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Bin-Alamer O, Pikis S, Mantziaris G, Abdulbaki A, Mallela AN, Lu VM, Peker S, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, El-Shehaby AMN, Abdelkarim K, Emad Eldin RM, Sheehan D, Sheehan K, Liscak R, Chytka T, Tripathi M, Madan R, Speckter H, Hernández W, Barnett GH, Hori YS, Dabhi N, Aldakhil S, Mathieu D, Kondziolka D, Bernstein K, Wei Z, Niranjan A, Kersh CR, Lunsford LD, Sheehan JP, Abou-Al-Shaar H. Adjuvant Stereotactic Radiosurgery With or Without Postresection Fractionated Radiation Therapy for the Management of Clival Chordomas in Adults: An International Multicenter Case Series. Neurosurgery 2023; 93:892-900. [PMID: 37052386 DOI: 10.1227/neu.0000000000002488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/13/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Clival chordomas are challenging because of their proximity to critical neurovascular structures. Stereotactic radiosurgery (SRS) has been proven effective with minimal adverse effects. OBJECTIVE To compare the outcomes of histologically confirmed primary clival chordomas in adults who underwent SRS alone (SRS group) vs SRS after fractionated radiotherapy (FRT+SRS group). METHODS We collected patient data from 10 institutions affiliated with the International Radiosurgery Research Foundation. We evaluated overall survival, tumor control, and freedom from additional treatment (FFAT). RESULTS Fifty-seven (77%) patients were included in the SRS group and 17 (23%) in the FRT+SRS group. The median radiological follow-up was 48 months (IQR, 24-85) in the SRS group and 36 months (IQR, 25-41) in the FRT+SRS group. During the follow-up, 8 SRS and 2 FRT+SRS patients died ( P = .80). The groups had comparable 10-year overall survival (SRS: 76% vs FRT+SRS: 80%; logrank test, P = .75) and tumor control rates (SRS: 34% vs FRT+SRS: 45%; logrank test, P = .29). The SRS group had a superior 10-year FFAT rate (40%) compared with FRT+SRS (23%; logrank test, P = .02). This finding persisted in the multivariate analysis of the Cox proportional hazards illustrating a 2.40-fold increase in the relative risk of requiring additional treatment among the FRT+SRS group ( P = .04). CONCLUSION Adjuvant FRT with subsequent boost SRS did not provide superior overall survival or tumor control compared with patients who underwent adjuvant SRS alone. Further studies are required to refine management guidelines among adults with clival chordomas.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Arif Abdulbaki
- Department of Neurosurgery, Hannover Medical School, Hannover , Germany
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Victor M Lu
- Department of Neurological Surgery, University of Miami School of Medicine, Miami , Florida , USA
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Benha University, Benha , Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Neurosurgery, Ain Shams University, Cairo , Egypt
| | - Reem M Emad Eldin
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo , Egypt
| | - Darrah Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Kimball Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Roman Liscak
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Tomas Chytka
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Manjul Tripathi
- Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh , India
| | - Renu Madan
- Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh , India
| | - Herwin Speckter
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo , Dominican Republic
| | - Wenceslao Hernández
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo , Dominican Republic
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland , Ohio , USA
| | - Yusuke S Hori
- Department of Neurosurgery, Cleveland Clinic, Cleveland , Ohio , USA
| | - Nisha Dabhi
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Salman Aldakhil
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke , Quebec , Canada
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke , Quebec , Canada
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone, New York , New York , USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, New York University Langone, New York , New York , USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Charles R Kersh
- Department of Radiation Oncology, University of Virginia, Charlottesville , Virginia , USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
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Brown NJ, Gendreau J, Kuo CC, Nguyen O, Yang C, Catapano JS, Lawton MT. Assessing survival outcomes and complication profiles following surgical excision and radiotherapy as interventions for skull base chordoma: a systematic review of operative margins and surgical approaches. J Neurooncol 2023; 165:41-51. [PMID: 37880419 DOI: 10.1007/s11060-023-04477-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/08/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Despite their precarious behavioral classification (benign and low grade on histopathology yet behaviorally malignant), great strides have been taken to improve prognostication and treatment paradigms for patients with skull base chordoma. With respect to surgical techniques, lateral transcranial (TC) approaches have traditionally been used, however endoscopic endonasal approaches (EEA) have been advocated for midline lesions. Nonetheless, due to the rarity of this pathology (0.2% of all intracranial neoplasms), investigations within the literature remain limited to small retrospective series. Furthermore, radiotherapeutic treatments investigated to date have proven largely ineffective. METHODS Accordingly, we performed a systematic review in order to profile surgical and survival outcomes for skull base chordoma. Fixed and random-effect meta-analyses were performed for categorical variables including GTR, STR, 5-year OS, 10-year OS, 5-year PFS, and 10-year PFS. Additionally, we pooled eligible studies for formal meta-analysis to compare outcomes by surgical approach (lateral versus midline). Statistical analyses were performed using R Studio 'metafor' package or Cochrane Review Manager. Furthermore, meta-analysis of pooled mortality rates and sub-analyses of operative margin and surgical complications were used to compare midline versus lateral approaches via the Mantel-Haenszel method. We considered all p-values < 0.05 to be statistically significant. RESULTS Following the systematic search and screen, 55 studies published between 1993 and 2022 reporting data for 2453 patients remained eligible for analysis. Sex distribution was comparable between males and females, with a slight predominance of male-identifying patients (0.5625 [95% CI: 0.5418; 0.3909]). Average age at diagnosis was 42.4 ± 12.5 years, while average age of treatment initiation was 43.0 ± 10.6 years. Overall, I2 value indicated notable heterogeneity across the 55 studies [I2 = 56.3% (95%CI: 44.0%; 65.9%)]. With respect to operative margins, the rate of GTR was 0.3323 [95% CI: 0.2824; 0.3909], I2 = 91.9% [95% CI: 90.2%; 93.4%], while the rate of STR was significantly higher at 0.5167 [95% CI: 0.4596; 0.5808], I2 = 93.1% [95% CI: 91.6%; 94.4%]. The most common complication was CSF leak (5.4%). In terms of survival outcomes, 5-year OS rate was 0.7113 [95% CI: 0.6685; 0.7568], I2 = 91.9% [95% CI: 90.0%; 93.5%]. 10-year OS rate was 0.4957 [95% CI: 0.4230; 0.5809], I2 = 92.3% [95% CI: 89.2%; 94.4%], which was comparable to the 5-year PFS rate of 0.5054 [95% CI: 0.4394; 0.5813], I2 = 84.2% [95% CI: 77.6%; 88.8%] and 10-yr PFS rate of 0.4949 [95% CI: 0.4075; 0.6010], I2 = 14.9% [95% CI: 0.0%; 87.0%]. There were 55 reported deaths for a perioperative mortality rate of 2.5%. The relative risk for mortality in the midline group versus the lateral approach group did not indicate any substantial difference in survival according to laterality of approach (-0.93 [95% CI: -1.03, -0.97], I2 = 95%, (p < 0.001). CONCLUSION Overall, these results indicate good 5-year survival outcomes for patients with skull base chordoma; however, 10-year prognosis for skull base chordoma remains poor due to its radiotherapeutic resistance and high recurrence rate. Furthermore, mortality rates among patients undergoing midline versus lateral skull base approaches appear to be equivocal.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Julian Gendreau
- Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| | - Cathleen C Kuo
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Oanh Nguyen
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Chenyi Yang
- Department of Neurological Surgery, University of California-Irvine, Orange, CA, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ, 85013, USA.
