately to ensure more risk adapted local treatments for these challenging tumors. METHODS We analyzed 142 patients treated for skull base chordomas between 2004 and 2016. We focused the analysis on the 5 criteria proposed for the SGSCC (tumor size, number of anatomic regions and vessels involved, intradural invasion, as well as recurrence after prior treatment) and classified our patients according to their score (based on the above mentioned criteria) into three prognostic groups, low-risk, intermediate-risk and high-risk. The three groups were then analyzed in regards of local control, local recurrence-free survival and overall survival. RESULTS The median follow up was 52 months (range, 3-152). We observed 34 (24%) patients with a local recurrence, resulting in a local control of 75% at 5 years. Overall survival was 83% at 5 years, 12 (9%) patients had died due to local progression. When split into the three prognostic groups according to the SGSCC the observed local control was 90, 72 and 64% (p = 0.07) in the low-, intermediate- and high-risk group, respectively. A similar correlation was observed for local recurrence-free survival with 93, 89 and 66% (p = 0.05) and for overall survival with 89, 83 and 76% (p = 0.65) for the same prognostic groups. CONCLUSIONS After splitting our patient cohort into the three SGSCC risk groups, we found a trend towards better outcome for those patients with lower as opposed to higher scores. These results suggest that this prognostic grading system published by Sekhar et al. could be integrated in the management decision-tree for patients with skull base chordoma.
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Affiliation(s)
- Anna-Lena Hottinger
- Center for Proton Therapy, Paul Scherrer Institute, 5232 PSI West, Villigen, Switzerland
| | - Beat Bojaxhiu
- Center for Proton Therapy, Paul Scherrer Institute, 5232 PSI West, Villigen, Switzerland
| | - Frank Ahlhelm
- Neuroradiology Department, Kantonsspital Baden, Baden, Switzerland
| | - Marc Walser
- Center for Proton Therapy, Paul Scherrer Institute, 5232 PSI West, Villigen, Switzerland
| | - Barbara Bachtiary
- Center for Proton Therapy, Paul Scherrer Institute, 5232 PSI West, Villigen, Switzerland
| | - Stefan Zepter
- Center for Proton Therapy, Paul Scherrer Institute, 5232 PSI West, Villigen, Switzerland
| | - Tony Lomax
- Center for Proton Therapy, Paul Scherrer Institute, 5232 PSI West, Villigen, Switzerland
- Department of Physics, ETH Zürich, Zürich, Switzerland
| | - Alessia Pica
- Center for Proton Therapy, Paul Scherrer Institute, 5232 PSI West, Villigen, Switzerland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, 5232 PSI West, Villigen, Switzerland.
- Radiation Oncology Department, University Hospital of Bern, Bern, Switzerland.
- Radiation Oncology Department, University Hospital of Zürich, Zürich, Switzerland.
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Yaniv D, Soudry E, Strenov Y, Cohen MA, Mizrachi A. Skull base chordomas review of current treatment paradigms. World J Otorhinolaryngol Head Neck Surg 2020; 6:125-131. [PMID: 32596658 PMCID: PMC7296475 DOI: 10.1016/j.wjorl.2020.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 01/19/2020] [Indexed: 11/04/2022] Open
Abstract
Background Chordomas are locally invasive neoplasms, arising from notochordal remnants and can appear anywhere along the axial skeleton. Local recurrences are common, and distant metastases may occur years after the initial presentation. Methods Literature review of current treatment strategies for chordomas of the skull base. Results Surgery is the mainstay of treatment and complete resection has paramount importance for prognosis. When complete resection is not achieved recurrent disease is common. The anatomical complexity of the skull base makes resection complex. Endonasal endoscopic approaches to the clivus has become increasingly favored in recent years although addressing reconstruction of the skull base to prevent CSF leak may be challenging. Evidence suggests that radiotherapy should not be considered as a primary single modality when trying to achieve cure of the disease. Nonetheless, immediate post-operative radiotherapy improves survival. Many strategies have been suggested to preserve sensitive vital structures in the skull base during treatment but as for survival there is no evidence of advantage when comparing adjuvant therapy with photon radiotherapy, gamma knife surgery, proton beam therapy, and carbon ion radiation therapy. There is no evidence to support cytotoxic chemotherapy in the treatment of chordomas but targeted therapies have started to show promise. Several optional molecular targets exist. Brachyury is overexpressed in 95% of chordomas but not in other mesenchymal neoplasms. However, its precise role in chordoma pathogenesis is currently unclear, and its cellular location in the nucleus makes it difficult to target. The inhibition of brachyury in chordoma cell lines induces growth arrest and apoptosis. This does not have clinical application to date. There are retrospective results with different molecular targeted therapies for advanced chordomas with some effectiveness. Conclusion Despite improvements made in the past 10 years in our knowledge of chordoma biology, available therapies still offer a limited benefit. There is an unmet need for new therapeutic options for patients with advanced disease. Therefore, patients with advanced disease should be encouraged to participate in clinical trials when and where available.
