Multidisciplinary surgical planning for en bloc resection of malignant primary cervical spine tumors involving 3D-printed models and neoadjuvant therapies: report of 2 cases

A. Karim Ahmed Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and

Search for other papers by A. Karim Ahmed in
jns
Google Scholar
PubMed
Close
 BS
,
Zachary Pennington Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and

Search for other papers by Zachary Pennington in
jns
Google Scholar
PubMed
Close
 BS
,
Camilo A. Molina Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and

Search for other papers by Camilo A. Molina in
jns
Google Scholar
PubMed
Close
 MD
,
Yuanxuan Xia Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and

Search for other papers by Yuanxuan Xia in
jns
Google Scholar
PubMed
Close
 BA
,
C. Rory Goodwin Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina

Search for other papers by C. Rory Goodwin in
jns
Google Scholar
PubMed
Close
 MD, PhD
, and
Daniel M. Sciubba Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland; and

Search for other papers by Daniel M. Sciubba in
jns
Google Scholar
PubMed
Close
 MD
Full access

Effective en bloc resection of primary spinal tumors necessitates careful consideration of adjacent anatomical structures in order to achieve negative margins and reduce surgical morbidity. This can be particularly challenging in the cervical spine, where vital neurovascular and connective tissues are present in the region. Early multidisciplinary surgical planning that includes clinicians and engineers can both optimize surgical planning and enable a more feasible resection with oncological margins. The aim of the current work was to demonstrate two cases that involved multidisciplinary surgical planning for en bloc resection of primary cervical spine tumors, successfully utilizing 3D-printed patient models and neoadjuvant therapies.

ABBREVIATIONS

SBRT = stereotactic body radiation therapy.

Effective en bloc resection of primary spinal tumors necessitates careful consideration of adjacent anatomical structures in order to achieve negative margins and reduce surgical morbidity. This can be particularly challenging in the cervical spine, where vital neurovascular and connective tissues are present in the region. Early multidisciplinary surgical planning that includes clinicians and engineers can both optimize surgical planning and enable a more feasible resection with oncological margins. The aim of the current work was to demonstrate two cases that involved multidisciplinary surgical planning for en bloc resection of primary cervical spine tumors, successfully utilizing 3D-printed patient models and neoadjuvant therapies.

For primary tumors, definitive treatment involves en bloc surgical resection, with adjuvant radiotherapy, as this regimen offers the best chance of disease-free and overall survival.9,23,33–36 To achieve negative margins while minimizing surgical morbidity, en bloc resection necessitates careful consideration of the paraspinal structures, especially in cervical cases, given the complex regional anatomy.3,5,6,10,14,24 One strategy that may improve the odds of oncological cure is early multidisciplinary management.15,33,36 This includes both neoadjuvant therapy to reduce the tumor volume in sensitive pathologies,15,23,24,30,34 and current 3D printing technologies, which produce unparalleled representations of unique patient anatomy during surgical planning.16,19,39 The aim of this work is to describe two cases of this multidisciplinary planning for en bloc resection of primary cervical malignancies.

Multidisciplinary Management

All primary spine tumors receive multidisciplinary management at our institution beginning with imaging, biopsy, and staging of the lesion.15,17,21,30,33 Following acquisition of these studies, multidisciplinary conferences composed of medical oncology, neurosurgery, orthopedic surgery, and radiation oncology specialists then meet to discuss optimal patient management and determine the need for additional diagnostic data prior to commencing treatment. This include a spine tumor board and sarcoma conference, consisting of specialized medical oncology, neurosurgery, orthopedic surgery, plastic and reconstructive surgery, radiation oncology, interventional radiology, pathology, and pain management teams. Once clinical and radiographic characterization is sufficient, a consensus treatment plan is formulated, including all neoadjuvant, operative, and adjuvant therapies thought to optimize patient outcome. Of note, neoadjuvant chemotherapy and radiotherapy—as recommended by oncologists and radiation oncologists—can be invaluable for their ability to minimize surgical morbidity and facilitate en bloc tumor delivery.

