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Mazzucco M, Hwang S, Linos K, Hameed M, Shahzad F, Schmitt A, Boland P, Vaynrub M. Chordoma arising from the coccygeal disc and mimicking a pilonidal cyst. Skeletal Radiol 2024; 53:1431-1435. [PMID: 37953332 DOI: 10.1007/s00256-023-04492-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/29/2023] [Accepted: 10/19/2023] [Indexed: 11/14/2023]
Abstract
Chordomas are rare, low-grade malignant tumors often found in the sacrococcygeal region and prone to local recurrence. We report an atypical presentation of a 40-year-old patient with a symptomatic midline retrococcygeal lesion that was presumptively treated as a pilonidal cyst due to its clinical and imaging features. After surgical pathology rendered the diagnosis of chordoma, the patient required salvage surgery in the form of partial sacrectomy with soft tissue flap coverage. In addition to the unusually predominant retrococcygeal location, surgical pathology identified an intervertebral disc origin rather than the typical osseous origin. To our knowledge, this presentation of chordoma with coccygeal intervertebral origin and a large subcutaneous mass at imaging has rarely been reported in the literature. We describe this case to raise awareness of atypical presentations of sacrococcygeal chordoma that may lead to erroneous presumptive diagnosis and treatment.
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Affiliation(s)
- Michael Mazzucco
- Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD Program, New York, NY, 10065, USA
| | - Sinchun Hwang
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Konstantinos Linos
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Meera Hameed
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Farooq Shahzad
- Plastic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Adam Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Patrick Boland
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Max Vaynrub
- Plastic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Ioakeim-Ioannidou M, Rose M, Chen YL, MacDonald SM. The Use of Proton and Carbon Ion Radiation Therapy for Sarcomas. Semin Radiat Oncol 2024; 34:207-217. [PMID: 38508785 DOI: 10.1016/j.semradonc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
The unique physical and biological characteristics of proton and carbon ions allow for improved sparing of normal tissues, decreased integral dose to the body, and increased biological effect through high linear energy transfer. These properties are particularly useful for sarcomas given their histology, wide array of locations, and age of diagnosis. This review summarizes the literature and describes the clinical situations in which these heavy particles have advantages for treating sarcomas.
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Affiliation(s)
| | - Melanie Rose
- Department of Radiation Oncology, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA.
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Yeung CM, Bilsky M, Boland PJ, Vaynrub M. The Role of En Bloc Resection in the Modern Era for Primary Spine Tumors. Spine (Phila Pa 1976) 2024; 49:46-57. [PMID: 37732462 PMCID: PMC10750970 DOI: 10.1097/brs.0000000000004821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/27/2023] [Indexed: 09/22/2023]
Abstract
STUDY DESIGN A literature review. OBJECTIVE The aim of this review is to provide an overview of benign and malignant primary spine tumors and a balanced analysis of the benefits and limitations of (and alternatives to) surgical treatment with en bloc resection. SUMMARY OF BACKGROUND DATA Primary spine tumors are rare but have the potential to cause severe morbidity, either from the disease itself or as a result of treatment. The prognosis, goals, and treatment options vary significantly with the specific disease entity. Appropriate initial management is critical; inappropriate surgery before definitive treatment can lead to recurrence and may render the patient incurable, as salvage options are often inferior. METHODS We performed a comprehensive search of the PubMed database for articles relevant to primary spine neoplasms and en bloc spine surgery. Institutional review board approval was not needed. RESULTS Although Enneking-appropriate en bloc surgery can be highly morbid, it often provides the greatest chance for local control and/or patient survival. However, there is growing data to support modern radiotherapy as a feasible and less morbid approach to certain primary neoplasms that historically were considered radioresistant. CONCLUSIONS Choosing the optimal approach to primary spine tumors is complex. A comprehensive and up-to-date assessment of the evidence is required to guide patient care and to balance the often-competing goals of prolonging life and preserving quality of life.
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Affiliation(s)
- Caleb M. Yeung
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Patrick J. Boland
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Max Vaynrub
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Redmond KJ, Schaub SK, Lo SFL, Khan M, Lubelski D, Bilsky M, Yamada Y, Fehlings M, Gogineni E, Vajkoczy P, Ringel F, Meyer B, Amin AG, Combs SE, Lo SS. Radiotherapy for Mobile Spine and Sacral Chordoma: A Critical Review and Practical Guide from the Spine Tumor Academy. Cancers (Basel) 2023; 15:cancers15082359. [PMID: 37190287 DOI: 10.3390/cancers15082359] [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: 01/10/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Chordomas are rare tumors of the embryologic spinal cord remnant. They are locally aggressive and typically managed with surgery and either adjuvant or neoadjuvant radiation therapy. However, there is great variability in practice patterns including radiation type and fractionation regimen, and limited high-level data to drive decision making. The purpose of this manuscript was to summarize the current literature specific to radiotherapy in the management of spine and sacral chordoma and to provide practice recommendations on behalf of the Spine Tumor Academy. A systematic review of the literature was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) approach. Medline and Embase databases were utilized. The primary outcome measure was the rate of local control. A detailed review and interpretation of eligible studies is provided in the manuscript tables and text. Recommendations were defined as follows: (1) consensus: approved by >75% of experts; (2) predominant: approved by >50% of experts; (3) controversial: not approved by a majority of experts. Expert consensus supports dose escalation as critical in optimizing local control following radiation therapy for chordoma. In addition, comprehensive target volumes including sites of potential microscopic involvement improve local control compared with focal targets. Level I and high-quality multi-institutional data comparing treatment modalities, sequencing of radiation and surgery, and dose/fractionation schedules are needed to optimize patient outcomes in this locally aggressive malignancy.
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Affiliation(s)
- Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Stephanie K Schaub
- Department of Radiation Oncology, The University of Washington, Seattle, WA 98195, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY 11549, USA
| | - Majid Khan
- Department of Radiology, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurological Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michael Fehlings
- Department of Neurosurgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Emile Gogineni
- Department of Radiation Oncology, The Ohio State University, Columbus, OH 43210, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charite University Hospital, 10117 Berlin, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, 55131 Mainz, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich, 80333 Munich, Germany
| | - Anubhav G Amin
- Department of Neurological Surgery, University of Washington, Seattle, WA 98115, USA
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, 81675 Munich, Germany
| | - Simon S Lo
- Department of Radiation Oncology, The University of Washington, Seattle, WA 98195, USA
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Patel S, Nunna RS, Nie J, Ansari D, Chaudhry NS, Mehta AI. Incidence, Management, and Outcomes of Adult Spinal Chordoma Patients in the United States. Global Spine J 2023; 13:334-343. [PMID: 33583227 PMCID: PMC9972264 DOI: 10.1177/2192568221995155] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Spinal chordomas are rare primary malignant neoplasms of the primitive notochord. They are slow growing but locally aggressive lesions that have high rates of recurrence and metastasis after treatment. Gold standard treatment remains en-bloc surgical resection with questionable efficacy of adjuvant therapies such as radiation and chemotherapy. Here we provide a comprehensive analysis of prognostic factors, treatment modalities, and survival outcomes in patients with spinal chordoma. METHODS Patients with diagnosis codes specific for chordoma of spine, sacrum, and coccyx were queried from the National Cancer Database (NCDB) during the years 2004-2016. Outcomes were investigated using Cox univariate and multivariate regression analyses, and survival curves were generated for comparative visualization. RESULTS 1,548 individuals were identified with a diagnosis of chordoma, 60.9% of which were at the sacrum or coccyx and 39.1% at the spine. The mean overall survival of patients in our cohort was 8.2 years. Increased age, larger tumor size, and presence of metastases were associated with worsened overall survival. 71.2% of patients received surgical intervention and both partial and radical resection were associated with significantly improved overall survival (P < 0.001). Neither radiotherapy nor chemotherapy administration improved overall survival; however, amongst patients who received radiation, those who received proton-based radiation had significantly improved overall survival compared to traditional radiation. CONCLUSION Surgical resection significantly improves overall survival in patients with spinal chordoma. In those patients receiving radiation, those who receive proton-based modalities have improved overall survival. Further studies into proton radiotherapy doses are required.
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Affiliation(s)
- Saavan Patel
- Department of Neurosurgery, University of Illinois at
Chicago, IL, USA
| | - Ravi S. Nunna
- Department of Neurosurgery, University of Illinois at
Chicago, IL, USA
| | - James Nie
- Department of Neurosurgery, University of Illinois at
Chicago, IL, USA
| | - Darius Ansari
- Department of Neurosurgery, University of Illinois at
Chicago, IL, USA
| | | | - Ankit I. Mehta
- Department of Neurosurgery, University of Illinois at
Chicago, IL, USA,Ankit I. Mehta, Department of Neurosurgery,
University of Illinois at Chicago, 912 South Wood Street, 451-N, Chicago, IL,
60612, USA.
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6
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Outcomes of Recurrent Mobile Spine Chordomas. J Am Acad Orthop Surg 2023; 31:e278-e286. [PMID: 36729745 DOI: 10.5435/jaaos-d-22-00621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/20/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Chordomas of the mobile spine are rare malignant tumors. The purpose of this study was to review the outcomes of treatment for patients with recurrent mobile spine chordomas. METHODS The oncologic outcomes and survival of 30 patients undergoing treatment of a recurrent mobile spine chordoma were assessed over a 24-year period. The mean follow-up was 3.5 years. RESULTS In patients presenting with a recurrent mobile spine chordoma, the mean 2- and 5-year overall survival was 73% and 39%, respectively. Enneking appropriate resection trended toward improved overall survival at 5 years (100% vs. 32%, P = 0.24). Those undergoing surgical resection for recurrence had improved metastatic-free survival (hazard ratio 0.29, CI 0.08 to 0.99, P = 0.05). Positive margins were found to be a risk factor of further local recurrence (hazard ratio 7.92, CI 1.02 to 61.49, P = 0.04). Those undergoing nonsurgical management trended toward having an increase in new neurologic deficits (P = 0.09), however, there was no difference in overall complications based on treatment type (P = 0.13). CONCLUSION Recurrent mobile spine chordoma portends a poor prognosis with an overall survival of less than 40% at 5 years. Surgical resection may help prevent new neurologic deficits and tumor metastasis while en bloc excision with negative surgical margins is associated with improved local recurrence-free survival.
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Gaito S, Hwang EJ, France A, Aznar MC, Burnet N, Crellin A, Holtzman AL, Indelicato DJ, Timmerman B, Whitfield GA, Smith E. Outcomes of Patients Treated in the UK Proton Overseas Programme: Central Nervous System Group. Clin Oncol (R Coll Radiol) 2023; 35:283-291. [PMID: 36804292 DOI: 10.1016/j.clon.2023.01.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/15/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
AIMS In 2008, the UK National Health Service started the Proton Overseas Programme (POP), to provide access for proton beam therapy (PBT) abroad for selected tumour diagnoses while two national centres were being planned. The clinical outcomes for the patient group treated for central nervous system (CNS), base of skull, spinal and paraspinal malignancies are reported here. MATERIALS AND METHODS Since the start of the POP, an agreement between the National Health Service and UK referring centres ensured outcomes data collection, including overall survival, local tumour control and late toxicity data. Clinical and treatment-related data were extracted from this national patient database. Grade ≥3 late toxicities were reported following Common Terminology Criteria for Adverse Events (CTCAE) v 4.0 definition, occurring later than 90 days since the completion of treatment. RESULTS Between 2008 and September 2020, 830 patients were treated within the POP for the above listed malignancies. Overall survival data were available for 815 patients and local control data for 726 patients. Toxicity analysis was carried out on 702 patients, with patients excluded due to short follow-up (<90 days) and/or inadequate toxicity data available. After a median follow-up of 3.34 years (0.06-11.58), the overall survival was 91.2%. The local control rate was 85.9% after a median follow-up of 2.81 years (range 0.04-11.58). The overall grade ≥3 late toxicity incidence was 11.97%, after a median follow-up of 1.72 years (0.04-8.45). The median radiotherapy prescription dose was 54 GyRBE (34.8-79.2). CONCLUSIONS The results of this study indicate the safety of PBT for CNS tumours. Preliminary clinical outcomes following PBT for paediatric/teen and young adult and adult CNS tumours treated within the POP are encouraging, which reflects accurate patient selection and treatment quality. The rate of late effects compares favourably with published cohorts. Clinical outcomes from this patient cohort will be compared with those of UK-treated patients since the start of the national PBT service in 2018.