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Muhonen EG, Yasaka TM, Lehrich BM, Goshtasbi K, Papagiannopoulos P, Tajudeen BA, St John MA, Harris JP, Hsu FP, Kuan EC. Impact of Treatment Modalities upon Survival Outcomes in Skull Base and Clival Chordoma: An NCDB Analysis. J Neurol Surg B Skull Base 2022; 84:60-68. [PMID: 36743709 PMCID: PMC9897903 DOI: 10.1055/a-1733-9475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 01/06/2022] [Indexed: 02/07/2023] Open
Abstract
Objectives Skull base chordomas are locally aggressive malignant tumors derived from the notochord remnant. There are limited large-scale studies examining the role and extent of surgery and radiation therapy. Design Analysis of the National Cancer Database (NCDB) was performed to evaluate the survival outcomes of various treatments, and to assess for predictors of overall survival (OS). Participants This is a retrospective, population-based cohort study of patients diagnosed with a clival/skull base chordoma between 2004 and 2015 in the NCDB. Main Outcome Measures The primary outcome was overall survival (OS). Results In all, 468 cases were identified. Forty-nine percent of patients received surgery and 20.7% had positive margins. Mean age at diagnosis was 48.4 years in the surgical cohort, and 55% were males. Of the surgical cohort, 33.8% had negative margins, 20.7% had positive margins, and 45.5% had unknown margin status. Age ≥ 65 (hazard ratio [HR]: 3.07; 95% confidence interval [CI]: 1.63-5.76; p < 0.001), diagnosis between 2010 and 2015 (HR: 0.49; 95% CI: 0.26-0.90; p = 0.022), tumor size >5 cm (HR: 2.29; 95% CI: 1.26-4.15; p = 0.007), and government insurance (HR: 2.28; 95% CI: 1.24-4.2; p = 0.008) were independent predictors of OS. When comparing surgery with or without adjuvant radiation, no survival differences were found, regardless of margin status ( p = 0.66). Conclusion Surgery remains the mainstay of therapy. Advanced age (>65 years), large tumor size, and government insurance were predictors of worse OS. Whereas negative margins and the use of adjuvant radiation did not appear to impact OS, these may very well reduce local recurrences. A multidisciplinary approach is critical in achieving optimal outcomes in this challenging disease.
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Affiliation(s)
- Ethan G. Muhonen
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States
| | - Tyler M. Yasaka
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States
| | - Brandon M. Lehrich
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States
| | - Khodayar Goshtasbi
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States
| | - Peter Papagiannopoulos
- Department of Otolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Bobby A. Tajudeen
- Department of Otolaryngology–Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Maie A. St John
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, United States
| | - Jeremy P. Harris
- Department of Radiation Oncology, University of California, Irvine, Orange, California, United States
| | - Frank P.K. Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, California, United States
| | - Edward C. Kuan
- Department of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, California, United States,Department of Neurological Surgery, University of California, Irvine, Orange, California, United States,Address for correspondence Edward C. Kuan, MD, MBA Department of Otolaryngology–Head and Neck Surgery, University of CaliforniaIrvine, 101 The City Drive South Orange, CA 92868-3201United States
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4
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Napieralska A, Blamek S. Intracranial chordoma: radiosurgery, hypofractionated stereotactic radiotherapy and treatment outcomes. Rep Pract Oncol Radiother 2021; 26:764-772. [PMID: 34760311 DOI: 10.5603/rpor.a2021.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/04/2021] [Indexed: 11/25/2022] Open
Abstract
Background The aim of the study was to assess the results of stereotactic radiosurgery and hypofractionated stereotactic radiotherapy (SRS/SRT) for skull base chordomas. Materials and methods Twenty-three patients aged 12-75 were treated with SRS/SRT due to skull base chordoma. In 19 patients SRS/SRT was a part of the primary therapy, while in 4, a part of the treatment of recurrence. In 4 patients SRS/SRT was used as a boost after conventional radiotherapy and in 19 cases it was the only irradiation method applied. Patients were irradiated to total dose of 6-35 Gy and median total equivalent dose of 52 Gy. Results During median follow-up of 39 months, 4 patients died. One-, two- and five-year OS was 95%, 89% and 69%, respectively. In nine patients, progression of the disease was diagnosed during study period. One-, two- and five-year progression free survival (PFS) from the end of radiotherapy was 81%, 59% and 43%, respectively. Radiotherapy was well tolerated and only two patients in our group experienced moderate treatment-related toxicity. Conclusion SRS/SRT alone or in combination with surgery is a safe and effective method of irradiation of patients with skull base chordomas. High EQD2 is necessary to achieve satisfactory treatment results.
