Intradural retroclival chordoma without bone involvement: no tumor regrowth 5 years after operation. Case report

An Ecchordosis Physaliphora, a Rare Entity, Involving the Central Nervous System: A Systematic Review of the Literature

Ecchordosis physaliphora (EP) is a benign notochordal remnant, which is often an incidental finding; however, it can rarely present with neurological symptoms. We performed a systematic review of the literature for cases of symptomatic EP published in PubMed, Web of Science and Embase from January 1982 to May 2023. This is the largest review to date and revealed 60 cases including ours. Headache (55%) and CSF rhinorrhea (32%) were the most frequent clinical manifestations. The majority of symptomatic EP lesions were located in the prepontine region (77%) and required surgical resection (75%). EP should be considered in patients with neurologic symptoms in the setting of prepontine or posterior sphenoid sinus lesions. While symptomatic patients often require surgical intervention, rare cases may respond to oral corticosteroids.

Long-Term Outcomes after Multimodal Treatment for Clival Chordoma: Efficacy of the Endonasal Transclival Approach with Early Adjuvant Radiation Therapy

This study investigates the long-term outcomes of clival chordoma patients treated with the endonasal transclival approach (ETCA) and early adjuvant radiation therapy. A retrospective review of 17 patients (2002-2013) showed a 10-year progression-free survival (PFS) rate of 67.4%, with the ETCA group showing fewer progressions and cranial neuropathies than those treated with combined approaches. The ETCA, a minimally invasive technique, provided a similar extent of resection compared to conventional skull-base approaches and enabled safe delivery of high-dose adjuvant radiotherapy. The findings suggest that ETCA is an effective treatment for centrally located clival chordomas.

Unrecognized notochordal lesions as a likely cause of idiopathic clival cerebrospinal fluid leaks

OBJECTIVE

To examine an association between idiopathic transclival cerebrospinal fluid (CSF) leak and notochordal lesions.

METHODS

This study consisted of the illustrations of institutional patients who underwent surgery for transclival CSF leak between January 1, 2009 and April 25, 2020 and comprehensive review of the existing literature conducted on April 25, 2020. The cases were classified based on the presumed etiologies that were originally proposed in the articles ("idiopathic" vs. "secondary"). The baseline characteristics were compared between the groups, and the surgical outcomes were summarized.

RESULTS

In 3 institutional cases, ecchordosis physaliphora (EP) was confirmed at the fistula either pathologically (1) or radiologically (2). Among 42 literature cases, 28 were recognized as idiopathic, while 14 were secondary cases with histologically (n = 12) or radiologically (n = 2) confirmed notochordal lesion at the fistula. Thus, any notochordal lesions were histologically confirmed in 13 among a total of 45 cases (28.9%). Fourteen of the idiopathic cases had undescribed radiographic signs suggestive of small ecchordosis physaliphora at the fistula. Both idiopathic and secondary cases demonstrated resemblance in their ages (mean, 51.4 and 56.6 years; p = 0.102), female predominance (male, 36% vs. 25%; P = 0.521), no association with obesity (7% vs. 18%; P = 0.350) or increased intracranial pressure (7% vs. 6%; P = 1.000). All the fistulas were in the midline or paramidline clivus within several millimeters below the dorsum sellae. All the patients were treated surgically with a multilayer closure, resulting in a success rate of 93% with one surgery.

CONCLUSION

Our analyses suggest the association of transclival CSF leak and notochord lesions. A prospective study is needed for definitive conclusion.

Do All Notochordal Lesions Require Proton Beam Radiotherapy? A Proposed Reclassification of Ecchordosis Physaliphora as Benign Notochord Cell Tumor

Objectives Ecchordosis physaliphora (EP) is a benign notochord lesion of the clivus arising from the same cell line as chordoma, its malignant counterpart. Although usually asymptomatic, it can cause spontaneous cerebrospinal fluid (CSF) rhinorrhea. Benign notochordal cell tumor (BNCT) is considered another indolent, benign variant of chordoma. Although aggressive forms of chordoma require maximal safe resection followed by proton beam radiotherapy, BNCT and EP can be managed with close imaging surveillance without resection or radiotherapy. However, while BNCT and EP can be distinguished from more aggressive forms of chordoma, differentiating the two is challenging as they are radiologically and histopathologically identical. This case series aims to characterize the clinicopathological features of EP and to propose classifying EP and BNCT together for the purposes of clinical management.

Design Case series.

Setting Tertiary referral center, United Kingdom.

Participants Patients with suspected EP from 2015 to 2019.

Main Outcome Measures Diagnosis of EP.

Results Seven patients with radiological suspicion of EP were identified. Five presented with CSF rhinorrhea and two were asymptomatic. Magnetic resonance imaging features consistently showed T1-hypointense, T2-hyperintense nonenhancing lesions. Diagnosis was made on biopsy for patients requiring repair and radiologically where no surgery was indicated. The histological features of EP included physaliphorous cells of notochordal origin (positive epithelial membrane antigen, S100, CD10, and/or MNF116) without mitotic activity.

Conclusion EP is indistinguishable from BNCT. Both demonstrate markers of notochord cell lines without malignant features. Their management is also identical. We therefore propose grouping EP with BNCT. Close imaging surveillance is required for both as progression to chordoma remains an unquantified risk.

Clinical Grading System, Surgical Outcomes and Prognostic Analysis of Cranial Base Chordomas

Objective

Cranial base chordomas are rare, but their treatment is challenging. Tumor recurrence is still common despite improvements in microsurgical techniques and postoperative radiotherapy. We retrospectively analyzed the course of treatment, overall survival, and recurrence/progression of chordomas over the past 10 years.

Methods

We retrospectively reviewed 50 patients who underwent surgery at Tianjin Huanhu Hospital between 2010 and 2020 and were pathologically diagnosed with chordomas. Tumor resection was performed within the maximum safe range in all patients; the extent of resection was evaluated by imaging; and the incidence of complications, recurrence or progression, and overall survival were assessed.