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Affiliation(s)
- S Gaito
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK.
| | - E J Hwang
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK; Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - A France
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK
| | - M C Aznar
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - N Burnet
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - A Crellin
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK; NHS England National Clinical Lead Proton Beam Therapy, UK
| | - A L Holtzman
- Department of Radiation Oncology, University of Florida, Gainesville, Florida, USA
| | - D J Indelicato
- Department of Radiation Oncology, University of Florida, Gainesville, Florida, USA
| | - B Timmerman
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Centre (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - G A Whitfield
- Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - E Smith
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Clinical Cancer Science, School of Medical Sciences, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
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Tobert DG, Kelly SP, Xiong GX, Chen YL, MacDonald SM, Bongers ME, Lozano-Calderon SA, Newman ET, Raskin KA, Schwab JH. The impact of radiotherapy on survival after surgical resection of chordoma with minimum five-year follow-up. Spine J 2023; 23:34-41. [PMID: 35470086 DOI: 10.1016/j.spinee.2022.04.009] [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: 01/14/2022] [Revised: 03/20/2022] [Accepted: 04/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Local control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up. PURPOSE The purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up. STUDY DESIGN/SETTING Retrospective, single-center, cohort study. PATIENT SAMPLE Patients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral. OUTCOME MEASURES The outcome measures were local recurrence-free interval (LRFI) and overall survival (OS). METHODS Demographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method. FUNDING STATEMENT No funding was obtained for this work. RESULTS Seventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1-24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810). CONCLUSION Chordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence.
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Affiliation(s)
- Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sean P Kelly
- Department of Orthopaedic Surgery, Pali Moma Medical Center, Honolulu, HI, USA
| | - Grace X Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michiel E Bongers
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Santiago A Lozano-Calderon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Erik T Newman
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin A Raskin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Pinter ZW, Moore EJ, Rose PS, Nassr AN, Currier BL. En bloc resection of a high cervical chordoma followed by reconstruction with a free vascularized fibular graft: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22305. [PMID: 36536523 PMCID: PMC9764371 DOI: 10.3171/case22305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Wide excision of chordoma provides better local control than intralesional resection or definitive radiotherapy. The en bloc excision of high cervical chordomas is a challenging endeavor because of the complex anatomy of this region and limited reconstructive options. OBSERVATIONS This is the first case report to describe reconstruction with a free vascularized fibular graft following the en bloc excision of a chordoma involving C1-3. LESSONS This report demonstrates the durability of this construct at 10-year follow-up and is the first case report demonstrating satisfactory long-term oncological outcomes after a true margin-negative resection of a high cervical chordoma.
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Affiliation(s)
| | - Eric J. Moore
- Department of Otorhinolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S. Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Ahmad N. Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; and
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Jae-Min Park A, McDowell S, Mesfin A. Management of Chordoma of the Sacrum and Mobile Spine. JBJS Rev 2022; 10:01874474-202212000-00004. [PMID: 36639876 DOI: 10.2106/jbjs.rvw.22.00162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
➢ Chordomas account for 1% to 4% of primary tumors of the spine and sacrum. ➢ En bloc resection is the preferred surgical treatment for the management of chordomas. ➢ Proton beam radiation is increasingly being used as a postoperative radiation modality for the treatment of chordomas.
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Affiliation(s)
- Andrew Jae-Min Park
- Department of Orthopedic Surgery and Physical Performance, University of Rochester School of Medicine & Dentistry, Rochester, New York
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11
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Nie M, Chen L, Zhang J, Qiu X. Pure proton therapy for skull base chordomas and chondrosarcomas: A systematic review of clinical experience. Front Oncol 2022; 12:1016857. [PMID: 36505855 PMCID: PMC9732011 DOI: 10.3389/fonc.2022.1016857] [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: 08/11/2022] [Accepted: 10/31/2022] [Indexed: 11/27/2022] Open
Abstract
Background Skull base chordoma and chondrosarcoma are exceptionally rare bone tumors with high propensity for local recurrence. Different postoperative radiation modalities are often used to improve the clinical efficacy. Proton therapy (PT) might be among the most promising ones because of the unique ballistic characteristics of high-energy particles. However, previous meta-analysis often included studies with combined radiation techniques. No systematic review to date has directly analyzed the survival and toxicity of pure PT for these two types of malignancies. Methods By following the PRISMA guidelines, a systematic search of three databases was conducted. Articles were screened and data were extracted according to a prespecified scheme. R 4.2.0 software was used to conduct the meta-analysis. Normal distribution test was used for the incidence rate of each subgroup. Results A total of seven studies involving 478 patients were included in this analysis. The quality of included articles ranged from moderate to high quality. All patients were histopathologically diagnosed with chordoma or chondrosarcoma, and the follow-up time of the cohort ranged from 21 to 61.7 months. For PT planning, the median target volume ranged from 15 cc to 40 cc, and the administered median dose varied from 63 to 78.4 GyRBE at 1.8-2.0 GyRBE per fraction. The 1-, 2-, 3-, 5-, and 7-year local control and overall survival rates were 100%, 93%, 87%, 78%, and 68%, and 100%, 99%, 89%, 85%, and 68%, respectively. The late grade 3 or higher toxicities were reported in only two involved articles. Conclusions Until now, medical centers worldwide have exerted PT to improve outcomes of skull base chordomas and chondrosarcomas. PT not combined with other radiation modalities showed favorable local control and survival with a low incidence of severe radiation-induced toxicities, which manifests promising clinical benefits. However, high-quality evidence is still limited, requiring future clinical trials and prospective studies in selected patients.
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Affiliation(s)
- Menglin Nie
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liying Chen
- Laboratory of Pathology, Hebei Cancer Institute, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jing Zhang
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoguang Qiu
- Department of Radiation Oncology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,*Correspondence: Xiaoguang Qiu,
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Chang C, Charyyev S, Harms J, Slopsema R, Wolf J, Refai D, Yoon T, McDonald MW, Bradley JD, Leng S, Zhou J, Yang X, Lin L. A component method to delineate surgical spine implants for proton Monte Carlo dose calculation. J Appl Clin Med Phys 2022; 24:e13800. [PMID: 36210177 PMCID: PMC9859997 DOI: 10.1002/acm2.13800] [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: 06/14/2022] [Revised: 09/09/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Metallic implants have been correlated to local control failure for spinal sarcoma and chordoma patients due to the uncertainty of implant delineation from computed tomography (CT). Such uncertainty can compromise the proton Monte Carlo dose calculation (MCDC) accuracy. A component method is proposed to determine the dimension and volume of the implants from CT images. METHODS The proposed component method leverages the knowledge of surgical implants from medical supply vendors to predefine accurate contours for each implant component, including tulips, screw bodies, lockers, and rods. A retrospective patient study was conducted to demonstrate the feasibility of the method. The reference implant materials and samples were collected from patient medical records and vendors, Medtronic and NuVasive. Additional CT images with extensive features, such as extended Hounsfield units and various reconstruction diameters, were used to quantify the uncertainty of implant contours. RESULTS For in vivo patient implant estimation, the reference and the component method differences were 0.35, 0.17, and 0.04 cm3 for tulips, screw bodies, and rods, respectively. The discrepancies by a conventional threshold method were 5.46, 0.76, and 0.05 cm3 , respectively. The mischaracterization of implant materials and dimensions can underdose the clinical target volume coverage by 20 cm3 for a patient with eight lumbar implants. The tulip dominates the dosimetry uncertainty as it can be made from titanium or cobalt-chromium alloys by different vendors. CONCLUSIONS A component method was developed and demonstrated using phantom and patient studies with implants. The proposed method provides more accurate implant characterization for proton MCDC and can potentially enhance the treatment quality for proton therapy. The current proof-of-concept study is limited to the implant characterization for lumbar spine. Future investigations could be extended to cervical spine and dental implants for head-and-neck patients where tight margins are required to spare organs at risk.
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Affiliation(s)
- Chih‐Wei Chang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Serdar Charyyev
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Joseph Harms
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Roelf Slopsema
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jonathan Wolf
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Daniel Refai
- Department of NeurosurgeryEmory UniversityAtlantaGeorgiaUSA
| | - Tim Yoon
- Department of OrthopaedicsEmory UniversityAtlantaGeorgiaUSA
| | - Mark W. McDonald
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jeffrey D. Bradley
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Shuai Leng
- Department of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA,Department of Biomedical InformaticsEmory UniversityAtlantaGeorgiaUSA
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
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13
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Gao J, Huang R, Yin H, Song D, Meng T. Research hotspots and trends of chordoma: A bibliometric analysis. Front Oncol 2022; 12:946597. [PMID: 36185236 PMCID: PMC9523362 DOI: 10.3389/fonc.2022.946597] [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: 05/17/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Chordoma is a type of mesenchymal malignancy with a high recurrence rate and poor prognosis. Due to its rarity, the tumorigenic mechanism and optimal therapeutic strategy are not well known. Methods All relevant articles of chordoma research from 1 January 2000 to 26 April 2022 were obtained from Web of Science Core Collection database. Blibliometrix was used to acquire basic publication data. Visualization and data table of collaboration network, dynamic analysis, trend topics, thematic map, and factorial analysis were acquired using Blibliometrix package. VOSviewer was used to generate a visualization map of co-citation analysis and co-occurrence. Results A total of 2,285 articles related to chordoma were identified. The most influential and productive country/region was the United States, and Capital Medical University has published the most articles. Among all high-impact authors, Adrienne M. Flanagan had the highest average citation rate. Neurosurgery was the important periodical for chordoma research with the highest total/average citation rate. We focused on four hotspots in recent chordoma research. The research on surgical treatment and radiotherapy was relatively mature. The molecular signaling pathway, targeted therapy and immunotherapy for chordoma are not yet mature, which will be the future trends of chordoma research. Conclusion This study indicates that chordoma studies are increasing. Surgery and radiotherapy are well reported and always play fundamental roles in chordoma treatment. The molecular signaling pathway, targeted therapy, and immunotherapy of chordoma are the latest research hotspots.
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Affiliation(s)
- Jianxuan Gao
- Department of Spine Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Tongji University Cancer Center, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Runzhi Huang
- Department of Spine Surgery, Tongji Hospital, Tongji University School of Medicine, Tongji University, Shanghai, China
| | - Huabin Yin
- Department of Spine Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Dianwen Song
- Department of Spine Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- *Correspondence: Tong Meng, ; Dianwen Song,
| | - Tong Meng
- Department of Spine Surgery, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- Tongji University Cancer Center, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Tong Meng, ; Dianwen Song,
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14
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Aoki S, Koto M, Ikawa H, Imai R, Tokuhiko O, Shinoto M, Takiyama H, Yamada S, Tsuji H. Long-term outcomes of high dose carbon-ion radiation therapy for unresectable upper cervical (C1-2) chordoma. Head Neck 2022; 44:2162-2170. [PMID: 35734902 PMCID: PMC9544549 DOI: 10.1002/hed.27127] [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: 02/16/2022] [Revised: 05/12/2022] [Accepted: 06/07/2022] [Indexed: 11/06/2022] Open
Abstract
Background Chordoma is a rare, locally invasive neoplasm of the axial skeleton. Complete resection is often difficult, especially for the upper‐cervical (C1‐2) spine. We evaluated the efficacy and safety of carbon‐ion radiotherapy (CIRT) for unresectable C1‐2 chordoma. Methods Patients with C1‐2 chordoma treated with definitive CIRT (60.8 Gy [RBE] in 16 fractions) were retrospectively analyzed. We evaluated OS, LC, PFS, and toxicity. Results Nineteen eligible patients all completed the planned course of CIRT. With the median follow‐up 68 months (range: 29–144), median OS was 126 months (range: 36‐NA). Five‐year OS, LC, and PFS were 68.4% (95% CI, 42.8%–84.4%), 75.2% (46.1%–90.0%), and 64.1% (36.3%–82.3%), respectively. Regarding acute toxicity of grade ≥3, there was only one grade 3 mucositis. Late toxicity included radiation‐induced myelitis (grade 3 in 1 patient; 5.3%), and compression fractures (n = 5; 26.3%). Conclusions High‐dose CIRT is a promising treatment option for unresectable upper cervical chordoma.
