Journal of Radiation Oncology

, Volume 3, Issue 1, pp 57–64 | Cite as

Preliminary experience in treating skull base chordomas with high-dose hyperfractionated stereotactic photon radiation therapy

  • Arshin Sheybani
  • Raheel Ahmed
  • Mindi TenNapel
  • Edward C. Pennington
  • Daniel E. Hyer
  • Kathleen M. Anderson
  • Arnold H. Menezes
  • Patrick Hitchon
  • John M. Buatti
Original Research



Skull base chordomas (SBC) are characterized by persistent progression. Conventional radiation following resection increases 5- and 10-year local control (LC) to 36 and 23 %, respectively. Patients treated with protons result in 10-year LC of 50 %. Brainstem dose constraints have inhibited higher prescription doses with photons. We reviewed our experience using high-dose fractionated stereotactic photon radiation therapy (HD-FSRT) to 81 Gy for SBC.


We reviewed patients diagnosed with SBC and treated with radiation from 1999 to 2010. We excluded those with metastatic disease and prior radiation. Dose distributions and target volumes were obtained from radiation records.


Twelve patients met the search criteria. Median dose was 81 Gy (76.8–82.5) using a hyperfractionated regimen. Eleven patients with available data had median max and mean doses to the brainstem of 81 Gy (46.7–85.7) and 38 Gy (6.6–58.1). Mean target volume was 22 cm3 (5.3–193. 3). LC at 3 and 5 years was 69 and 46 %. Overall survival was 90 and 68 % with a mean follow-up of 55 months. There was a trend for improved LC in patients treated adjuvantly.


HD-FSRT can achieve comparable doses to proton therapy plans, and preliminary results are an improvement from conventional photon therapy.


Chordoma Radiation Clivus 


Conflict of interest

Arshin Sheybani, Raheel Ahmed, Mindi J TenNapel, Edward C Pennington, Daniel E Hyer, Kathleen M Anderson, Arnold H Menezes, Patrick Hitchon, and John M Buatti declare that no actual or potential conflict of interest exists in relation to the publication of this manuscript.

Ethical standards statement

Institutional Review Board approval was obtained for this retrospective study. This retrospective series does not contain any studies with human tissues or animal subjects performed by any of the authors.