Despite this, resection with wide margins is challenging for upper cervical lesions, as the tumor capsule may not be appreciable on imaging alone. Of particular concern are irregular lesions necessitating wide margins, which require tumor delivery without direct visualization. To address this, our multidisciplinary approach now includes biomedical engineers and patient-specific 3D-printed models. These models use multiplanar reconstruction (MPR) of preoperative imaging to recreate both the tumor capsule and osseoligamentous anatomy from preoperative imaging—features not readily appreciated on 2D imaging. Additionally, said models are autoclave-safe, allowing their use as intraoperative references.

Case Reports

Case 1

A 21-year-old man was referred from an outside institution to Johns Hopkins School of Medicine for a left-sided cervical myxoid spindle cell proliferation. Repeat imaging confirmed an 11-cm, left-sided prevertebral lesion involving the left common carotid artery, esophagus, thyroid gland, and C4–T1 vertebrae, with partial encasement of the left vertebral artery and infiltration into the C5–7 roots (Fig. 1A and B). Staging by PET/CT failed to demonstrate metastatic disease.

Fig. 1.
Fig. 1.

Case 1. Preoperative imaging of a young patient with a myxoid liposarcoma extending from C4 to T1. A: Sagittal MR image. B: Axial MR image. C: Sagittal MR image following 6 rounds of neoadjuvant chemotherapy. D: Axial MR image following 6 rounds of neoadjuvant chemotherapy. E: 3D-printed spine model constructed from preoperative imaging. Asterisks indicate the tumor.

Given the nondiagnostic outside pathology result, a repeat biopsy was performed and demonstrated myxoid liposarcoma. The patient’s case was presented at our multidisciplinary conference, where musculoskeletal oncologists recommended preoperative chemotherapy based on recent literature suggesting the lesion was chemosensitive, particularly in young patients.7,18,26 Concomitant neoadjuvant radiation was declined by radiation oncology given the large lesion size, relative radiation resistance, and involvement of paraspinal neurovascular structures. Based on this input, the final treatment plan included neoadjuvant chemotherapy, wide-margin en bloc resection, and postoperative stereotactic radiation therapy.

Neoadjuvant chemotherapy with doxorubicin and ifosfamide7 produced a substantial tumor volume reduction, allowing en bloc resection with negative margins to be feasible (Fig. 1C and D). A sterilizable, anatomical, 3D-printed model of acrylic and epoxy photopolymers (DePuy Synthes Spine) was produced for preoperative approach planning (Fig. 1E) and intraoperative planning of osteotomies that excluded the tumor capsule.

The patient underwent a staged operation beginning with posterior instrumentation and tumor release. Prior to incision, a CT scan was obtained using the O-arm (Medtronic) to facilitate intraoperative navigation (StealthStation, Medtronic). A midline approach was then pursued with subperiosteal exposure of C2–T3. Instrumentation was placed bilaterally at the C2, T2, and T3 pedicles and at the C3 lateral masses. The right-sided T1 pedicle and C4–6 right-sided lateral masses were also instrumented. An en bloc C3–T1 laminectomy and Schwab type 2 osteotomies at C3–4 through T1–2 were then performed using an ultrasonic blade (BoneScalpel, Misonix). This exposed the left C5–7 roots, which were sacrificed due to tumoral involvement. The ipsilateral, involved vertebral artery was also sacrificed from C3–4 to T1 after transient occlusion failed to demonstrate signal changes on intraoperative monitoring. Midsagittal osteotomies were then performed from C4 to T1 followed by posterior discectomy at C3–4 (Fig. 2A–D).

Fig. 2.
Fig. 2.

Case 1. Intraoperative imaging of stage I (posterior). A: Posterior osteotomy across C4–T1. B: Instrumented arthrodesis from C2 to T3. C: Preoperative axial MR images for comparison. D: Postoperative axial MR images demonstrating osteotomies across vertebral bodies of C4–T1 and posterior instrumentation. E: Coronal CT scan demonstrating posterior instrumented arthrodesis from C2 to T3.

A Silastic sheath was placed in the ventral epidural space for the anterior stage. Rods were then connected bilaterally from C2 to T3, the instrumented levels were decorticated, and local autograft was placed to facilitate fusion. Following confirmation of alignment on the O-arm (Fig. 2E), a drain was placed and closure was performed in the typical neurosurgical fashion.