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Affiliation(s)
- Shuri Aoki
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan.,Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Masashi Koto
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Hiroaki Ikawa
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Reiko Imai
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Omatsu Tokuhiko
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Makoto Shinoto
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Hirotoshi Takiyama
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Shigeru Yamada
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Hiroshi Tsuji
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
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15
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McCoy R, Brandon MA, Jackson J, Rubenstein J, Jain S. Hyperbaric oxygen therapy treatment as an alternative for a chronic sinus tract after chordoma surgery and radiation. J Wound Care 2022; 31:S30-S32. [PMID: 35576200 DOI: 10.12968/jowc.2022.31.sup5.s30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Chordoma is a rare form of cancer that forms from the notochord remnants, and affects the skull and the spine. The standard treatment for a sacrococcygeal chordoma is surgery and radiation. Chordoma has a high rate of recurrence and surgery with radiation treatment can leave patients with surgical site complications, such as wounds, fistulas or sinus tracts. Repeat surgical intervention on an irradiated surgical site increases incidence of complications leading to decreased quality of life, and increased morbidity and mortality. Treatment of wound complications after surgery and high-dose radiation for a chordoma tumour is rarely reported in the literature. Herein, the author describes the case of a chronic sinus tract after surgery and radiation for a sacral chordoma tumour successfully healed by hyperbaric oxygen therapy (HBOT) in conjunction with topical antibiotics.
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Affiliation(s)
- Rachel McCoy
- Graduates of Lincoln Memorial University-Debusk College of Osteopathic Medicine, Harrogate, TN, US
| | - Michelé A Brandon
- Graduates of Lincoln Memorial University-Debusk College of Osteopathic Medicine, Harrogate, TN, US
| | - Jordan Jackson
- Graduates of Lincoln Memorial University-Debusk College of Osteopathic Medicine, Harrogate, TN, US
| | - Jane Rubenstein
- Graduates of Lincoln Memorial University-Debusk College of Osteopathic Medicine, Harrogate, TN, US
| | - Surbhi Jain
- Advent Health North Pinellas Wound Healing Institute of Trinity, New Port Richey, FL, US
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16
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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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17
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Chen ATC, Hong CBC, Narazaki DK, Rubin V, Serante AR, Ribeiro Junior U, de Lima LGCA, Coimbra BGMM, Cristante AF, Teixeira WGJ. High dose image-guided, intensity modulated radiation therapy (IG-IMRT) for chordomas of the sacrum, mobile spine and skull base: preliminary outcomes. J Neurooncol 2022; 158:23-31. [PMID: 35451720 DOI: 10.1007/s11060-022-04003-w] [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: 02/09/2022] [Accepted: 04/03/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To report preliminary outcomes of high dose image-guided intensity modulated radiotherapy (IG-IMRT) in the treatment of chordomas of the sacrum, mobile spine and skull base. METHODS Retrospective analysis of chordoma patients treated with surgery and/or radiotherapy (RT) in a single tertiary cancer center. Initial treatment was categorized as (A) Adjuvant or definitive high-dose RT (78 Gy/39fx or 24 Gy/1fx) vs (B) surgery-only or low dose RT. The primary endpoint was the cumulative incidence of local failure. RESULTS A total of 31 patients were treated from 2010 through 2020. Median age was 55 years, tumor location was 64% sacrum, 13% lumbar, 16% cervical and 6% clivus. Median tumor volume was 148 cc (8.3 cm in largest diameter), 42% of patients received curative-intent surgery and 65% received primary RT (adjuvant or definitive). 5-year cumulative incidence of local failure was 48% in group A vs 83% in group B (p = 0.041). Tumor size > 330 cc was associated with local failure (SHR 2.2, 95% CI 1.12 to 7.45; p = 0.028). Eight patients developed distant metastases, with a median metastases-free survival of 56.1 months. 5-year survival for patients that received high dose RT was 72% vs 76% in patients that received no or low dose RT (p = 0.63). CONCLUSION Our study suggests high-dose photon IG-IMRT improves local control in the initial management of chordomas. Health systems should promote reference centers with clinical expertise and technical capabilities to improve outcomes for this complex disease.
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Affiliation(s)
- Andre Tsin Chih Chen
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, Av. Dr. Arnaldo, 251, 4SS, São Paulo, SP, CEP 01246-000, Brazil.
| | - Carlos Bo Chur Hong
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, Av. Dr. Arnaldo, 251, 4SS, São Paulo, SP, CEP 01246-000, Brazil
| | - Douglas Kenji Narazaki
- Department of Spine Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
| | - Virginio Rubin
- Department of Radiology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
| | - Alexandre Ruggieri Serante
- Department of Radiation Oncology, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, Av. Dr. Arnaldo, 251, 4SS, São Paulo, SP, CEP 01246-000, Brazil
| | - Ulysses Ribeiro Junior
- Department of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
| | | | | | - Alexandre Fogaça Cristante
- Department of Spine Surgery of Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
| | - William Gemio Jacobsen Teixeira
- Department of Spine Surgery, Instituto do Câncer do Estado de São Paulo, Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil
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18
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Baldi GG, Lo Vullo S, Grignani G, Vincenzi B, Badalamenti G, Mastore M, Buonomenna C, Morosi C, Barisella M, Frezza AM, Provenzano S, Simeone N, Picozzi F, Mariani L, Casali PG, Stacchiotti S. Weekly cisplatin with or without imatinib in advanced chordoma: A retrospective case-series analysis from the Italian Rare Cancers Network. Cancer 2022; 128:1439-1448. [PMID: 35026050 DOI: 10.1002/cncr.34083] [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: 10/13/2021] [Revised: 11/20/2021] [Accepted: 12/06/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND To report on a retrospective case-series analysis of weekly cisplatin (wCDDP) as a single agent or combined with imatinib (wCDDP/I) in patients with advanced chordoma treated within the Italian Rare Cancer Network. METHODS Adult patients with a diagnosis of advanced, brachyury-positive chordoma, treated from April 2007 to October 2020 with wCDDP or wCDDP/I were retrospectively identified. Imatinib was withheld at the same time as wCDDP. Response according to Response Evaluation Criteria in Solid Tumors, overall survival (OS), and progression-free survival (PFS) were analyzed. RESULTS Thirty-three consecutive patients were identified (wCDDP as front-line n = 8 [24.2%]; wCDDP as a further line n = 25 [75.8%]; prior imatinib n = 25 [75.8%]; evidence of progression before starting wCDDP n = 33). Of 32 patients evaluable for response (wCDDP, n = 22 [68.8%]; wCDDP/I, n = 10 [31.3%]), best response was stable disease (SD) in 27 patients (84.3%) and progression in 5 patients (15.6%). At a median follow-up of 54 months, the median OS (m-OS) was 30.3 months (interquartile range [IQR], 18.1-56.6), the m-PFS was 8.0 months (IQR, 5.1-17.0), the 6-month PFS rate was 65.2%, and the 12-month PFS rate was 30.3%. Of 22 patients who received wCDDP, the best response was SD in 18 patients (81.8%) and progression in 4 patients (18.2%), and the m-PFS was 8.0 months (IQR, 5.1-17.0 months). Of 10 patients who received treatment with wCDDP/I, the best response was SD in 9 patients (90%) and progression in 1 patient (10%), and the m-PFS was 9.3 months (IQR, 4.9-26.5 months). CONCLUSIONS This series suggests that wCDDP, both as a single agent and combined with imatinib, has antitumor activity in chordoma. Although no dimensional responses were observed, 65% and 30% of previously progressive patients were progression-free at 6 and 12 months, respectively. A prospective study is warranted.
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Affiliation(s)
- Giacomo G Baldi
- Department of Medical Oncology, Hospital of Prato, Prato, Italy
| | - Salvatore Lo Vullo
- Unit of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Giovanni Grignani
- Division of Medical Oncology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo (TO), Italy
| | - Bruno Vincenzi
- Department of Medical Oncology, Campus Biomedico University of Rome, Rome, Italy
| | - Giuseppe Badalamenti
- Department of Surgical, Oncological, and Oral Sciences - Section of Medical Oncology, University of Palermo, Palermo, Italy
| | | | - Ciriaco Buonomenna
- Department of Radiology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Carlo Morosi
- Department of Radiology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Marta Barisella
- Department of Diagnostic Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Anna Maria Frezza
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Salvatore Provenzano
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Noemi Simeone
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Fernanda Picozzi
- Deparment of Medical Oncology, Azienda Ospedaliera di Rilievo Nazionale dei Colli Monaldi-Cotugno, Naples, Italy.,Department of Electrical Engineering and Information Technology, Federico II University of Naples, Naples, Italy
| | - Luigi Mariani
- Unit of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Paolo G Casali
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Silvia Stacchiotti
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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19
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Mehta M, Patel M, Parikh A, Suryanarayan U, Singh J, Thimmarayappa A, Pandya A. Chordoma: Retrospective analysis of patients treated with radiotherapy at a single institution. JOURNAL OF RADIATION AND CANCER RESEARCH 2022. [DOI: 10.4103/jrcr.jrcr_18_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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20
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Brinkmann EJ, Wenger DE, Johnson JD, Karim SM, Blezek DJ, Rose PS, Houdek MT. Impact of preoperative sarcopenia in patients undergoing sacral tumor resection. J Surg Oncol 2021; 125:790-795. [PMID: 34932215 DOI: 10.1002/jso.26776] [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] [Received: 07/19/2021] [Revised: 11/21/2021] [Accepted: 12/12/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Sacral tumor resection is known for a high rate of complications. Sarcopenia has been found to be associated with wound complications; however, there is a paucity of data examining the impact of sarcopenia on the outcome of sacral tumor resection. METHODS Forty-eight patients (31 primary sarcomas, 17 locally recurrent carcinomas) undergoing sacrectomy were reviewed. Central sarcopenia was assessed by measuring the psoas:lumbar vertebra index (PLVI), with the 50th percentile (0.97) used to determine which patients were high (>0.97) versus low (<0.97). RESULTS Twenty-four (50%) patients had a high PLVI and 24 (50%) had a low PLVI (sarcopenic). There was no difference (p > 0.05) in the demographics of patients with or without sarcopenia. There was no difference in the incidence of postoperative wound complications (odds ratio [OR] = 1.0, p = 1.0) or deep infection (OR = 0.83, p = 1.0). Sarcopenia was not associated with death due to disease (hazard ratio [HR] = 2.04, p = 0.20) or metastatic disease (HR = 2.47, p = 0.17), but was associated with local recurrence (HR = 6.60, p = 0.01). CONCLUSIONS Central sarcopenia was not predictive of wound complications or infection following sacral tumor resection. Sarcopenia was, however, an independent risk factor for local tumor recurrence following sacrectomy and should be considered when counseling patients on the outcome of sacrectomy.
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Affiliation(s)
- Elyse J Brinkmann
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Doris E Wenger
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua D Johnson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Syed M Karim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Blezek
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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21
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Karampouga M, Tsetsos F, Sakellariou P, Baltas I. Outcomes and issues of 12 chordomas treated in a single center. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00306-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Chordomas stem from notochordal vestiges and rank as low-grade bone malignancies although fraught with high risk of recurrence. This study assesses the clinical outcomes of twelve chordoma cases treated in our clinic, in an effort to shed light on the often under-represented pool of results deriving from non-referral centers.
Methods
We reviewed the clinicopathological traits of all chordoma patients registered in our center since 1991. Major endpoints were overall survival (OS) and progression-free survival (PFS) estimated using the Kaplan–Meier and Nelson–Aalen methods.