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Affiliation(s)
- Aleksandra Napieralska
- Radiotherapy Department, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
| | - Sławomir Blamek
- Radiotherapy Department, Maria Sklodowska-Curie National Research Institute of Oncology Gliwice Branch, Gliwice, Poland
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5
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Soule E, Baig S, Fiester P, Holtzman A, Rutenberg M, Tavanaiepour D, Rao D. Current Management and Image Review of Skull Base Chordoma: What the Radiologist Needs to Know. J Clin Imaging Sci 2021; 11:46. [PMID: 34513210 PMCID: PMC8422542 DOI: 10.25259/jcis_139_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/14/2021] [Indexed: 11/04/2022] Open
Abstract
Chordomas of the skull-base are typically slow-growing, notochord-derived tumors that most commonly originate along the clivus. Skull base chordoma is treated with surgery and radiotherapy. Local recurrence approaches 50% at 10 years. Radiologists play a critical role in diagnosis, treatment planning, and follow-up. Surgeons and radiation oncologists rely on radiologists for pre-operative delineation of tumor and adjacent anatomy, identification of post-treatment changes and disease recurrence, and radiation treatment effects. This review provides an overview of clinical characteristics, surgical anatomy, indications for radiotherapy, identification of treatment complications, and patterns of disease recurrence for radiologists to provide value in the management of these lesions.
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Affiliation(s)
- Erik Soule
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Saif Baig
- Department of Radiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Peter Fiester
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Adam Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Michael Rutenberg
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Dinesh Rao
- Department of Neuroradiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Champagne PO, Passeri T, Jabre R, Bernat AL, Voormolen EH, Froelich S. Vertebrobasilar Artery Encasement by Skull Base Chordomas: Surgical Outcome and Management Strategies. Oper Neurosurg (Hagerstown) 2020; 19:375-383. [PMID: 32324880 DOI: 10.1093/ons/opaa091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/10/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Vascular encasement by skull base chordomas can increase surgical risk and hinder completeness of resection. However, the evidence behind this remains anecdotic. OBJECTIVE To give a better portrayal of chordomas encasing vertebrobasilar arteries mainly in regard of surgical vascular risk and its impact on extent of resection. METHODS A retrospective cohort study comparing skull base chordomas with encasement (≥180o encirclement) of the vertebrobasilar arteries to a control group of skull base chordomas with intradural extension. Data gathered involved pre- and postoperative volumetric analysis of the tumor, degree of encasement of involved vessel, occurrence of complication, and survival data including progression-free survival (PFS) and overall survival (OS). RESULTS A total of 24 patients with vertebrobasilar encasement were included in the study and an equal number of control cases were randomly selected from the same time period, totalizing 48 patients. Lower clival tumors with condyle involvement were more likely to have encasement. Gross total resection (GTR) rate was significantly lower in the encasement group (13% vs 42%, P = .023). Rates of postoperative new neurological deficit, CFS leak and 30 d postoperative mortality were not statistically different between groups. There was no statistically significant difference in mean PFS (P = .608) and OS (P = .958). CONCLUSION Skull base chordomas encasing vertebrobasilar arteries are highly challenging tumors. This study demonstrates that although safe resection is possible, GTR is hindered by the presence of encasement. We advocate letting the tumor's adherence to vessels lead the resection, leaving a small piece of tumor behind if adherent to the vessels.
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Affiliation(s)
| | - Thibault Passeri
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
| | - Roland Jabre
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
- Neurosurgery Service, Department of Surgery, Centre hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Canada
| | - Anne-Laure Bernat
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
| | - Eduard H Voormolen
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
| | - Sébastien Froelich
- Department of Neurosurgery, Lariboisiere Hospital, University of Paris Diderot, Paris, France
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Metwali H, Samii A, Gerganov V, Giordano M, Fahlbusch R, Samii M. The Significance of Intraoperative Magnetic Resonance Imaging in Resection of Skull Base Chordomas. World Neurosurg 2019; 128:e185-e194. [DOI: 10.1016/j.wneu.2019.04.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/26/2022]
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8
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Fukuhara N, Tsuruta W, Hosoo H, Sato M, Matsumaru Y, Yamaguchi-Okada M, Yoshino M, Hara T, Yamada S, Nishioka H. Magnetic Resonance Angiography-based Prediction of the Results of Balloon Test Occlusion. Neurol Med Chir (Tokyo) 2019; 59:384-391. [PMID: 31353325 PMCID: PMC6796060 DOI: 10.2176/nmc.oa.2019-0070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Precautious balloon test occlusion (BTO) is sometimes performed in cases of high-risk intraoperative internal carotid artery injury. We investigated whether magnetic resonance angiography (MRA) findings could predict BTO results to thus avoid the use of precautious BTO. This retrospective study, included 96 patients who underwent BTO, eight of whom underwent bilateral BTO. The relationship between the BTO results for 104 internal carotid arteries and the MRA findings obtained in 96 patients were retrospectively evaluated. On MRA, anterior cerebral artery (A1)–anterior communicating artery–A1 was defined as anterior collateral circulation (ACC), and posterior cerebral artery–posterior communicating artery was defined as posterior collateral circulation (PCC). BTO was tolerated in all 27 sides with thick ACC regardless of PCC thickness. In 31 of 44 cases with a thin ACC, the tested sides were BTO-tolerant (70.5%). Of these 44 tested sides, all five with a thick PCC were BTO-tolerant, but eight with a thin PCC and 31 with an invisible PCC showed results other than tolerance. Among cases with an invisible ACC, 10 of 33 tested sides were BTO-tolerant (30.3%). Among these 33 tested sides, outcomes other than tolerance were observed regardless of PCC thickness. Thick, thin, and invisible ACCs were assigned 3, 1, and 0 points, respectively; and thick, thin, and invisible PCCs were assigned 2, 1, and 0 points, respectively. A sum of 3 points in the ACC and PCC indicated that all sides were BTO-tolerant. In conclusion, a thick ACC or a thin ACC with a thick PCC indicates BTO-tolerance. The BTO prediction score is useful for predicting results of BTO.