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Affiliation(s)
- Dan Yaniv
- Department of Otolaryngology- Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ethan Soudry
- Department of Otolaryngology- Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yulia Strenov
- Department of Pathology, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marc A Cohen
- Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Aviram Mizrachi
- Department of Otolaryngology- Head and Neck Surgery, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Endoscopic Resection of Clival Chordoma: A Tertiary Care Experience. Indian J Otolaryngol Head Neck Surg 2020; 72:74-78. [PMID: 32158660 DOI: 10.1007/s12070-019-01746-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022] Open
Abstract
The primary management of the rare tumor chordoma is always surgical. This study indicates the advantage of endoscopic approach for clival chordoma resection. This is a Retrospective case series of 7 endoscopically operated clival chordoma patients between May 2015 and April 2018 in our tertiary care hospital. 5 patients presented with primary disease and 2 were recurrent disease cases. Endoscopic endonasal transphenoidal approach with wide clearance of margins of tumor were performed in all 7 cases. High energy photon radiotherapy were delivered to all. All patients with primary disease as well as recurrent disease had no evidence of disease 24-32 months post surgery. Endoscopic endonasal transphenoidal approach for clival chordoma provides a safe and reliable tumor resection. This less invasive surgery can be considered as an alternative to traditional surgical technique with reduced morbidity. This approach represents a combination of various endoscopic surgical techniques which are minimally invasive and can be applied to ventral skull base surgery.
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Michmerhuizen NL, Owen JH, Heft Neal ME, Mann JE, Leonard E, Wang J, Zhai J, Jiang H, McHugh JB, Brenner JC, Prince MEP. Rationale for the advancement of PI3K pathway inhibitors for personalized chordoma therapy. J Neurooncol 2020; 147:25-35. [PMID: 32067197 DOI: 10.1007/s11060-020-03418-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/30/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Chordomas are rare and serious tumors with few effective treatments outside of aggressive surgery and radiation. Targeted therapies may present a more effective option for a subset of patients with lesions possessing certain genetic biomarkers. METHODS A small molecule inhibitor library was tested in patient-derived UM-Chor1 cells to identify targeted therapies with potential efficacy. Targeted exome sequencing of UM-Chor1 and UM-Chor2 cells was performed to investigate genetic aberrations in relevant pathways. Chordoma cell lines were treated with inhibitors of the phosphotidylinositol 3-kinase (PI3K), epidermal growth factor receptor (EGFR), and cyclin dependent kinase (CDK) pathways, and responses were determined using resazurin cell viability assays, Annexin V apoptosis assays, and western blotting. Pan-PI3K inhibitor BKM120 was also tested in five chordoma xenograft models. RESULTS Unbiased small molecule profiling nominated PI3K-AKT-mTOR pathway inhibitors as a promising therapy in chordoma, and genetic analyses of UM-Chor1 and UM-Chor2 cell lines revealed aberrations in PTEN, EGFR, and CDKN2A. Treatment of UM-Chor1 and UM-Chor2 with targeted PI3K, EGFR, and CDK inhibitors inhibited growth and proliferation and induced apoptosis more robustly than imatinib, a currently used chordoma therapy. Furthermore, BKM120 significantly inhibited tumor growth in a subset of the xenograft models tested. CONCLUSION Targeted therapies, especially those inhibiting PI3K, display promising effects in multiple chordoma cell line and xenograft models. Nevertheless, the limited effects of PI3K, EGFR, and CDK targeting agents in other models reveal the presence of resistance mechanisms, which motivates future research to both identify biomarkers of response and develop combination therapies.