Results
Twelve patients, aged on average 47.9 years, were treated for primary or recurrent disease. Seven had chordomas originating in the cranium, 5 in the spine, including a bifocal tumor, and the mean time lapse between the beginning of symptoms and diagnosis was 15.4 months, marked by dull ache. Subtotal resection was achieved in 5 cases, incomplete in 5, while in 2, only biopsy was accomplished. Conformal radiotherapy was administered to 5 and stereotactic radiosurgery to 2 in the setting of recurrence. Protons were used once and targeted agents induced no clinical response in 3 patients. Median OS and PFS were 36 and 12 months, respectively, with the best outlook linked to maximal resection, spinal location, and good preoperative functional status. In all, 6 patients died of chordoma, 4 are alive, and 1 was lost. Relapse was the rule for most cases, except 2, and pulmonary metastases were ascertained in 1.
Conclusions
Our cases were typical of chordomas, implying that inadequate surgical margins and successive recurrence are negative determinants of prognosis and that interinstitutional cooperation counterbalances shortages in non-referral institutes.
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22
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Baig Mirza A, Bartram J, Okasha M, Al Banna Q, Vastani A, Maratos E, Gullan R, Thomas N. Surgical Management of Spinal Chordoma: A Systematic Review and Single-Center Experience. World Neurosurg 2021; 156:e111-e129. [PMID: 34506978 DOI: 10.1016/j.wneu.2021.09.001] [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: 07/13/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Chordoma is a rare neoplasm of the neuraxis derived from remnants of the primitive notochord. The importance of wide margins and use of adjuvant therapy in spinal chordomas are still contentious points in the management of spinal chordomas. We conducted a systematic review of the surgical management of spinal chordomas alongside our 10-year institutional experience. METHODS A systematic search of the literature was performed in November 2020 using Embase and MEDLINE for articles regarding the surgical management of chordomas arising from the mobile spine and sacrum. We also searched for all adult patients who were surgically managed for spinal chordomas at our institute between 2010 and 2020. In both the systematic review and our institutional case series, data on adequacy of resection, use of adjuvant therapy, complications, recurrence (local or metastatic), and survival outcomes were collected. RESULTS We identified and analyzed 42 articles, yielding 1531 patients, from which the overall gross total or wide resection rate was 54.9%. Among the 8 cases in our institutional experience (4 sacral, 3 cervical, and 1 lumbar), we achieved gross total resection in 50% of initial operations. The recurrence rate was 25% in our gross total resection group and 50% where initial resection was subtotal. Of patients, 75% had no evidence of recurrence at most recent follow-up. CONCLUSIONS Albeit difficult at times because of the proximity to neurovascular tissue, achieving a wide resection followed by adjuvant therapy for spinal chordomas is of great importance. Multidisciplinary discussion is valuable to ensure the best outcome for the patient.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom.
| | - James Bartram
- 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
| | - Qusai Al Banna
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Amisha Vastani
- 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
| | - Richard Gullan
- 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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23
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Chen X, Lo SFL, Bettegowda C, Ryan DM, Gross JM, Hu C, Kleinberg L, Sciubba DM, Redmond KJ. High-dose hypofractionated stereotactic body radiotherapy for spinal chordoma. J Neurosurg Spine 2021; 35:674-683. [PMID: 34388713 DOI: 10.3171/2021.2.spine202199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal chordoma is locally aggressive and has a high rate of recurrence, even after en bloc resection. Conventionally fractionated adjuvant radiation leads to suboptimal tumor control, and data regarding hypofractionated regimens are limited. The authors hypothesized that neoadjuvant stereotactic body radiotherapy (SBRT) may overcome its intrinsic radioresistance, improve surgical margins, and allow preservation of critical structures during surgery. The purpose of this study is to review the feasibility and early outcomes of high-dose hypofractionated SBRT, with a focus on neoadjuvant SBRT. METHODS Electronic medical records of patients with spinal chordoma treated using image-guided SBRT between 2009 and 2019 at a single institution were retrospectively reviewed. RESULTS Twenty-eight patients with 30 discrete lesions (24 in the mobile spine) were included. The median follow-up duration was 20.8 months (range 2.3-126.3 months). The median SBRT dose was 40 Gy (range 15-50 Gy) in 5 fractions (range 1-5 fractions). Seventeen patients (74% of those with newly diagnosed lesions) received neoadjuvant SBRT, of whom 15 (88%) underwent planned en bloc resection, all with negative margins. Two patients (12%) developed surgical wound-related complications after neoadjuvant SBRT and surgery, and 4 (two grade 3 and two grade 2) experienced postoperative complications unrelated to the surgical site. Of the remaining patients with newly diagnosed lesions, 5 received adjuvant SBRT for positive or close surgical margins, and 1 received SBRT alone. Seven recurrent lesions were treated with SBRT alone, including 2 after failure of prior conventional radiation. The 2-year overall survival rate was 92% (95% confidence interval [CI] 71%-98%). Patients with newly diagnosed chordoma had longer median survival (not reached) than those with recurrent lesions (27.7 months, p = 0.006). The 2-year local control rate was 96% (95% CI 74%-99%). Among patients with radiotherapy-naïve lesions, no local recurrence was observed with a biologically effective dose ≥ 140 Gy, maximum dose of the planning target volume (PTV) ≥ 47 Gy, mean dose of the PTV ≥ 39 Gy, or minimum dose to 80% of the PTV ≥ 36 Gy (5-fraction equivalent doses). All acute toxicities from SBRT were grade 1-2, and no myelopathy was observed. CONCLUSIONS Neoadjuvant high-dose, hypofractionated SBRT for spinal chordoma is safe and does not increase surgical morbidities. Early outcomes at 2 years are promising, although long-term follow-up is pending.
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Affiliation(s)
- Xuguang Chen
- Departments of1Radiation Oncology and Molecular Radiation Sciences
| | | | | | | | - John M Gross
- 4Pathology, Johns Hopkins University School of Medicine; and
| | - Chen Hu
- 5Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Clinical Outcome of Sacral Chordoma Patients Treated with Pencil Beam Scanning Proton Therapy. Clin Oncol (R Coll Radiol) 2021; 33:e578-e585. [PMID: 34340918 DOI: 10.1016/j.clon.2021.07.012] [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: 11/11/2020] [Revised: 05/25/2021] [Accepted: 07/16/2021] [Indexed: 11/22/2022]
Abstract
AIMS Sacral chordomas are locally aggressive, radio-resistant tumours. Proton therapy has the potential to deliver high radiation doses, which may improve the therapeutic ratio when compared with conventional radiotherapy. We assessed tumour control and radiation-induced toxicity in a cohort of sacral chordoma patients treated with definitive or postoperative pencil beam scanning proton therapy. METHODS AND MATERIALS Sixty patients with histologically proven sacral chordoma treated between November 1997 and October 2018 at the Paul Scherrer Institute with postoperative (n = 50) or definitive proton therapy (n = 10) were retrospectively analysed. Only 10 (17%) patients received combined photon radiotherapy and proton therapy. Survival rates were calculated using the Kaplan-Meier actuarial method. The Log-rank test was used to compare different functions for local control, freedom from distant recurrence and overall survival. Acute and late toxicity were assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. RESULTS The median follow-up was 48 months (range 4-186). Local recurrence occurred in 20 (33%) patients. The 4-year local control, freedom from distant recurrence and overall survival rates were 77%, 89% and 85%, respectively. On univariate analysis, subtotal resection/biopsy (P = 0.02), tumour extension restricted to bone (P = 0.01) and gross tumour volume >130 ml (P = 0.04) were significant predictors for local recurrence. On multivariate analysis, tumour extension restricted to bone (P = 0.004) and gross total resection (P = 0.02) remained independent favourable prognostic factors for local recurrence. Twenty-four (40%), 28 (47%) and eight (11%) patients experienced acute grade 1, 2 and 3 toxicities, respectively. The 4-year late toxicity-free survival was 91%. Two patients developed secondary malignancies to the bladder 3-7 years after proton therapy. CONCLUSIONS Our data indicate that pencil beam scanning proton therapy for sacral chordomas is both safe and effective. Gross total resection, tumour volume <130 ml and tumour restricted to the bone are favourable prognostic factors for local tumour control.
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El Sayed I, Trifiletti DM, Lehrer EJ, Showalter TN, Dutta SW. Protons versus photons for the treatment of chordoma. Cochrane Database Syst Rev 2021; 7:CD013224. [PMID: 34196007 PMCID: PMC8245311 DOI: 10.1002/14651858.cd013224.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Chordoma is a rare primary bone tumour with a high propensity for local recurrence. Surgical resection is the mainstay of treatment, but complete resection is often morbid due to tumour location. Similarly, the dose of radiotherapy (RT) that surrounding healthy organs can tolerate is frequently below that required to provide effective tumour control. Therefore, clinicians have investigated different radiation delivery techniques, often in combination with surgery, aimed to improve the therapeutic ratio. OBJECTIVES To assess the effects and toxicity of proton and photon adjuvant radiotherapy (RT) in people with biopsy-confirmed chordoma. SEARCH METHODS We searched CENTRAL (2021, Issue 4); MEDLINE Ovid (1946 to April 2021); Embase Ovid (1980 to April 2021) and online registers of clinical trials, and abstracts of scientific meetings up until April 2021. SELECTION CRITERIA We included adults with pathologically confirmed primary chordoma, who were irradiated with curative intent, with protons or photons in the form of fractionated RT, SRS (stereotactic radiosurgery), SBRT (stereotactic body radiotherapy), or IMRT (intensity modulated radiation therapy). We limited analysis to studies that included outcomes of participants treated with both protons and photons. DATA COLLECTION AND ANALYSIS The primary outcomes were local control, mortality, recurrence, and treatment-related toxicity. We followed current standard Cochrane methodological procedures for data extraction, management, and analysis. We used the ROBINS-I tool to assess risk of bias, and GRADE to assess the certainty of the evidence. MAIN RESULTS We included six observational studies with 187 adult participants. We judged all studies to be at high risk of bias. Four studies were included in meta-analysis. We are uncertain if proton compared to photon therapy worsens or has no effect on local control (hazard ratio (HR) 5.34, 95% confidence interval (CI) 0.66 to 43.43; 2 observational studies, 39 participants; very low-certainty evidence). Median survival time ranged between 45.5 months and 66 months. We are uncertain if proton compared to photon therapy reduces or has no effect on mortality (HR 0.44, 95% CI 0.13 to 1.57; 4 observational studies, 65 participants; very low-certainty evidence). Median recurrence-free survival ranged between 3 and 10 years. We are uncertain whether proton compared to photon therapy reduces or has no effect on recurrence (HR 0.34, 95% CI 0.10 to 1.17; 4 observational studies, 94 participants; very low-certainty evidence). One study assessed treatment-related toxicity and reported that four participants on proton therapy developed radiation-induced necrosis in the temporal bone, radiation-induced damage to the brainstem, and chronic mastoiditis; one participant on photon therapy developed hearing loss, worsening of the seventh cranial nerve paresis, and ulcerative keratitis (risk ratio (RR) 1.28, 95% CI 0.17 to 9.86; 1 observational study, 33 participants; very low-certainty evidence). There is no evidence that protons led to reduced toxicity. There is very low-certainty evidence to show an advantage for proton therapy in comparison to photon therapy with respect to local control, mortality, recurrence, and treatment related toxicity. AUTHORS' CONCLUSIONS There is a lack of published evidence to confirm a clinical difference in effect with either proton or photon therapy for the treatment of chordoma. As radiation techniques evolve, multi-institutional data should be collected prospectively and published, to help identify persons that would most benefit from the available radiation treatment techniques.
