Abstract
Background
The treatment of choice in sacral chordoma is surgical resection, although the risk of local recurrence and metastasis remains high. The quality of surgical margins obtained at initial surgery is the primary factor to improve survival reducing the risk of local recurrence, but proximal sacral resections are associated with substantial perioperative morbidity.
Questions/purposes
We considered survivorship related to local recurrence in terms of surgical margins, level of resection, and previous surgery.
Methods
We retrospectively reviewed 56 patients with sacral chordomas treated with surgical resection. Thirty-seven were resected above S3 by a combined anterior and posterior approach and 19 at or below S3 by a posterior approach. Nine of these had had previous intralesional surgery elsewhere. The minimum followup was 3 years (mean, 9.5 years; range, 3–28 years).
Results
Overall survival was 97% at 5 years, 71% at 10 years, and 47% at 15 years. Survivorship to local recurrence was 65% at 5 years and 52% at 10 years. Thirty percent of patients developed metastases. Wide margins were associated with increased survivorship to local recurrence. We found no differences in local recurrence between wide and wide-contaminated margins (that is, if the tumor or its pseudocapsule was exposed intraoperatively, but further tissue was removed to achieve wide margins). Previous intralesional surgery was associated with an increased local recurrence rate. We observed no differences in the recurrence rate in resections above S3 or at and below S3.
Conclusions
Surgical margins affect the risk of local recurrence. Previous intralesional surgery was associated with a higher rate of local recurrence. Intraoperative contamination did not affect the risk of local recurrence when wide margins were subsequently attained.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Similar content being viewed by others
References
Ahmed AR. Safety margins in resection of sacral chordoma: analysis of 18 patients. Arch Orthop Trauma Surg. 2009;129:483–487.
Atalar H, Selek H, Yildiz Y, Sağlik Y. Management of sacrococcygeal chordomas. Int Orthop. 2006;30:514–518.
Azzarelli A, Quagliuolo V, Cerasoli S, Zucali R, Bignami P, Mazzaferro V, Dossena G, Gennari L. Chordoma: natural history and treatment results in 33 cases. J Surg Oncol. 1988;37:185–191.
Baratti D, Gronchi A, Pennacchioli E, Lozza L, Colecchia M, Fiore M, Santinami M. Chordoma: natural history and results in 28 patients treated at a single institution. Ann Surg Oncol. 2003;10:291–296.
Bergh P, Kindblom LG, Gunterberg B, Remotti F, Ryd W, Meis-Kindblom JM. Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients. Cancer. 2000;88:2122–2134.
Bethke KP, Neifeld JP, Lawrence WJ. Diagnosis and management of sacrococcygeal chordoma. J Surg Oncol. 1991;48:232–238.
Biagini R, Ruggieri P, Briccoli A, Fasano D, Montanari FM, Gamberini G, Perin S, Mercuri M. Use of the trans-abdominal rectus abdominis flap in sacrum surgery. Chir Organi Mov. 2001;86:1–5.
Biagini R, Ruggieri P, Mercuri M, Capanna R, Briccoli A, Perin S, Orsini U, Demitri S, Arlecchini S. Neurologic deficit after resection of the sacrum. Chir Organi Mov. 1997;82:357–372.
Boriani S, Bandiera S, Biagini R, Bacchini P, Boriani L, Cappuccio M, Chevalley F, Gasbarrini A, Picci P, Weinstein JN. Chordoma of the mobile spine: fifty years of experience. Spine. 2006;31:493–503.
Breteu N, Demasure M, Favre A, Leloup R, Lescrainier J, Sabattier R. Fast neutron therapy for inoperable or recurrent sacrococcygeal chordoma. Bull Cancer Radiother. 1996;83:142S–145S.
Capanna R, Briccoli A, Campanacci LC, et al. Benign and malignant tumors of the sacrum. In: Frymore JW, Ducker TB, Hadler NM, Kostuik JP, Weinstein JN, Whitecloud III TS, eds. The Adult Spine: Principles and Practice. Philadelphia, PA: Lippincott-Raven Publishers; 1997:2367–2405.
Catton C, O’Sullivan B, Bell R, Laperriere N, Cummings B, Fornasier V, Wunder J. Chordoma: long-term follow-up after radical photon irradiation. Radiother Oncol. 1996;41:67–72.
Chandawarkar RY. Sacrococcygeal chordoma: review of 50 consecutive patients. World J Surg. 1996;20:717–719.