Results

Fifty patients were divided into the low-risk group (LRG) and high-risk group (HRG) based on the cranial chordoma grading system (CCGS). The Karnofsky Performance Scale scores and gross total resection rate of the LRG were significantly higher than those of the HRG (p<0.05). The incidence of complications and mortality in the LRG were lower than those of HRG. The analysis of cumulative survival and cumulative recurrence free survival/progression free survival (RFS/PFS) showed no statistical differences in the extent of resection for survival, recurrence, or progression. Univariate and multivariate analyses showed that Ki-67 was significantly associated with tumor recurrence and was an independent hazard factor (p=0.02).

Conclusion

The CCGS can help neurosurgeons anticipate surgical outcomes. Pathological results are important in evaluating the possibility of tumor recurrence, and postoperative radiotherapy improves overall survival and RFS/PFS.

Atypical Presentation and Neuroradiological Features of Giant Ecchordosis Physalyphora in a Seven-Year-Old Patient: A Case Report

This study presented the rare case of a seven-year-old patient with atypical presentation and neuroradiological features of giant ecchordosis physaliphora. The patient underwent cross-sectional imaging due to persistent headache without neurological or visual symptoms. CT scan imaging of the head revealed a hypodense tumor in the prepontine cistern. This lesion caused smooth scalloping of the dorsal clivus without aggressive erosion or calcification, and an osseous stalk was also identified between the lesion and the dorsal wall of the clivus. Sagittal T1 weighted image (T1WI) MRI showed a bilobed, solid and cystic, well-defined lesion, measuring 3.5 cm in terms of craniocaudal diameter, found alongside the midline within the prepontine cistern. After the evaluation of radiological images, the patient was then subjected to endoscopic transnasal complete tumor excision. Histological examination revealed sheets and lobules of clear cells with cytoplasmic globules "physaliphorous cells", and myxoid stroma. There was nuclear pleomorphism associated with focal areas of necrosis. After full recovery and discharge, the patient was followed up for the first year with four-month interval brain MRI scans showing no evidence of residual tumors. On the 12 months follow-up scan, the MRI scan revealed a 1.5 x 0.7 cm recurrent mass in the retroclival right paramidline prepontine cistern, which was most notably seen on the diffusion-weighted images. Series of proton beam therapy with annual MRI scans demonstrated regression of the tumor, eventually allowing the patient to live free of neurological symptoms up to this day. Results suggest that the utilization of radiological imaging such as CT and MRI scans was successful in identifying the ecchordosis physaliphora and differentiating it from chordomas. It can also be inferred that atypical radiological and histopathological findings of ecchordosis physaliphora lesions might suggest that they are prone to recurrence, which is an atypical feature for such entities. Further studies are recommended to explore and better understand these uncommon observations in patients with ecchordosis physaliphora.

MRI enhancement patterns in 28 cases of clival chordomas

Clival chordomas are classically thought of as locally aggressive tumors of the skull base and differentiate themselves from their benign counterparts by demonstrating moderate to marked contrast enhancement, reported as 95-100% in prior studies. The purpose of this review was to evaluate the imaging characteristics of lesions from a single institution classified as clival chordomas with an emphasis of highlighting lesions that do not follow the prevalent current description for chordoma. We searched our institutional databases for all patients with pathologically proven clival chordomas from 1997 to 2017 who had pre-operative imaging available. The images were evaluated for degree of contrast enhancement, MRI signal characteristics, osseous involvement, location, aggressiveness of appearance, and presence of calcifications. 28 cases were identified that had preoperative imaging available for review. Over half of the patients demonstrated either no/minimal (11/28, 39%) or mild enhancement (7/28, 25%). The remaining cases demonstrated moderate (4/28, 14%) and marked enhancement (6/28, 21%). The 4 lesions measuring less than 20 mm all had mild to minimal/no enhancement and lacked aggressive features on CT. Our experience finds that over half (64%) of clival chordomas will demonstrate mild or no enhancement at all. These findings suggest that the lack of MRI contrast enhancement should not be synonymous with a benign clival mass.

A Cystic Clival Chordoma with CT and MRI Unconventional Appearances

We present the first case of clival cystic chordoma with extradural location, transdural transgression, and moderate bone involvement in a 10-year-old girl. Chordoma showed unconventional appearances on computed tomography (CT) and magnetic resonance imaging (MRI), due to cystic components, extradural space location with extensive intradural extension, moderate superficial bone involvement. Surgery confirmed the extradural location and histopathological examination revealed cystic chordoma. MRI and CT findings were not characteristic for a single lesion; differential diagnoses included cystic lesions such as epidermoid and dermoid cyst, ecchordosis physaliphora, and benign notochordal cell tumors.

Chordomas: Histopathological Study in View of Anatomical Location

BACKGROUND

Chordomas are aggressive bone tumors that have a predilection for the axial skeleton including the skull base and spinal/sacral bones. However, the histopathological and clinical differences between skull base chordoma (SBC) and sacral/spinal chordoma (SC) are unclear as previous studies have been focused on patient prognosis and treatment outcome. This study aimed to evaluate the clinicopathologic features and prognosis of chordoma according to its location.

METHODS

Patients with chordomas were enrolled, and the histopathologic features were compared according to the tumor location.

RESULTS

A total of 52 patients were enrolled. SBCs had more abundant chondroid matrix and diffuse growth pattern, while SCs had non-chondroid, myxoid matrix and a lobulating pattern, typical of chordoma. Old age and residual tumors were risk factors for shorter overall survival in SBCs. The chondroid matrix was an independent risk factor for shorter disease-free survival in the overall population.

CONCLUSION

Chordomas have different histopathologic features depending on the anatomical location.

Gamma knife surgery efficacy in controlling postoperative residual clival chordoma growth

OBJECTIVE

This study primarily aims to evaluate the efficacy of gamma knife surgery in controlling growth progression rate of residual clival chordoma through retrospective outcome analysis of 12 consecutive patients.

PATIENTS AND METHODS

Data for 12 consecutive patients underwent GKS for post-operative residual histologically verified clival chordoma at our institution (IMC - Cairo- Egypt) from 2006 through end of 2017 were retrospectively reviewed and analyzed with mean follow-up period of 45 months (range12-120 months).