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Affiliation(s)
- Iman El Sayed
- Department of Biomedical Informatics and Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | | | - Eric J Lehrer
- Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Sunil W Dutta
- Department of Radiation Oncology, Emory University, Atlanta, USA
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26
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Zhang GJ, Cui YS, Li H. Survival and treatment of cranial and spinal chordomas: a population-based study. Neurosurg Rev 2021; 45:637-647. [PMID: 34156550 DOI: 10.1007/s10143-021-01583-5] [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: 03/09/2021] [Revised: 05/30/2021] [Accepted: 06/07/2021] [Indexed: 02/08/2023]
Abstract
Chordomas are rare, slow-growing malignant tumors. Given the paucity of data of the disease, the treatment strategies are disputed. We collected clinical and survival information of patients with chordoma diagnosed between 1975 and 2016 from the Surveillance, Epidemiology, and End Results database. A total of 1797 patients were initially enrolled, including 762 (42.4%) cranial and 1035 (57.6%) spinal chordoma. A total of 1504 patients were further evaluated after screening. In the cranial group, the surgery (gross total resection (GTR): p = 0.001 for overall survival (OS); p = 0.009 for cancer-specific survival (CSS)), tumor extension (distant metastasis: p = 0.001 for OS; p = 0.002 for CSS), and the age (p < 0.001 for OS) were independent prognostic factors for survival. In the spinal group, the age (p = 0.004), location (p < 0.001), GTR (p < 0.001), and tumor extension (distant metastasis, p < 0.001) were independent prognostic factors for OS; the age (p = 0.007), histological type (p < 0.001), GTR (p < 0.001), radiation (p = 0.018), chemotherapy (p = 0.006), and tumor extension (p < 0.001) were independent prognostic factors for CSS. In this large cohort, a significant association was noted between extent of resection and outcome. Even though adjuvant radiation or chemotherapy did not benefit patients with chordoma, the effect on prognosis can be explored in a further study based on our findings.
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Affiliation(s)
- Gui-Jun Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yu-Shi Cui
- Department of Orthopedic, Beijing Hospital of Traditional Chinese Medicine, Beijing University of Traditional Chinese Medicine, Chaoyang District, Beijing, CN100029, China
| | - Huan Li
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital Nansihuanxilu 119, Beijing, 100070, China.
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27
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Dandurand C, Fisher CG, Rhines LD, Boriani S, Charest-Morin R, Gasbarrini A, Luzzati A, Reynolds JJ, Wei F, Gokaslan ZL, Bettegowda C, Sciubba DM, Lazary A, Kawahara N, Clarke MJ, Rampersaud YR, Disch AC, Chou D, Shin JH, Hornicek FJ, Laufer II, Sahgal A, Dea N. Feasibility of achieving planned surgical margins in primary spine tumor: a PTRON study. Neurosurg Focus 2021; 50:E16. [PMID: 33932923 DOI: 10.3171/2021.2.focus201091] [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: 12/31/2020] [Accepted: 02/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Oncological resection of primary spine tumors is associated with lower recurrence rates. However, even in the most experienced hands, the execution of a meticulously drafted plan sometimes fails. The objectives of this study were to determine how successful surgical teams are at achieving planned surgical margins and how successful surgeons are in intraoperatively assessing tumor margins. The secondary objective was to identify factors associated with successful execution of planned resection. METHODS The Primary Tumor Research and Outcomes Network (PTRON) is a multicenter international prospective registry for the management of primary tumors of the spine. Using this registry, the authors compared 1) the planned surgical margin and 2) the intraoperative assessment of the margin by the surgeon with the postoperative assessment of the margin by the pathologist. Univariate analysis was used to assess whether factors such as histology, size, location, previous radiotherapy, and revision surgery were associated with successful execution of the planned margins. RESULTS Three hundred patients were included. The surgical plan was successfully achieved in 224 (74.7%) patients. The surgeon correctly assessed the intraoperative margins, as reported in the final assessment by the pathologist, in 239 (79.7%) patients. On univariate analysis, no factor had a statistically significant influence on successful achievement of planned margins. CONCLUSIONS In high-volume cancer centers around the world, planned surgical margins can be achieved in approximately 75% of cases. The morbidity of the proposed intervention must be balanced with the expected success rate in order to optimize patient management and surgical decision-making.
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Affiliation(s)
- Charlotte Dandurand
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles G Fisher
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Raphaële Charest-Morin
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Feng Wei
- 6Peking University Third Hospital, Beijing, China
| | | | | | - Daniel M Sciubba
- 8Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aron Lazary
- 9National Center for Spinal Disorders, Budapest, Hungary
| | | | | | | | | | - Dean Chou
- 14University of California, San Francisco, California
| | - John H Shin
- 15Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - IIya Laufer
- 17Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Arjun Sahgal
- 18Sunnybrook Hospital, University of Toronto, Ontario, Canada
| | - Nicolas Dea
- 1Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
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28
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Pennington Z, Ehresman J, Elsamadicy AA, Shin JH, Goodwin CR, Schwab JH, Sciubba DM. Systematic review of charged-particle therapy for chordomas and sarcomas of the mobile spine and sacrum. Neurosurg Focus 2021; 50:E17. [PMID: 33932924 DOI: 10.3171/2021.2.focus201059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Long-term local control in patients with primary chordoma and sarcoma of the spine and sacrum is increasingly reliant upon en bloc resection with negative margins. At many institutions, adjuvant radiation is recommended; definitive radiation is also recommended for the treatment of unresectable tumors. Because of the high off-target radiation toxicities associated with conventional radiotherapy, there has been growing interest in the use of proton and heavy-ion therapies. The aim of this study was to systematically review the literature regarding these therapies. METHODS The PubMed, OVID, Embase, and Web of Science databases were queried for articles describing the use of proton, combined proton/photon, or heavy-ion therapies for adjuvant or definitive radiotherapy in patients with primary sarcoma or chordoma of the mobile spine and sacrum. A qualitative synthesis of the results was performed, focusing on overall survival (OS), progression-free survival (PFS), disease-free survival (DFS), and disease-specific survival (DSS); local control; and postradiation toxicities. RESULTS Of 595 unique articles, 64 underwent full-text screening and 38 were included in the final synthesis. All studies were level III or IV evidence with a high risk of bias; there was also significant overlap in the reported populations, with six centers accounting for roughly three-fourths of all reports. Five-year therapy outcomes were as follows: proton-only therapies, OS 67%-82%, PFS 31%-57%, and DFS 52%-62%; metastases occurred in 17%-18% and acute toxicities in 3%-100% of cases; combined proton/photon therapy, local control 62%-85%, OS 78%-87%, PFS 90%, and DFS 61%-72%; metastases occurred in 12%-14% and acute toxicities in 84%-100% of cases; and carbon ion therapy, local control 53%-100%, OS 52%-86%, PFS (only reported for 3 years) 48%-76%, and DFS 50%-53%; metastases occurred in 2%-39% and acute toxicities in 26%-48%. There were no studies directly comparing outcomes between photon and charged-particle therapies or comparing outcomes between radiation and surgical groups. CONCLUSIONS The current evidence for charged-particle therapies in the management of sarcomas of the spine and sacrum is limited. Preliminary evidence suggests that with these therapies local control and OS at 5 years are comparable among various charged-particle options and may be similar between those treated with definitive charged-particle therapy and historical surgical cohorts. Further research directly comparing charged-particle and photon-based therapies is necessary.
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Affiliation(s)
- Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aladine A Elsamadicy
- 2Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - John H Shin
- 3Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - C Rory Goodwin
- 4Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Joseph H Schwab
- 5Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Mizumoto M, Fuji H, Miyachi M, Soejima T, Yamamoto T, Aibe N, Demizu Y, Iwata H, Hashimoto T, Motegi A, Kawamura A, Terashima K, Fukushima T, Nakao T, Takada A, Sumi M, Oshima J, Moriwaki K, Nozaki M, Ishida Y, Kosaka Y, Ae K, Hosono A, Harada H, Ogo E, Akimoto T, Saito T, Fukushima H, Suzuki R, Takahashi M, Matsuo T, Matsumura A, Masaki H, Hosoi H, Shigematsu N, Sakurai H. Proton beam therapy for children and adolescents and young adults (AYAs): JASTRO and JSPHO Guidelines. Cancer Treat Rev 2021; 98:102209. [PMID: 33984606 DOI: 10.1016/j.ctrv.2021.102209] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/02/2021] [Accepted: 04/11/2021] [Indexed: 11/19/2022]
Abstract
Children and adolescents and young adults (AYAs) with cancer are often treated with a multidisciplinary approach. This includes use of radiotherapy, which is important for local control, but may also cause adverse events in the long term, including second cancer. The risks for limited growth and development, endocrine dysfunction, reduced fertility and second cancer in children and AYAs are reduced by proton beam therapy (PBT), which has a dose distribution that decreases irradiation of normal organs while still targeting the tumor. To define the outcomes and characteristics of PBT in cancer treatment in pediatric and AYA patients, this document was developed by the Japanese Society for Radiation Oncology (JASTRO) and the Japanese Society of Pediatric Hematology/Oncology (JSPHO).
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Affiliation(s)
- Masashi Mizumoto
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroshi Fuji
- Department of Radiology and National Center for Child Health and Development, Tokyo, Japan
| | - Mitsuru Miyachi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Toshinori Soejima
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Norihiro Aibe
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Demizu
- Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Takayuki Hashimoto
- Department of Radiation Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Atsushi Motegi
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Atsufumi Kawamura
- Department of Neurosurgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keita Terashima
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Fukushima
- Department of Pediatric Hematology and Oncology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Tomohei Nakao
- Department of Pediatrics, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akinori Takada
- Department of Radiology, Mie University Hospital, Tsu-shi, Mie, Japan
| | - Minako Sumi
- Department of Radiation Oncology and Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Radiation Oncology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | | | - Kensuke Moriwaki
- Department of Medical Statistics, Kobe Pharmaceutical University, Kobe, Hyogo, Japan
| | - Miwako Nozaki
- Department of Radiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Yuji Ishida
- Department of Pediatrics, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Keisuke Ae
- Department of Orthopaedic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ako Hosono
- Department of Pediatric Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Hideyuki Harada
- Division of Radiation Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Etsuyo Ogo
- Department of Radiology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Tetsuo Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Takashi Saito
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroko Fukushima
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ryoko Suzuki
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mitsuru Takahashi
- Department of Orthopaedic Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Medicine, Nagasaki, Japan
| | - Akira Matsumura
- Departments of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hidekazu Masaki
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Sakurai
- Departments of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, Japan.
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30
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Akinduro OO, Garcia DP, Domingo RA, Vivas-Buitrago T, Sousa-Pinto B, Bydon M, Clarke MJ, Gokaslan ZL, Kalani MA, Abode-Iyamah K, Quiñones-Hinojosa A. Cervical chordomas: multicenter case series and meta-analysis. J Neurooncol 2021; 153:65-77. [PMID: 33811630 DOI: 10.1007/s11060-021-03742-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND En bloc spondylectomy is the gold standard for surgical resection of sacral chordomas (CHO), but the effect of extent of resection on recurrence and survival in patients with CHO of the cervical spine remains elusive. METHODS MEDLINE, Embase, Scopus, and Cochrane were systematically reviewed. Patients with cervical CHO treated at three tertiary-care academic institutions were reviewed for inclusion. We performed an individual participant data meta-analysis to assess the overall survival (OS) and progression free survival (PFS) after en bloc-gross total resection (GTR) and intralesional-GTR compared to subtotal resection (STR). We then performed an intention-to-treat analysis including all patients with attempted en bloc resection in the en bloc group, regardless of the surgical margins. RESULTS There was a total of 13 series including 161 patients with cervical CHO, including our current series of 22 patients. GTR (en bloc-GTR + intralesional-GTR) was associated with a significant decrease in the risk of local progression (pooled hazard ratio (PHR) = 0.22; 95% CI 0.08-0.59; p = 0.003) and risk of death (PHR 0.31; 95%; CI 0.12-0.83; p = 0.020). A meta-regression analyses determined that intralesional-GTR improved PFS (PHR 0.35; 95% CI 0.16-0.76; p = 0.009) as well as OS (PHR 0.25; 95% CI 0.08-0.79; p = 0.019) when compared to STR. En bloc-GTR was associated with a significant reduction in the risk of local progression (PHR 0.06; 95% CI 0.01-0.77; p = 0.030), but not a decreased OS (PHR 0.50; 95% CI 0.19-1.27; p = 0.145). Our intention-to-treat analyses revealed a near significant improvement in OS for the en bloc group (PHR: 0.15; 95% CI 0.02-1.22; p = 0.054), and nearly identical improvement in PFS. Radiation data was not available for the studies included in the meta-analysis. CONCLUSION This is the first and only meta-analysis of patients with cervical CHO. We found that both en bloc-GTR and intralesional-GTR resulted in improved local tumor control when compared to STR.