Cheng EY, Ozerdemoglu RA, Transfeldt EE, Thompson RC. Lumbosacral chordoma: prognostic factors and treatment. Spine 1999;24:1639–1645.
Dahlin DC, MacCarthy CS. Chordoma: a study of 59 cases. Cancer. 1952;5:1170–1178.
Devin C, Chong PY, Holt GE, Feurer I, Gonzalez A, Merchant N, Schwartz HS. Level-adjusted perioperative risk of sacral amputations. J Surg Oncol. 2006;94:203–211.
Dickey ID, Hugate RR, Fuchs B, Yaszemski MJ, Sim FH. Reconstruction after total sacrectomy. Clin Orthop Relat Res. 2005;438:42–50.
Doita M, Harada T, Iguchi T, Sumi M, Sha H, Yoshiya S, Kurosaka M. Total sacrectomy and reconstruction for sacral tumors. Spine. 2003;28:E296–E301.
Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop Relat Res. 1986;204:9–24.
Fuchs B, Dickey ID, Yaszemski MJ, Inwards CY, Sim FH. Operative management of sacral chordoma. J Bone Joint Surg Am. 2005;87:2211–2116.
Gerber S, Ollivier L, Leclère J, Vanel D, Missenard G, Brisse H, de Pinieux G, Neuenschwander S. Imaging of sacral tumours. Skeletal Radiol. 2008;37:277–289.
Gunterberg B. Effects of major resection of the sacrum: clinical studies on urogenital and anorectal function and a biomechanical study on pelvic strength. Acta Orthop Scand Suppl. 1976;162:1–38.
Gunterberg B, Norlen L, Stener B, Sundin T. Neurourologic evaluation after resection of the sacrum. Invest Urol. 1975;13:183–188.
Gunterberg B, Romanus B, Stener B. Pelvic strength after major amputation of the sacrum: an experimental study. Acta Orthop Scand. 1976;47:635–642.
Guo Y, Yadav R. Improving function after total sacrectomy by using a lumbar-sacral corset. Am J Phys Med Rehabil. 2002;81:72–76.
Hanna SA, Aston WJ, Briggs TW, Cannon SR, Saifuddin A. Sacral chordoma: can local recurrence after sacrectomy be predicted? Clin Orthop Relat Res. 2008;466:2217–2223.
Higinbotham NL, Phillips RF, Farr HW, Hustu HO. Chordoma: thirty-five-year study at Memorial Hospital. Cancer. 1967;20:1841–1850.
Hüfner T, Kfuri M Jr, Galanski M, Bastian L, Loss M, Pohlemann T, Krettek C. New indications for computer-assisted surgery: tumor resection in the pelvis. Clin Orthop Relat Res. 2004;426:219–225.
Hulen CA, Temple HT, Fox WP, Sama AA, Green BA, Eismont FJ. Oncologic and functional outcome following sacrectomy for sacral chordoma. J Bone Joint Surg Am. 2006;88:1532–1539.
Imai R, Kamada T, Tsuji H, Yanagi T, Baba M, Miyamoto T, Kato S, Kandatsu S, Mizoe J, Tsujii H, Tatezaki S; Working Group for Bone, Soft Tissue Sarcomas. Carbon ion radiotherapy for unresectable sacral chordomas. Clin Cancer Res. 2004;10:5741–5746.
Ishii K, Chiba K, Watanabe M, Yabe H, Fujimura Y, Toyama Y. Local recurrence after S2-3 sacrectomy in sacral chordoma: report of four cases. J Neurosurg. 2002;97(Suppl):98–101.
Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin. 2007;57:43–66.
Kaiser T, Pritchard D, Unni KK. Clinicopathologic study of sacrococcygeal chordoma. Cancer. 1984;53:2574–2578.
Michel A. Total sacrectomy and lower spine resection for giant cell tumor: one case report. Chir Organi Mov. 1990;75:117–118.
Mindell ER. Risk of sacral amputations. J Surg Oncol. 2006;94:173–174.
Osaka S, Kodoh O, Sugita H, Osaka E, Yoshida Y, Ryu J. Clinical significance of a wide excision policy for sacrococcygeal chordoma. J Cancer Res Clin Oncol. 2006;132:213–218.
Osaka S, Kondoh O, Yoshida Y, Ryu J. Radical excision of malignant sacral tumors using a modified threadwire saw. J Surg Oncol. 2006;93:312–317.
Ozaki T, Hillmann A, Winkelmann W. Surgical treatment of sacrococcygeal chordoma. J Surg Oncol. 1997;64:274–279.
