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Koch K, Pal Varga P, Ronai M, Klemencsics I, Szoverfi Z, Lazary A. Complication Pattern of Sacral Primary Tumor Resection: A Study on the Risk Factors of Surgical Site Infection and Bowel or Bladder Dysfunction and Their Associations with Length of Hospital Stay. Asian Spine J 2023; 17:851-861. [PMID: 37690989 PMCID: PMC10622823 DOI: 10.31616/asj.2022.0404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/02/2023] [Accepted: 06/18/2023] [Indexed: 09/12/2023] Open
Abstract
STUDY DESIGN Retrospective open cohort study. PURPOSE The current study aimed to explore the pattern of complications after primary sacral tumor resection, to investigate the possible effect of several perioperative parameters on the development of complications, and to identify which complications are associated with the length of hospital stay (LOS). OVERVIEW OF LITERATURE Primary sacral tumor (pST) resection is associated with a high complication rate. However, the number of studies on these complications and their effect on LOS is limited. METHODS The clinical data of 140 patients with pST surgeries and 106 subsequent patients with local recurrence surgeries in four subgroups (index surgery, local recurrence surgery, malignant, and benign tumor) were prospectively collected and analyzed. The prognostic value of several perioperative factors on the development of surgical site infection (SSI), bowel and bladder dysfunction (BBD), and LOS was investigated using the logistic and linear regression models. RESULTS The overall complication rates were 61.2% after index surgeries and 50.9% after local recurrence surgeries. The most frequent complications were SSI, vegetative dysfunction, urinary tract infections, and neurological deterioration. Age >55 years, malignant tumors, and red blood cell transfusion had a predictive effect on the development of SSI in the logistic model (p<0.01, R2=0.43). Bilateral S2 or S3 resection commonly caused postoperative BBD (chi-square test=62.5, degrees of freedom=4, p<0.001). In the multiple linear regression model, wound dehiscence, BBD, systemic and urinary tract infection, cerebrospinal fluid leak, and neurologic deterioration were associated with a significantly long LOS (p<0.01, R2=0.62). CONCLUSIONS Surgical resection of pSTs has a high complication rate. Its common complications are SSI and BBD, both of which can have a significant influence on global therapeutic outcome. Malignant tumor diagnosis, old age, and red blood cell transfusion can remarkably increase the risk of SSI. Further, the development of BBD is significantly associated with the number of resected sacral nerve roots. By decreasing perioperative complications, LOS can decrease significantly.
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Affiliation(s)
- Kristof Koch
- National Center for Spinal Disorders, Buda Health Center, Budapest,
Hungary
- School of PhD Studies, Semmelweis University, Budapest,
Hungary
| | - Peter Pal Varga
- National Center for Spinal Disorders, Buda Health Center, Budapest,
Hungary
| | - Marton Ronai
- National Center for Spinal Disorders, Buda Health Center, Budapest,
Hungary
| | - Istvan Klemencsics
- National Center for Spinal Disorders, Buda Health Center, Budapest,
Hungary
- Department of Spine Surgery, Department of Orthopaedics, Semmelweis University, Budapest,
Hungary
| | - Zsolt Szoverfi
- National Center for Spinal Disorders, Buda Health Center, Budapest,
Hungary
- Department of Spine Surgery, Department of Orthopaedics, Semmelweis University, Budapest,
Hungary
| | - Aron Lazary
- National Center for Spinal Disorders, Buda Health Center, Budapest,
Hungary
- Department of Spine Surgery, Department of Orthopaedics, Semmelweis University, Budapest,
Hungary
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Compagnone D, Cecchinato R, Pezzi A, Langella F, Damilano M, Redaelli A, Vanni D, Lamartina C, Berjano P, Boriani S. Diagnostic Approach and Differences between Spinal Infections and Tumors. Diagnostics (Basel) 2023; 13:2737. [PMID: 37685273 PMCID: PMC10487270 DOI: 10.3390/diagnostics13172737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/08/2023] [Accepted: 08/19/2023] [Indexed: 09/10/2023] Open
Abstract
STUDY DESIGN A systematic review of the literature about differential diagnosis between spine infection and bone tumors of the spine. BACKGROUND AND PURPOSE The differential diagnosis between spine infection and bone tumors of the spine can be misled by the prevalence of one of the conditions over the other in different areas of the world. A review of the existing literature on suggestive or even pathognomonic imaging aspects of both can be very useful for correctly orientating the diagnosis and deciding the most appropriate area for biopsy. The purpose of our study is to identify which imaging technique is the most reliable to suggest the diagnosis between spine infection and spine bone tumor. METHODS A primary search on Medline through PubMed distribution was made. We identified five main groups: tuberculous, atypical spinal tuberculosis, pyogenic spondylitis, and neoplastic (primitive and metastatic). For each group, we evaluated the commonest localization, characteristics at CT, CT perfusion, MRI, MRI with Gadolinium, MRI diffusion (DWI) and, in the end, the main features for each group. RESULTS A total of 602 studies were identified through the database search and a screening by titles and abstracts was performed. After applying inclusion and exclusion criteria, 34 articles were excluded and a total of 22 full-text articles were assessed for eligibility. For each article, the role of CT-scan, CT-perfusion, MRI, MRI with Gadolinium and MRI diffusion (DWI) in distinguishing the most reliable features to suggest the diagnosis of spine infection versus bone tumor/metastasis was collected. CONCLUSION Definitive differential diagnosis between infection and tumor requires biopsy and culture. The sensitivity and specificity of percutaneous biopsy are 72% and 94%, respectively. Imaging studies can be added to address the diagnosis, but a multidisciplinary discussion with radiologists and nuclear medicine specialists is mandatory.