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Affiliation(s)
| | - Diogo P Garcia
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Bernardo Sousa-Pinto
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
- CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Alfredo Quiñones-Hinojosa
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA.
- Brain Tumor Stem Cell Laboratory, Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd. S, Jacksonville, FL, 32224, USA.
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31
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Passer JZ, Alvarez-Breckenridge C, Rhines L, DeMonte F, Tatsui C, Raza SM. Surgical Management of Skull Base and Spine Chordomas. Curr Treat Options Oncol 2021; 22:40. [PMID: 33743089 DOI: 10.1007/s11864-021-00838-z] [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] [Accepted: 02/18/2021] [Indexed: 12/22/2022]
Abstract
OPINION STATEMENT Management of chordoma along the cranial-spinal axis is a major challenge for both skull base and spinal surgeons. Although chordoma remains a rare tumor, occurring in approximately 1 per 1 million individuals, its treatment poses several challenges. These tumors are generally poorly responsive to radiation and chemotherapy, leading to surgical resection as the mainstay of treatment. Due to anatomic constraints and unique challenges associated with each primary site of disease, gross total resection is often not feasible and is associated with high rates of morbidity. Additionally, chordoma is associated with high rates of recurrence due to the tumor's aggressive biologic features, and postoperative radiation is increasingly incorporated as a treatment option for these patients. Despite these challenges, modern-day surgical techniques in both skull base and spinal surgery have facilitated improved patient outcomes. For example, endoscopic endonasal techniques have become the mainstay in resection of skull base chordomas, improving the ability to achieve gross total resection, while reducing associated morbidity of open transfacial techniques. Resection of spinal chordomas has been facilitated by emerging techniques in preoperative imaging, intraoperative navigation, spinal reconstruction, and radiotherapy. Taken collectively, the treatment of chordoma affecting the skull base and spinal requires a multidisciplinary team of surgeons, radiation oncologists, and medical oncologists who specialize in the treatment of this challenging disease.
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Affiliation(s)
- Joel Z Passer
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Christopher Alvarez-Breckenridge
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Laurence Rhines
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Franco DeMonte
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Claudio Tatsui
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 442, Houston, TX, 77030-4009, USA.
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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: 33] [Impact Index Per Article: 11.0] [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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Pennington Z, Ehresman J, McCarthy EF, Ahmed AK, Pittman PD, Lubelski D, Goodwin CR, Sciubba DM. Chordoma of the sacrum and mobile spine: a narrative review. Spine J 2021; 21:500-517. [PMID: 33589095 DOI: 10.1016/j.spinee.2020.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/11/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
Chordoma is a notochord-derived primary tumor of the skull base and vertebral column known to affect 0.08 to 0.5 per 100,000 persons worldwide. Patients commonly present with mechanical, midline pain with or without radicular features secondary to nerve root compression. Management of these lesions has classically revolved around oncologic resection, defined by en bloc resection of the lesion with negative margins as this was found to significantly improve both local control and overall survival. With advancement in radiation modalities, namely the increased availability of focused photon therapy and proton beam radiation, high-dose (>50 Gy) neoadjuvant or adjuvant radiotherapy is also becoming a standard of care. At present chemotherapy does not appear to have a role, but ongoing investigations into the ontogeny and molecular pathophysiology of chordoma promise to identify therapeutic targets that may further alter this paradigm. In this narrative review we describe the epidemiology, histopathology, diagnosis, and treatment of chordoma.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA
| | - Edward F McCarthy
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA
| | - Patricia D Pittman
- Department of Neuropathology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 5-185A, Baltimore, MD 21287, USA.
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Kolz JM, Wellings EP, Houdek MT, Clarke MJ, Yaszemski MJ, Rose PS. Surgical treatment of primary mobile spine chordoma. J Surg Oncol 2021; 123:1284-1291. [PMID: 33567141 DOI: 10.1002/jso.26423] [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: 12/10/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Chordomas of the mobile spine (C1-L5) are rare malignant tumors. The purpose of this study was to review the outcome of surgical treatment for patients with primary mobile spine chordomas. METHODS The oncologic outcomes and survival of 26 patients undergoing surgical resection for a primary mobile spine chordoma were assessed over a 25-year period. The mean follow-up was 12 ± 6 years. RESULTS The 2-, 5-, and 10-year disease-free survivals were 95%, 61%, and 55%. The local recurrence-free survival was improved in patients receiving en bloc resection with negative margins (83% vs. 35%, p = 0.02) and similar in patients receiving adjuvant radiation therapy (43% vs. 45%, p = 0.30) at 10 years. Debulking of the tumor (hazard ratio [HR] = 6.41, p = 0.01) and a local recurrence (HR = 9.52, p = 0.005) were associated with death due to disease. Complications occurred in 19 (73%) patients, leading to reoperation in 9 (35%) patients; this rate was similar in intralesional and en bloc procedures. CONCLUSION Surgical resection of mobile spine chordomas is associated with a high rate of complications; however, en bloc resection can provide a hope for cure and appears to confer better oncologic outcomes for these tumors without an increase in complications compared to lesser resections.
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Affiliation(s)
- Joshua M Kolz
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Beddok A, Saint-Martin C, Mammar H, Feuvret L, Helfre S, Bolle S, Froelich S, Goudjil F, Zefkili S, Amessis M, Peurien D, Cornet S, Dendale R, Alapetite C, Calugaru V. High-dose proton therapy and tomotherapy for the treatment of sacral chordoma: a retrospective monocentric study. Acta Oncol 2021; 60:245-251. [PMID: 33095672 DOI: 10.1080/0284186x.2020.1834140] [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] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Radiation therapy (RT) is used for the treatment of sacral chordoma, in combination with surgery or alone for unresected tumours, to improve local control (LC) and potentially overall survival (OS). The purpose of the present study was to evaluate efficacy and toxicity of proton therapy (PT), and/or intensity modulated radiation therapy (IMRT), particularly Tomotherapy, for sacral chordoma treatment. Material: Between November 2005 and June 2018, 41 consecutive patients who were not included in clinical trials, received sacral chordoma radiation treatment in Institut Curie with Tomotherapy alone in 13 patients, and combined PT and Tomotherapy boost (Proton - Tomo) in 28 patients. RT was delivered as the exclusive local treatment in 11 patients, and as a post-operative complementary treatment in 30 patients. RESULTS After a median follow-up of 46 months (range, 0-125 months), eight local relapses were observed, and seven patients developed distant metastasis (particularly bone and lung). The 2- and 5- year local relapse rates were 11.4% CI (0.65-22.2%) and 29% (10.5-47.4%), respectively. Over the follow-up period, ten patients died (24.4%). The estimated 2- and 5-year OS rates were 91.4% CI (82.5-100%) and 74.5% (59.4-93.5%), respectively. Fibrosis, cauda equina syndrome, and pain were the most common late toxicities. The comparison between Tomotherapy alone and Proton - Tomo revealed that acute and late cystitis were significantly more frequent in the Tomotherapy group: SHR = 0.12 IC95% (0.01-0.90 [p = .04]), as well as late proctitis. A dosimetric comparison confirmed the interest of PT to spare rectum and bladder in this context. CONCLUSION RT remains essential to improve local control in sacral chordoma. The combination of proton and photon seems to improve organ at risk sparing, resulting in a decreased rate of reported late toxicities.
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Affiliation(s)
- Arnaud Beddok
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
- Department of Radiation oncology, Curie Institute, Paris, France
| | | | - Hamid Mammar
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
- Department of Radiation oncology, Curie Institute, Paris, France
| | - Loïc Feuvret
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
- Department of Radiation Oncology, Pitié-Salpêtrière Hospital, Paris, France
| | - Sylvie Helfre
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
- Department of Radiation oncology, Curie Institute, Paris, France
| | - Stéphanie Bolle
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
- Department of Radiation Oncology, Gustave Roussy Institute, Villejuif, France
| | | | - Farid Goudjil
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
| | - Sofia Zefkili
- Department of Radiation oncology, Curie Institute, Paris, France
| | - Malika Amessis
- Department of Radiation oncology, Curie Institute, Paris, France
| | | | - Sophie Cornet
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
| | - Rémi Dendale
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
- Department of Radiation oncology, Curie Institute, Paris, France
| | - Claire Alapetite
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
- Department of Radiation oncology, Curie Institute, Paris, France
| | - Valentin Calugaru
- Department of Radiation Oncology, Proton Therapy Centre, Curie Institute, Orsay, France
- Department of Radiation oncology, Curie Institute, Paris, France
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Konieczkowski DJ, DeLaney TF, Yamada YJ. Radiation Strategies for Spine Chordoma: Proton Beam, Carbon Ions, and Stereotactic Body Radiation Therapy. Neurosurg Clin N Am 2020; 31:263-288. [PMID: 32147017 DOI: 10.1016/j.nec.2019.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgery alone provides suboptimal local control of spine and sacral chordomas. Radiotherapy (RT) may improve local control in patients undergoing surgery and be used as definitive-intent treatment in patients not undergoing surgery. Although conventional-dose RT is inadequate for these radioresistant tumors, newer techniques allow treatment of the tumor to higher, more effective doses while limiting spinal cord dose to safe levels. The best local control is achieved when RT is delivered in the primary setting; RT dose is a critical determinant of local control. RT should be considered for all spine and sacral chordoma patients.
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Affiliation(s)
- David J Konieczkowski
- Harvard Radiation Oncology Program, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Yoshiya Josh Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Poel R, Belosi F, Albertini F, Walser M, Gisep A, Lomax AJ, Weber DC. Assessing the advantages of CFR-PEEK over titanium spinal stabilization implants in proton therapy—a phantom study. ACTA ACUST UNITED AC 2020; 65:245031. [DOI: 10.1088/1361-6560/ab8ba0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Bongers MER, Ogink PT, Chu KF, Patel A, Rosenthal B, Shin JH, Lee SG, Hornicek FJ, Schwab JH. The use of autologous free vascularized fibula grafts in reconstruction of the mobile spine following tumor resection: surgical technique and outcomes. J Neurosurg Spine 2020; 34:283-292. [PMID: 33157532 DOI: 10.3171/2020.6.spine20521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Reconstruction of the mobile spine following total en bloc spondylectomy (TES) of one or multiple vertebral bodies in patients with malignant spinal tumors is a challenging procedure with high failure rates. A common reason for reconstructive failure is nonunion, which becomes more problematic when using local radiation therapy. Radiotherapy is an integral part of the management of primary malignant osseous tumors in the spine. Vascularized grafts may help prevent nonunion in the radiotherapy setting. The authors have utilized free vascularized fibular grafts (FVFGs) for reconstruction of the spine following TES. The purpose of this article is to describe the surgical technique for vascularized reconstruction of defects after TES. Additionally, the outcomes of consecutive cases treated with this technique are reported. METHODS Thirty-nine patients were treated at the authors' tertiary care institution for malignant tumors in the mobile spine using FVFG following TES between 2010 and 2018. Postoperative union, reoperations, complications, neurological outcome, and survival were reported. The median follow-up duration was 50 months (range 14-109 months). RESULTS The cohort consisted of 26 males (67%), and the median age was 58 years. Chordoma was the most prevalent tumor (67%), and the lumbar spine was most affected (46%). Complete union was seen in 26 patients (76%), the overall complication rate was 54%, and implant failure was the most common complication, with 13 patients (33%) affected. In 18 patients (46%), one or more reoperations were needed, and the fixation was surgically revised 15 times (42% of reoperations) in 10 patients (26%). A reconstruction below the L1 vertebra had a higher proportion of implant failure (67%; 8 of 12 patients) compared with higher resections (21%; 5 of 24 patients) (p = 0.011). Graft length, number of resected vertebrae, and docking the FVFG on the endplate or cancellous bone was not associated with union or implant failure on univariate analysis. CONCLUSIONS The FVFG is an effective reconstruction technique, particularly in the cervicothoracic spine. However, high implant failure rates in the lumbar spine have been seen, which occurred even in cases in which the graft completely healed. Methods to increase the weight-bearing capacity of the graft in the lumbar spine should be considered in these reconstructions. Overall, the rates of failure and revision surgery for FVFG compare with previous reports on reconstruction after TES.