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Affiliation(s)
- Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital.,Department of Comprehensive Pathology, Tokyo Medical and Dental University.,Okinaka Memorial Institute for Medical Research
| | - Wataro Tsuruta
- Okinaka Memorial Institute for Medical Research.,Department of Neuro-Endovascular Therapy, Toranomon Hospital
| | - Hisayuki Hosoo
- Department of Neuro-Endovascular Therapy, Toranomon Hospital
| | - Masayuki Sato
- Division of Stroke, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | - Yuji Matsumaru
- Division of Stroke, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba
| | | | - Masanori Yoshino
- Okinaka Memorial Institute for Medical Research.,Department of Neurosurgery, Tokyo Metropolitan Police Hospital
| | - Takayuki Hara
- Okinaka Memorial Institute for Medical Research.,Department of Neurosurgery, Toranomon Hospital
| | - Shozo Yamada
- Okinaka Memorial Institute for Medical Research.,Department of Neurosurgery, Tokyo Neurological Center
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital.,Okinaka Memorial Institute for Medical Research
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9
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Hafez RFA, Fahmy OM, Hassan HT. Gamma knife surgery efficacy in controlling postoperative residual clival chordoma growth. Clin Neurol Neurosurg 2019; 178:51-55. [PMID: 30710730 DOI: 10.1016/j.clineuro.2019.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 12/07/2018] [Accepted: 01/24/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Raef F A Hafez
- Department of Neurosurgery and Gamma Knife Center, International Medical Center (IMC), 42km. Ismailia Desert Road, Cairo, Egypt.
| | - Osama M Fahmy
- Department of Neurosurgery and Gamma Knife Center, International Medical Center (IMC), 42km. Ismailia Desert Road, Cairo, Egypt.
| | - Hamdy T Hassan
- Department of Neurosurgery and Gamma Knife Center, International Medical Center (IMC), 42km. Ismailia Desert Road, Cairo, Egypt.
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10
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Hao S, Song H, Zhang W, Seldomridge A, Jung J, Giles AJ, Hutchinson MK, Cao X, Colwell N, Lita A, Larion M, Maric D, Abu-Asab M, Quezado M, Kramp T, Camphausen K, Zhuang Z, Gilbert MR, Park DM. Protein phosphatase 2A inhibition enhances radiation sensitivity and reduces tumor growth in chordoma. Neuro Oncol 2019; 20:799-809. [PMID: 29294092 DOI: 10.1093/neuonc/nox241] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Standard therapy for chordoma consists of surgical resection followed by high-dose irradiation. Protein phosphatase 2A (PP2A) is a ubiquitously expressed serine/threonine phosphatase involved in signal transduction, cell cycle progression, cell differentiation, and DNA repair. LB100 is a small-molecule inhibitor of PP2A designed to sensitize cancer cells to DNA damage from irradiation and chemotherapy. A recently completed phase I trial of LB100 in solid tumors demonstrated its safety. Here, we show the therapeutic potential of LB100 in chordoma. Methods Three patient-derived chordoma cell lines were used: U-CH1, JHC7, and UM-Chor1. Cell proliferation was determined with LB100 alone and in combination with irradiation. Cell cycle progression was assessed by flow cytometry. Quantitative γ-H2AX immunofluorescence and immunoblot evaluated the effect of LB100 on radiation-induced DNA damage. Ultrastructural evidence for nuclear damage was investigated using Raman imaging and transmission electron microscopy. A xenograft model was established to determine potential clinical utility of adding LB100 to irradiation. Results PP2A inhibition in concert with irradiation demonstrated in vitro growth inhibition. The combination of LB100 and radiation also induced accumulation at the G2/M phase of the cell cycle, the stage most sensitive to radiation-induced damage. LB100 enhanced radiation-induced DNA double-strand breaks. Animals implanted with chordoma cells and treated with the combination of LB100 and radiation demonstrated tumor growth delay. Conclusions Combining LB100 and radiation enhanced DNA damage-induced cell death and delayed tumor growth in an animal model of chordoma. PP2A inhibition by LB100 treatment may improve the effectiveness of radiation therapy for chordoma.
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Affiliation(s)
- Shuyu Hao
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA.,Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hua Song
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Wei Zhang
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Ashlee Seldomridge
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Jinkyu Jung
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Amber J Giles
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Marsha-Kay Hutchinson
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Xiaoyu Cao
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Nicole Colwell
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Adrian Lita
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Mioara Larion
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Dragan Maric
- Flow Cytometry Core Facility, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Mones Abu-Asab
- Ultrastructural Pathology Section, National Eye Institute, Bethesda, Maryland, USA
| | - Martha Quezado
- Neuropathology Section, Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland, USA
| | - Tamalee Kramp
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Kevin Camphausen
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Zhengping Zhuang
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Mark R Gilbert
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Deric M Park
- Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
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Leah P, Dower A, Vescovi C, Mulcahy M, Al Khawaja D. Clinical experience of intracranial chordoma – A systematic review and meta-analysis of the literature. J Clin Neurosci 2018; 53:6-12. [DOI: 10.1016/j.jocn.2018.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/09/2018] [Indexed: 01/31/2023]
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12
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Batista KMP, Reyes KYA, Lopez FP, Pelaz AC, Vega IF, Pendás JLL, Ayala AS, Astudillo A, Rojas JAN, Fernandez PB. Immunophenotypic features of dedifferentiated skull base chordoma: An insight into the intratumoural heterogeneity. Contemp Oncol (Pozn) 2017; 21:267-73. [PMID: 29416431 DOI: 10.5114/wo.2017.72385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 08/26/2017] [Indexed: 01/05/2023] Open
Abstract
Chordomas are rare and low-grade malignant solid tumours, despite their histologically benign appearance, that arise in the bone from embryonic notochordal vestiges of the axial skeleton, a mesoderm-derived structure that is involved in the process of neurulation and embryonic development. Chordomas occurring in the skull base tend to arise in the basiocciput along the clivus. Three major morphological variants have been described (classical, chondroid, and atypical/dedifferentiated). The pathogenesis and molecular mechanisms involved in chordoma development remain uncertain. From a pathological standpoint, the microenvironment of a chordoma is heterogeneous, showing a dual epithelial-mesenchymal differentiation. These tumours are characterised by slow modality of biologic growth, local recurrence, low incidence of metastasis rates, and cancer stem cell (CSC) phenotype. The main molecular findings are connected with brachyury immunoexpression and activation of the downstream Akt and mTOR signalling pathways. The differentiation between typical and atypical chordomas is relevant because the tumoural microenvironment and prognosis are partially different. This review provides an insight into the recent and relevant concepts and histochemical markers expressed in chordomas, with special emphasis on dedifferentiated chordomas and their prognostic implications.