RESULTS

In the last follow up MR, tumor growth control was achieved in 33.3% of patients (mean treated tumors volume was 2.7cc with mean peripheral prescription dose of 16 Gy), and 66.7% of patients reported lost tumor growth control (mean treated tumor volume was 9.2 cc with mean peripheral dose was 13.5 Gy). The overall tumor free progression with mean follow up period of 45mos was 33.3%. The Actuarial 2, 3 and 5 year tumor control rates after initial GKS was 35%, 30% and 25% respectively.

CONCLUSION

Without satisfactory maximum tumor reduction and sufficient high peripheral prescription radiation tumor dose, it should not be expected that GKS could efficiently control the progression of residual clival chordoma, especially for long term.

Chordoma of the corpus callosum: case report

Chordomas are neoplasms that typically arise from midline skeletal structures and rarely originate within the intradural compartment of the CNS. A chordoma arising from the corpus callosum has not been previously described. The authors report the surgical management of a chordoma originating within the splenium of the corpus callosum. To determine the incidence and distribution of intracranial intradural chordoma, a literature search for additional cases was performed. MEDLINE was searched using the MeSH keyword "chordoma," yielding 2010 articles. These articles were screened for cases of primary intradural chordoma rostral to the craniocervical junction, which led to the identification of 46 relevant articles. The authors report the case of a 69-year-old man who initially presented with nonspecific neurological symptoms including spatial disorientation and cognitive decline. These symptoms eventually prompted intracranial imaging, including MRI, which revealed a ring-enhancing, heterogeneous, cystic mass localized within the splenium of the corpus callosum and extending into the bilateral ventricles. The lesion was believed to represent a high-grade glioma and the patient underwent a left interhemispheric approach and subtotal resection. After pathologic evaluation confirmed a diagnosis of an anaplastic chordoma, the patient underwent further resection. A gross-total resection (GTR) was achieved with a transfalcine approach to the contralateral portion of the tumor. Postoperatively, the patient had a partial left homonymous quadrantanopsia, but was otherwise at his neurological baseline. Proton beam radiotherapy was performed to the resection cavity but diffuse intraventricular disease ensued. The results of a literature search suggest that a chordoma arising in the corpus callosum has not been previously described. The present case demonstrates that chordomas can occur in the corpus callosum, and illustrates the utility of a transfalcine approach for GTR of lesions in this location, as well as the need for improved strategies to prevent intraventricular dissemination.

Intradural cervical chordoma with diffuse spinal leptomeningeal spread: case report and review of the literature

PURPOSE

Chordoma is a low-grade malignant bone tumor derived from embryonic notochord remnants along the axial skeleton. About 50% of chordomas occur in the sacral vertebrae and 35% in the skull base. Most chordomas are extradural and cause extensive bone destruction. Intradural spinal tumors without bone involvement are rare.

METHODS

We herein describe the clinical features of a patient with a chordoma as well as the imaging and pathological manifestations of the tumor.

RESULTS

We encountered an unusual presentation of a C6 and C7 spinal intradural chordoma in a 23-year-old man. He presented with a 5-day history of discomfort over the lumbosacral region. Magnetic resonance imaging and enhanced scanning of the cervical spine showed an intradural soft tissue mass at C6 and C7 and linear enhancement of the spinal meninges. The tumor was excised because the patient had been previously misdiagnosed with an intraspinal neurogenic tumor with spinal meningitis. Postoperative pathological examination confirmed the diagnosis of chordoma. On postoperative day 7, the patient underwent brain magnetic resonance imaging because of severe headache. The images showed multiple soft tissue nodules in the skull base cistern. To the best of our knowledge, this is the first case report of an entirely extraosseous and spinal intradural chordoma with diffuse spinal leptomeningeal spread. The patient died 2 months postoperatively.

CONCLUSIONS

An intradural spinal chordoma is difficult to distinguish from a neurogenic tumor by imaging. When the lesion is dumbbell-shaped, it is easily misdiagnosed as a schwannoma. In the present case, the tumor was intradural and located at the level of the C6 and C7 vertebrae. Preoperative diagnosis was difficult, and the final diagnosis required pathological examination.

Skull base chordomas: clinical outcome in a consecutive series of 45 patients with long-term follow-up and evaluation of clinical and biological prognostic factors

OBJECTIVE

Skull base chordomas (SBCs) are rare dysembryogenetic invasive tumors with a variable tendency for recurrence. According to previous studies, the recurrence rate seems to be affected by both clinical variables and tumor biological features. The authors present the results of treatment of SBCs in a large series of patients and investigate the role of 1p36 chromosomal region loss of heterozygosity (LOH) as a prognostic factor.

METHODS

Between 1990 and 2011, 45 patients were treated for SBCs. The mean follow-up was 76 months (range 1–240 months). An LOH analysis was performed in 27 cases. Survival analysis was performed to determine clinical and biological parameters correlating with clinical outcome.

RESULTS

The 5- and 10-year overall survival rates were 67% and 57%, respectively. Five- and 10-year progression-free survival rates were 58% and 44%, respectively. Multivariate analysis showed that extent of resection, adjuvant radiation therapy, and absence of rhinopharynx invasion were positive independent predictors of overall survival. The latter 2 variables and a younger patient age were positive independent predictors of progression-free survival. Twenty-one patients showed 1p36 LOH. All events of recurrence and death clustered in the group of patients with 1p36 LOH; however, this biological marker was not statistically significant on multivariate analysis.

CONCLUSIONS

Resection is the treatment of choice in primary and recurrent SBC. Patient age, rhinopharynx invasion at diagnosis, extent of tumor removal, and postoperative radiation therapy influence SBC prognosis. Genetic analysis, even while showing interesting results, did not reveal 1p36 LOH as an independent predictor of clinical outcome.

