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Long-term control of clival chordoma with initial aggressive surgical resection and gamma knife radiosurgery for recurrence

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Abstract

Purpose

Chordomas are locally destructive tumors with high rates of recurrence, and therapeutic strategies remain controversial. This study analyzed long-term outcomes for clival chordomas after initial aggressive surgical resection and gamma knife radiosurgery for recurrence and investigated clinical factors predicting recurrence.

Methods

Clinical records were reviewed for 19 consecutive patients (11 men, 8 women; mean age, 43.1 years) with clival chordoma who underwent initial surgical resection using skull base approaches (mean follow-up after surgical resection, 87.2 months). All tumors were aggressively removed, along with the surrounding bone. Four patients were treated with radiotherapy after surgical resection. Recurrent lesions were treated with gamma knife radiosurgery or reoperation. Factors predicting tumor recurrence were analyzed, including age, tumor extension, extent of resection and MIB-1 labeling index. Patient status was evaluated using the Karnofsky performance scale (KPS).

Results

Tumor resection was total, subtotal and partial in 14, 4 and 1 patients, respectively. Tumors recurred in 11 patients. Overall, 2- and 5-year progression-free survival rates were 77.9% and 47.9%, respectively. The MIB-1 labeling index was independently associated with recurrence. The optimum cutoff point for the MIB-1 labeling index was 3.44%. All recurrent tumors were totally resected or controlled by gamma knife (mean follow-up after recurrence, 71.2 months). All patients survived and were active (mean KPS at final follow-up, 89.5%).

Conclusion

Long-term control of clival chordomas was achieved. Recurrent tumors were controlled with gamma knife radiosurgery, since lesions were localized and small after initial aggressive resection. The MIB-1 labeling index can provide important information for predicting tumor recurrence.

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan

    Eiji Ito & Kiyoshi Saito

  2. Department of Neurosurgery, Kainan Hospital, Yatomi, Japan

    Takeshi Okada

  3. Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan

    Tetsuya Nagatani

  4. Department of Clinical Pathology, Nagoya University Graduate School of Medicine, Nagoya, Japan

    Tetsuro Nagasaka

Authors
  1. Eiji Ito
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  2. Kiyoshi Saito
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  3. Takeshi Okada
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  4. Tetsuya Nagatani
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  5. Tetsuro Nagasaka
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Corresponding author

Correspondence to Kiyoshi Saito.

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Comments

The authors describe their experience managing the 19 patients with chordomas using a combination of microsurgery and gamma knife radiosurgery (and in 4 cases radiotherapy). Radiosurgery was used for residual tumors as well as recurrences, and larger recurrent tumors were also considered for reoperation. Impressively, using this combination management, the tumors were either totally resected (that is at the time of review there was no visible recurrence yet) or controlled.

Management of chordomas is notoriously difficult, and so it is unclear which modality one should use and in which order. Admittedly, most centers that have access to high quality microsurgery and radiosurgery would choose to use a very similar, very sensible approach. Nevertheless, this publication is very useful, and it would help the general readership of this journal.

The reason for the relative lack of similar articles in the literature is that focal radiosurgical treatment was often dismissed as an option because of the size of the presenting or representing tumor. Fractionated techniques, interstitial radiotherapy, etc., have all been described. With the advances in safer microsurgery, a surgical reduction in size is extremely helpful before radiosurgery, and some turn out to be completely successful. This paper is tribute to the multidisciplinary combination.

Andras Kemeny

Sheffield, UK

The authors retrospectively report their management strategy in the treatment of 19 patients with clival chordoma over a 16-year period, which includes initial aggressive surgical removal, close follow-up and radiosurgical treatment for recurrence, sometimes repeated or combined with reoperation. The versatility of tailored skull base approaches described, without mortality and with a low rate of acceptable morbidity given their complexity, is to be commended.

An interesting aspect in the current series is the apparent lack of mid- and long-term morbidity from repeated radiosurgical treatments, some of them on top of conventional or stereotactic fractionated radiation.

As previously reported by other groups, RS seems to be a good option for complementary therapy in patients with a low residual (or recurrent) tumor volume achieved by aggressive surgery, given its availability and cost when compared with proton-beam therapy.

Manuel Cunha e Sá, MD

Bruno Santiago, MD

Almada, Portugal

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Ito, E., Saito, K., Okada, T. et al. Long-term control of clival chordoma with initial aggressive surgical resection and gamma knife radiosurgery for recurrence. Acta Neurochir 152, 57–67 (2010). https://doi.org/10.1007/s00701-009-0535-7

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  • DOI: https://doi.org/10.1007/s00701-009-0535-7

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