For the anterior stage, an intraoperative 3D CT scan was again acquired for intraoperative navigation. A curvilinear incision was fashioned along the left sternocleidomastoid muscle, dividing the omohyoid muscle and separating the sternocleidomastoid muscle from the deeper esophagus. The anterior soft tissue was released from the tumor, and the osteotomy cuts from the prior stage were identified. The tumor was then delivered en bloc, leaving an anterior column defect from C3 to T2. This defect was repaired using a fibular allograft–filled titanium cage that was secured with screws. Complex wound closure was performed by plastic surgery (Fig. 3A–H). At 11 months postoperatively, the patient has stable left upper-extremity deficits secondary to the C5–7 root sacrifice, and there was no evidence of tumor recurrence.

Fig. 3.
Fig. 3.

Case 1. Intraoperative neck dissection of stage II (anterior). A: The patient was placed supine, draped, and prepared. B: Neck dissection was carried down to the tumor. C: Neuronavigation was utilized throughout the procedure. D and E: The tumor was released and resected en bloc. F and G: Anterior column reconstruction from C3 to T2 with a structural fibular graft. H: Postoperative lateral radiograph.

Case 2

A 55-year-old man presented to our service with a several-month history of neck pain and bilateral hand paresthesias. Outside imaging and biopsy sampling demonstrated a right-sided C2–4 chordoma with epidural compression at C3 and involvement of the C2 posterior elements, ipsilateral vertebral artery, and ipsilateral C3–5 roots. Repeat imaging and CT-guided biopsy were consistent with these findings (Fig. 4A and B) and staging revealed no sites of metastases.

Fig. 4.
Fig. 4.

Case 2. Preoperative imaging of a 55-year-old man with a cervical chordoma, most prominent at C2–3. A: Preoperative sagittal MR image. B: Preoperative axial MR image. C: Sagittal MR image following neoadjuvant SBRT. D: Axial MR image following neoadjuvant SBRT. E and F: 3D-printed spine model constructed from preoperative images. Asterisks indicate the tumor.

The patient’s case was presented to the multidisciplinary team, who determined that neoadjuvant radiation might aid resection. The patient subsequently underwent stereotactic body radiation therapy (SBRT) comprising 5 fractions of 800 cGy, which resulted in moderate tumor volume reduction (Fig. 4C and D). Following this, the reconvened team agreed that wide-margin en bloc resection, followed by focused radiation therapy, would yield the best prognosis.11,15,24,33,36 As with case 1, a sterilizable model was created (K2M/3D Systems Partnership) (Fig. 4E and F) and employed for both preoperative planning and intraoperative reference.

The patient was prepared for a two-stage en bloc transmandibular circumglossal resection. A board-certified plastic surgeon with oral/maxillofacial training was consulted to assist with the exposure and complex wound closure. Tracheostomy and CT angiography were also performed preoperatively to provide airway support and evaluate the posterior circulation. Stage I involved a posterior approach with the patient prone on a Jackson table. Subperiosteal dissection was carried out over C1–T2 followed by cannulation of the C4–6 lateral masses bilaterally. Schwab type 2 osteotomies were performed at the C1–2 through C3–4 levels with sacrifice of the C2–4 roots bilaterally due to tumor involvement. Bilateral Schwab type 1 osteotomies were performed at T1–2, and pedicle screws were placed at those levels. The C2–6 laminectomies were then performed to allow placement of a Silastic sheath in the ventral epidural space for stage II. As with case 1, transient occlusion of the vertebral artery involved in the lesion demonstrated it to be superfluous. Accordingly, it was clipped at the tumor margins and resected. Lateral mass screws were placed at C1 and C4–6 bilaterally, and rods were connected from C1–T2 (Fig. 5A–C). The levels were decorticated and healthy C5 and C6 lamina autograft was placed.

Fig. 5.
Fig. 5.

Case 2. Operative techniques and postoperative images. A–C: Stage I involved posterior decompression and instrumented arthrodesis from C1 to T2. D–G: Stage II involved anterior total en bloc tumor resection, including the C2 and C3 vertebral bodies. H–J: Anterior column reconstruction with cage placement and structural fibular allograft. K: Revision surgery for wound infection and dehiscence, with removal of the anterior cage and extension of the posterior instrumentation from the occiput to T3.