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Affiliation(s)
| | | | - Andrea Pezzi
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, 20157 Milan, Italy
- Residency Program in Orthopaedics and Traumatology, University of Milan, 20141 Milan, Italy
| | | | - Marco Damilano
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, 20157 Milan, Italy
| | | | - Daniele Vanni
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, 20157 Milan, Italy
| | | | - Pedro Berjano
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, 20157 Milan, Italy
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Murphey MD, Minn MJ, Contreras AL, Koeller KK, Shih RY, Inwards CY, Yamaguchi T. Imaging of spinal chordoma and benign notochordal cell tumor (BNCT) with radiologic pathologic correlation. Skeletal Radiol 2023; 52:349-363. [PMID: 36063190 DOI: 10.1007/s00256-022-04158-7] [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: 05/05/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 02/02/2023]
Abstract
Benign notochordal cell tumor (BNCT) and chordoma are neoplasms of notochordal differentiation. BNCT represents notochordal rests, commonly an incidental lesion present in the spine in 19% of cadaveric specimens. BNCTs are often radiographically occult. CT of BNCT frequently reveals patchy sclerosis between areas of maintained underlying trabeculae. BNCT demonstrates marrow replacement on T1-weighted MR images with high signal intensity on T2-weighting. BNCTs are frequently smaller than 35 mm and lack significant enhancement, bone destruction, cortical permeation, or soft tissue components. Biopsy or surgical resection of BNCT is usually not warranted, although imaging surveillance may be indicated. Chordoma is a rare low-grade locally aggressive malignancy representing 1-4% of primary malignant bone tumors. Chordoma is most frequent between the ages of 50-60 years with a male predilection. Clinical symptoms, while nonspecific and location dependent, include back pain, numbness, myelopathy, and bowel/bladder incontinence. Unfortunately, lesions are often large at presentation owing to diagnosis delay. Imaging of chordoma shows variable mixtures of bone destruction and sclerosis, calcification (50-70% at CT) and large soft tissue components. MR imaging of chordoma reveals multilobulated areas of marrow replacement on T1-weighting and high signal intensity on T2-weighting reflecting the myxoid component within the lesion and areas of hemorrhage seen histologically. Treatment of chordoma is primarily surgical with prognosis related to resection extent. Unfortunately, complete resection is often not possible (21-75%) resulting in high local recurrence incidence (19-75%) and a 5-year survival rate of 45-86%. This article reviews and illustrates the clinical characteristics, pathologic features, imaging appearance spectrum, treatment, and prognosis of BNCT and spinal chordoma.
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Affiliation(s)
- Mark D Murphey
- Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology (AIRP), 1100 Wayne Avenue, Suite 1020, Silver Spring, MD, 20910, USA. .,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA. .,Department of Radiology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD, 20889, USA.
| | - Matthew J Minn
- Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology (AIRP), 1100 Wayne Avenue, Suite 1020, Silver Spring, MD, 20910, USA.,Department of Radiology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD, 20889, USA.,Department of Radiology, Scripps Green Hospital, 10666 N. Torrey Pines Road, La Jolla, CA, 92037, USA
| | | | - Kelly K Koeller
- Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology (AIRP), 1100 Wayne Avenue, Suite 1020, Silver Spring, MD, 20910, USA.,Department of Radiology, Head and Neck Cancer Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert Y Shih
- Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic Pathology (AIRP), 1100 Wayne Avenue, Suite 1020, Silver Spring, MD, 20910, USA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Department of Radiology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD, 20889, USA
| | - Carrie Y Inwards
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Takehiko Yamaguchi
- Department of Pathology, Nikko Medical Center, Dokkyo Medical University, 632 Takatoku, Nikko, Tochigi, 321-2593, Japan
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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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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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Rose PS. The management of sacral tumours. Bone Joint J 2022; 104-B:1284-1291. [DOI: 10.1302/0301-620x.104b12.bjj-2022-0734.r1] [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] [Indexed: 12/03/2022]
Abstract
Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours. Cite this article: Bone Joint J 2022;104-B(12):1284–1291.