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Affiliation(s)
| | - Paul T Ogink
- Departments of1Orthopedic Surgery, Orthopedic Oncology Service
| | | | - Anuj Patel
- Departments of1Orthopedic Surgery, Orthopedic Oncology Service
| | - Brett Rosenthal
- Departments of1Orthopedic Surgery, Orthopedic Oncology Service
| | | | - Sang-Gil Lee
- 4Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Francis J Hornicek
- 5Department of Orthopedic Surgery, Orthopedic Oncology Service, University of California, Los Angeles Medical Center, Los Angeles, California
| | - Joseph H Schwab
- Departments of1Orthopedic Surgery, Orthopedic Oncology Service
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Denaro L, Berton A, Ciuffreda M, Loppini M, Candela V, Brandi ML, Longo UG. Surgical management of chordoma: A systematic review. J Spinal Cord Med 2020; 43:797-812. [PMID: 30048230 PMCID: PMC7808319 DOI: 10.1080/10790268.2018.1483593] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Context: Chordomas are rare primary tumors of bone characterized by local aggressiveness and poor prognosis. The surgical exeresis plays a critical role for their management. Objective: The aim was to provide an overview of the surgical management of chordomas of the mobile spine and sacrum, describing the most common surgical approaches, the role of surgical margins, the difficulties of en block resection, the outcomes of surgery, the recurrence rate and the use of associated therapies. Methods: We performed a systematic search using the keywords "chordoma" in combination with "surgery", "spine", "sacrum" and "radiotherapy". Results: Fifty-eight studies, describing 1359 patients with diagnosis of chordoma were retrieved. 17 studies were performed on subjects with cervical chordomas and 49 focused on patients with sacrococcygeal chordomas. The remaining studies included patients with chordomas in cranial region and/or mobile spine and/or sacroccygeal region. The recurrence rate ranged from 25% to 60% for cervical chordomas, and from 18% to 89% for sacrococcygeal chordomas. Conclusion: Despite the remarkable advances in the local management of chordoma performed in the last decades, the current results of surgery alone are still unsatisfactory. The radical en bloc excision of tumour is technically demanding, particularly in the cervical spine. Although radical surgery must still be considered the gold standard for the management of chordomas, a multidisciplinary approach is required to improve the local control of the disease in patients who undergo both radical and non-radical surgery. Adjuvant radiation therapy increases the continuous disease-free survival and the local recurrence-free survival. Level of evidence: Systematic review; level III.
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Affiliation(s)
- Luca Denaro
- Department of Neuroscience, University of Padua, Padua, Italy
| | - Alessandra Berton
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Vincenzo Candela
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | | | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
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Rustagi T, Schwab JH, Iwenofu H, Mendel E. Overview of the management of primary tumors of the spine. Int J Neurosci 2020; 132:543-557. [PMID: 32942943 DOI: 10.1080/00207454.2020.1825423] [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: 10/23/2022]
Abstract
STUDY DESIGN Narrative review. OBJECTIVE To provide a narrative review for diagnosis and management of Primary spine tumors. METHODS A detailed review of literature was done to identify relevant and well cited manuscripts to construct this narrative review. RESULTS Primary tumors of the spine are rare with some racial differences reported. There are numerous adjuvant technologies and developments that influence the way we currently manage these tumors. Collimated radiation allows for heavy dosage to be delivered and have been reported to give good local control both as an adjuvant and neoadjuvant setting. These have made surgical decision making even more intricate needing a multicentric approach. Dedicated care has been shown to significantly improve health quality of life measures and survival. CONCLUSION While, it is beyond the scope of this paper to discuss all primary tumors subtypes individually, this review highlights the developments and approach to primary spine tumors.
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Affiliation(s)
- Tarush Rustagi
- Department of Neurosurgery, The Ohio State University and Wexner Medical Center, The James Cancer Hospital and Solvo Research Institute, Columbus, OH, USA.,Department of Orthopedics and Spine Surgery, Indian Spinal Injuries Centre, New Delhi, India
| | - Joseph H Schwab
- Department of Orthopedic Oncology, Massachusetts General Hospital, Boston, MA, USA.,Department of Orthopedics, Harvard Medical School, Boston, MA, USA
| | - Hans Iwenofu
- Division of Soft Tissue & Bone Pathology, Department of Pathology & Laboratory Medicine, The Ohio State University Wexner Medical Center, The James Cancer Hospital and Solvo Research Institute, Columbus, OH, USA
| | - Ehud Mendel
- Department of Neurosurgery, The Ohio State University and Wexner Medical Center, The James Cancer Hospital and Solvo Research Institute, Columbus, OH, USA
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Bostel T, Mattke M, Nicolay NH, Welzel T, Wollschläger D, Akbaba S, Mayer A, Sprave T, Debus J, Uhl M. High-dose carbon-ion based radiotherapy of primary and recurrent sacrococcygeal chordomas: long-term clinical results of a single particle therapy center. Radiat Oncol 2020; 15:206. [PMID: 32831113 PMCID: PMC7447564 DOI: 10.1186/s13014-020-01647-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to analyze the oncological long-term results and late toxicity of carbon ion-based radiotherapy (RT) of patients with sacral chordoma and to identify potential prognostic factors for local control (LC) and overall survival (OS). METHODS A total of 68 patients with sacral chordoma treated at the Heidelberg Ion Beam Therapy Center were included in this study. Of these 52 patients (77%) received a primary RT and 16 patients (23%) received a RT in a recurrent situation. All patients were treated with carbon ion RT (CIRT), either in combination with photons (n = 22; 32%) or as a monotherapy (n = 46; 68%), with a median radiation dose of 66 Gy RBE (range 60-74 Gy). In 40 patients (59%), RT was performed in the postoperative situation. Postoperative care included regular MRI scans. Local progression was defined as an enlargement of the maximum tumor diameter by 10% or a new tumor growth within the planning target volume (PTV). LC and OS were determined using the Kaplan-Meier method. Furthermore, the relevance of various prognostic factors for LC and OS was assessed by univariate and multivariate analysis. RESULTS The median follow-up period was 60 months (range 1.3-97.4 months). The 5-year rates for LC, progression-free survival, metastasis-free survival and OS were 53, 53, 52 and 74%, respectively. Local recurrence was observed in 31 patients (46%), occurring after a median follow-up time of 25 months (range 2.5-73.1 months). Only 10% of local recurrences occurred later than 5 years after RT. Statistical analysis showed that RT in the relapse situation corresponded to inferior LC rates compared to the primary situation, while other factors such as the GTV, radiation dose (EQD2) and treatment approach (CIRT alone vs. CIRT combined with photons) were insignificant. For OS after RT, patient age and PTV size proved to be significant predictors. The incidence of late toxicity ≥ III° according to CTCAE v5.0 was 21%. Sacral insufficiency fractures occurred in 49% of patients (maximum III°: 16%) and were thus by far the most frequent late side effect in our analysis. Radiogenic damage to the peripheral nerves, intestinal tract and skin was observed in only 9% (≥ III°: 5%), 3% (all II°) and 9% (all I°) of patients. CONCLUSION Our analysis showed only moderate long-term LC rates after carbon ion-based RT, with sacral chordomas having a particularly poor prognosis in the recurrent situation. Therefore, future studies should evaluate the safety and effectiveness of further dose escalation and hypofractionation of RT in sacral chordoma and weight potential benefits of dose escalation against side effects.
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Affiliation(s)
- Tilman Bostel
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany. .,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
| | - Matthias Mattke
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Nils Henrik Nicolay
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Daniel Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Mainz, Germany
| | - Sati Akbaba
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Arnulf Mayer
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany
| | - Jürgen Debus
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Matthias Uhl
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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Bongers MER, Shin JH, Srivastava SD, Morse CR, Lee SG, Schwab JH. Free Vascularized Fibula Graft with Femoral Allograft Sleeve for Lumbar Spine Defects After Spondylectomy of Malignant Tumors: A Case Report. JBJS Case Connect 2020; 10:e2000075. [PMID: 32773710 DOI: 10.2106/jbjs.cc.20.00075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present a 65-year-old man with an L4 conventional chordoma. Total en bloc spondylectomy (TES) of the involved vertebral bodies and surrounding soft tissues with reconstruction of the spine using a free vascularized fibula autograft (FVFG) is a proven technique, limiting complications and recurrence. However, graft fracture has occurred only in the lumbar spine in our institutional cases. We used a technique in our patient to ensure extra stability and support, with the addition of a femoral allograft sleeve encasing the FVFG. CONCLUSIONS Our technique for the reconstruction of the lumbar spine after TES of primary malignant spinal disease using a femoral allograft sleeve encasing the FVFG is viable to consider.
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Affiliation(s)
- Michiel E R Bongers
- 1Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 3Department of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 4Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 5Department of Orthopedic Surgery, Hand and Upper Extremity Service, Orthopedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Jiang P, Zhang X, Jiang W, Meng N, Aili A, Wang J. Analysis of long-term outcome of image-guided volumetric modulated arc therapy (VMAT) for primary malignant tumor of the cervical spine. Cancer Biol Ther 2020; 21:623-628. [PMID: 32298199 DOI: 10.1080/15384047.2020.1743149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE Retrospective analysis of the long-term clinical outcome and acute toxicity of the primary malignant tumor of cervical spine receiving CBCT image-guided VMAT. METHODS Thirty patients with primary malignant tumor of the cervical spine included in our center, from December 2013 to January 2016, 28 patients were retrospectively studied. The prescription dosage 95% PTV volume dose was 44 Gy, 2.0 Gy/fraction, and a total of 22 times. The median PGTV synchronized volume dose was 60 Gy (45-62.1 Gy), median 2.5 Gy (2-2.7 Gy)/fraction. In volumetric modulated, two arc volumetric modulated arc therapy (VMAT) was used, with spinal cord dosage DMAX< 45 Gy. Early response rate and acute toxicities were analyzed. RESULT The follow-up duration was 6-76 months (median 53 months). At the end of follow-up of June 1, 2019, 78.6% (22/28) patients were still alive. 3 and 5-y local control rates were 67.3% and 56.5% while 3 and 5-y OS were both 78.6% in the whole group of patients, respectively. Fourteen patients with chordoma 5-y local control rates and OS were 57.1% and 85.7%, respectively. Nine patients with giant-cell tumor of bone had a 5-y local control rate and OS were 77.8% and 85.7%, respectively. The response rate for moderate pain or above was 80% (8/10). Eleven patients (39.3%) suffered from grade 1 acute skin toxicity. Twenty-four patients (85.7%) had grade 1/2 mucositis. No radiation-induced spinal cord injury was found. CONCLUSION The image-guided VMAT for primary malignant tumor of the cervical spine provided a satisfactory long-term local control rate.
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Affiliation(s)
- Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital , Beijing, China
| | - Xile Zhang
- Department of Radiation Oncology, Peking University Third Hospital , Beijing, China
| | - Weijuan Jiang
- Department of Radiation Oncology, Peking University Third Hospital , Beijing, China
| | - Na Meng
- Department of Radiation Oncology, Peking University Third Hospital , Beijing, China
| | | | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital , Beijing, China
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Comparison of Wide Margin and Inadequate Margin for Recurrence in Sacral Chordoma: A Meta-Analysis. Spine (Phila Pa 1976) 2020; 45:814-819. [PMID: 31977678 DOI: 10.1097/brs.0000000000003386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN .: A meta-analysis. OBJECTIVE .: The goal of this study was to accurately evaluate the risk ratio (RR) of recurrence in chordoma patients with wide margin after removing the tumors using surgery, compared with inadequate margin (intralesional or marginal). SUMMARY OF BACKGROUND DATA .: As a rare malignant bone cancer, the more effective treatment for sacral chordoma is still surgical resection. However, there is no convincing evidence and risk ratio about sacral chordoma patients would be benefit from which kind of surgical margin. METHODS .: We searched the PubMed, Cochrane Library, Web of Science, and EMBASE from inception to December 2018. The heterogeneity analysis and calculation of the pooled risk ratio were performed using RevMan 5.3 software. The assessment of publication bias and sensitivity analysis was conducted using StataSE 15.1 software. The protocol for this meta-analysis was registered on International prospective register of systematic reviews (PROSPERO, CRD42019127441). RESULTS .: Twelve studies with a total of 436 patients who met the inclusion criteria were included. The pooled results indicated that patients in the wide group had lower recurrence rate than those in the inadequate group (RR = 0.42, 95% confidence interval [CI] 0.31-0.57; P < 0.001). And patients in the wide group had lower mortality rate than those in the inadequate group (RR = 0.49, 95% CI 0.26-0.91; P = 0.02). No significant differences in the risk of mortality were found between relapsed patients in the two groups (RR = 0.64, 95% CI 0.35-1.15; P = 0.13). CONCLUSION .: In sacral chordoma patients, wide margin is associated with low recurrence risk, when it is feasible, a wide excision should be considered appropriate for sacrum chordoma. LEVEL OF EVIDENCE 2.