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Affiliation(s)
- N L Michmerhuizen
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, 1150 E. Medical Center Dr., 9301B MSRB3, Ann Arbor, MI, 48109-0602, USA
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - J H Owen
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, 1150 E. Medical Center Dr., 9301B MSRB3, Ann Arbor, MI, 48109-0602, USA
| | - M E Heft Neal
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, 1150 E. Medical Center Dr., 9301B MSRB3, Ann Arbor, MI, 48109-0602, USA
| | - J E Mann
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, 1150 E. Medical Center Dr., 9301B MSRB3, Ann Arbor, MI, 48109-0602, USA
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - E Leonard
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, 1150 E. Medical Center Dr., 9301B MSRB3, Ann Arbor, MI, 48109-0602, USA
| | - J Wang
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, 1150 E. Medical Center Dr., 9301B MSRB3, Ann Arbor, MI, 48109-0602, USA
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - J Zhai
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - H Jiang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - J B McHugh
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - J C Brenner
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, 1150 E. Medical Center Dr., 9301B MSRB3, Ann Arbor, MI, 48109-0602, USA.
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI, USA.
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - M E P Prince
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, 1150 E. Medical Center Dr., 9301B MSRB3, Ann Arbor, MI, 48109-0602, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI, USA
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Yoo SK, Strickland BA, Zada G, Bian SX, Garsa A, Ye JC, Yu C, Weiss MH, Wrobel BB, Giannotta S, Chang EL. Use of Salvage Surgery or Stereotactic Radiosurgery for Multiply Recurrent Skull Base Chordomas: A Single-Institution Experience and Review of the Literature. J Neurol Surg B Skull Base 2020; 82:161-174. [PMID: 33777630 DOI: 10.1055/s-0039-3402019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/09/2019] [Indexed: 10/25/2022] Open
Abstract
Introduction Chordomas are locally destructive neoplasms characterized by appreciable recurrence rates after initial multimodality treatment. We examined the outcome of salvage treatment in recurrent/progressive skull base chordomas. Methods This is a retrospective review of recurrent/progressive skull base chordomas at a tertiary urban academic medical center. The outcomes evaluated were overall survival, progression-free survival (PFS), and incidence of new toxicity. Results Eighteen consecutive patients who underwent ≥1 course of treatment (35.3% salvage surgery, 23.5% salvage radiation, and 41.2% both) were included. The median follow-up was 98.6 months (range 16-215 months). After initial treatment, the median PFS was 17.7 months (95% confidence interval [CI]: 4.9-22.6 months). Following initial therapy, age ≥ 40 had improved PFS on univariate analysis ( p = 0.03). All patients had local recurrence, with 15 undergoing salvage surgical resections and 16 undergoing salvage radiation treatments (mostly stereotactic radiosurgery [SRS]). The median PFS was 59.2 months (95% CI: 4.0-99.3 months) after salvage surgery, 58.4 months (95% CI: 25.9-195 months) after salvage radiation, and 58.4 months (95% CI: 25.9.0-98.4 months) combined. Overall survival for the total cohort was 98.7% ± 1.7% at 2 years and 92.8% ± 5.5% at 5 years. Salvage treatments were well-tolerated with two patients (11%) reporting tinnitus and one patient each (6%) reporting headaches, visual field deficits, hearing loss, anosmia, dysphagia, or memory loss. Conclusion Refractory skull base chordomas present a challenging treatment dilemma. Repeat surgical resection or SRS seems to provide adequate salvage therapy that is well-tolerated when treated at a tertiary center offering multimodality care.
