Factors Predicting Recurrence After Resection of Clival Chordoma Using Variable Surgical Approaches and Radiation Modalities

Abstract

BACKGROUND: Clival chordomas frequently recur because of their location and invasiveness. OBJECTIVE: To investigate clinical, operative, and anatomic factors associated with clival chordoma recurrence. METHODS: Retrospective review of clival chordomas treated at our center from 1993 to 2013. RESULTS: Fifty patients (56% male) with median age of 59 years (range, 8–76) were newly diagnosed with clival chordoma of mean diameter 3.3 cm (range, 1.5-6.7). Symptoms included headaches (38%), diplopia (36%), and dysphagia (14%). Procedures included transsphenoidal (n = 34), transoral (n = 4), craniotomy (n = 5), and staged approaches (n = 7). Gross total resection (GTR) rate was 52%, with 83% mean volumetric reduction, values that improved over time. While the lower third of the clivus was the least likely superoinferior zone to contain tumor (upper third = 72%/middle third = 82%/lower third = 42%), it most frequently contained residual tumor (upper third = 33%/middle third = 38%/lower third = 63%; P < .05). Symptom improvement rates were 61% (diplopia) and 53% (headache). Postoperative radiation included proton beam (n = 19), cyberknife (n = 7), intensity-modulated radiation therapy (n = 6), external beam (n = 10), and none (n = 4). At last follow-up of 47 patients, 23 (49%) remain disease-free or have stable residual tumor. Lower third of clivus progressed most after GTR (upper/mid/lower third = 32%/41%/75%). In a multivariate Cox proportional hazards model, male gender (hazard ratio [HR] = 1.2/P = .03), subtotal resection (HR = 5.0/P = .02), and the preoperative presence of tumor in the middle third (HR = 1.2/P = .02) and lower third (HR = 1.8/P = .02) of the clivus increased further growth or regrowth, while radiation modality did not. CONCLUSION: Our findings underscore long-standing support for GTR as reducing chordoma recurrence. The lower third of the clivus frequently harbored residual or recurrent tumor, despite staged approaches providing mediolateral (transcranial + endonasal) or superoinferior (endonasal + transoral) breadth. There was no benefit of proton-based over photon-based radiation, contradicting conventional presumptions.

Clinical and Histopathological Findings of Chordomas: a Case Report

“…Some studies have suggested that chordomas are radioresistant, and therefore the role of radiotherapy in their treatment is unclear. [13][14][15] Nonetheless, the standard treatment of chordomas remains as complete resection and postoperative radiotherapy. More aggressive resections can be performed with technological advances in recent years (such as endoscopic surgery, navigation, neurophysiologic monitoring).…”

Cranial Chordoma: A New Preoperative Grading System

“…Previous studies have found tumor location, size, and prior treatment, where all have been significantly associated increased risk of tumor recurrence. 3,6,10 Anecdotal experience shows that encasement of major intracranial blood vessels, dural transgression, and brainstem invasion all increase surgical risks and decrease the likelihood of safely achieving a complete resection in patients with skull base chordomas. 1,5 Assigning a simple point-based scoring system to these 6 easily identified preoperative features yielded a normally distributed total score that enabled us to successfully group patients into low-risk (group 1), intermediate-risk (group 2), and high-risk (group 3) cohorts.…”

“…While many groups, including ours, favor the use of particle-beam radiation (proton or carbon-ion based), 7-9 a recent meta-analysis failed to show a difference in either RFS or overall survival (OS) across various radiation modalities. 10 There are ongoing efforts to use tumor genetics and proteomics to develop targeted chemotherapies but none are in clinical use beyond experimental studies. 11-15 …”

Extended endoscopic endonasal posterior (transclival) approach to tumors of the clival region and ventral posterior cranial fossa. Part 2. Topographic and anatomical aspects and surgical technique

“…Хорошо развитая дуральная венозная сеть, расположенная вокруг ПК, соединяется с краевым синусом вокруг БО и подъязычного венозного сплетения внутри ПК. Дуральные синусы могут представлять опасность в плане развития венозного кровотечения при рассечении ТМО нижних отделов ската [5].…”