Chordoma of the spine: clinicopathological features, diagnosis, and treatment

Indolent multicentric chordoma – A previously undescribed entity: A Case report and literature review

Background:

Chordomas are rare neuraxial tumors arising from remnants of primitive notochord. They are generally slow-growing malignant neoplasms. Only four adult cases of multicentric chordomas have been reported, all with aggressive and rapid growth. Here, we present an unusual case of indolent multicentric chordomas involving cervical and thoracic spine, sacrum, and calvarium.

Case Description:

A 60-year-old male was found to have multiple lesions throughout his neuroaxis incidentally on workup for colitis. A needle biopsy documented the diagnosis of chordoma. This has been followed for more than 4 years with no progression.

Conclusion:

We present the first reported case of indolent multicentric chordomas. Due to the extreme rarity of indolent multicentric chordomas, close follow-up is needed and recommended.

Chondrosarcoma and Chordoma of the Skull Base and Spine: Implication of Tumor Location on Patient Survival

BACKGROUND

Chondrosarcoma and chordoma are often grouped together because of their similar anatomic locations, clinical presentations, histopathological and radiological findings, and growth patterns. In the present study, we investigated the clinical and prognostic differences of chondrosarcomas and chordomas of the skull base and spine.

METHODS

We accessed the Surveillance, Epidemiology, and End Results database to search for patients from 2000 to 2018 with chondrosarcomas and chordomas of the skull base and spine for inclusion in the present study.

RESULTS

We included 1346 and 1536 cases of chondrosarcoma and chordoma for analysis, respectively. Chondrosarcomas of the cranial base and spine were seen in younger patients and were associated with a larger tumor size compared with chordomas. Among the tumors of the skull base, chondrosarcomas were more common in women, with a male predominance found for chordomas. We also observed a male predilection for both spinal chondrosarcomas and chordomas. Distinct metastatic patterns were found for chondrosarcomas versus chordomas, and spinal chondrosarcomas showed a greater risk of distant metastases at presentation compared with spinal chordomas. Cranial base chondrosarcomas were associated with superior outcomes compared with chordomas. However, we demonstrated an opposite survival pattern for spinal chondrosarcomas and chordomas.

CONCLUSIONS

Chondrosarcomas and chordomas have divergent clinical manifestations and prognoses depending on the anatomic location.

Managing bowel and bladder impairments in sacral chordoma patients: a case-based approach

Introduction

Chordomas are primary bone tumors that occur in the axial spine and most commonly in the sacrum. Because of their location, chordomas can affect bowel and bladder continence resulting in either an upper or a lower motor neuron functional pattern.

Case presentation

We present two cases describing chordoma's impact on bowel and bladder function and the management plan used for improvement.

Discussion

The accurate identification of an upper or lower motor neuron pattern in the setting of chordoma aims to significantly improve management of bowel and bladder impairment.

Leukemia Inhibitory Factor Promotes Aggressiveness of Chordoma

Chordomas are rare tumors of the spine and skull base that are locally destructive and resistant to chemotherapy and radiation therapy, with a poor prognosis and limited therapeutic options. Chordoma patients have a long life expectancy with high mortality from the disease. Cancer stem cells, which are known to exist in chordomas, have extensive proliferative and self-renewal potential and are responsible for maintaining tumor heterogeneity along with chemotherapy and radiotherapy resistance. Leukemia inhibitory factor (LIF) has multiple functions in stem cell biology, the immune response, and cancer, and is potentially a key molecule that allows cancer stem cells to self-renew. The purpose of this study was to determine whether LIF increases the aggressive traits of chordoma cells and leads to a poor prognosis in patients. Chordoma cell lines were treated with LIF, and functional tests were done. Twenty skull base chordoma samples were checked for levels of LIF and a correlation with clinicopathological features. The whole transcriptome microarray was used to observe changes in gene expression. We observed increased migration, invasion, tumorosphere formation, colony formation, epithelial–mesenchymal transition, and chemoresistance accompanied by a dramatic elevation in inflammatory gene networks and pathways in chordomas. The expression of LIF was associated with tumor size and a poorer overall survival. Microarray and quantitative real-time polymerase chain reaction assessments suggest that LIF can facilitate tumor-promoting inflammation. Results indicate that LIF plays a role in maintaining cancer stem cells in chordomas.