Intradural prepontine chordoma in an 11-year-old boy. A case report

CASE REPORT

The authors report a case of an 11-year-old boy that presented with headache and vomiting that was present for several months. CT and MR imaging revealed a large prepontine mass and an obstructive hydrocephalus. A ventriculoperitoneal shunt was inserted, and in a second operation, a radiologically proven total resection was performed, using a left frontotemporal transsylvian approach. The tumour showed no involvement of the dura or clivus. Histological examination showed the characteristics of a chordoma. No further adjuvant treatment was given. The patient remained disease or tumour free after a 6-year follow-up.

DISCUSSION

Intradural chordomas are extremely rare tumours that originate from notochordal remnants. Only three other cases have been reported in the paediatric population. Ecchordosis physaliphora (EP) is an ectopic notochordal remnant that has a similar biological behaviour and is difficult to distinguish from intradural chordomas. They might exist in a continuum from benign notochordal tumour to malignant chordoma. A surgical resection without adjuvant radiation therapy is suggested to be the treatment of choice in the paediatric population.

CONCLUSION

The authors describe a rare case of an intradural prepontine chordoma in an 11-year-old boy that stayed disease free after a 6-year follow-up.

Intradural clival chordoma: a case report

Clival chordoma is a rare intracranial neoplasm located in the clivus with bony extension and destruction. It is difficult to resect completely and generally has a poor prognosis. However, intradural clival chordomas have been reported with good surgical outcomes. We present a rare case of intradural chordoma and a review of the literature.

Skull base chondroid chordoma: atypical case manifesting as intratumoral hemorrhage and literature review

OBJECTIVE

Chondroid chordoma (CC) is a rare but commonest subtype of chordoma with little reported clinical information. The present study summarizes and updates present knowledge of CC.

METHODS

Literature search for demographic data and clinical appearance of cranial CCs except for those entirely confined to the sinonasal region.

RESULTS

A total of 48 English language papers published from 1968-2013 were retrieved describing 132 CCs as skull base tumors. The male-to-female ratio was 1:1. The mean age at diagnosis was 43 years, predisposing to the third to fifth decades of life. The clival (34%) and spheno-occipital (29%) regions were the most frequent sites of origin followed by the sellar (12%) and sphenoid (5%) regions. Intratumoral calcification and bony erosion were identified as the characteristic neuroimaging findings. Surgical resection by the transcranial, transsphenoidal, transnasal, transpharyngeal, or transpalatal route with or without adjuvant radiotherapy was the main treatment option. The initial treatment outcome was satisfactory in 82% of cases with considerably better prognosis compared with typical chordomas.

CONCLUSION

CC is a distinct entity to be discriminated from the typical type of chordoma. There are no distinguishing features on magnetic resonance imaging between CC and typical chordoma. Intratumoral calcification and concurrent bony erosion on neuroimaging should suggest the possibility of CC. Extensive surgical resection and adjuvant radiotherapy can achieve satisfactory outcome.

Giant petroclival primary intradural chordoma: case report and systematic review of the literature

Background Chordomas are rare, locally aggressive neoplasms thought to arise from notochordal remnants in the axial skeleton. Primary intradural chordomas are considered to be extremely rare. In this article a giant intradural petroclival chordoma is presented, and a synthesis of the available literature is performed to measure overall survival (OS) and recurrence-free survival (RFS) and to identify prognostic factors.

Methods A systematic Medline review yielded 47 patients with purely intradural tumors from 38 publications including 39 chordomas, 8 cases of ecchordosis physaliphora, and 1 case with features of both. The 5-year OS and RFS were calculated based on the Kaplan-Meier method. Risk factors for progression or mortality were analyzed using binomial logistic regression.

Results Maximal tumor diameter varied from 1.5 to 6.0 cm (mean: 3.2 cm). Tumors were located predominantly in the prepontine area (66.7%). Combined 5-year Kaplan-Meier OS and RFS were 77% ± 11% and 74% ± 11%, respectively. Incomplete surgical resection, larger tumor diameter, and an elevated Ki-67 index were statistically more frequent in cases of recurrence and mortality.

Conclusions Based on a systematic literature review, the behavior of primary intradural chordomas may be closer to typical chordomas than was previously thought.

[Chordoma]

PURPOSES

To review in the literature, all the epidemiological, clinical, radiological, histological and therapeutic data regarding chordomas as well as various notochordal entities: ecchordosis physaliphora, intradural and intraparenchymatous chordomas, benign notochordal cell tumors, parachordomas and extra-axial chordomas. To identify different types of chordomas, including familial forms, associations with tuberous sclerosis, Ollier's disease and Maffucci's syndrome, forms with metastasis and seeding. To assess the recent data regarding molecular biology and progress in targeted therapy. To compare the different types of radiotherapy, especially protontherapy and their therapeutic effects. To review the largest series of chordomas in their different localizations (skull base, sacrum and mobile spine) from the literature.

MATERIALS

The series of 136 chordomas treated and followed up over 20 years (1972-2012) in the department of neurosurgery at Lariboisière hospital is reviewed. It includes: 58 chordomas of the skull base, 47 of the craniocervical junction, 23 of the cervical spine and 8 from the lombosacral region. Similarly, 31 chordomas in children (less than 18 years of age), observed in the departments of neurosurgery of les Enfants-Malades and Lariboisière hospitals, are presented. They were observed between 1976 and 2010 and were located intracranially (n=22 including 13 with cervical extension), 4 at the craniocervical junction level and 5 in the cervical spine.

METHODS

In the entire Lariboisière series and in the different groups of localization, different parameters were analyzed: the delay of diagnosis, of follow-up, of occurrence of metastasis, recurrence and death, the number of primary patients and patients referred to us after progression or recurrence and the number of deaths, recurrences and metastases. The influence of the quality of resection (total, subtotal and partial) on the prognosis is also presented. Kaplan-Meier actuarial curves of overall survival and disease free survival were performed in the entire series, including the different groups of localization based on the following 4 parameters: age, primary and secondary patients, quality of resection and protontherapy. In the pediatric series, a similar analysis was carried-out but was limited by the small number of patients in the subgroups.