Park L, Delaney TF, Liebsch NJ, Hornicek FJ, Goldberg S, Mankin H, Rosenberg AE, Rosenthal DI, Suit HD. 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. 2006;65:1514–1521.
Petrie A. Statistics in orthopaedic papers. J Bone Joint Surg Br. 2006;88:1121–1136.
Randall R, Bruckner J, Lloyd C, Pohlman TH, Conrad EU III. Sacral resection and reconstruction for tumors and tumor-like conditions. Orthopedics. 2005;28:307–313.
Samson IR, Springfield DS, Suit HD, Mankin HJ. Operative treatment of sacrococcygeal chordoma: a review of twenty-one cases. J Bone Joint Surg Am. 1993;75:1476–1484.
Saxton JP. Chordoma. Int J Radiat Oncol Biol Phys. 1981;7:913–915.
Schwab JH, Healey JH, Rose P, Casas-Ganem J, Boland PJ. The surgical management of sacral chordomas. Spine (Phila Pa 1976). 2009;34:2700–2704.
Shen FH, Harper M, Foster WC, Marks I, Arlet V. A novel ‘four-rod technique’ for lumbo-pelvic reconstruction: theory and technical considerations. Spine. 2006;31:1395–1401.
Simpson AH, Porter A, Davis A, Griffin A, McLeod RS, Bell RS. Cephalad sacral resection with a combined extended ilioinguinal and posterior approach. J Bone Joint Surg Am. 1995;77:405–411.
Soo MY. Chordoma: review of clinicoradiological features and factors affecting survival. Australas Radiol. 2001;45:427–434.
Sopta J, Tulic G, Mijucic V, Mamontov P, Mandic N. Solitary lymph node metastasis without local recurrence of primary chordoma. Eur Spine J. 2009;18(Suppl 2):191–195.
Stener B, Gunterberg B. High amputation of the sacrum for extirpation of tumors: principles and technique. Spine. 1978;3:351–366.
Sundaresan N, Huvos AG, Krol G, Lane JM, Brennan M. Surgical treatment of spinal chordomas. Arch Surg. 1987;122:1479–1482.
Thieblemont C, Biron P, Rocher F, Bouhour D, Bobin JY, Gérard JP, Blay JY. Prognostic factors in chordoma: role of postoperative radiotherapy. Eur J Cancer. 1995;31:2255–2259.
Tomita K, Kawahara N: The threadwire saw: a new device for cutting bone. J Bone Joint Surg Am. 1996;78:1915–1917.
Unni KK. Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases. 5th ed. Philadelphia: Lippincott-Raven; 1996:291–305.
Virkus WW, Marshall D, Enneking WF, Scarborough MT. The effect of contaminated surgical margins revisited. Clin Orthop Relat Res. 2002;397:89–94.
Wuisman P, Lieshout O, Sugihara S, van Dijk M. Total sacrectomy and reconstruction: oncologic and functional outcome. Clin Orthop Relat Res. 2000;381:192–203.
Yonemoto T, Tatezaki S, Takenouchi T, Ishii T, Satoh T, Moriya H. The surgical management of sacrococcygeal chordoma. Cancer. 1999;85:878–883.
York JE, Kaczaraj A, Abi-Said D, Fuller GN, Skibber JM, Janjan NA, Gokaslan ZL. Sacral chordoma: 40-year experience at a major cancer center. Neurosurgery. 1999;44:74–79.
Zileli M, Hoscoskun C, Brastianos P, Sabah D. Surgical treatment of primary sacral tumors: complications associated with sacrectomy. Neurosurg Focus. 2003;15:E9.
Acknowledgments
We thank Dr Marco Alberghini for the histologic evaluation; Dr Eugenio Rimondi for the imaging analysis; Prof Antonio Briccoli and Dr Michele Rocca for surgical assistance of most patients in this series; and Dr Andreas F. Mavrogenis for reviewing our paper. Special thanks to Mrs Alba Balladelli, BA, who reviewed our paper and substantially improved our English.
Author information
Authors and Affiliations
Corresponding author
Additional information
Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
Each author certifies that his or her institution has approved the reporting of these cases, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
About this article
Cite this article
Ruggieri, P., Angelini, A., Ussia, G. et al. Surgical Margins and Local Control in Resection of Sacral Chordomas. Clin Orthop Relat Res 468, 2939–2947 (2010). https://doi.org/10.1007/s11999-010-1472-8
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11999-010-1472-8