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Affiliation(s)
- Peter S. Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Journal of the American Academy of Orthopaedic Surgeons, Rosemont, Illinois, USA
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Marengo N, Di Perna G, Baldassarre BM, Cofano F, De Marco R, Zeppa P, Petrone S, Ajello M, Garbossa D, Zenga F. 3D-printed guides for cervical pedicle screw placement in primary spine tumor: Case report and technical description. Front Surg 2022; 9:1011846. [PMID: 36504577 PMCID: PMC9727165 DOI: 10.3389/fsurg.2022.1011846] [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: 08/04/2022] [Accepted: 10/24/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction For spine surgeons, dealing with unstable cervical spine has been usually challenging, and this becomes more difficult when facing a primary craniovertebral junction tumor. Primary spine tumor surgery should always include column reconstruction in order to guarantee biomechanical stability of the spine, but surgeons should always be aware that instrumentations could create interferences with postoperative radiations. However, although carbon fiber instrumentations have started to be used in thoracolumbar oncology for few years, these options are still not available for cervical spine. In the reported case, the adopted strategy to obtain adequate column reconstruction was based on the idea of reducing the amount of titanium needed for posterior fixation and maximizing the distance between the radiation target and titanium rods. Case report and aim We present the case of a 53-year-old woman harboring a craniovertebral junction chordoma. A short occipito-C3 construct was selected. Specifically, titanium cervical pedicle screws were placed by using a new technology consisting in patient-tailored and customized 3D-printed guides. The aim of this case report is to determine the feasibility and safety of 3D-printed guides for cervical pedicle screw (CPS) positioning, even in the case of cervical spine tumor. Conclusion CPS could represent a good solution by providing strong biomechanical purchase and tailored 3D-printed guides could increase the safety and the accuracy of this challenging screw placement, even in oncological patients.
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Affiliation(s)
- Nicola Marengo
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Casa di Cura Clinica Città di Bra, Bra, Italy
| | - Bianca Maria Baldassarre
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Raffaele De Marco
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy,Correspondence: Raffaele De Marco
| | - Pietro Zeppa
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Salvatore Petrone
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Marco Ajello
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
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Survival of Patients With Primary Osseous Malignancies of the Mobile Spine Is Associated With Access to "Standard Treatment" Protocols. J Am Acad Orthop Surg 2022; 30:841-850. [PMID: 35507547 DOI: 10.5435/jaaos-d-22-00072] [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: 01/23/2022] [Accepted: 03/17/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Malignancies of the mobile spine carry high morbidity and mortality. This study sought to examine factors associated with receipt of "standard" treatment and survival for patients with primary mobile spine tumors in the California Cancer Registry (CCR). METHODS The CCR (1988 to 2016) data were obtained for patients with primary tumors of the mobile spine and at least 1-year follow-up. Sacrum/pelvis tumors were excluded. Age at diagnosis, sex, race, neighborhood socioeconomic status, insurance, Charlson Comorbidity Index, histologic diagnosis, stage at diagnosis, and treatment at a National Cancer Institute-designated Cancer Center (NCICC) were collected. Multivariate analyses were done to identify factors associated with all-cause mortality and receipt of "standard" treatment. RESULTS Four hundred eighty-four patients (64% White, 56% low neighborhood socioeconomic status, and 36% privately insured) were included. Chordoma (37%) was the most common diagnosis. Only 16% had metastatic disease at presentation. Only 29% received treatment at an NCICC. Lower age, Charlson Comorbidity Index, less extensive stage of disease, and private insurance were associated with lower all-cause mortality (all P < 0.05). Medicaid/public insurance (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.13 to 2.41) and Medicare (HR, 1.80; 95% CI, 1.25 to 2.59) were associated with higher mortality compared with private insurance. Patients who received no known treatment (HR, 2.41; CI, 1.51 to 3.84) or treatment other than the "standard" (HR, 1.45; CI, 1.11 to 1.91) had higher mortality compared with those who received the standard protocols. A critical predictor of receiving the standard treatment protocol was being treated at an NCICC. If patients did not receive care at such institutions, they received optimal treatment only 40% of the time (HR, 0.5; P = 0.004). CONCLUSIONS Receipt of defined "standard treatment" protocols was associated with care received at an NCICC and lower all-cause mortality in patients with primary osseous malignancies of the mobile spine. Patients with public insurance are vulnerable to worse outcomes, regardless of age, disease burden, or receipt of standard treatment. LEVEL OF EVIDENCE III.