RESULTS

In the Lariboisière series, the mean delay of diagnosis is 10 months and the mean follow-up is 80 months in each group. The delay before recurrence, metastasis and death is always better for the skull base chordomas and worse for those of the craniocervical junction, which have similar results to those of the cervical spine. Similar figures were observed as regards the number of deaths, metastases and recurrences. Quality of resection is the major factor of prognosis with 20.5 % of deaths and 28 % of recurrences after total resection as compared to 52.5 % and 47.5 % after subtotal resection. This is still more obvious in the group of skull base chordomas. Adding protontherapy to a total resection can still improve the results but there is no change after subtotal resection. The actuarial curve of overall survival shows a clear cut in the slope with some chordomas having a fast evolution towards recurrence and death in less than 4 years and others having a long survival of sometimes more than 20 years. Also, age has no influence on the prognosis. In primary patients, disease free survival is better than in secondary patients but not in overall survival. Protontherapy only improves the overall survival in the entire series and in the skull base group. Total resection improves both the overall and disease free survival in each group. Finally, the adjunct of protontherapy after total resection is clearly demonstrated. In the pediatric series, the median follow-up is 5.7 years. Overall survival and disease free survival are respectively 63 % and 54.3 %. Factors of prognosis are the histological type (atypical forms), localization (worse for the cervical spine and better for the clivus) and again it will depend on the quality of resection.

CONCLUSIONS

Many different pathologies derived from the notochord can be observed: some are remnants, some may be precursors of chordomas and some have similar features but are probably not genuine chordomas. To-day, immuno-histological studies should permit to differentiate them from real chordomas. Improving knowledge of molecular biology raises hopes for complementary treatments but to date the quality of surgical resection is still the main factor of prognosis. Complementary protontherapy seems useful, especially in skull base chordomas, which have better overall results than those of the craniocervical junction and of the cervical spine. However, we are still lacking an intrinsic marker of evolution to differentiate the slow growing chordomas with an indolent evolution from aggressive types leading rapidly to recurrence and death on which more aggressive treatments should be applied.

Diagnostic imaging dilemma of a clival lesion and its clinical management implications

Background A retroclival lesion can represent a notochordal remnant-derived mass. The differential diagnoses includes benign lesions such as ecchordosis physaliphora (EP) and neuroenteric cyst or malignant ones such as chordomas. In the case of EP and chordoma, although both types arise from remnants of fetal notochord tissues, they represent two separate entities with different radiographic and biologic behaviors. Case Description We present a case of an incidental finding of a retroclival lesion. The magnetic resonance imaging (MRI) characteristics of the lesion match the neuroimaging profile of a benign lesion and are suggestive of an EP. There was no enhancement noted with the addition of gadolinium. Nonetheless, pathology determined the lesion to be a malignant chordoma. Conclusion The differential diagnosis of a retroclival lesion includes benign and malignant notochordal lesions. Here we present a case of a patient with an incidental finding of a retroclival lesion. Radiographic findings were suggestive of a benign lesion, possibly EP, yet the pathology revealed a chordoma. This report suggests that despite benign imaging, chordoma cannot be excluded and the implications for treatment can be significant. It is important to achieve the correct diagnosis because the prognostic and therapeutic implications are different.

Brachyury: a diagnostic marker for the differential diagnosis of chordoma and hemangioblastoma versus neoplastic histological mimickers

Brachyury is a transcription factor which is required for posterior mesoderm formation and differentiation as well as for notochord development during embryogenesis. Due to its expression in the neoplastic cells of chordoma, a malignant tumour deriving from notochordal remnants, but not in tumors showing a similar histology, brachyury has been proposed as a diagnostic marker of this neoplasia. Though commonly considered a hallmark of chordoma, the expression of brachyury has been also documented in the stromal cells of hemangioblastoma (HBL), a slow growing tumor which may involve the central nervous system (CNS) and, rarely, the kidney. Herein we review the role of brachyury immunohistochemical detection in the identification and differential diagnosis of chordoma and HBL towards histological mimickers and suggest that brachyury is added to the panel of immunohistochemical markers for the recognition of HBL in routinary practice, principally in unusual sites.

Giant ecchordosis physaliphora in an adolescent girl: case report

The authors describe a rare case of giant ecchordosis physaliphora (EP) in a 16-year-old female patient who presented with diplopia. Magnetic resonance imaging of the brain with Gd contrast revealed a 3.0 × 1.7 × 1.8-cm nonenhancing, extraaxial epidural mass along the dorsal aspect of the clivus that was T2 hyperintense and T1 isointense with intermediate signal on diffusion sequences. Resection via a transnasal transsphenoidal approach to the ventral clival wall resulted in a stable tumor size with no evidence of interval growth after 30 months. Although this case features a strictly extradural EP, this tumor more commonly occurs in the subdural space and requires differentiation from intradural chordoma. Unlike EP, intradural chordoma may enhance with Gd contrast, is more likely to be associated with cranial nerve palsies and brainstem symptoms, and will occasionally have an elevated MIB-1 index. In this paper the authors highlight the different possible midline locations for both EP and chordoma, the difficulty in distinguishing between intradural giant EP and intradural chordoma, and the potential occurrence of these lesions in young people despite their typically slow rate of growth, while also underscoring the need for further investigation into the tumors' cytogenetic behavior.

Stereotactic radiosurgery of intracranial chordomas, chondrosarcomas, and glomus tumors

Chordomas and chondrosarcomas are rare, slow-glowing, locally aggressive tumors with high recurrence rates. Stereotactic radiosurgery (SRS) is an important management option for patients with recurrent or residual chordomas and chondrosarcomas. Glomus jugulare tumor are rare highly vascularized tumors that arise from the paraganglionic structures of the glossopharyngeal and vagal nerves. Because of their highly vascular nature and surgically formidable anatomic location, curative resection often proves challenging. SRS can be used as an up-front treatment or as an additional treatment for patients with recurrent or residual glomus jugulare tumor after surgical resection.

Benign notochordal lesions of the posterior clivus: retrospective review of prevalence and imaging characteristics

BACKGROUND AND PURPOSE

Distinguishing BNCT from chordoma with imaging is critical because of the profound differences in prognosis and management. Yet few reports define the variable imaging characteristics of BNCT. This study aims to evaluate the prevalence and characteristics of BNCT.