  1. 1.
    McMaster ML, Goldstein AM, Bromley CM, Ishibe N, Parry DM (2001) Chordoma: incidence and survival patterns in the United States, 1973–1995. Cancer Causes Control 12(1):1–11PubMedCrossRefGoogle Scholar
  2. 2.
    Casali PG, Stacchiotti S, Sangalli C, Olmi P, Gronchi A (2007) Chordoma. Curr Opin Oncol 19(4):367–370. doi: 10.1097/CCO.0b013e3281214448 PubMedCrossRefGoogle Scholar
  3. 3.
    al-Mefty O, Borba LA (1997) Skull base chordomas: a management challenge. J Neurosurg 86(2):182–189, 10.3171/jns.1997.86.2.0182PubMedCrossRefGoogle Scholar
  4. 4.
    Gay E, Sekhar LN, Rubinstein E, Wright DC, Sen C, Janecka IP, Snyderman CH (1995) Chordomas and chondrosarcomas of the cranial base: results and follow-up of 60 patients. Neurosurgery 36(5):887–896, discussion 896–887PubMedCrossRefGoogle Scholar
  5. 5.
    Maira G, Pallini R, Anile C, Fernandez E, Salvinelli F, La Rocca LM, Rossi GF (1996) Surgical treatment of clival chordomas: the transsphenoidal approach revisited. J Neurosurg 85(5):784–792. doi: 10.3171/jns.1996.85.5.0784 PubMedCrossRefGoogle Scholar
  6. 6.
    Sen CN, Sekhar LN, Schramm VL, Janecka IP (1989) Chordoma and chondrosarcoma of the cranial base: an 8-year experience. Neurosurgery 25(6):931–940, discussion 940–931PubMedCrossRefGoogle Scholar
  7. 7.
    Uttley D, Moore A, Archer DJ (1989) Surgical management of midline skull-base tumors: a new approach. J Neurosurg 71(5 Pt 1):705–710. doi: 10.3171/jns.1989.71.5.0705 PubMedCrossRefGoogle Scholar
  8. 8.
    Gunderson LL, Tepper JE (2007) Clinical radiation oncology, 2nd edn. Elsevier, PhiladelphiaGoogle Scholar
  9. 9.
    Amichetti M, Cianchetti M, Amelio D, Enrici RM, Minniti G (2009) Proton therapy in chordoma of the base of the skull: a systematic review. Neurosurg Rev 32(4):403–416. doi: 10.1007/s10143-009-0194-4 PubMedCrossRefGoogle Scholar
  10. 10.
    Ryken TC, Meeks SL, Pennington EC, Hitchon P, Traynelis V, Mayr NA, Bova FJ, Friedman WA, Buatti JM (2001) Initial clinical experience with frameless stereotactic radiosurgery: analysis of accuracy and feasibility. Int J Radiat Oncol Biol Phys 51(4):1152–1158PubMedCrossRefGoogle Scholar
  11. 11.
    Tai PT, Craighead P, Bagdon F (1995) Optimization of radiotherapy for patients with cranial chordoma. A review of dose-response ratios for photon techniques Cancer 75(3):749–756Google Scholar
  12. 12.
    Lanzino G, Dumont AS, Lopes MB, Laws ER Jr (2001) Skull base chordomas: overview of disease, management options, and outcome. Neurosurg Focus 10(3):E12PubMedCrossRefGoogle Scholar
  13. 13.
    Sciubba DM, Chi JH, Rhines LD, Gokaslan ZL (2008) Chordoma of the spinal column. Neurosurg Clin N Am 19(1):5–15. doi: 10.1016/ PubMedCrossRefGoogle Scholar
  14. 14.
    Samii A, Gerganov VM, Herold C, Hayashi N, Naka T, Mirzayan MJ, Ostertag H, Samii M (2007) Chordomas of the skull base: surgical management and outcome. J Neurosurg 107(2):319–324. doi: 10.3171/JNS-07/08/0319 PubMedCrossRefGoogle Scholar
  15. 15.
    Eid AS, Chang UK, Lee SY, Jeon DG (2011) The treatment outcome depending on the extent of resection in skull base and spinal chordomas. Acta Neurochirurgica 153(3):509–516. doi: 10.1007/s00701-010-0928-7 PubMedCrossRefGoogle Scholar
  16. 16.
    Park L, Delaney TF, Liebsch NJ, Hornicek FJ, Goldberg S, Mankin H, Rosenberg AE, Rosenthal DI, Suit HD (2006) Sacral chordomas: impact of high-dose proton/photon-beam radiation therapy combined with or without surgery for primary versus recurrent tumor. Int J Radiat Oncol Biol Phys 65(5):1514–1521. doi: 10.1016/j.ijrobp.2006.02.059 PubMedCrossRefGoogle Scholar