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Marmouset D, Haseny B, Dukan R, Saint-Etienne A, Missenard G, Court C, Bouthors C. Characteristics, survivals and risk factors of surgical site infections after En Bloc sacrectomy for primary malignant sacral tumors at a single center. Orthop Traumatol Surg Res 2022; 108:103197. [PMID: 35007788 DOI: 10.1016/j.otsr.2022.103197] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION For prolonged survival, primary malignant sacral tumors (PMST) are treated by En Bloc sacrectomy. Few studies analyzed specifically the surgical site infections (SSI) for this condition and whether they impact on the patients' survivals. OBJECTIVES The objectives were to (1) describe their characteristics; (2) compare the survivals of infected and non-infected patients; (3) identify patients- and surgery-related risk factors. METHODS We conducted a retrospective single center study on 51 consecutive patients with PMST who underwent an En Bloc sacrectomy. Mean follow-up was 89±68months (range, 13-256months). Histology consisted of 46 chordoma, 3 chondrosarcoma, 1 Ewing tumor, 1 malignant peripheral nerve sheet tumor. Mean age was 57.4±13.7years with 26 (51%) male. Approaches were mainly anterior-and-posterior with, for the anterior approach, 18 laparotomy and 32 laparoscopy. Other surgical characteristics included 39 (76%) sacrectomy above S3; 7 (14%) instrumented cases; 8 (16%) colostomy. A pedicled omental flap with artificial mesh was used for posterior wall reconstruction. Overall and disease-free survivals were compared between infected and non-infected patients using Kaplan-Meier curves and log-rank test. RESULTS A total of 29 (57%) patients developed a SSI (7 deep, 22 organ/space) at mean 13.2±7.7days. One patient had also an infected intraperitoneal hematoma at day 150. SSIs were polymicrobial in 26 (90%) cases with Enterococcus sp. (27%) and E. coli (24%) as predominant organisms. Overall and disease-free survivals were not statistically different between infected and non-infected patients. Factors associated with increased likelihood of SSI included age>65years (OR=3.64; 1.06-12.50; p=0.04) and an elevated ASA score (OR=3.28, 1.05-10.80; p=0.046). Neoadjuvant radiotherapy (OR=2.86; 0.97-9.37; p=0.08) demonstrated a trend towards increased risk of SSI. Tumor volume, sacrectomy level, operating time, laparoscopy, colostomy, instrumentation, bowel incontinence were not associated to an increased risk of SSI. CONCLUSION En Bloc sacrectomy for PMST led to frequent and early SSI which, however, did not seem to impact survivals. Preoperative frailty was the predominant risk factor found in this series. Further studies are required to identify protective measures. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- Damien Marmouset
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Basel Haseny
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Ruben Dukan
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Adrien Saint-Etienne
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Gilles Missenard
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Charles Court
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Charlie Bouthors
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Chirurgie Orthopédique et Traumatologique, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France.
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Court C, Briand S, Mir O, Le Péchoux C, Lazure T, Missenard G, Bouthors C. Management of chordoma of the sacrum and mobile spine. Orthop Traumatol Surg Res 2022; 108:103169. [PMID: 34890865 DOI: 10.1016/j.otsr.2021.103169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 02/03/2023]
Abstract
Chordoma is a very rare, poorly known malignancy, with slow progression, mainly located in the sacrum and spine. All age groups may be affected, with a diagnostic peak in the 5th decade of life. Clinical diagnosis is often late. Histologic diagnosis is necessary, based on percutaneous biopsy. Specific markers enable diagnosis and prediction of response to novel treatments. New radiation therapy techniques can stabilize the tumor for 5 years in inoperable patients, but en-bloc resection is the most effective treatment, and should be decided on after a multidisciplinary oncology team meeting in an expert reference center. The type of resection is determined by fine analysis of invasion. According to the level of resection, the patients should be informed and prepared for the expected vesico-genito-sphincteral neurologic sequelae. In tumors not extending above S3, isolated posterior resection is possible. Above S3, a double approach is needed. Anterior release of the sacrum is performed laparoscopically or by robot; resection uses a posterior approach. Posterior wall reconstruction is performed, with an associated flap. Spinopelvic stabilization is necessary in trans-S1 resection. Total or partial sacrectomy shows high rates of complications: intraoperative blood loss, infection or mechanical issues. Neurologic sequelae depend on the level of root sacrifice. No genital-sphincteral function survives S3 root sacrifice. Patient survival depends on initial resection quality and the center's experience. Immunotherapy is an ongoing line of research.