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The Role of Radiotherapy for Chordoma Patients Managed With Surgery: Analysis of the National Cancer Database. Spine (Phila Pa 1976) 2020; 45:E742-E751. [PMID: 32032324 PMCID: PMC7649561 DOI: 10.1097/brs.0000000000003406] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To determine if adjuvant radiation therapy (RT) improves overall survival (OS) following surgical resection of chordomas. SUMMARY OF BACKGROUND DATA The role of RT for the treatment of chordomas remains incompletely described. Previous studies have not found adjuvant RT to improve OS, but these studies did not group patients based on surgical margin status or radiation dose or modality. We used the National Cancer Database to investigate the role of RT in chordomas following surgical resection. METHODS Patients were stratified based on surgical margin status (positive vs. negative). Utilizing the Kaplan-Meier method, OS was compared between treatment modalities (surgical resection alone, therapeutic RT alone, and surgical resection plus therapeutic RT). OS was subsequently compared between patients treated with palliative dose (<40 Gy), low dose (40-65 Gy), and high dose (>65 Gy) RT. Similarly, OS was compared between advanced RT modalities including proton beam therapy (PBT) and intensity-modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), and external beam radiation therapy (EBRT). A multivariable model was used to determine adjusted variables predictive of mortality. RESULTS One thousand four hundred seventy eight chordoma patients were identified; skull base (n = 567), sacral (n = 551), and mobile spine (n = 360). Surgical resection and therapeutic adjuvant RT improved 5-year survival in patients with positive surgical margins (82% vs. 71%, P = 0.03). No clear survival benefit was observed with the addition of adjuvant RT in patients with negative surgical margins. High dose RT was associated with improved OS compared with palliative and low dose RT (P < 0.001). Advanced RT techniques and SRS were associated with improved OS compared with EBRT. In the multivariate analysis high dose advanced RT (>65 Gy) was superior to EBRT. CONCLUSION Patients with positive surgical margins benefit from adjuvant RT. Optimal OS is associated with adjuvant RT administered with advanced techniques and cumulative dose more than 65 Gy. LEVEL OF EVIDENCE 4.
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The sacral chordoma margin. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:1415-1422. [PMID: 32402509 DOI: 10.1016/j.ejso.2020.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/15/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Aim of the manuscript is to discuss how to improve margins in sacral chordoma. BACKGROUND Chordoma is a rare neoplasm, arising in half cases from the sacrum, with reported local failure in >50% after surgery. METHODS A multidisciplinary meeting of the "Chordoma Global Consensus Group" was held in Milan in 2017, focusing on challenges in defining and achieving optimal margins in chordoma with respect to surgery, definitive particle radiation therapy (RT) and medical therapies. This review aims to report on the outcome of the consensus meeting and to provide a summary of the most recent evidence in this field. Possible new ways forward, including on-going international clinical studies, are discussed. RESULTS En-bloc tumor-sacrum resection is the cornerstone of treatment of primary sacral chordoma, aiming to achieve negative microscopic margins. Radical definitive particle therapy seems to offer a similar outcome compared to surgery, although confirmation in comparative trials is lacking; besides there is still a certain degree of technical variability across institutions, corresponding to different fields of treatment and different tumor coverage. To address some of these questions, a prospective, randomized international study comparing surgery versus definitive high-dose RT is ongoing. Available data do not support the routine use of any medical therapy as (neo)adjuvant/cytoreductive treatment. CONCLUSION Given the significant influence of margins status on local control in patients with primary localized sacral chordoma, the clear definition of adequate margins and a standard local approach across institutions for both surgery and particle RT is vital for improving the management of these patients.
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Houdek MT, Hevesi M, Griffin AM, Yaszemski MJ, Sim FH, Ferguson PC, Rose PS, Wunder JS. Can the ACS-NSQIP surgical risk calculator predict postoperative complications in patients undergoing sacral tumor resection for chordoma? J Surg Oncol 2020; 121:1036-1041. [PMID: 32034772 DOI: 10.1002/jso.25865] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The ACS-NSQIP surgical risk calculator is an online tool that estimates the risk of postoperative complications. Sacrectomies for chordoma are associated with a high rate of complications. This study was to determine if the ACS-NSQIP calculator can predict postoperative complications following sacrectomy. METHODS Sixty-five (42 male, 23 female) patients who underwent sacrectomy were analyzed using the Current Procedural Terminology (CPT) codes: 49215 (excision of presacral/sacral tumor), 63001 (laminectomy of sacral vertebrae), 63728 (laminectomy for biopsy/excision of sacral neoplasm) and 63307 (sacral vertebral corpectomy for intraspinal lesion). The predicted rates of complications were compared to the observed rates. RESULTS Complications were noted in 44 (68%) patients. Of the risk factors available to input to the ACS-NSQIP calculator, tobacco use (OR, 20.4; P < .001) was predictive of complications. The predicted risk of complications based off the CPT codes were: 49215 (16%); 63011 (6%); 63278 (11%) and 63307 (15%). Based on ROC curves, the use of the ACS-NSQIP score were poor predictors of complications (49215, AUC 0.65); (63011, AUC 0.66); (63307, AUC 0.67); (63278, AUC 0.64). CONCLUSION The ACS-NSQIP calculator was a poor predictor of complications and was marginally better than a coin flip in its ability to predict complications following sacrectomy for chordoma.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | | | - Franklin H Sim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
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Houdek MT, Hevesi M, Schwab JH, Yaszemski MJ, Griffin AM, Healey JH, Ferguson PC, Hornicek FJ, Boland PJ, Sim FH, Rose PS, Wunder JS. Association between patient age and the risk of mortality following local recurrence of a sacral chordoma. J Surg Oncol 2020; 121:267-271. [PMID: 31758570 PMCID: PMC7242148 DOI: 10.1002/jso.25774] [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] [Received: 11/05/2019] [Accepted: 11/08/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Local recurrence (LR) of sacral chordoma is a difficult problem and the mortality risk associated with LR remains poorly described. The purpose of this study was to evaluate the risk of mortality in patients with LR and determine if patient age is associated with mortality. METHODS A total of 218 patients (144 male, 69 female; mean age 59 ± 15 years) with sacrococcygeal chordomas were reviewed. Cumulative incidence functions and competing risks for death due to disease and nondisease mortality were employed to analyze mortality trends following LR. RESULTS The 10-year overall survival (OS) was 55%. Patients with LR had 44% 10-year OS, similar to patients without (59%; P = .38). The 10-year OS between those less than 55 compared with ≥55 years were similar (69% vs 48%; P = .52). The 10-year death due to disease was worse in patients with LR compared with those without (44% vs 84%; P < .001). In patients without LR, patients ≥55 years were 1.6-fold more likely to experience death due to other causes. CONCLUSIONS Patients with an LR are more likely to die due to disease. Advanced patient age was associated with higher all-cause mortality following resection of sacral chordoma. LR of chordoma was associated with increased disease-specific mortality, regardless of age.
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Affiliation(s)
- Matthew T. Houdek
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN,Corresponding Author: , 200 First St. SW, Rochester, MN 55905, (507) 284-2511
| | - Mario Hevesi
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, MA
| | | | - Anthony M. Griffin
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - John H. Healey
- Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center and Weill College of Medicine, Cornell University, New York, NY
| | - Peter C. Ferguson
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Francis J. Hornicek
- Department of Orthopedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Patrick J. Boland
- Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center and Weill College of Medicine, Cornell University, New York, NY
| | - Franklin H. Sim
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN
| | - Peter S. Rose
- Mayo Clinic, Department of Orthopedic Surgery, Rochester, MN
| | - Jay S. Wunder
- University Musculoskeletal Oncology Unit Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
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Murray FR, Snider JW, Schneider RA, Walser M, Bolsi A, Pica A, Lomax AJ, Weber DC. Prognostic factors for spinal chordomas and chondrosarcomas treated with postoperative pencil-beam scanning proton therapy: a large, single-institution experience. J Neurosurg Spine 2020; 32:921-930. [PMID: 32005008 DOI: 10.3171/2019.11.spine1927] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 11/15/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this paper was to evaluate the prognostic factors in surgical and adjuvant care for spinal chordomas and chondrosarcomas after surgery followed by high-dose pencil-beam scanning proton therapy (PBS-PT). METHODS From 1997 to 2016, 155 patients (61 female patients; median age 55 years) with spinal (cervical, n = 61; thoracic, n = 29; lumbar, n = 13; sacral, n = 46; pelvic, n = 6) classic chordomas (n = 116) and chondrosarcomas (n = 39; most were low grade) were treated with maximal safe resection followed by PBS-PT (median dose prescribed: 74 Gy [relative biological effectiveness], range 48.6-77 Gy). The majority of patients (n = 153, 98.7%) had undergone at least 1 resection prior to PBS-PT (median 1, range 0-5; biopsy only, n = 2). Fewer than half (45.1%) of the surgeries were rated as gross-total resections (GTRs) prior to PBS-PT. Surgical stabilization (SS) was present in 39% of all patients (n = 60). Ninety-one patients (59%) presented with macroscopic tumor at the start of PBS-PT. The median follow-up duration was 64.7 months (range 12.2-204.8 months). RESULTS The 5-year local tumor control, disease-free survival (DFS), and overall survival were 64.9% (95% CI 56.3%-73.5%), 59.4% (95% CI 50.6%-68.2%), and 77.9% (95% CI 70.6%-85.2%), respectively. In total, 63 patients (40.6%) experienced failure during the follow-up period: local only in 32 (20.6%), distal only in 7 (4.5%), local + distal in 19 (12.3%), surgical pathway failure (SPF) only in 2 (1.3%), local + SPF in 2 (1.3%), and distal + SPF in 1 (< 1%). Univariate analysis identified gross residual disease, the presence of SS, and treatment era prior to 2008 as highly significant for worse outcome, with all 3 remaining significant on multivariate analysis. The type of surgery (GTR or subtotal resection/biopsy) and whether GTR was achieved by en bloc or curettage did not show a significant prognostic effect. Surgical complications prior to PBS-PT were present in 42.5% of all surgically treated patients and were seen more commonly in patients with multiple surgical interventions (p = 0.005) and those operated on with the intent of en bloc resection (p = 0.006). CONCLUSIONS The extent of resection and metallic stabilization substantially influenced clinical outcomes for patients with spinal chordoma or chondrosarcoma despite high-dose adjuvant PBS-PT. Optimal upfront surgical management of these tumors continues to include GTR, as possible, with prompt adjuvant proton therapy.
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Affiliation(s)
- Fritz R Murray
- 1Center for Proton Therapy, Paul Scherrer Institute, Villigen
| | - James W Snider
- 2Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Marc Walser
- 1Center for Proton Therapy, Paul Scherrer Institute, Villigen
| | | | - Alessia Pica
- 1Center for Proton Therapy, Paul Scherrer Institute, Villigen
| | - Antony J Lomax
- 1Center for Proton Therapy, Paul Scherrer Institute, Villigen
- 3Department of Physics, ETH, Zurich
| | - Damien C Weber
- 1Center for Proton Therapy, Paul Scherrer Institute, Villigen
- 4Radiation Oncology Department, University Hospital of Bern
- 5Radiation Oncology Department, University Hospital of Zurich, Switzerland; and
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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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