Surgical and Functional Outcomes of En Bloc Resection of Sacral Chordoma: a Retrospective Analysis
Tóm tắt
Conventional chordomas occur most commonly in the sacral region. Currently, wide local excision remains the only hope for a cure in this disease. However, given the substantial morbidity caused by sacrectomy, a delicate balance needs to be established. This study elaborates our experience in managing these complicated cases with the help of a multidisciplinary team approach and outlines the various surgical and functional outcomes of sacrectomy. This was a retrospective observational study. Ten cases of biopsy proven sacral chordoma underwent en bloc resection by a posterior approach from 2011 to 2018 after multidisciplinary evaluation. Data collected and analyzed included demographics, extent of the disease, and operative parameters such as operative time, estimated blood loss, level of vertebral resection, level and number of the most caudal nerve roots preserved, surgical margins, soft tissue, or spinal reconstruction. Postoperative outcomes included time to recurrence and neurological function at 1 year. Mean size of the tumor was 116.1 mm. Three (30%) patients had positive margins. The median time to recurrence was 32 months. Four patients eventually succumbed to the disease due to local or distant recurrence. Bladder and bowel functions were excellent in those with preserved S3. Two patients remained wheelchair bound; the rest were able to walk with or without support. Management of sacral chordoma remains an onerous journey for both the treating surgeon and the patient. A multidisciplinary team approach, with careful preservation of sacral nerve roots, negative surgical margins, and excellent postoperative rehabilitation, can achieve optimum results.
Tài liệu tham khảo
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):1–11
Walcott BP, Nahed BV, Mohyeldin A, Coumans J-V, Kahle KT, Ferreira MJ (2012) Chordoma: current concepts, management, and future directions. Lancet Oncol 13(2):e69–e76
Zuckerman SL, Bilsky MH, Laufer I (2018) Chordomas of the skull base, mobile spine, and sacrum: an epidemiologic investigation of presentation, treatment, and survival. World Neurosurg 113:e618–ee27
Mukherjee D, Chaichana KL, Parker SL, Gokaslan ZL, McGirt MJ (2013) Association of surgical resection and survival in patients with malignant primary osseous spinal neoplasms from the Surveillance, Epidemiology, and End Results (SEER) database. European Spine J 22(6):1375–1382
Bergh P, Kindblom LG, Gunterberg B, Remotti F, Ryd W, Meis-Kindblom JM (2000) Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients. Cancer: Interdisciplinary Int J Am Cancer Soc 88(9):2122–2134
Zabel-du Bois A, Nikoghosyan A, Schwahofer A, Huber P, Schlegel W, Debus J et al (2010) Intensity modulated radiotherapy in the management of sacral chordoma in primary versus recurrent disease. Radiother Oncol 97(3):408–412
Clarke MJ, Dasenbrock H, Bydon A, Sciubba DM, McGirt MJ, Hsieh PC et al (2012) Posterior-only approach for en bloc sacrectomy: clinical outcomes in 36 consecutive patients. Neurosurgery 71(2):357–364
Biagini R, Ruggieri P, Mercuri M, Capanna R, Briccoli A, Perin S et al (1997) Neurologic deficit after resection of the sacrum. La Chirurgia degli organi di movimento 82(4):357–372
Sciubba DM, Petteys RJ, Garces-Ambrossi GL, Noggle JC, McGirt MJ, Wolinsky J-P et al (2009) Diagnosis and management of sacral tumors: a review. J Neurosurg: Spine 10(3):244–256
Bakker S, Jacobs W, Pondaag W, Gelderblom H, Nout R, Dijkstra P et al (2018) Chordoma: a systematic review of the epidemiology and clinical prognostic factors predicting progression-free and overall survival. European Spine J 27(12):3043–3058
Hulen CA, Temple HT, Fox WP, Sama AA, Green BA, Eismont FJ (2006) Oncologic and functional outcome following sacrectomy for sacral chordoma. JBJS 88(7):1532–1539