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Shimony N, Gonen L, Shofty B, Abergel A, Fliss DM, Margalit N. Surgical resection of skull-base chordomas: experience in case selection for surgical approach according to anatomical compartments and review of the literature. Acta Neurochir (Wien) 2017; 159:1835-45. [PMID: 27924417 DOI: 10.1007/s00701-016-3032-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Chordoma is a rare bony malignancy known to have a high rate of local recurrence after surgery. The best treatment paradigm is still being evaluated. We report our experience and review the literature. We emphasize on the difference between endoscopic and open craniotomy in regard to the anatomical compartment harboring the tumor, the limitations of the approaches and the rate of surgical resection. METHOD We retrospectively collected all patients with skull-base chordomas operated on between 2004 and 2014. Detailed radiological description of the compartments being occupied by the tumor and the degree of surgical resection is discussed. RESULTS Eighteen patients were operated on in our facility for skull-base chordoma. Seventeen endoscopic surgeries were done in 15 patients, and 7 craniotomies were done in 5 patients. The mean age was 48.9 years (±19.8 years). When reviewing the anatomical compartments, we found that the most common were the upper clivus (95.6%) and lower clivus (58.3%), left cavernous sinus (66.7%) and petrous apex (∼60%). Most of the patients had intradural tumor involvement (70.8%). In all craniotomy cases, there was residual tumor in multiple compartments. In the endoscopic cases, the most difficult compartments for total resection were the lower clivus, and lateral extensions to the petrous apex or cavernous sinus. CONCLUSIONS Our experience shows that the endoscopic approach is a good option for midline tumors without significant lateral extension. In cases with very lateral or lower extensions, additional approaches should be added trying to achieve complete resection.
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Abstract
The sellar region is a tiny anatomic compartment in which many lesions and developmental diseases can be found. If pituitary adenomas represent most of the sellar mass, it is important to recognize other pathologic conditions before any surgical procedure, because the optimal treatment may differ considerably from one lesion to another. A careful clinical evaluation followed by neuroimaging studies and an endocrinologic and ophtalmologic workup will lead, in most cases, to a diagnosis with near certainty. This article provides an overview of sellar diseases with emphasis on their most useful characteristics for clinical practice.
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Affiliation(s)
- Damien Bresson
- Neurosurgery Department, Assistance Publique-Hôpitaux de Paris, 2 rue Ambroise Paré, Paris 75010, France
| | - Philippe Herman
- ENT Department, Lariboisière Hospital, Université Paris VII - Diderot, 2 rue Ambroise Paré, Paris 75010, France
| | - Marc Polivka
- Department of Pathology, Lariboisiere Hospital, 2 rue Ambroise Paré, Paris 75010, France
| | - Sébastien Froelich
- Neurosurgery Department, Assistance Publique-Hôpitaux de Paris, Université Paris VII - Diderot, 2 rue Ambroise Paré, Paris 75010, France.
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15
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Boari N, Gagliardi F, Cavalli A, Gemma M, Ferrari L, Riva P, Mortini P. 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. J Neurosurg 2016; 125:450-60. [DOI: 10.3171/2015.6.jns142370] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Nicola Boari
- 1Unit of Neurosurgery and Gamma Knife Radiosurgery
| | | | | | - Marco Gemma
- 3Service of Anesthesia and Intensive Care Unit, Head and Neck Department, I.R.C.C.S. San Raffaele Hospital
| | - Luca Ferrari
- 4Department of Medical Biotechnology and Translational Medicine, University of Milan, Italy
| | - Paola Riva
- 4Department of Medical Biotechnology and Translational Medicine, University of Milan, Italy
| | - Pietro Mortini
- 1Unit of Neurosurgery and Gamma Knife Radiosurgery
- 2Vita-Salute San Raffaele University; and
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Weber DC, Malyapa R, Albertini F, Bolsi A, Kliebsch U, Walser M, Pica A, Combescure C, Lomax AJ, Schneider R. Long term outcomes of patients with skull-base low-grade chondrosarcoma and chordoma patients treated with pencil beam scanning proton therapy. Radiother Oncol 2016; 120:169-74. [PMID: 27247057 DOI: 10.1016/j.radonc.2016.05.011] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/26/2016] [Accepted: 05/16/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the long term tumor control and toxicity of skull base tumors treated with pencil beam scanning proton therapy (PT). MATERIALS AND METHODS PT was delivered to 151 (68%) and 71 (32%) chordoma and chondrosarcoma (ChSa) patients, respectively. Mean age of patients was 40.8±18.4years and the male to female ratio was 0.53. The postoperative tumor was abutting the brainstem or optic apparatus in 71 (32.0%) patients. The postoperative mean gross tumor volume (GTV) was 35.7±29.1cm(3). The delivered mean PT dose was 72.5±2.2GyRBE. RESULTS After a mean follow-up of 50 (range, 4-176) months, 35 local (15.8%) failures were observed between 10.9 and 85.4months. The estimated 7-year LC rate for chordoma (70.9%; CI95% 61.5-81.8) was significantly lower compared to the LC rate for ChSa patients (93.6%; 95%CI 87.8-99.9; P=0.014). The estimated 7-year distant metastasis-free- and overall survival rate was 91.6% (95%CI 91.6-98.6) and 81.7% (95%CI 74.7-89.5), respectively. On multivariate analysis, optic apparatus and/or brainstem compression, histology and GTV were independent prognostic factors for LC and OS. The 7-year high grade toxicity-free survival was 87.2 (95%CI 82.4-92.3). CONCLUSIONS PBS PT is an effective treatment for skull base tumors with acceptable late toxicity. Optic apparatus and/or brainstem compression, histology and GTV allow independent prediction of the risk of local failure and death in skull base tumor patients.
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Affiliation(s)
- Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; University of Bern, Switzerland; University of Zürich, Switzerland.