METHODS

A total of 916 patients with 64-section CT and 1.5T MR imaging through the posterior fossa between 2004 and 2009 were evaluated to catalogue the prevalence, clinical presentation, morphology, and imaging properties associated with BNCT.

RESULTS

BNCTs were identified in 7 patients (imaging prevalence of 0.76%). All were midline, T1 hypointense, and T2 hyperintense. When present, the bony stalk often associated with EP measured between 1.65 and 3.72 mm. Five cases demonstrated atypical features such as absence of bony stalk (one case), arterial enhancement (one case), clival erosion (four cases), clinical symptoms (one case), and mass effect (one case).

CONCLUSION

Many notochordal lesions do not fit neatly into the diagnostic criteria for either EP or chordoma. It may be useful to consider these atypical cases along a spectrum of notochord remnant lesions. Close inspection of imaging reveals BNCTs at a similar frequency to its pathologic prevalence. BNCTs such as EP vary in size and may be easily overlooked.

Skull base chordomas: clinical features, prognostic factors, and therapeutics

Chordomas of the skull base are one of the rarest intracranial malignancies that arise from ectopic remnants of embryonal notochod. The proximity of many chordomas to neurovascular structures makes gross total resection difficult, and the tendency for recurrence leads to the routine use of adjuvant postoperative radiation. Several surgical approaches are used ranging from extensive craniotomies to minimally invasive endonasal endoscopic approaches. In this review, the histopathology and epidemiology, imaging characteristics, surgical approaches, adjuvant therapies, prognostic factors, and molecular biology of chordomas are described.

Multiple epidural lumbar chordomas without bone involvement in a 17-year-old female: a case report

BACKGROUND CONTEXT

Chordomas are rare slow-growing neoplasms or malignant tumors that arise from embryonic rudiments of the primitive notochord. They account for 1% to 4% of all primary malignant bone tumors. Surgery in addition to radiotherapy is often used as the optimum treatment but with marginal effectiveness as these tumors are relatively radioresistant. To the best of our knowledge, there have been no reported cases of multiple and distinct epidural lesions without bone involvement in the literature.

PURPOSE

To describe an unusual case of two separate epidural chordomas occurring in the lumbar spine without bone involvement.

STUDY DESIGN

Case report.

METHODS

Clinical, radiologic, and histopathologic evaluation of a 17-year-old female with two separate adjacent lumbar epidural chordomas without bone involvement treated with complete surgical excision is discussed.

RESULTS

Four years after surgical resection of the tumors, the patient remains asymptomatic, and radiologic results revealed no recurrent lumbar epidural tumor.

CONCLUSIONS

Epidural chordomas appear to have a better prognosis due, at least in part, to the ability to more easily completely excise them.

Intradural invasion of chordoma: two case reports

Chordomas are rare tumors of the central nervous system and primarily occur in the extradural space. We report two patients with intracranial chordomas located in the region of the clivus that invaded the prepontine cisterns. The patients, 45 and 62 years old, had histories of cranial neuropathies and headache, respectively. Petrosal approaches were performed in both with radical resection of the tumors. Anatomopathological studies confirmed the diagnosis of chordoma. The symptoms of both patients resolved, and they have had no recurrence after 18 months of follow-up. Intradural chordomas or extradural chordomas that invade the intradural space are difficult to differentiate from ecchordoses physaliphorae, a non-neoplastic entity with similar radiological features. MBI-1 studies were therefore performed to confirm the diagnosis of chordoma. The differential diagnosis for these two entities, the different modalities of treatment, and prognosis are reviewed.

A comprehensive analysis of intracranial chordoma and survival: a systematic review

OBJECTIVE

Despite the published information on cranial chordoma, most of the data regarding survival in these patients has come from a single institution. Here, we perform a systematic review of the literature to evaluate across multiple institutions the overall survival after treatment for intracranial chordoma.

MATERIALS AND METHODS

We systematically analysed every study published in English and found a total of over 2000 patients being treated for intracranial chordoma. The overall 5-year and 10-year survivals in these patients were stratified according to the age (<5 years vs. >5 years and  <40 years vs. >40 years), treatment (surgery and radiation vs. surgery alone) and histological findings (chondroid vs. typical). Data were analysed via Pearson chi-square test and student t-test when appropriate.

RESULTS

A total of 560 non-duplicated patients treated for cranial chordoma met inclusion criteria for this systematic analysis. The survival rate among these patients was 63% (299 patients) and 16% (176 patients) for 5-year and 10-year survivals, respectively. There was no difference in overall survival between the two groups when a cut-off age of 40 years was used (<40 years = 50% vs.  >40 years = 51% at 5-year survival; p = 0.1), but when 5 years was used as the cut-off age, then survival was better for patients in the group older than 5 years of age (<5 years = 14% vs.  >5 years = 66%; p = 0.001). There was no difference between 5-year survival in patients with chordoma with histological chondroid features and those with chordoma possessing typical histology (45% vs. 67%; p = 0.06). When patients who only received surgery were compared to those patients who were treated with surgical intervention in combination with adjuvant radiation treatment, no difference in survival rate was found (54% vs. 56% at 5 years; p = 0.8).

CONCLUSION

The results of our systematic study provide data to predict the survival of intracranial chordoma patients across multiple institutions. Our data suggest that patients younger than 5 years of age may be associated with a worse prognosis, and adjuvant radiation therapy and histological type were not associated with the improvement of survival rates.

Chordoma in the lateral medullary cistern in a patient with tuberous sclerosis: A case report and review of the literature

Background:

Chordomas are rare intracranial tumors. There are several reported cases of these tumors arising in patients with tuberous sclerosis (TSC), a neurocutaneous disorder inherited in autosomal dominant fashion that predisposes patients to hamartomatous and neoplastic lesions.

Case Description:

A 38-year-old man with the diagnosis of TSC presented with the complaint of dizziness and near syncope. Imaging revealed a mass in the lateral medullary cistern that was found at the time of surgery to be a chordoma. The patient underwent a left far lateral approach for removal of the tumor. Upon opening of the dura, the tumor could be seen under the arachnoid. The tumor was carefully debulked within the limits of safety. The patient did well postoperatively and was referred to the radiation oncology department at our institution for follow-up radiotherapy of the tumor bed.