For stage II of the operation, plastic surgery assisted with the transmandibular approach, and anterior subperiosteal dissection was carried out from C1 to C4 (Fig. 5D–F). An ultrasonic blade was used to resect the anterior atlantal arch, exposing the dens. A C3–4 discectomy was performed to release the inferior tumor border and allow en bloc delivery of the C2 and C3 vertebral bodies (Fig. 5G). The 3D-printed model was utilized throughout to achieve wide margins. Anterior column reconstruction from C1 to C4 was performed with a cage packed with fibula allograft and secured with screws (Fig. 5H–J). Plastic surgery assisted with closure. The postoperative course was complicated by a wound infection, pharyngeal dehiscence, and CSF leak from the ventral dura mater. The patient required multiple revisions, including cage removal and extension of fusion from the occiput to T3 (Fig. 5K). He is doing well 12 months postoperatively, with good neurological function and no evidence of recurrence.

Discussion

En bloc resection is first-line treatment for primary vertebral malignancies because it offers superior disease-free survival.9,23,24,33–36 However, surgeons attempting such resections face conflicting goals as they attempt to completely resect the lesion while minimizing morbidity and preserving vital adjacent structures, a nontrivial task for cervical lesions.3,5,6,10,14,24 The present work describes the application of multidisciplinary management to two patients with such lesions, demonstrating the benefit of utilizing the expertise of both clinicians and engineers.

Both neoadjuvant radiotherapy and chemotherapy can be beneficial, depending upon the sensitivities of the primary tumor.15,30,33 In the current report, neoadjuvant therapies critically influenced surgical planning by reducing tumor volume. In the patient with a chordoma (case 2), this was achieved through neoadjuvant SBRT, which was recommended based on prior literature on extremity soft-tissue sarcomas that demonstrated that SBRT reduced surgical morbidity and improved preservation of native tissue function.7,12 Similarly, neoadjuvant chemotherapy use in the patient with a liposarcoma (case 1) was based on the results of a prior randomized controlled trial of 340 patients with high-grade, soft-tissue sarcomas, which demonstrated superior responses among those treated with neoadjuvant chemotherapy.2 Despite these reports, the literature on the application of neoadjuvant chemotherapy to soft-tissue spinal/paraspinal sarcomas is scarce.25 Of the available reports, the present case is the most extensive (5 vertebrae) and represents the only one utilizing neoadjuvant chemotherapy in this setting.4,8,31 Reports of neoadjuvant radiation therapy use in chordoma are similarly rare.28 In one report by Yamada et al.,38 the authors observed good survival in cases of lumbar and sacral chordomas in 6 patients who underwent preoperative, high-dose, single-fraction radiotherapy. The patients received a median dose of 2400 cGy and were all disease free at an average follow-up of 35 months. In the current report, we elected to use a 4000-cGy dose spread over 5 fractions given the potential survival benefits, although such doses increase the risk of dehiscence, pseudarthrosis, and hardware failure.20,27,32

Despite the ability of neoadjuvant therapies to reduce tumor volume preoperatively, planning for en bloc resection still requires one to appreciate the tumor morphology (i.e., volume, boundaries, and shape). This can be particularly difficult for lesions with irregular shapes and those for which a wide-margin resection precludes direct visualization.13,29 Multidisciplinary approaches, including biomedical engineering and 3D printing technology, can help to overcome these mechanical considerations and improve a surgeon’s visuospatial awareness intraoperatively by generating patient-specific models that include local anatomy and tumor characteristics.

Mobbs et al.22 reported on two cases in which they used similar models for surgical planning and prosthesis. The authors described the following: 1) a patient with a C1–2 chordoma treated with posterior occiput–C3 fixation followed by anterior transoral resection and 2) a case of lumbar deformity secondary to a congenital L5 hemivertebra. Compared to the chordoma case of these authors,22 the present case involved a more complex surgical dissection and reconstruction, including both a transmandibular approach for wide en bloc resection and a total C2 spondylectomy. In another report by Xiao et al.,37 5 patients with chordomas or chondrosarcomas of the subaxial cervical spine underwent en bloc resection assisted by preoperative 3D-printed models. In the 2 chordomas, only marginal margins were achieved, compared to the current study, which achieved negative margins in both cases. Additionally, the chordoma reported here involved the axis, making exposure and reconstruction more difficult.1

Limitations to this report include those inherent to all case reports and single-institution studies. To our knowledge, this is the first report describing multidisciplinary surgical planning for primary spinal malignancies consisting of neoadjuvant chemotherapy/radiotherapy and 3D-printed models, involving surgeons, radiation oncologists, medical oncologists, and biomedical engineers.