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Affiliation(s)
- Charles Court
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France.
| | - Sylvain Briand
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Olivier Mir
- Service d'Oncologie, Institut Gustave Roussy, Université Paris Saclay, 114, rue Edouard-Vaillant, 94805 Villejuif Cedex, France
| | - Cécile Le Péchoux
- Service d'Oncologie, Institut Gustave Roussy, Université Paris Saclay, 114, rue Edouard-Vaillant, 94805 Villejuif Cedex, France
| | - Thierry Lazure
- Service d'Anatomopathologie de l'Hôpital de Bicêtre, Université Paris Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Gilles Missenard
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - Charlie Bouthors
- Service d'Orthopédie et Traumatologie de l'Hôpital de Bicêtre, Université Paris-Saclay, 78, rue du Général Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
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Baldassarre BM, Di Perna G, Portonero I, Penner F, Cofano F, Marco RD, Marengo N, Garbossa D, Pecorari G, Zenga F. Craniovertebral junction chordomas: Case series and strategies to overcome the surgical challenge. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:420-431. [PMID: 35068826 PMCID: PMC8740819 DOI: 10.4103/jcvjs.jcvjs_87_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/28/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction: Chordomas are rare and malignant primary bone tumors. Different strategies have been proposed for chordomas involving the craniovertebral junction (CVJ) compared to other locations. The impossibility to achieve en bloc excision, the impact on stability and the need for proper reconstruction make their surgical management challenging. Objective: The objective is to discuss surgical strategies in CVJ chordomas operated in a single-center during a 7 years' experience (2013-2019). Methods: Adult patients with CVJ chordoma were retrospectively analyzed. The clinical, radiological, pathological, and surgical data were discussed. Results: A total number of 8 patients was included (among a total number of 32 patients suffering from skull base chordoma). Seven patients underwent endoscopic endonasal approach (EEA), and posterior instrumentation was needed in three cases. Three explicative cases were reported: EEA for midline tumor involving lower clivus and upper cervical spine (case 1), EEA and complemental posterior approach for occurred occipitocervical instability (case 2), C2 chordoma which required aggressive bone removal and consequent implant positioning, focusing on surgical planning (timing and type of surgical stages, materials and customization of fixation system) (case 3). Conclusion: EEA could represent a safe route to avoid injuries to neurovascular structure in clival locations, while a combined approach could be considered when tumor spreads laterally. Tumor involvement or surgical procedures could give raise to CVJ instability with the need of complementary posterior instrumentation. Thus, a tailored preoperative planning should play a key role, especially when aggressive bone removal and implant positioning are needed.
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Affiliation(s)
- Bianca Maria Baldassarre
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Irene Portonero
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Federica Penner
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy.,Spine Surgery Unit, Humanitas Cellini Hospital, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy.,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Raffaele De Marco
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Nicola Marengo
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Giancarlo Pecorari
- Department of Surgical Sciences, ENT Surgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
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12
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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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13
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Massaad E, Shankar GM, Shin JH. Novel Applications of Spinal Navigation in Deformity and Oncology Surgery-Beyond Screw Placement. Oper Neurosurg (Hagerstown) 2021; 21:S23-S38. [PMID: 34128068 DOI: 10.1093/ons/opaa322] [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: 04/28/2020] [Accepted: 06/09/2020] [Indexed: 12/30/2022] Open
Abstract
Computer-assisted navigation has made a major impact on spine surgery, providing surgeons with technological tools to safely place instrumentation anywhere in the spinal column. With advances in intraoperative image acquisition, registration, and processing, many surgeons are now using navigation in their practices. The incorporation of navigation into the workflow of surgeons continues to expand with the evolution of minimally invasive techniques and robotic surgery. While numerous investigators have demonstrated the benefit of navigation for improving the accuracy of instrumentation, few have reported applying this technology to other aspects of spine surgery. Surgeries to correct spinal deformities and resect spinal tumors are technically demanding, incorporating a wide range of techniques not only for instrumentation placement but also for osteotomy planning and executing the goals of surgery. Although these subspecialties vary in their objectives, they share similar challenges with potentially high complications, invasiveness, and consequences of failed execution. Herein, we highlight the utility of using spinal navigation for applications beyond screw placement: specifically, for planning and executing osteotomies and guiding the extent of tumor resection. A narrative review of the work that has been done is supplemented with illustrative cases demonstrating these applications.