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Affiliation(s)
- Stella K Yoo
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Ben A Strickland
- Department of Neurosurgery, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Shelly X Bian
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Adam Garsa
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Jason C Ye
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Martin H Weiss
- Department of Neurosurgery, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Bozena B Wrobel
- Caruso Department of Otolaryngology Head and Neck Surgery, University of Southern California, Los Angeles, California, United States
| | - Steven Giannotta
- Department of Neurosurgery, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California, United States
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48
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Quality of life considerations for patients with anterior and central skull base malignancies. J Neurooncol 2020; 150:501-508. [DOI: 10.1007/s11060-019-03367-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
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Kremenevski N, Schlaffer SM, Coras R, Kinfe TM, Graillon T, Buchfelder M. Skull Base Chordomas and Chondrosarcomas. Neuroendocrinology 2020; 110:836-847. [PMID: 32541136 DOI: 10.1159/000509386] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 11/19/2022]
Abstract
Skull base chordomas account for less than 0.2% and chondrosarcomas for less than 0.15% of all intracranial tumors. Although their clinical and imaging presentations are similar, they derive from different origins. Chordomas arise from embryonic remnants of the primitive notochord and chondrosarcomas from primitive mesenchymal cells or from the embryonic rest of the cranial cartilaginous matrix. Both entities are characterized by infiltration and destruction of the surrounding bone and soft tissue and a high locoregional recurrence rate. Chondrosarcomas, when treated with similar complex strategies, display a much better prognosis than chordomas. The overall survival is approximately 65% for chordomas and 80% for chondrosarcomas at 5 years and 30 and 50%, respectively, at 10 years. Chordomas are divided into the following 3 histological types: classical (conventional), chondroid, and dedifferentiated. Chondrosarcomas have conventional, mesenchymal, clear cell, and dedifferentiated subgroups. Both tumor entities often present with nonspecific symptoms, and headaches are the most reported initial symptom. Computed tomography and magnetic resonance imaging are required to determine the tumor localization and the extent of tumor growth. The treatment philosophy is to maximize tumor resection, minimize morbidity, and preserve function. Neurosurgical approaches commonly used for the resection of intracranial chordomas and chondrosarcomas are transsphenoidal, transbasal, cranio-orbitozygomatic, transzygomatic extended middle fossa, transcondylar, and transmaxillary approaches. Chordomas and chondrosarcomas are not sensitive to chemotherapy and there are no approved drugs for their treatment. The present treatment concept is a combination of surgical resection with a maximal excision and preserving patients' quality of life by adjuvant radiotherapy for both chordomas and chondrosarcomas.
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Affiliation(s)
- Natalia Kremenevski
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany,
| | | | - Roland Coras
- Institute of Neuropathology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Mehari Kinfe
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Graillon
- Department of Neurosurgery, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
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50
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[From bench to bedside for new treatment paradigms in chordomas: An update]. Bull Cancer 2019; 107:129-135. [PMID: 31882268 DOI: 10.1016/j.bulcan.2019.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 11/23/2022]
Abstract
Chordomas are rare malignant tumours, which typically occur in the axial skeleton and skull base. They arise from embryonic remnants of the notochord. They constitute less than 5 % of primary bone tumours. They are characterised by their locally aggressive potential with high frequency of recurrences and a median overall survival of 6 years. The initial therapeutic strategy must be discussed in an expert centre and may involve surgery, preoperative radiotherapy, exclusive radiotherapy or therapeutic abstention. Despite this, more than 50 % of patients will be facing recurrences with few therapeutic options available at this advanced stage. This review aims to outline current treatment options available in chordomas, as well as discussing potentiality of new therapeutic approaches through their molecular characterization and the comprehension of their immunological environment.
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