| | - Robert Malyapa
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland
| | | | | | - Ulrike Kliebsch
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland
| | - Marc Walser
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland
| | - Alessia Pica
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland
| | | | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; ETH, Zürich, Switzerland
| | - Ralf Schneider
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland
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17
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Muto J, Prevedello DM, Ditzel Filho LFS, Tang IP, Oyama K, Kerr EE, Otto BA, Kawase T, Yoshida K, Carrau RL. Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region. J Neurosurg 2016; 125:1171-1186. [PMID: 26848916 DOI: 10.3171/2015.8.jns15302] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) offers direct access to midline skull base lesions, and the anterior transpetrosal approach (ATPA) stands out as a method for granting entry into the upper and middle clival areas. This study evaluated the feasibility of performing EEA for tumors located in the petroclival region in comparison with ATPA. METHODS On 8 embalmed cadaver heads, EEA to the petroclival region was performed utilizing a 4-mm endoscope with either 0° or 30° lenses, and an ATPA was performed under microscopic visualization. A comparison was executed based on measurements of 5 heads (10 sides). Case illustrations were utilized to demonstrate the advantages and disadvantages of EEA and ATPA when dealing with petroclival conditions. RESULTS Extradurally, EEA allows direct access to the medial petrous apex, which is limited by the petrous and paraclival internal carotid artery (ICA) segments laterally. The ATPA offers direct access to the petrous apex, which is blocked by the petrous ICA and abducens nerve inferiorly. Intradurally, the EEA allows a direct view of the areas medial to the cisternal segment of cranial nerve VI with limited lateral exposure. ATPA offers excellent access to the cistern between cranial nerves III and VIII. The quantitative analysis demonstrated that the EEA corridor could be expanded laterally with an angled drill up to 1.8 times wider than the bone window between both paraclival ICA segments. CONCLUSIONS The midline, horizontal line of the petrous ICA segment, paraclival ICA segment, and the abducens nerve are the main landmarks used to decide which approach to the petroclival region to select. The EEA is superior to the ATPA for accessing lesions medial or caudal to the abducens nerve, such as chordomas, chondrosarcomas, and midclival meningiomas. The ATPA is superior to lesions located posterior and/or lateral to the paraclival ICA segment and lesions with extension to the middle fossa and/or infratemporal fossa. The EEA and ATPA are complementary and can be used independently or in combination with each other in order to approach complex petroclival lesions.
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Affiliation(s)
- Jun Muto
- Departments of 1 Neurosurgical Surgery and.,Department of Neurosurgery, Keio University, School of Medicine, Tokyo, Japan
| | - Daniel M Prevedello
- Departments of 1 Neurosurgical Surgery and.,Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | | | - Ing Ping Tang
- Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | | | | | - Bradley A Otto
- Departments of 1 Neurosurgical Surgery and.,Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Takeshi Kawase
- Department of Neurosurgery, Keio University, School of Medicine, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University, School of Medicine, Tokyo, Japan
| | - Ricardo L Carrau
- Departments of 1 Neurosurgical Surgery and.,Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
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Vellutini EDAS, Balsalobre L, Hermann DR, Stamm AC. The endoscopic endonasal approach for extradural and intradural clivus lesions. World Neurosurg 2015; 82:S106-15. [PMID: 25496620 DOI: 10.1016/j.wneu.2014.07.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/25/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report the use of the endoscopic transnasal transclival approach to treat tumors involving the clivus region. METHODS The clinical records of 38 patients with clivus lesions were retrospectively reviewed to determine the surgical technique used. All patients were surgically treated using any of the options of the endoscopic transnasal transclival approach at the São Paulo Skull Base Center from 2000-2011. A transsphenoidal, transpterygoidal, retropharyngeal, or a combination of approaches was chosen based on the tumor topography. RESULTS Chordomas were the most frequent tumor (26 of 38), followed by chondrosarcoma (2 of 38). Biopsy only was performed in 6 patients with metastasis to the clivus, and 1 patient with fibrous dysplasia underwent a planned partial resection. Gross total resection (GTR) was achieved in 15 of 31 (48%) patients with indications for GTR. For centrally located tumors, GTR was achieved in 75% (15 of 20 patients). Fistula was the most frequent complication (6 of 31; 19%) but was much lower in the most recent series using the nasoseptal flap (1 of 16; 6%). Tumors with lateral extensions or with previous treatment had the worst results. The presence of intradural extension was not a limiting factor for GTR. CONCLUSION Endoscopic transnasal surgery is an alternative approach to treatment of clivus lesions, and, in expert hands, this technique can obtain good results. Lateral extension and previous treatment were factors that could make the surgery more difficult. Intradural extension did not limit the radicality of the removal.
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Affiliation(s)
| | - Leonardo Balsalobre
- São Paulo Skull Base Center, São Paulo, Brazil; Department of Otolaryngology, Head and Neck Surgery, Federal University of São Paulo, São Paulo, Brazil
| | | | - Aldo Cassol Stamm
- São Paulo Skull Base Center, São Paulo, Brazil; Department of Otolaryngology, Head and Neck Surgery, Federal University of São Paulo, São Paulo, Brazil
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19
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Muro K, Das S, Raizer JJ. Chordomas of the craniospinal axis: multimodality surgical, radiation and medical management strategies. Expert Rev Neurother 2014; 7:1295-312. [DOI: 10.1586/14737175.7.10.1295] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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20
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Cutler AR, Mundi JS, Solomon N, Suh JD, Wang MB, Bergsneider M. Critical appraisal of extent of resection of clival lesions using the expanded endoscopic endonasal approach. J Neurol Surg B Skull Base 2013; 74:217-24. [PMID: 24436915 DOI: 10.1055/s-0033-1342915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 01/22/2013] [Indexed: 12/29/2022] Open
Abstract
Objectives To present a critical evaluation of our experience using an expanded endoscopic endonasal approach (EEEA) to clival lesions and evaluate, based on the location of residual tumor, what the anatomic limitations to the approach are. Design A retrospective review of all endoscopic endonasal operations performed at our institution identified 19 patients with lesions involving the clivus. Extent of resection was determined by preoperative and postoperative tumor volumes. Results Three patients underwent planned subtotal resections. Of the remaining patients, gross total resection was achieved in 8/16 (50%), > 95% in 5/16 (31%), and < 95% in 3/16 (19%). Residual tumor occurred, most commonly with extension posterior and lateral to the internal carotid artery, with inferior, lateral invasion of the occipital condyle and with deep inferior extension to the midportion of the dens. Conclusions The EEEA represents a safe and effective technique for the resection of clival lesions. Despite excellent overall visualization of this region we found that adequate exposure of the most lateral and inferior portions of large tumors is often difficult. Knowledge of these limitations allows us to determine which tumors are best suited for an EEEA and which may be more appropriate for an open skull base or combined technique.