The potential function of microRNA in chordomas

Little is known about the molecular biology of chordomas, which are rare, chemoresistant tumors with no well-established treatment. miRNAs regulate gene networks and pathways. We aimed to evaluate the effects of dysregulated miRNA in chordomas would help reveal the underlying mechanisms of chordoma initiation and progression. In this study, miR-31, anti-miR-140-3p, anti-miR148a, and miR-222 were transiently transfected to chordoma cell lines and an MTS assay, apoptosis assay, and cell-cycle analysis were conducted to evaluate the effects. The mRNA level of predicted and confirmed targets of each miRNA, as well as the EMT and MET markers of U-CH1 and MUG-Chor1, were assessed with real-time polymerase chain reaction. Transient transfection of miRNA mimics was achieved, as each mimic increased or decreased the level of its corresponding miRNA. miR-31 decreased cell viability in MUG-Chor1 and U-CH2 after 72h, which is consistent with previous findings for U-CH1. Both miR-31 and anti-miR-148a induced apoptosis in all three cell lines. Although each miRNA had a similar pattern, miR-31 had the most effective S-phase arrest in all three cell lines. RDX, MET, DNMT1, DNMT3B, TRPS1, BIRC5, and KIT were found to be targeted by the selected miRNAs. The level of miR-222 in chordoma cell lines U-CH1 and MUG-Chor1 correlated positively with EMT markers and negatively with MET markers. This study uncovered the potential of miR-31, miR-140-3p, miR-148a, and miR-222-3p to be key molecules in the cell viability, cell cycle, and apoptosis in chordomas, as well as initiation, differentiation, and progression.

The molecular aspects of chordoma

Chordomas are one of the rarest bone tumors, and they originate from remnants of embryonic notochord along the spine, more frequently at the skull base and sacrum. Although they are relatively slow growing and low grade, chordomas are highly recurrent, aggressive, locally invasive, and prone to metastasize to the lungs, bone, and the liver. Chordomas highly and generally show a dual epithelial-mesenchymal differentiation. These tumors resist chemotherapy and radiotherapy; therefore, radical surgery and high-dose radiation are the most used treatments, although there is no standard way to treat the disease. The molecular biology process behind the initiation and progression of a chordoma needs to be revealed for a better understanding of the disease and to develop more effective therapies. Efforts to discover the mysteries of these molecular aspects have delineated several molecular and genetic alterations in this tumor. Here, we review and describe the emerging insights into the molecular landscape of chordomas.

Benign Notochordal Cell Tumor of the Sacrum with Atypical Imaging Features: The Value of CT Guided Biopsy for Diagnosis

We report a case of a benign notochordal cell tumor (BNCT) of the sacrum with atypical imaging features, which was incidentally discovered in a 74-year-old man undergoing evaluation for progressively worsening hip and back pain. It is important for radiologists, pathologists and orthopedic surgeons to be aware of the diagnosis of BNCT and be familiar with its radiographic features to avoid unnecessary treatment. This case illustrates the advantage of percutaneous computed tomography (CT)-guided biopsy as a minimally invasive technique for definitive diagnosis of a BNCT with atypical imaging features.

Paravertebral high cervical chordoma. A case report

Spinal chordomas are more often located on the midline and are associated with marked destruction of the vertebral bodies. We report a rare case of large cervical (C2-C3) right lateral paravertebral chordoma extending into the spinal canal through a very enlarged intervertebral foramen. The tumor was initially diagnosed as a mucous adenocarcinoma on a percutaneous needle biopsy. However, the neuroradiological features, including the well-defined tumor margins, the regular and sclerosing lytic bone changes with regular enlargement of the intervertebral C2-C3 foramen, were in favor of a more slowly growing lesion, such as schwannoma or neurofibroma. At surgery a well-demarcated capsulated tumor involving the nerve root was partially resected. Histology was in favor of a low-grade chordoma (Ki-67/MIB-1<1%). Postoperative proton beam therapy was also performed. The differential neuroradiological diagnosis is discussed.

From notochord formation to hereditary chordoma: the many roles of Brachyury

Chordoma is a rare, but often malignant, bone cancer that preferentially affects the axial skeleton and the skull base. These tumors are both sporadic and hereditary and appear to occur more frequently after the fourth decade of life; however, modern technologies have increased the detection of pediatric chordomas. Chordomas originate from remnants of the notochord, the main embryonic axial structure that precedes the backbone, and share with notochord cells both histological features and the expression of characteristic genes. One such gene is Brachyury, which encodes for a sequence-specific transcription factor. Known for decades as a main regulator of notochord formation, Brachyury has recently gained interest as a biomarker and causative agent of chordoma, and therefore as a promising therapeutic target. Here, we review the main characteristics of chordoma, the molecular markers, and the clinical approaches currently available for the early detection and possible treatment of this cancer. In particular, we report on the current knowledge of the role of Brachyury and of its possible mechanisms of action in both notochord formation and chordoma etiogenesis.