Disclosures

The 3D-printed models were acquired from a partnership between K2M and 3D Systems (K2M/3D Systems Partnership) and DePuy Synthes Spine.

Dr. Sciubba is a consultant for Medtronic, DePuy Synthes Spine, Stryker, NuVasive, K2M, and Baxter.

This manuscript does include off-label use of spinal instrumentation, including mesh cages in the cervical spine, and posterior cervical screws.

Author Contributions

Conception and design: Sciubba, Ahmed. Acquisition of data: Ahmed, Xia. Analysis and interpretation of data: Ahmed, Pennington. Drafting the article: Ahmed, Pennington, Molina, Xia. Critically revising the article: Sciubba, Ahmed, Pennington, Molina, Goodwin. Reviewed submitted version of manuscript: Sciubba, Ahmed, Pennington, Molina, Goodwin. Approved the final version of the manuscript on behalf of all authors: Sciubba. Study supervision: Sciubba, Goodwin.

References

  • 1

    Aboulaflia AJ, Levine AM: Musculoskeletal and metastatic tumors, in Fardon DF, Garfin SR (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2002, pp 411431

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Antman K, Crowley J, Balcerzak SP, Rivkin SE, Weiss GR, Elias A, et al.: An intergroup phase III randomized study of doxorubicin and dacarbazine with or without ifosfamide and mesna in advanced soft tissue and bone sarcomas. J Clin Oncol 11:12761285, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Barrenechea IJ, Perin NI, Triana A, Lesser J, Costantino P, Sen C: Surgical management of chordomas of the cervical spine. J Neurosurg Spine 6:398406, 2007

  • 4

    Borghei-Razavi H, Daabak K, Bakhti S, Schick U: Primary epidural liposarcoma of the cervical spine: Technical case report and review of the literature. Interdiscip Neurosurg 2:15, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Boriani S, Bandiera S, Biagini R, Bacchini P, Boriani L, Cappuccio M, et al.: Chordoma of the mobile spine: fifty years of experience. Spine (Phila Pa 1976) 31:493503, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Carpentier A, Blanquet A, George B: Suboccipital and cervical chordomas: radical resection with vertebral artery control. Neurosurg Focus 10(3):E4, 2001

  • 7

    Children’s Oncology Group: Observation, radiation therapy, combination chemotherapy, and/or surgery in treating young patients with soft tissue sarcoma (NCT00346164). ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT00346164) [Accessed October 18, 2018]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Cho SH, Rhim SC, Hyun SJ, Bae CW, Khang SK: Intradural involvement of multicentric myxoid liposarcoma. J Korean Neurosurg Soc 48:276280, 2010

  • 9

    Cloyd JM, Acosta FL Jr, Polley MY, Ames CP: En bloc resection for primary and metastatic tumors of the spine: a systematic review of the literature. Neurosurgery 67:435445, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Cloyd JM, Chou D, Deviren V, Ames CP: En bloc resection of primary tumors of the cervical spine: report of two cases and systematic review of the literature. Spine J 9:928935, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    De Amorim Bernstein K, DeLaney T: Chordomas and chondrosarcomas—the role of radiation therapy. J Surg Oncol 114:564569, 2016

  • 12

    Donahue TR, Kattan MW, Nelson SD, Tap WD, Eilber FR, Eilber FC: Evaluation of neoadjuvant therapy and histopathologic response in primary, high-grade retroperitoneal sarcomas using the sarcoma nomogram. Cancer 116:38833891, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Fujita T, Kawahara N, Matsumoto T, Tomita K: Chordoma in the cervical spine managed with en bloc excision. Spine (Phila Pa 1976) 24:18481851, 1999