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Affiliation(s)
- Aaron R Cutler
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jagmeet S Mundi
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Noriko Solomon
- Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jeffrey D Suh
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Marilene B Wang
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Marvin Bergsneider
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Miin JC, Precheur HV, Krolls SO. Lesion presenting as an expanding mass of the palate. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113:442-7. [PMID: 22668426 DOI: 10.1016/j.oooo.2011.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 08/11/2011] [Accepted: 08/30/2011] [Indexed: 11/23/2022]
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Komotar RJ, Starke RM, Raper DMS, Anand VK, Schwartz TH. Endoscopic skull base surgery: a comprehensive comparison with open transcranial approaches. Br J Neurosurg 2012; 26:637-48. [PMID: 22324437 DOI: 10.3109/02688697.2012.654837] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Little data exists comparing endoscopic endonasal approaches to pathology of the anterior skull base with more traditional transcranial and transsphenoidal microscopic approaches. In order to more fully characterize the role of endoscopy in the management of pathology of the anterior cranial base, we conducted a systematic review of case series and case reports documenting surgical and clinical outcomes. We found that for craniopharyngiomas, clival chordomas, esthesioneuroblastomas and giant pituitary adenomas, the endonasal endoscopic approach can result in equivalent or higher rates of gross total resection than open approaches. For meningiomas, however, open transcranial approaches are still able to achieve higher rates of total resection. CSF leak rates are higher for patients undergoing endoscopic surgery for meningiomas and craniopharyngiomas, but not for chordomas, esthesioneuroblastomas or giant pituitary adenomas. In certain patients, the endonasal endoscopic approach may be a safe and effective alternative for the treatment of a wide variety of skull base pathology, particularly those with small midline tumours.
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Affiliation(s)
- Ricardo J Komotar
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
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Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. The Endoscope-Assisted Ventral Approach Compared with Open Microscope-Assisted Surgery for Clival Chordomas. World Neurosurg 2011; 76:318-27. [DOI: 10.1016/j.wneu.2011.02.026] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 02/07/2011] [Indexed: 10/16/2022]
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Yasuda M, Bresson D, Chibbaro S, Cornelius JF, Polivka M, Feuvret L, Takayasu M, George B. Chordomas of the skull base and cervical spine: clinical outcomes associated with a multimodal surgical resection combined with proton-beam radiation in 40 patients. Neurosurg Rev 2011; 35:171-82; discussion 182-3. [PMID: 21863225 DOI: 10.1007/s10143-011-0334-5] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 03/03/2011] [Accepted: 05/03/2011] [Indexed: 11/24/2022]
Abstract
Previous studies of chordoma have focused on either surgery, radiotherapy, or particular tumor locations. This paper reviewed the outcomes of surgery and proton radiotherapy with various tumor locations. Between 2001 and 2008, 40 patients with chordomas of the skull base and cervical spine had surgery at our hospital. Most patients received proton therapy. Their clinical course was reviewed. Age, sex, tumor location, timing of surgery, extent of resection, and chondroid appearance were evaluated in regard to the progression-free survival (PFS) and overall survival (OS). The primary surgery (PS) group was analyzed independently. The extensive resection rate was 42.5%. Permanent neurological morbidity was seen in 3.8%. Radiotherapy was performed in 75% and the mean dose was 68.9 cobalt gray equivalents. The median follow-up was 56.5 months. The 5-year PFS and OS rates were 70% and 83.4%, respectively. Metastasis was seen in 12.5%. The tumor location at the cranio-cervical junction (CCJ) was associated with a lower PFS (P = 0.007). In the PS group, a younger age and the CCJ location were related to a lower PFS (P = 0.008 and P < 0.001, respectively). The CCJ location was also related to a lower OS (P = 0.043) and it was more common in young patients (P = 0.002). Among the survivors, the median of the last Karnofsky Performance Scale score was 80 with 25.7% of patients experiencing an increase and 11.4% experiencing a decrease. Multimodal surgery and proton therapy thus improved the chordoma treatment. The CCJ location and a younger age are risks for disease progression.
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Affiliation(s)
- Muneyoshi Yasuda
- Department of Neurosurgery, Lariboisiere Hospital (AP-HP), Paris, France.
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Di Maio S, Temkin N, Ramanathan D, Sekhar LN. Current comprehensive management of cranial base chordomas: 10-year meta-analysis of observational studies. J Neurosurg 2011; 115:1094-105. [PMID: 21819197 DOI: 10.3171/2011.7.jns11355] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECT The role of surgery and adjuvant radiation therapy for cranial base chordomas is not well established. This meta-analysis measures the relationship of complete resection and type of adjuvant radiation therapy to 5-year progression-free survival (PFS) and overall survival (OS) of cranial base chordomas. METHODS A systematic MEDLINE search (1999-present) yielded 23 observational studies and 807 patients who fit inclusion criteria. The following analyses were performed: 1) Kaplan-Meier 5-year PFS and OS compared based on the extent of resection and type of adjuvant radiation therapy using the log-rank method; 2) a random-effects model comparing 5-year PFS with complete or incomplete resection; and 3) paired z-test comparisons of weighted average 5-year OS and PFS grouped by type of adjuvant radiation therapy. RESULTS The weighted average follow-up was 53.6 months. The weighted average 5-year PFS and OS were 50.8% and 78.4%, respectively. Complete resection conferred a higher 5-year PFS than incomplete resection from the random effects model (mean difference in PFS 20.7%; 95% CI 6.57%-34.91%). Patients with incomplete resection were 3.83 times more likely to experience a recurrence (95% CI 1.63-9.00) and 5.85 times more likely to die (95% CI 1.40-24.5) at 5 years versus patients with complete resection. There was no difference in 5-year OS by type of adjuvant radiation, although 5-year PFS was lower in patients receiving Gamma Knife surgery relative to carbon ion radiotherapy (p = 0.042) on paired z-test. No survival difference occurred between radiation therapy techniques on Kaplan-Meier analysis of compiled patient data. CONCLUSIONS Patients with complete resection of cranial base chordomas have a prolonged 5-year PFS and OS. Adjuvant proton-beam, carbon ion, and modern fractionated photon radiation therapy techniques offered a similar rate of PFS and OS at 5 years.
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Affiliation(s)
- Salvatore Di Maio
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, Washington 98104, USA
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Abstract
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.
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Affiliation(s)
- Brian J Jian
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California, USA
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Jian BJ, Bloch OG, Yang I, Han SJ, Aranda D, Tihan T, Parsa AT. Adjuvant radiation therapy and chondroid chordoma subtype are associated with a lower tumor recurrence rate of cranial chordoma. J Neurooncol 2010; 98:101-8. [PMID: 19953297 DOI: 10.1007/s11060-009-0068-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 11/08/2009] [Indexed: 10/20/2022]
Abstract
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.