Paraspinal chordoma mimicking a neurofibroma: a rare but important radiological pitfall

We present an unusual case of a chordoma presenting as an extradural spinal tumour with extension through an expanded intervertebral foramen to form a large paraspinal mass. The magnetic resonance imaging appearances closely mimicked a neurofibroma; however, pre-operative biopsy confirmed the diagnosis of chordoma. This is, to our knowledge, the tenth reported case of chordoma presenting as a mass expanding the intervertebral foramen. Thus, while it is a rare form of chordoma, it can lead to a recognised radiological pitfall. Making the distinction from neurofibroma before surgery is essential, as radical dissection of chordoma is required to reduce the risk of local recurrence.

Imaging of primary malignant bone tumors (nonhematological)

Primary malignant bone tumors are uncommon and are diagnosed typically based on radiographic and microscopic findings combined with clinical and demographic features. CT and MR imaging scans are useful in further staging the tumors by determining intraosseous and extraosseous spread.

Chordoma masquerading as a nerve root tumour -- a clinical lesson

Chordomas usually arise in bone and are most commonly found in the midline axial skeleton. An accurate pre-operative diagnosis of chordoma is crucial, as survival is optimal when radical en bloc resection is performed at primary surgery. We report a rare case of cervical chordoma masquerading radiologically as an extracranial nerve sheath tumour. A laterally situated chordoma (centred extra-osseously in the neural foramen) was diagnosed radiologically as a neurofibroma pre-operatively. We review the key radiological features for diagnosis of chordoma. We consider the importance of pre-operative diagnosis of chordoma in guiding management and in determining survival.

Chordomas involving multiple neuraxial bones

We present a patient with multifocal symptomatic osseous chordomas having unusual growth patterns with review of the pertinent literature. The patient was 62-year-old male and had multiple osseous chordomas located in sacral, thoracic, and paraclival jugular foramen areas. There was no metastasis in other organs. All affected sites were osseous. The multicentric chordomas are extremely rare. This case could be considered as a chordoma involving multiple neuraxial bones. But, the possibility of multicentricity could also be thought. In such cases radical resection should be performed for each lesion at the initial diagnosis. If complete surgical resections are infeasible or impossible, preoperative or postoperative radiation therapy should be planned for the highest possibility of successful treatment.

Chordomas involving multiple neuraxial bones

We present a patient with multifocal symptomatic osseous chordomas having unusual growth patterns with review of the pertinent literature. The patient was 62-year-old male and had multiple osseous chordomas located in sacral, thoracic, and paraclival jugular foramen areas. There was no metastasis in other organs. All affected sites were osseous. The multicentric chordomas are extremely rare. This case could be considered as a chordoma involving multiple neuraxial bones. But, the possibility of multicentricity could also be thought. In such cases radical resection should be performed for each lesion at the initial diagnosis. If complete surgical resections are infeasible or impossible, preoperative or postoperative radiation therapy should be planned for the highest possibility of successful treatment.

Total en bloc spondylectomy of C5 vertebra for chordoma

STUDY DESIGN

En bloc resection of a chordoma of the C5 vertebra with wide surgical margins.

OBJECTIVE

To present the surgical technique of total spondylectomy for a chordoma of the C5 vertebral body.

SUMMARY OF BACKGROUND DATA

Malignant bone tumors require wide resection. Wide resection by total en bloc spondylectomy is difficult or not feasible for malignant vertebral tumors of the cervical spine due to the peculiar anatomic complexity of this region, including the vertebral arteries and the neural structures. There are no previous reports of en bloc resection of cervical spine tumors with wide surgical margins.

METHODS

Using staged posterior and anterior approaches, a total en bloc spondylectomy and spine arthrodesis was performed. En bloc excision of a C5 chordoma was achieved using a threadwire T-saw (Tomita and Kawahara, Kanazawa, Japan) with surgical margins free of tumor. The patient received postoperative adjuvant proton beam radiation therapy.

RESULTS

The patient remains disease-free 9 years after the operation.

CONCLUSION

Total en bloc spondylectomy with wide surgical margins is feasible for malignant bone tumors of the cervical spine.