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Affiliation(s)
- Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Spiessberger A, Dietz N, Arvind V, Nasim M, Gruter B, Nevzati E, Hofer S, Cho SK. Spondylectomy in the treatment of neoplastic spinal lesions - A retrospective outcome analysis of 582 patients using a patient-level meta-analysis. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:107-116. [PMID: 34194155 PMCID: PMC8214243 DOI: 10.4103/jcvjs.jcvjs_211_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/31/2021] [Indexed: 01/23/2023] Open
Abstract
This study aims at identifying predictors of postoperative complications, lesion recurrence, and overall survival in patients undergoing en bloc spondylectomy (EBS) for spinal tumors. For this purpose a systematic review of the literature was conducted and patient-level data extracted. Linear-regression models were calculated to predict postoperative complications, lesion recurrence and overall survival based on age, tumor etiology, surgical approach, mode of resection (extra- vs. intralesional), tumor extension, and number of levels treated. A total of 582 patients were identified from the literature: 45% of females, median age 46 years (5-78); most common etiologies were: sarcoma (46%), metastases (31%), chordoma (11%); surgical approach was anterior (2.5%), combined (45%), and posterior (52.4%); 68.5% underwent EBS; average levels resected were 1.6 (1-6); average survival was 2.6 years; Complication rate was 17.7%. The following significant correlations were found: postoperative complications and resection mode (Odds ratio [OR] 1.35) as well as number of levels treated (OR 1.35); tumor recurrence and resection mode (OR 0.78); 5-year survival and age (OR 0.79), tumor grade (OR 0.65), tumor stage at diagnosis (OR 0.79), and resection mode (OR 1.68). EBS was shown to improve survival, decreases recurrence rates but also has a higher complication rate. Interestingly, the complication rate was not influenced by tumor extension or tumor etiology.
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Affiliation(s)
- Alexander Spiessberger
- Department of Orthopedic Surgery, Icahn School of Medicine - Mount Sinai Hospital, NY, USA.,Department of Neurosurgery, Hofstra School of Medicine, North Shore University Hospital, NY, USA
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Varun Arvind
- Department of Orthopedic Surgery, Icahn School of Medicine - Mount Sinai Hospital, NY, USA
| | - Mansoor Nasim
- Department of Pathology and Laboratory Medicine, Zucker School of Medicine at Hofstra Northwell, NY, USA
| | - Basil Gruter
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Edin Nevzati
- Department of Neurosurgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Silvia Hofer
- Department of Medical Oncology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Samuel K Cho
- Department of Orthopedic Surgery, Icahn School of Medicine - Mount Sinai Hospital, NY, USA
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15
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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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16
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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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17
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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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18
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Cherix S, Traverso A, Bazan AA, Gallusser N, Heutschi-Ozturk H, Abou-Khalil S, Goetti P, Letovanec I, Montemurro M, Bize P. Image-guided percutaneous cryoablation of unresectable sacrococcygeal chordoma: Feasibility and outcome in a selected group of patients with long term follow-up. J Surg Oncol 2020; 123:497-504. [PMID: 33146425 DOI: 10.1002/jso.26288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/16/2020] [Accepted: 10/06/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chordoma is a rare malignant tumor of the axial skeleton. Percutaneous cryoablation (PCA) is a minimally invasive technique that allows freezing of tumors under imaging control. The purpose of our retrospective study was to investigate the outcome of PCA in a selected cohort of patients with sacrococcygeal chordoma, with a minimum of 5 years follow-up. MATERIALS AND METHODS Four patients were treated in 10 sessions. The mean follow-up was 57.3 months. We evaluated the feasibility, the procedure-related complications, the impact on pain control and oncological outcomes. RESULTS Freezing of 100% of the tumor volume was possible in 60%. Pain control was not reliably evaluable. Local recurrence occurred in 90% of the treated lesions; the mean time to progression was 8.1 months (range 1.5-16). At last follow-up, one patient had died of the disease, one of another cause and one was receiving the best supportive care. The only patient alive without the disease had received additional carbon-ion radiotherapy. The 5-year survival rate after index PCA was 50%. CONCLUSION Complete freezing of the tumor was technically challenging, mainly due to the complex local anatomy. Recurrence occurred in 90% of the lesions treated. PCA should be considered with caution in the curative management of sacrococcygeal chordoma.