  • 14

    Hsieh PC, Gallia GL, Sciubba DM, Bydon A, Marco RAW, Rhines L, et al.: En bloc excisions of chordomas in the cervical spine: review of five consecutive cases with more than 4-year follow-up. Spine (Phila Pa 1976) 36:E1581E1587, 2011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Hsu W, Kosztowski TA, Zaidi HA, Dorsi M, Gokaslan ZL, Wolinsky JP: Multidisciplinary management of primary tumors of the vertebral column. Curr Treat Options Oncol 10:107125, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Jentzsch T, Vlachopoulos L, Fürnstahl P, Müller DA, Fuchs B: Tumor resection at the pelvis using three-dimensional planning and patient-specific instruments: a case series. World J Surg Oncol 14:249, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Kaloostian PE, Zadnik PL, Etame AB, Vrionis FD, Gokaslan ZL, Sciubba DM: Surgical management of primary and metastatic spinal tumors. Cancer Contr 21:133139, 2014

  • 18

    Katz D, Boonsirikamchai P, Choi H, Lazar AJ, Wang WL, Xiao L, et al.: Efficacy of first-line doxorubicin and ifosfamide in myxoid liposarcoma. Clin Sarcoma Res 2:2, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kim MP, Ta AH, Ellsworth WA IV, Marco RA, Gaur P, Miller JS: Three dimensional model for surgical planning in resection of thoracic tumors. Int J Surg Case Rep 16:127129, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kim TK, Cho W, Youn SM, Chang UK: The effect of perioperative radiation therapy on spinal bone fusion following spine tumor surgery. J Korean Neurosurg Soc 59:597603, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Laufer I, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, et al.: The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist 18:744751, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Mobbs RJ, Coughlan M, Thompson R, Sutterlin CE III, Phan K: The utility of 3D printing for surgical planning and patient-specific implant design for complex spinal pathologies: case report. J Neurosurg Spine 26:513518, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Mukherjee D, Chaichana KL, Gokaslan ZL, Aaronson O, Cheng JS, McGirt MJ: Survival of patients with malignant primary osseous spinal neoplasms: results from the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2003. J Neurosurg Spine 14:143150, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Noël G, Feuvret L, Ferrand R, Boisserie G, Mazeron JJ, Habrand JL: Radiotherapeutic factors in the management of cervical-basal chordomas and chondrosarcomas. Neurosurgery 55:12521262, 2004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Pasquali S, Gronchi A: Neoadjuvant chemotherapy in soft tissue sarcomas: latest evidence and clinical implications. Ther Adv Med Oncol 9:415429, 2017

  • 26

    Patel SR, Burgess MA, Plager C, Papadopoulos NE, Linke KA, Benjamin RS: Myxoid liposarcoma. Experience with chemotherapy. Cancer 74:12651269, 1994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Pedreira R, Abu-Bonsrah N, Karim Ahmed A, De la Garza-Ramos R, Goodwin CR, Gokaslan ZL, et al.: Hardware failure in patients with metastatic cancer to the spine. J Clin Neurosci 45:166171, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Pennicooke B, Laufer I, Sahgal A, Varga PP, Gokaslan ZL, Bilsky MH, et al.: Safety and local control of radiation therapy for chordoma of the spine and sacrum: a systematic review. Spine (Phila Pa 1976) 41 (Suppl 20):S186S192, 2016

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Rodallec MH, Feydy A, Larousserie F, Anract P, Campagna R, Babinet A, et al.: Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics 28:10191041, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Ropper AE, Cahill KS, Hanna JW, McCarthy EF, Gokaslan ZL, Chi JH: Primary vertebral tumors: a review of epidemiologic, histological and imaging findings, part II: locally aggressive and malignant tumors. Neurosurgery 70:211219, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Rovlias A, Balanika A, Nomikos A, Melissaris S: Primary myxoid liposarcoma of the upper thoracic spine in an elderly patient. J Neurosci Rural Pract 8 (Suppl 1):S120S122, 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Sanpakit S, Mansfield TL, Liebsch J: Role of onlay grafting with minimal internal fixation for occipitocervical fusion in oncologic patients. J Spinal Disord 13:382390, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Sundaresan N, Rosen G, Boriani S: Primary malignant tumors of the spine. Orthop Clin North Am 40:2136, v, 2009

  • 34

    Talac R, Yaszemski MJ, Currier BL, Fuchs B, Dekutoski MB, Kim CW, et al.: Relationship between surgical margins and local recurrence in sarcomas of the spine. Clin Orthop Relat Res (397):127132, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Tomita K, Kawahara N, Murakami H, Demura S: Total en bloc spondylectomy for spinal tumors: improvement of the technique and its associated basic background. J Orthop Sci 11:312, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Walcott BP, Nahed BV, Mohyeldin A, Coumans JV, Kahle KT, Ferreira MJ: Chordoma: current concepts, management, and future directions. Lancet Oncol 13:e69e76, 2012