  17. 17.
    Munzenrider JE, Liebsch NJ (1999) Proton therapy for tumors of the skull base. Strahlenther Onkol 175(Suppl 2):57–63PubMedCrossRefGoogle Scholar
  18. 18.
    Ares C, Hug EB, Lomax AJ, Bolsi A, Timmermann B, Rutz HP, Schuller JC, Pedroni E, Goitein G (2009) Effectiveness and safety of spot scanning proton radiation therapy for chordomas and chondrosarcomas of the skull base: first long-term report. Int J Radiat Oncol Biol Phys 75(4):1111–1118. doi: 10.1016/j.ijrobp.2008.12.055 PubMedCrossRefGoogle Scholar
  19. 19.
    Noel G, Feuvret L, Ferrand R, Boisserie G, Mazeron JJ, Habrand JL (2004) Radiotherapeutic factors in the management of cervical-basal chordomas and chondrosarcomas. Neurosurgery 55(6):1252–1260, discussion 1260–1252PubMedGoogle Scholar
  20. 20.
    Austin-Seymour M, Munzenrider J, Linggood R, Goitein M, Verhey L, Urie M, Gentry R, Birnbaum S, Ruotolo D, Crowell C et al (1990) Fractionated proton radiation therapy of cranial and intracranial tumors. Am J Clin Oncol 13(4):327–330PubMedCrossRefGoogle Scholar
  21. 21.
    Jiang B, Veeravagu A, Lee M, Harsh GR, Lieberson RE, Bhatti I, Soltys SG, Gibbs IC, Adler JR, Chang SD (2012) Management of intracranial and extracranial chordomas with CyberKnife stereotactic radiosurgery. Journal of Clinical Neuroscience: Official Journal of the Neurosurgical Society of Australasia 19(8):1101–1106. doi: 10.1016/j.jocn.2012.01.005 CrossRefGoogle Scholar
  22. 22.
    Koga T, Shin M, Saito N (2010) Treatment with high marginal dose is mandatory to achieve long-term control of skull base chordomas and chondrosarcomas by means of stereotactic radiosurgery. Journal of Neuro-Oncology 98(2):233–238. doi: 10.1007/s11060-010-0184-y PubMedCrossRefGoogle Scholar
  23. 23.
    Di Maio S, Temkin N, Ramanathan D, Sekhar LN (2011) Current comprehensive management of cranial base chordomas: 10-year meta-analysis of observational studies. J Neurosurg 115(6):1094–1105. doi: 10.3171/2011.7.JNS11355 PubMedCrossRefGoogle Scholar
  24. 24.
    Muthukumar N, Kondziolka D, Lunsford LD, Flickinger JC (1998) Stereotactic radiosurgery for chordoma and chondrosarcoma: further experiences. Int J Radiat Oncol Biol Phys 41(2):387–392PubMedCrossRefGoogle Scholar
  25. 25.
    Kano H, Iqbal FO, Sheehan J, Mathieu D, Seymour ZA, Niranjan A, Flickinger JC, Kondziolka D, Pollock BE, Rosseau G, Sneed PK, McDermott MW, Lunsford LD (2011) Stereotactic radiosurgery for chordoma: a report from the North American Gamma Knife Consortium. Neurosurgery 68(2):379–389. doi: 10.1227/NEU.0b013e3181ffa12c PubMedCrossRefGoogle Scholar
  26. 26.
    Debus J, Schulz-Ertner D, Schad L, Essig M, Rhein B, Thillmann CO, Wannenmacher M (2000) Stereotactic fractionated radiotherapy for chordomas and chondrosarcomas of the skull base. Int J Radiat Oncol Biol Phys 47(3):591–596PubMedCrossRefGoogle Scholar
  27. 27.
    Hauptman JS, Barkhoudarian G, Safaee M, Gorgulho A, Tenn S, Agazaryan N, Selch M, De Salles AA (2012) Challenges in linear accelerator radiotherapy for chordomas and chondrosarcomas of the skull base: focus on complications. Int J Radiat Oncol Biol Phys 83(2):542–551. doi: 10.1016/j.ijrobp.2011.08.004 PubMedGoogle Scholar
  28. 28.
    Emami B, Lyman J, Brown A, Coia L, Goitein M, Munzenrider JE, Shank B, Solin LJ, Wesson M (1991) Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys 21(1):109–122PubMedCrossRefGoogle Scholar
  29. 29.
    Hall EJ, Giaccia AJ (2006) Radiobiology for the radiologist, 6th edn. Lippincott Williams & Wilkins, Philadelphia, PAGoogle Scholar
  30. 30.