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Affiliation(s)
- Stéphane Cherix
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Aurélien Traverso
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Alexander A Bazan
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Nicolas Gallusser
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Hafize Heutschi-Ozturk
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Sami Abou-Khalil
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Patrick Goetti
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Igor Letovanec
- Department of Pathology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Michael Montemurro
- Department of Medical Oncology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Pierre Bize
- Department of Radiodiagnostic and Interventional Radiology, Clinique Genolier, University of Lausanne, Lausanne, Switzerland
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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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20
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Westbroek EM, Pennington Z, Ehresman J, Ahmed AK, Gailloud P, Sciubba DM. Vertebral Artery Sacrifice versus Skeletonization in the Setting of Cervical Spine Tumor Resection: Case Series. World Neurosurg 2020; 139:e601-e607. [PMID: 32330623 DOI: 10.1016/j.wneu.2020.04.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tumors of the cervical spine often encase 1 or both vertebral arteries (VA), presenting the treating surgeon with the dilemma of whether to sacrifice or skeletonize the artery. We propose an algorithm for VA management in surgeries for cervical neoplasms METHODS: A retrospective review was carried out of 67 patients undergoing resection of cervical spine tumors with VA involvement. Patients were categorized by tumor origin (primary vs. metastatic) and degree of circumferential VA involvement: 1) abutment only; 2) <180° circumferential involvement; 3) >180° circumferential involvement without complete encasement; or 4) complete encasement. RESULTS Twelve patients (18%) underwent VA sacrifice, whereas 55 (82%) underwent VA skeletonization. Compared with 11/30 patients with primary tumors (37%), only 1/37 patients (3%) with metastatic disease underwent VA sacrifice (P < 0.01). This patient had invasion of the V2 arterial wall, requiring VA sacrifice. Odds of VA sacrifice also increased with increasing circumferential involvement (P < 0.01). No patients with simple abutment or 0°-180° circumferential involvement underwent sacrifice, whereas 6 of 10 (60%) with 180°-359° involvement and 6 of 29 (21%) with complete encasement underwent VA sacrifice. Of the 27 patients with ≥180° involvement, the reasons for preserving the VA were metastatic disease at the time of treatment (n = 18), a compromised contralateral VA (n = 7), vertebrobasilar junction aplasia (n = 1), and presence of a radiculomedullary artery at the affected level (n = 1). CONCLUSIONS Primary tumor disease and >180° of circumferential VA involvement should be considered as indications for intraoperative sacrifice of the VA pending preoperative angiographic evaluation for contraindications.
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Affiliation(s)
- Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Wright CH, Wright J, Cioffi G, Hdeib A, Kasliwal MK, Kruchko C, Barnholtz-Sloan JS, Sloan AE. Association of cancer center type with treatment patterns and overall survival for patients with sacral and spinal chordomas: an analysis of the National Cancer Database from 2004 to 2015. J Neurosurg Spine 2020; 32:311-320. [DOI: 10.3171/2019.7.spine19566] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/19/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEChordomas of the spine and sacrum are a rare but debilitating cancer and require complex multidisciplinary care. Studies of other such rare cancers have demonstrated an association of high-volume and/or multidisciplinary centers with improved outcomes and survival. Such an association has been proposed for chordomas, but evidence to support this claim is lacking. The authors performed a study to investigate if treatment facility type is associated with patterns of care and survival for patients with spinal and sacral chordomas by assessing records from a US-based cancer database.METHODSIn this observational retrospective cohort study, the authors identified 1266 patients from the National Cancer Database with vertebral column or sacral chordomas diagnosed between 2004 and 2015. The primary study outcome was overall survival, and secondary outcomes included odds of receiving treatment and time to treatment, defined as radiation therapy, surgery, and/or any treatment, including surgery, radiation therapy, chemotherapy, or participation in clinical trials. The results were adjusted for age, sex, race/ethnicity, level of education, income, and Charlson/Deyo score.RESULTSOf the 1266 patients identified, the mean age at diagnosis was 59.70 years (SD 16.2 years), and the patients were predominantly male (n = 791 [62.50%]). Patients treated at community cancer programs demonstrated an increased risk of death (HR 1.98, 95% CI 1.13–3.47, p = 0.018) when compared to patients treated at academic/research programs (ARPs). The median survival was longest for those treated at ARPs (131.45 months) compared to community cancer programs (79.34 months, 95% CI 48.99–123.17) and comprehensive community cancer programs (CCCPs) (109.34 months, 95% CI 84.76–131.45); 5-year survival rates were 76.08%, 52.71%, and 61.57%, respectively. Patients treated at community cancer programs and CCCPs were less likely to receive any treatment compared to those treated at ARPs (OR 6.05, 95% CI 2.62–13.95, p < 0.0001; OR 3.74, 95% CI 2.23–6.28, p < 0.0001, respectively). Patients treated at CCCPs and community cancer programs were less likely to receive surgery than those treated at ARPs (OR 2.69, 95% CI 1.82–3.97, p = 0.010; OR = 2.64, 95% CI 1.22–5.71, p = 0.014, respectively). Patients were more likely to receive any treatment (OR 0.59, 95% CI 0.40–0.87, p = 0.007) and surgery (OR 0.58, 95% CI 0.38–0.88, p < 0.0001) within 30 days at a CCCP compared to an ARP. There were no differences in odds of receiving radiation therapy or time to radiation by facility type.CONCLUSIONSClinical care at an ARP is associated with increased odds of receiving treatment that is associated with improved overall survival for patients with spinal and sacral chordomas, suggesting that ARPs provide the most comprehensive specialized care for patients with this rare and devastating oncological disease.