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Abstract
OBJECT Clival lesions pose significant challenges with regard to their surgical management. The expanded endoscopic endonasal (EEE) approach is a promising minimally invasive technique for lesions of the central skull base. The authors' aim in the current paper was to discuss the surgical treatment of clival lesions and to present the technical details, indications, and limitations of the EEE approach. Data from a recent endoscopically treated group will be compared with findings in a previous cohort of patients treated via classic open anterior and lateral approaches. METHODS Since June 2005, 17 patients with clival lesions underwent surgery via the EEE approach. Suitable candidates were chosen according to lesion characteristics, clinical parameters, and surgical goals. Neurological outcomes, Karnofsky Performance Scale scores, the extent of lesion resection, and complications were evaluated among these patients. Eighteen percent of the patients in the endoscopic group presented with recurrent disease. Another series of 43 patients, who had undergone resection of clival lesions via an anterior (rhinotomy, maxillectomy, microscopic transsphenoidal surgery, or transoral surgery) or lateral (pterional, frontoorbitozygomatic, or combined suprainfratentorial retrosigmoid) approach, was similarly reviewed. Twenty-three of these patients (53%) presented with recurrent disease and thus had undergone prior surgery. RESULTS Following the EEE approach, 11 (79%) of 14 patients who had presented with neurological symptoms experienced improvement, and gross-total resection was achieved in 59% of the patients and subtotal removal in 41%. Complications included CSF leakage (24%), tension pneumocephalus (6%), and intracranial hematoma (6%). The patient with the latter complication was the only one who experienced permanent neurological worsening. In the open resection group, neurological worsening occurred in 33% of the patients (14 of 43). Total and grosstotal removals were achieved in 84% of patients and subtotal removal in 14%. CONCLUSIONS The EEE approach has been shown to be a safe and effective technique for the resection of clival lesions with limited lateral extension. The choice of surgical approach must be tailored according to both patient and tumor characteristics. Although the 2 patient series featured in this paper are not comparable-because of a selection bias-higher rates of neurological morbidity and total and gross-total resections were observed in the open resection group. Given the long survival of some patients, the EEE approach should be favored whenever reasonable.
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Affiliation(s)
- Giorgio Carrabba
- Division of Neurosurgery, University Health Network, Toronto Western Hospital, University of Toronto, Ontario, Canada.
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Dassoulas K, Schlesinger D, Yen CP, Sheehan J. The role of Gamma Knife surgery in the treatment of skull base chordomas. J Neurooncol 2009; 94:243-8. [DOI: 10.1007/s11060-009-9846-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2008] [Accepted: 02/23/2009] [Indexed: 11/25/2022]
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Fatemi N, Dusick JR, Gorgulho AA, Mattozo CA, Moftakhar P, De Salles AAF, Kelly DF. Endonasal microscopic removal of clival chordomas. ACTA ACUST UNITED AC 2008; 69:331-8. [PMID: 18234296 DOI: 10.1016/j.surneu.2007.08.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Accepted: 08/15/2007] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Clival chordomas have traditionally been removed using a variety of anterior and lateral skull base approaches. Herein, we evaluate the outcomes of patients who underwent an extended endonasal transsphenoidal removal of a clival chordoma. METHOD All consecutive patients with a clival chordoma treated using an endonasal microscope approach were identified. In 8 cases, frameless surgical navigation was used, and in 4 cases, endoscopic assistance was used. Patients treated with prior radiotherapy were excluded. RESULT Over 5 years, 18 procedures were performed on 14 patients (7 females; mean age, 47 years). Patients were followed from 3 to 58 months (median, 20 months). Mean tumor diameter was 32 +/- 17 mm; 7 (50%) patients had intradural extension. Postoperative MRIs after the initial operation showed gross total, near-total (>90%), and subtotal resection in 43%, 43%, and 14% of patients, respectively. Use of the endoscope was associated with gross total or near-total tumor removal in 4 of 4 cases. Tumor regrowth occurred in 2 (14%) cases 10 and 12 months after the initial surgery and before radiotherapy. Two patients had multiple operations, in one as a planned staged operation, and in the other, 3 additional debulkings were performed despite an initial gross total removal. Nine patients, all with CS invasion, had subsequent stereotactic radiation. Of 10 patients with cranial neuropathy, 80% improved or resolved including 75% and 67% of sixth and fifth CN palsies, respectively. Complications included one each of adrenal insufficiency and chemical meningitis. There were no CSF leaks or new neurological deficits. CONCLUSION In this small series with relatively short follow-up, endonasal microscopic removal of clival chordomas proved safe and elfective with gross total or near-total removal in 86% of patients and improvement of cranial neuropathy in 80% of patients. Endoscopy for aiding tumor removal and assessing completeness of resection, as well as surgical navigation, are recommended for all cases.
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Affiliation(s)
- Nasrin Fatemi
- Division of Neurosurgery, University of California at Los Angeles David Geffen School of Medicine, Los Angeles, CA 90095, USA
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Abstract
Chordomas are rare, slow growing tumors of the axial skeleton, which derive from the remnants of the fetal notochord. They can be encountered anywhere along the axial skeleton, most commonly in the sacral area, skull base and less commonly in the spine. Chordomas have a benign histopathology but exhibit malignant clinical behavior with invasive, destructive and metastatic potential. Genetic and molecular pathology studies on oncogenesis of chordomas are very limited and there is little known on mechanisms governing the disease. Chordomas most commonly present with headaches and diplopia and can be readily diagnosed by current neuroradiological methods. There are 3 pathological subtypes of chordomas: classic, chondroid and dedifferentiated chordomas. Differential diagnosis from chondrosarcomas by radiology or pathology may at times be difficult. Skull base chordomas are very challenging to treat. Clinically there are at least two subsets of chordoma patients with distinct behaviors: some with a benign course and another group with an aggressive and rapidly progressive disease. There is no standard treatment for chordomas. Surgical resection and high dose radiation treatment are the mainstays of current treatment. Nevertheless, a significant percentage of skull base chordomas recur despite treatment. The outcome is dictated primarily by the intrinsic biology of the tumor and treatment seems only to have a secondary impact. To date we only have a limited understanding this biology; however better understanding is likely to improve treatment outcome. Hereby we present a review of the current knowledge and experience on the tumor biology, diagnosis and treatment of chordomas.
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