Conclusion:

This study presents an unusual presentation and location for a chordoma and contributes to the growing literature associating chordomas with TSC.

Long-term control of clival chordoma with initial aggressive surgical resection and gamma knife radiosurgery for recurrence

PURPOSE

Chordomas are locally destructive tumors with high rates of recurrence, and therapeutic strategies remain controversial. This study analyzed long-term outcomes for clival chordomas after initial aggressive surgical resection and gamma knife radiosurgery for recurrence and investigated clinical factors predicting recurrence.

METHODS

Clinical records were reviewed for 19 consecutive patients (11 men, 8 women; mean age, 43.1 years) with clival chordoma who underwent initial surgical resection using skull base approaches (mean follow-up after surgical resection, 87.2 months). All tumors were aggressively removed, along with the surrounding bone. Four patients were treated with radiotherapy after surgical resection.Recurrent lesions were treated with gamma knife radio surgery or reoperation. Factors predicting tumor recurrence were analyzed, including age, tumor extension, extent of resection and MIB-1 labeling index. Patient status was evaluated using the Karnofsky performance scale (KPS).

RESULTS

Tumor resection was total, subtotal and partial in 14, 4 and 1 patients, respectively. Tumors recurred in 11 patients. Overall, 2- and 5-year progression-free survival rates were 77.9% and 47.9%, respectively. The MIB-1 labeling index was independently associated with recurrence.The optimum cutoff point for the MIB-1 labeling index was 3.44%. All recurrent tumors were totally resected or controlled by gamma knife (mean follow-up after recurrence, 71.2 months). All patients survived and were active (mean KPS at final follow-up, 89.5%).

CONCLUSION

Long-term control of clival chordomas was achieved. Recurrent tumors were controlled with gamma knife radiosurgery, since lesions were localized and small after initial aggressive resection. The MIB-1 labeling index can provide important information for predicting tumor recurrence.

Adjuvant radiation therapy and chondroid chordoma subtype are associated with a lower tumor recurrence rate of cranial chordoma

Cranial chordomas are rare tumors that have been difficult to study given their low prevalence. Individual case series with decades of data collection provide some insight into the pathobiology of this tumor and its responses to treatment. This meta-analysis is an attempt to aggregate the sum experiences and present a comprehensive review of their findings. We performed a comprehensive review of studies published in English language literature and found a total of over 2,000 patients treated for cranial chordoma. Patient information was then extracted from each paper and aggregated into a comprehensive database. The tumor recurrences in these patients were then stratified according to age (<21 vs. >21 years), histological findings (chondroid vs. typical) and treatment (surgery and radiation vs. surgery only). Data was analyzed via Pearson chi-square and t-test. A total of 464 non-duplicated patients from 121 articles treated for cranial chordoma met the inclusion criteria. The recurrence rate among all patients was 68% (314 patients) with an average disease-free interval of 45 months (median, 23 months). The mean follow-up time was 39 months (median, 27 months). The patients in younger group, patients with chordoma with chondroid histologic type, and patients who received surgery and adjuvant radiotherapy had significantly lower recurrence rate than their respective counterparts. The results of our systematic analysis provide useful data for practitioners in objectively summarizing the tumor recurrence in patients with cranial chordomas. Our data suggests that younger patients with chondroid type cranial chordoma treated with both surgery and radiation may have improved rates of tumor recurrence in the treatment of these tumors.

Clivus chordoma in continuity with a large pontine cyst

Chordomas are tumors commonly of extradural origin associated with bone destruction; their central nervous system invasion has rarely been reported. The authors describe a rare case of a 37-year-old man presenting with a clivial chordoma invading the brainstem with a large pontine cyst. A median suboccipital approach was selected to remove the tumor.

Intradural retroclival chordoma

A 43-year-old woman presented with dizziness, ataxia and right hearing difficulty. Her magnetic resonance images demonstrated an inhomogeneously contrast-enhanced large tumor growing into right cavernous sinus and Meckel's cave located totally within intradural retroclival region. She underwent retromastoid suboccipital craniotomy to resect the tumor mass and adjuvant gamma knife radiosurgery for remnant tumor at 1 month after operation. Adjuvant radiosurgery after surgical excision seems to be effective for the treatment of intradural extraosseous chordomas.

Multiple synchronous spinal extra-osseous intradural chordomas: is it a distinct entity?

Chordomas are most commonly of extradural origin and are associated with bone destruction. Extra-osseous intradural chordomas are extremely rare and most of the cases described are located near the clivus. We report an extremely rare case of multiple extra-osseous intraspinal chordomas in a 36-year-old male patient with autopsy findings. This case highlights that behaviour of spinal intradural chordomas is not universally low grade, but is variable and aggressive.

INTRADURAL CLIVAL CHORDOMA AND ECCHORDOSIS PHYSALIPHORA

OBJECTIVE

Purely intradural clival chordomas are rare neoplasms, and only a few cases have been reported. The reported cases present features similar to ecchordosis physaliphora, which is a notochordal remnant. We describe these 2 entities and their differential diagnoses, clinical courses, and management. This is the first reported case to be treated using a neuroendoscopic technique.

CLINICAL PRESENTATION

A 60-year-old man presenting with memory loss underwent magnetic resonance imaging, which revealed an intradural retroclival mass without bone involvement.

INTERVENTION

The patient underwent an endoscopic transsphenoidal-transclival procedure with subtotal removal of the tumor. Histological findings confirmed the diagnosis of a chordoma.

CONCLUSION

Even if some parameters exist for a differential diagnosis, ecchordosis physaliphora and intradural chordoma may represent different aspects of the spectrum of the same pathology. Intradural clival chordomas have a better prognosis with respect to classic chordomas. Therefore, in subtotal removal such as that performed in our case, postoperative radiation therapy should be performed only if a regrowth of the remnant is seen during neuroradiological follow-up.