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Affiliation(s)
- Christina Huang Wright
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
| | - James Wright
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
| | - Gino Cioffi
- 4Case Comprehensive Cancer Center and Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
- 5Central Brain Tumor Registry of the United States, Hinsdale, Illinois
| | - Alia Hdeib
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
- 3Seidman Cancer Center and Case Comprehensive Cancer Center
| | - Manish K. Kasliwal
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
| | - Carol Kruchko
- 5Central Brain Tumor Registry of the United States, Hinsdale, Illinois
| | - Jill S. Barnholtz-Sloan
- 4Case Comprehensive Cancer Center and Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio; and
- 5Central Brain Tumor Registry of the United States, Hinsdale, Illinois
| | - Andrew E. Sloan
- 1Department of Neurological Surgery, University Hospitals Cleveland Medical Center
- 2Department of Neurosurgery, Case Western Reserve University
- 3Seidman Cancer Center and Case Comprehensive Cancer Center
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Abstract
Chordomas are rare tumors of the axial skeleton whose slow growth belies a relentless tumor with a propensity for recurrence and late metastasis. Local control remains an issue with chordoma in spite of aggressive operative management. High local failure rates have led to the exploration of alternative methods of treatment. Radiation continues to gain acceptance as an adjuvant to surgery and, in some cases, as a standalone treatment. However, the use of radiation remains controversial, and operative management remains the standard of care in spite of relatively high morbidity.
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Affiliation(s)
- Michiel E R Bongers
- Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, Yawkey Building, Room 3.550, 55 Fruit Street, Boston, MA 02114, USA.
| | - Nicolas Dea
- Division of Spine Surgery, Vancouver General Hospital and the University of British Columbia, Blusson Spinal Cord Center, 6th Floor, 818 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, Medical Center, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Joseph H Schwab
- Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, Yawkey Building, Room 3.922, 55 Fruit Street, Boston, MA 02114, USA
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Zuckerman SL, Rhines LD. The use of preoperative imaging in the treatment of sacral chordomas. JOURNAL OF SPINE SURGERY 2019; 5:390-391. [PMID: 31663054 DOI: 10.21037/jss.2019.08.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laurence D Rhines
- Department of Neurological Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Charest-Morin R, Fisher CG, Sahgal A, Boriani S, Gokaslan ZL, Lazary A, Reynolds J, Bettegowda C, Rhines LD, Dea N. Primary Bone Tumor of the Spine-An Evolving Field: What a General Spine Surgeon Should Know. Global Spine J 2019; 9:108S-116S. [PMID: 31157142 PMCID: PMC6512194 DOI: 10.1177/2192568219828727] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
STUDY DESIGN A narrative review of the literature. OBJECTIVE This article reviews the general principles of treatment and investigation for primary bone tumors of the spine. Furthermore, it explores the emerging alternatives. METHODS A review was performed using Medline, Embase, and Cochrane databases. RESULTS Primary bone tumors of the spine are rare entities that general spine surgeons may encounter only a few times in their career. The treatment algorithm of these complex tumors is filled with nuances and is evolving constantly. For these reasons, patients should be referred to experienced tertiary or quaternary centers who can offer a comprehensive multidisciplinary approach. For most malignant spinal bone tumors, surgery remains the cornerstone of treatment. Respecting oncologic principles has been associated with improved survival and decreased local recurrence in multiple settings. However, even in experienced centers, these surgeries carry a significant risk of adverse events and possible long-term neurologic impairment. The associated morbidity of these procedures and the challenges of local recurrence have encouraged professionals caring for these patients to explore alternatives or adjuncts to surgical treatment. CONCLUSIONS Over the past few years, several advances have occurred in medical oncology, radiation oncology and interventional radiology, changing the treatment paradigm for some tumors. Other advances still need to be refined before being applied in a clinical setting.
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Affiliation(s)
- Raphaële Charest-Morin
- University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Charles G Fisher
- University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Arjun Sahgal
- Sunnybrook Odette Cancer Center, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Ziya L Gokaslan
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
- The Miriam Hospital, Providence, RI, USA
| | - Aron Lazary
- National Center for Spinal Disorders and Buda Health Center, Budapest, Hungary
| | | | | | | | - Nicolas Dea
- University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
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