    Debus J, Hug EB, Liebsch NJ, O'Farrel D, Finkelstein D, Efird J, Munzenrider JE (1997) Brainstem tolerance to conformal radiotherapy of skull base tumors. Int J Radiat Oncol Biol Phys 39(5):967–975PubMedCrossRefGoogle Scholar
  31. 31.
    Hug EB, Slater JD (2000) Proton radiation therapy for chordomas and chondrosarcomas of the skull base. Neurosurg Clin N Am 11(4):627–638PubMedGoogle Scholar
  32. 32.
    O'Connell JX, Renard LG, Liebsch NJ, Efird JT, Munzenrider JE, Rosenberg AE (1994) Base of skull chordoma. A correlative study of histologic and clinical features of 62 cases. Cancer 74(8):2261–2267PubMedCrossRefGoogle Scholar
  33. 33.
    Berson AM, Castro JR, Petti P, Phillips TL, Gauger GE, Gutin P, Collier JM, Henderson SD, Baken K (1988) Charged particle irradiation of chordoma and chondrosarcoma of the base of skull and cervical spine: the Lawrence Berkeley Laboratory experience. Int J Radiat Oncol Biol Phys 15(3):559–565PubMedCrossRefGoogle Scholar
  34. 34.
    Forsyth PA, Cascino TL, Shaw EG, Scheithauer BW, O'Fallon JR, Dozier JC, Piepgras DG (1993) Intracranial chordomas: a clinicopathological and prognostic study of 51 cases. J Neurosurg 78(5):741–747. doi: 10.3171/jns.1993.78.5.0741 PubMedCrossRefGoogle Scholar
  35. 35.
    Crockard HA, Steel T, Plowman N, Singh A, Crossman J, Revesz T, Holton JL, Cheeseman A (2001) A multidisciplinary team approach to skull base chordomas. J Neurosurg 95(2):175–183. doi: 10.3171/jns.2001.95.2.0175 PubMedCrossRefGoogle Scholar
  36. 36.
    Colli B, Al-Mefty O (2001) Chordomas of the craniocervical junction: follow-up review and prognostic factors. J Neurosurg 95(6):933–943. doi: 10.3171/jns.2001.95.6.0933 PubMedCrossRefGoogle Scholar
  37. 37.
    Terahara A, Niemierko A, Goitein M, Finkelstein D, Hug E, Liebsch N, O'Farrell D, Lyons S, Munzenrider J (1999) Analysis of the relationship between tumor dose inhomogeneity and local control in patients with skull base chordoma. Int J Radiat Oncol Biol Phys 45(2):351–358PubMedCrossRefGoogle Scholar
  38. 38.
    Foweraker KL, Burton KE, Maynard SE, Jena R, Jefferies SJ, Laing RJ, Burnet NG (2007) High-dose radiotherapy in the management of chordoma and chondrosarcoma of the skull base and cervical spine: part 1 — clinical outcomes. Clin Oncol (R Coll Radiol) 19(7):509–516. doi: 10.1016/j.clon.2007.04.004 CrossRefGoogle Scholar
  39. 39.
    Potluri S, Jefferies SJ, Jena R, Harris F, Burton KE, Prevost AT, Burnet NG (2011) Residual postoperative tumour volume predicts outcome after high-dose radiotherapy for chordoma and chondrosarcoma of the skull base and spine. Clin Oncol (R Coll Radiol) 23(3):199–208. doi: 10.1016/j.clon.2010.09.011 CrossRefGoogle Scholar
  40. 40.
    Wu Z, Zhang J, Zhang L, Jia G, Tang J, Wang L, Wang Z (2010) Prognostic factors for long-term outcome of patients with surgical resection of skull base chordomas-106 cases review in one institution. Neurosurg Rev 33(4):451–456. doi: 10.1007/s10143-010-0273-6 PubMedCrossRefGoogle Scholar
  41. 41.
    Benk V, Liebsch NJ, Munzenrider JE, Efird J, McManus P, Suit H (1995) Base of skull and cervical spine chordomas in children treated by high-dose irradiation. Int J Radiat Oncol Biol Phys 31(3):577–581PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Arshin Sheybani
    • 1
  • Raheel Ahmed
    • 1
  • Mindi TenNapel
    • 1
  • Edward C. Pennington
    • 1
  • Daniel E. Hyer
    • 1
  • Kathleen M. Anderson
    • 1
  • Arnold H. Menezes
    • 1
  • Patrick Hitchon
    • 1
  • John M. Buatti
    • 1
  1. 1.University of Iowa Hospitals and ClinicsIowa CityUSA

Personalised recommendations