JUVENILE INTRADURAL CHORDOMA

OBJECTIVE

We report the youngest known case of a prepontine intradural chordoma. These tumors are exceedingly rare. Unlike their more common extradural counterparts, no recurrence of an intradural chordoma has been reported.

CLINICAL PRESENTATION

A 9-year-old boy underwent diagnostic imaging for evaluation of headaches. Although neurologically intact, a magnetic resonance imaging scan revealed a large prepontine mass with focal enhancement.

INTERVENTION

Endoscopic-assisted gross total resection was attained with staged bilateral retrosigmoid approaches. There were no additional adjuvant therapies. At the time of the 1-year follow-up evaluation, the patient had no recurrence.

CONCLUSION

By using an endoscopic-assisted procedure, we achieved complete resection of an intradural chordoma offering a potential for surgical cure. Resection is particularly advantageous because it spares the young child the need for radiation treatment. Close follow-up is warranted because we postulate that this tumor exists in a biological continuum between benign notochordal hamartomatous remnants and typical invasive chordomas.

Radiosurgery for chordomas and chondrosarcomas of the skull base

OBJECT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A rare symptomatic presentation of ecchordosis physaliphora: neuroradiological and surgical management

We report a case of ecchordosis physaliphora, an uncommon benign lesion originating from embryonic notochordal remnants, intradurally located in the prepontine cistern, that unusually presented associated with symptoms. MRI detected and precisely located the small mass. At surgery, a cystic gelatinous nodule was found ventral to the pons, contiguous with the dorsal wall of the clivus via a small pedicle. Histological examination diagnosed the lesion as an ecchordosis physaliphora. Here we focus on the analysis of the neuroradiological aspects that play a crucial role from both a diagnostic and a therapeutic standpoint.

Intradural cranial chordoma: a rare presentation of an uncommon tumor

Object

Intracranial intradural chordomas are extremely rare lesions, and only a few cases have been reported in the neurosurgical literature. The authors performed a retrospective analysis of cases treated at their institutions. They present an illustrative surgical scenario and discuss the published literature, pathogenesis, and histopathological features as well as available follow-up data on the clinical behavior of these intradural lesions.

Methods

The authors reviewed clinical, neuroimaging, operative and follow-up data from a series of 79 chordomas treated at their institutions over the last 17 years. They found that the tumors were confined exclusively to the intradural compartment in only three cases. Staining for MIB-1 was performed to support the differential diagnosis between ecchordosis physaliphora and intradural chordoma, and in all three patients the neoplastic nature of the lesions was confirmed. None of these three cases showed recurrence of the lesion at midterm follow up.

Conclusions

Complete resection, followed by close clinical and neuroradiological follow up, is warranted in cases of intradural cranial chordoma.

Patient Outcome at Long-term Follow-up after Aggressive Microsurgical Resection of Cranial Base Chordomas

OBJECTIVE:

In this study, we evaluated patients' clinical outcome and recurrence rates at long-term follow-up after aggressive microsurgical resection of cranial base chordomas.

METHODS:

Seventy-four patients with chordomas underwent operations during a 16-year period from 1988 to 2004. The philosophy was to perform complete resection whenever possible and to provide adjuvant radiotherapy for remnants. Staged operations were performed for extensive tumors or if a sizable tumor remnant was noted after the first resection. Patients included primary (previously untreated) and previously operated or irradiated cases. Information was prospectively gathered concerning the patients' neurological condition, Karnofsky Performance Scale score, and tumor status on magnetic resonance imaging scans.

RESULTS:

There were 47 primarily operated patients (63.5%) and 27 patients (36.5%) who had previously undergone surgery or radiotherapy. A total of 121 procedures were performed in 74 patients. The mean follow-up period was 96 months, with a range of 1 to 198 months. A single stage removal was performed in 41 (55.4%) of the patients and multiple stage removal was performed in 33 (44.5%) of the patients. Gross total removal was accomplished in 53 (71.6%) of the patients, and subtotal resection was accomplished in 21 (28.4%) of the patients. During the follow-up period, 24 (32%) of the patients had no evidence of disease, 37 (50%) of the patients were alive with evidence of disease, 11 (14.8%) of the patients died of disease, and two (2.7%) of the patients died of complications. Recurrence-free survival at 10 years was 31% for the whole group, 42% for the primarily operated patients, and 26% for the reoperation cases (P = 0.0001). The average Karnofsky Performance Scale score was 80 ± 11.7 preoperatively, 84 ± 8.9 at the 1-year follow-up, and 86 ± 12.8 at the last follow-up in surviving patients. No conclusion could be drawn regarding the value of radiotherapy because of the treatment philosophy and the small number of patients.

CONCLUSION:

Aggressive microsurgical resection of chordomas can be followed by long-term, tumor-free survival with good functional outcome. A more conservative strategy is recommended in reoperation cases, especially after previous radiotherapy, to reduce postoperative complications.

Epidural Chordoma of the Cervical Spine with Secondary Bone Involvement

A 53-year-old man presented with cervical myelopathy. magnetic resonance imagine (MRI) revealed a predominantly extraskeletal, extradural lesion extending along the posterior aspects of the C2 to C5 vertebral bodies, with greater than 60% spinal canal compromise and severe cord compression. Bone involvement was present, but was thought to be secondary. Based on histopathology and immunohistochemical stains, the final pathologic diagnosis was chordoma. The lesion was treated with embolization, surgical resection, and proton beam radiotherapy, and there was no evidence of recurrence or metastasis after five years.

Intradural Retroclival Chordoma Without Bone Involvement-Case Report-

A 63-year-old, previously healthy man presented with a rare large intradural retroclival chordoma without bone involvement. Computed tomography showed that the tumor was completely intradural and did not involve the bone, as confirmed at intraoperative inspection. The tumor was totally excised via the anterior transpetrosal approach. Surgery is the most effective first-line treatment for patients with chordoma despite the typical extradural extension and bone destruction. Complete resection is feasible for intradural extraosseous chordoma because of the sharply circumscribed margins and absence of bone involvement. Specialized skull base techniques should be used instead of conventional surgical approaches for intradural skull base chordoma.