Combination of microsurgery and Gamma Knife surgery for the treatment of intracranial chondrosarcomas

[Falcine chondrosarcoma (case report and literature review)]

Chondrosarcoma is a rare malignancy composed of transformed cells of cartilage. This cancer is characterized by slow growth. Almost 75% of intracranial chondrosarcomas are observed on the skull base and grow from bone synchondrosis. Other rarer localizations of tumor are cerebral falx, tentorium cerebelli, vascular plexuses of the ventricles, fourth ventricle, convexital surface of the brain, etc. In this manuscript, we report treatment of patient with falcine chondrosarcoma.

Falcine Myxoid Chondrosarcoma: A Rare Aggressive Case

Chondrosarcoma is the second most common primary malignancy of bone after osteosarcoma. Cranial primary chondrosarcomas mostly originate from the skull base cartilage formation zones. Parasagittal falcine origin is very rare for primary extra-skeletal intracranial chondrosarcomas. We report a rare case of primary myxoid chondrosarcoma at falx cerebri. The patient was a 35-year-old lady with right arm and leg weakness. Her brain magnetic resonance imaging depicted a left parasagittal mass lesion attached to the falx cerebri. En bloc resection via left frontal craniotomy was performed. Three more local recurrences occurred in 9 months’ time since the index surgery, which were all managed with re-surgeries and/or adjuvant stereotactic radiosurgeries. This is the second case of myxoid type parasagittal chondrosarcoma but with the most protracted disease course. Even though surgery remains the mainstay of treatment for parasagittal chondrosarcomas, adjuvant therapy might be necessary in aggressive ones.

Multidisciplinary management of clival chordomas; long-term clinical outcome in a single-institution consecutive series

OBJECTIVE

Chordomas of the skull base have high recurrence rates even after radical resection and adjuvant radiotherapy. We evaluate the long-term clinical outcome using multidisciplinary management in the treatment of clival chordomas.

METHODS

Between 1984 and 2015, 22 patients diagnosed with an intracranial chordoma were treated at the Karolinska University Hospital, Stockholm, Sweden. Sixteen of 22 were treated with Gamma Knife radiosurgery (GKRS) for tumour residual or progression during the disease course. Seven of 22 received adjuvant fractionated radiotherapy and 5 of these also received proton beam radiotherapy.

RESULTS

Fifteen of 22 (68%) patients were alive at follow-up after a median of 80 months (range 22-370 months) from the time of diagnosis. Six were considered disease free after >10-year follow-up. The median tumour volume at the time of GKRS was 4.7 cm³, range 0.8-24.3 cm³. Median prescription dose was 16 Gy, range 12-20 Gy to the 40-50% isodose curve. Five patients received a second treatment with GKRS while one received three treatments. After GKRS patients were followed with serial imaging for a median of 34 months (range 6-180 months). Four of 16 patients treated with GKRS were in need of a salvage microsurgical procedure compared to 5/7 treated with conventional or proton therapy.

CONCLUSION

After surgery, 7/22 patients received conventional and/or photon therapy, while 15/22 were treated with GKRS for tumour residual or followed with serial imaging with GKRS as needed upon tumour progression. With this multidisciplinary management, 5- and 10-year survivals of 82% and 50% were achieved, respectively.

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

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

A rare tentorial mesenchymal chondrosarcoma in posterior cranial fossa: case report

Intracranial extraskeletal mesenchymal chondrosarcoma is a very rare malignant tumor with predilection site of frontoparietal falx cerebri. Only few cases of mesenchymal chondrosarcoma in posterior cranial fossa are reported. Here, we report a 23-year-old young man with a dura-attached mass in left posterior cranial fossa misdiagnosed as a tentorial meningioma preoperatively. According to the following operation, the lesion was confirmed as mesenchymal chondrosarcoma surgically and pathologically. On MRI, the tumor was characterized by lobulated soft-tissue mass with dura-attached base, patchy calcifications and heterogeneous signal intensities. On contrast-enhanced MRI, it was well-defined, with marked enhancement. We consider that these imaging features above might remind us to consider the diagnosis of mesenchymal chondrosarcoma in posterior cranial fossa. The postoperative treatment of radiotherapy is still controversial. As for our case, according to the 24 months follow-up after postoperative γ-knife, our patient shows an optimistic prognosis so far.

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

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

Chondrosarcomas of the head and neck

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

Falcine and parasagittal chondrosarcomas

Intracranial chondrosarcomas are primary cartilaginous neoplasms that represent 6% of all skull base tumors. Intracranial extraskeletal chondrosarcomas are more rare, often arising from the meninges at the falx, tentorium, or cerebral convexity. They are generally characterized as classical or mesenchymal, with the latter associated with worse outcomes. We present our institutional series of falcine and parasagittal chondrosarcomas along with a review of the literature. Although skull base chondrosarcomas pose significant challenges due to their invasive biology and proximity to vital brainstem structures and cranial nerves, intracranial extraskeletal chondrosarcomas are generally associated with a good prognosis. Our review of the literature identified 29 patients with falcine and parasagittal chondrosarcomas. There were six recurrences, five among patients with the mesenchymal subtype and one in a patient with the classical subtype. All deaths occurred in patients with the mesenchymal subtype. Management of skull base chondrosarcomas is controversial but extraskeletal intracranial tumors can generally be managed by surgical resection alone. Treatment should be tailored to the biology of the tumor, with radiation therapy reserved for patients with the mesenchymal subtype.

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

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

[Surgical treatment of head and neck chondrosarcomas]

INTRODUCTION

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

MATERIAL AND METHOD

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

RESULTS

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

CONCLUSION

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