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Xiao JR, Huang WD, Yang XH, Yan WJ, Song DW, Wei HF, et al.: En bloc resection of primary malignant bone tumor in the cervical spine based on 3-dimensional printing technology. Orthop Surg 8:171178, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Yamada Y, Laufer I, Cox BW, Lovelock DM, Maki RG, Zatcky JM, et al.: Preliminary results of high-dose single-fraction radiotherapy for the management of chordomas of the spine and sacrum. Neurosurgery 73:673680, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Zhang Y, Wen L, Zhang J, Yan G, Zhou Y, Huang B: Three-dimensional printing and computer navigation assisted hemipelvectomy for en bloc resection of osteochondroma: a case report. Medicine (Baltimore) 96:e6414, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand

Multidisciplinary surgical planning for a patient with myxoid liposarcoma extending from C4 to T1. See the article by Ahmed et al. (pp 424–431).

  • Case 1. Preoperative imaging of a young patient with a myxoid liposarcoma extending from C4 to T1. A: Sagittal MR image. B: Axial MR image. C: Sagittal MR image following 6 rounds of neoadjuvant chemotherapy. D: Axial MR image following 6 rounds of neoadjuvant chemotherapy. E: 3D-printed spine model constructed from preoperative imaging. Asterisks indicate the tumor.

  • Case 1. Intraoperative imaging of stage I (posterior). A: Posterior osteotomy across C4–T1. B: Instrumented arthrodesis from C2 to T3. C: Preoperative axial MR images for comparison. D: Postoperative axial MR images demonstrating osteotomies across vertebral bodies of C4–T1 and posterior instrumentation. E: Coronal CT scan demonstrating posterior instrumented arthrodesis from C2 to T3.

  • Case 1. Intraoperative neck dissection of stage II (anterior). A: The patient was placed supine, draped, and prepared. B: Neck dissection was carried down to the tumor. C: Neuronavigation was utilized throughout the procedure. D and E: The tumor was released and resected en bloc. F and G: Anterior column reconstruction from C3 to T2 with a structural fibular graft. H: Postoperative lateral radiograph.

  • Case 2. Preoperative imaging of a 55-year-old man with a cervical chordoma, most prominent at C2–3. A: Preoperative sagittal MR image. B: Preoperative axial MR image. C: Sagittal MR image following neoadjuvant SBRT. D: Axial MR image following neoadjuvant SBRT. E and F: 3D-printed spine model constructed from preoperative images. Asterisks indicate the tumor.

  • Case 2. Operative techniques and postoperative images. A–C: Stage I involved posterior decompression and instrumented arthrodesis from C1 to T2. D–G: Stage II involved anterior total en bloc tumor resection, including the C2 and C3 vertebral bodies. H–J: Anterior column reconstruction with cage placement and structural fibular allograft. K: Revision surgery for wound infection and dehiscence, with removal of the anterior cage and extension of the posterior instrumentation from the occiput to T3.

  • 1

    Aboulaflia AJ, Levine AM: Musculoskeletal and metastatic tumors, in Fardon DF, Garfin SR (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2002, pp 411431

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Antman K, Crowley J, Balcerzak SP, Rivkin SE, Weiss GR, Elias A, et al.: An intergroup phase III randomized study of doxorubicin and dacarbazine with or without ifosfamide and mesna in advanced soft tissue and bone sarcomas. J Clin Oncol 11:12761285, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Barrenechea IJ, Perin NI, Triana A, Lesser J, Costantino P, Sen C: Surgical management of chordomas of the cervical spine. J Neurosurg Spine 6:398406, 2007

  • 4

    Borghei-Razavi H, Daabak K, Bakhti S, Schick U: Primary epidural liposarcoma of the cervical spine: Technical case report and review of the literature. Interdiscip Neurosurg 2:15, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Boriani S, Bandiera S, Biagini R, Bacchini P, Boriani L, Cappuccio M, et al.: Chordoma of the mobile spine: fifty years of experience. Spine (Phila Pa 1976) 31:493503, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Carpentier A, Blanquet A, George B: Suboccipital and cervical chordomas: radical resection with vertebral artery control. Neurosurg Focus 10(3):E4, 2001

