Current comprehensive management of cranial base chordomas: 10-year meta-analysis of observational studies

Clinical article

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Object

The role of surgery and adjuvant radiation therapy for cranial base chordomas is not well established. This meta-analysis measures the relationship of complete resection and type of adjuvant radiation therapy to 5-year progression-free survival (PFS) and overall survival (OS) of cranial base chordomas.

Methods

A systematic MEDLINE search (1999–present) yielded 23 observational studies and 807 patients who fit inclusion criteria. The following analyses were performed: 1) Kaplan-Meier 5-year PFS and OS compared based on the extent of resection and type of adjuvant radiation therapy using the log-rank method; 2) a random-effects model comparing 5-year PFS with complete or incomplete resection; and 3) paired z-test comparisons of weighted average 5-year OS and PFS grouped by type of adjuvant radiation therapy.

Results

The weighted average follow-up was 53.6 months. The weighted average 5-year PFS and OS were 50.8% and 78.4%, respectively. Complete resection conferred a higher 5-year PFS than incomplete resection from the random effects model (mean difference in PFS 20.7%; 95% CI 6.57%–34.91%). Patients with incomplete resection were 3.83 times more likely to experience a recurrence (95% CI 1.63–9.00) and 5.85 times more likely to die (95% CI 1.40–24.5) at 5 years versus patients with complete resection. There was no difference in 5-year OS by type of adjuvant radiation, although 5-year PFS was lower in patients receiving Gamma Knife surgery relative to carbon ion radiotherapy (p = 0.042) on paired z-test. No survival difference occurred between radiation therapy techniques on Kaplan-Meier analysis of compiled patient data.

Conclusions

Patients with complete resection of cranial base chordomas have a prolonged 5-year PFS and OS. Adjuvant proton-beam, carbon ion, and modern fractionated photon radiation therapy techniques offered a similar rate of PFS and OS at 5 years.

Abbreviations used in this paper: GKS = Gamma Knife surgery; OS = overall survival; PBRT = proton-beam radiation therapy; PFS = progression-free survival.

Article Information

Address correspondence to: Laligam N. Sekhar, M.D., Department of Neurological Surgery, Harborview Medical Center, Box 359766, Seattle, Washington 98104. email: lsekhar@u.washington.edu.

Please include this information when citing this paper: published online August 5, 2011; DOI: 10.3171/2011.7.JNS11355.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flow diagram of study selection.

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    Kaplan-Meier PFS (upper) and OS (lower) based on compiled individual patient data (199 patients). The vertical line indicates the 60-month time point. The 5-year PFS and OS were 54% and 70%, respectively.

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    Kaplan-Meier PFS (upper) and OS (lower) compared using log-rank analysis by extent of resection in 199 patients. The dashed line represents complete resection and the solid line incomplete resection. The vertical line indicates the 60-month time point. The 5-year PFS was 87% with complete resection versus 50% with incomplete resection (p < 0.0001). The 5-year OS was 95% with complete resection versus 71% without (p = 0.001).

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    Forest plot of random effects model from Table 2, comparing 5-year PFS and extent of resection in 526 patients. The mean weighted difference in 5-year PFS was in favor of complete resection. IV = inverse variance.

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    Kaplan-Meier PFS (upper) and OS (lower) grouped by type of adjunctive radiation therapy in 98 patients. The vertical line indicates the 60-month time point. No significant difference in 5-year PFS (p = 0.105) or OS (p = 0.209) was observed based on the type of adjunctive radiation therapy.

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    Kaplan-Meier PFS in patients with complete resection with (dashed line) and without (solid line) adjunctive radiation therapy. The vertical line indicates the 60-month time point. In this smaller cohort (58 patients), no significant difference in 5-year PFS was observed in patients with complete resection with or without adjuvant radiation therapy (p = 0.394).

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