Zang J, Guo W, Yang R, Tang X, Li D (2015) Is total en bloc sacrectomy using a posterior-only approach feasible and safe for patients with malignant sacral tumors? J Neurosurg: Spine 22(6):563–570
Waisman M, Kligman M, Roffman M (1997) Posterior approach for radical excision of sacral chordoma. Int Orthopaedics 21(3):181–184
Mohanty S, Kanhangad MP, Kundangar R (2019) The extended posterior approach for resection of sacral tumours. European Spine J 28(6):1461–1467
Asavamongkolkul A, Waikakul S (2012) Wide resection of sacral chordoma via a posterior approach. Int Orthopaedics 36(3):607–612
Gokaslan ZL, Romsdahl MM, Kroll SS, Walsh GL, Gillis TA, Wildrick DM et al (1997) Total sacrectomy and Galveston L-rod reconstruction for malignant neoplasms. Neurosurg Focus 3(3):E2
Mindea SA, Chinthakunta S, Moldavsky M, Gudipally M, Khalil S (2012) Biomechanical comparison of spinopelvic reconstruction techniques in the setting of total sacrectomy. Spine 37(26):E1622–E16E7
Kim JE, Pang J, Christensen JM, Coon D, Zadnik PL, Wolinsky J-P et al (2015) Soft-tissue reconstruction after total en bloc sacrectomy. J Neurosurg: Spine 22(6):571–581
Fourney DR, Rhines LD, Hentschel SJ, Skibber JM, Wolinsky J-P, Weber KL et al (2005) En bloc resection of primary sacral tumors: classification of surgical approaches and outcome. J Neurosurg: Spine 3(2):111–122
Guo Y, Palmer JL, Shen L, Kaur G, Willey J, Zhang T et al (2005) Bowel and bladder continence, wound healing, and functional outcomes in patients who underwent sacrectomy. J Neurosurg: Spine 3(2):106–110
Li D, Guo W, Qu H, Yang R, Tang X, Yan T et al (2013) Experience with wound complications after surgery for sacral tumors. European Spine J 22(9):2069–2076
Huang L, Guo W, Yang R, Tang X, Ji T (2016) Proposed scoring system for evaluating neurologic deficit after sacral resection: functional outcomes of 170 consecutive patients. Spine 41(7):628–637
Moran D, Zadnik PL, Taylor T, Groves ML, Yurter A, Wolinsky J-P et al (2015) Maintenance of bowel, bladder, and motor functions after sacrectomy. Spine J 15(2):222–229
Ji T, Guo W, Yang R, Tang X, Wang Y, Huang L (2017) What are the conditional survival and functional outcomes after surgical treatment of 115 patients with sacral chordoma? Clin Orthopaedics Related Res® 475(3):620–630
Kayani B, Hanna S, Sewell M, Saifuddin A, Molloy S, Briggs T (2014) A review of the surgical management of sacral chordoma. European J Surg Oncol (EJSO) 40(11):1412–1420
Radaelli S, Stacchiotti S, Ruggieri P, Donati D, Casali PG, Palmerini E et al (2016) Sacral chordoma: long-term outcome of a large series of patients surgically treated at two reference centers. Spine 41(12):1049–1057
Ruggieri P, Angelini A, Ussia G, Montalti M, Mercuri M (2010) Surgical margins and local control in resection of sacral chordomas. Clin Orthopaedics Related Res® 468(11):2939–2947
Jawad MU, Scully SP (2010) Surgery significantly improves survival in patients with chordoma. Spine 35(1):117–123
Rotondo RL, Folkert W, Liebsch NJ, Chen Y-LE, Pedlow FX, Schwab JH et al (2015) High-dose proton-based radiation therapy in the management of spine chordomas: outcomes and clinicopathological prognostic factors. J Neurosurg: Spine 23(6):788–797
Moojen WA, Vleggeert-Lankamp CL, Krol AD, Dijkstra SP (2011) Long-term results: adjuvant radiotherapy in en bloc resection of sacrococcygeal chordoma is advisable. Spine 36(10):E656–EE61
Pennicooke B, Laufer I, Sahgal A, Varga PP, Gokaslan ZL, Bilsky MH et al (2016) Safety and local control of radiation therapy for chordoma of the spine and sacrum: a systematic review. Spine 41(Suppl 20):S186
Demizu Y, Imai R, Kiyohara H, Matsunobu A, Okamoto M, Okimoto T et al (2021) Carbon ion radiotherapy for sacral chordoma: a retrospective nationwide multicentre study in Japan. Radiother Oncol 154:1–5
Chen Y-L, Liebsch N, Kobayashi W, Goldberg S, Kirsch D, Calkins G et al (2013) Definitive high-dose photon/proton radiotherapy for unresected mobile spine and sacral chordomas. Spine 38(15):E930–E9E6