  • 7

    Children’s Oncology Group: Observation, radiation therapy, combination chemotherapy, and/or surgery in treating young patients with soft tissue sarcoma (NCT00346164). ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT00346164) [Accessed October 18, 2018]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Cho SH, Rhim SC, Hyun SJ, Bae CW, Khang SK: Intradural involvement of multicentric myxoid liposarcoma. J Korean Neurosurg Soc 48:276280, 2010

  • 9

    Cloyd JM, Acosta FL Jr, Polley MY, Ames CP: En bloc resection for primary and metastatic tumors of the spine: a systematic review of the literature. Neurosurgery 67:435445, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Cloyd JM, Chou D, Deviren V, Ames CP: En bloc resection of primary tumors of the cervical spine: report of two cases and systematic review of the literature. Spine J 9:928935, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    De Amorim Bernstein K, DeLaney T: Chordomas and chondrosarcomas—the role of radiation therapy. J Surg Oncol 114:564569, 2016

  • 12

    Donahue TR, Kattan MW, Nelson SD, Tap WD, Eilber FR, Eilber FC: Evaluation of neoadjuvant therapy and histopathologic response in primary, high-grade retroperitoneal sarcomas using the sarcoma nomogram. Cancer 116:38833891, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Fujita T, Kawahara N, Matsumoto T, Tomita K: Chordoma in the cervical spine managed with en bloc excision. Spine (Phila Pa 1976) 24:18481851, 1999

  • 14

    Hsieh PC, Gallia GL, Sciubba DM, Bydon A, Marco RAW, Rhines L, et al.: En bloc excisions of chordomas in the cervical spine: review of five consecutive cases with more than 4-year follow-up. Spine (Phila Pa 1976) 36:E1581E1587, 2011

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Hsu W, Kosztowski TA, Zaidi HA, Dorsi M, Gokaslan ZL, Wolinsky JP: Multidisciplinary management of primary tumors of the vertebral column. Curr Treat Options Oncol 10:107125, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Jentzsch T, Vlachopoulos L, Fürnstahl P, Müller DA, Fuchs B: Tumor resection at the pelvis using three-dimensional planning and patient-specific instruments: a case series. World J Surg Oncol 14:249, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Kaloostian PE, Zadnik PL, Etame AB, Vrionis FD, Gokaslan ZL, Sciubba DM: Surgical management of primary and metastatic spinal tumors. Cancer Contr 21:133139, 2014

  • 18

    Katz D, Boonsirikamchai P, Choi H, Lazar AJ, Wang WL, Xiao L, et al.: Efficacy of first-line doxorubicin and ifosfamide in myxoid liposarcoma. Clin Sarcoma Res 2:2, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kim MP, Ta AH, Ellsworth WA IV, Marco RA, Gaur P, Miller JS: Three dimensional model for surgical planning in resection of thoracic tumors. Int J Surg Case Rep 16:127129, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kim TK, Cho W, Youn SM, Chang UK: The effect of perioperative radiation therapy on spinal bone fusion following spine tumor surgery. J Korean Neurosurg Soc 59:597603, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Laufer I, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, et al.: The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist 18:744751, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Mobbs RJ, Coughlan M, Thompson R, Sutterlin CE III, Phan K: The utility of 3D printing for surgical planning and patient-specific implant design for complex spinal pathologies: case report. J Neurosurg Spine 26:513518, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Mukherjee D, Chaichana KL, Gokaslan ZL, Aaronson O, Cheng JS, McGirt MJ: Survival of patients with malignant primary osseous spinal neoplasms: results from the Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 2003. J Neurosurg Spine 14:143150, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Noël G, Feuvret L, Ferrand R, Boisserie G, Mazeron JJ, Habrand JL: Radiotherapeutic factors in the management of cervical-basal chordomas and chondrosarcomas. Neurosurgery 55:12521262, 2004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Pasquali S, Gronchi A: Neoadjuvant chemotherapy in soft tissue sarcomas: latest evidence and clinical implications. Ther Adv Med Oncol 9:415429, 2017

  • 26

    Patel SR, Burgess MA, Plager C, Papadopoulos NE, Linke KA, Benjamin RS: Myxoid liposarcoma. Experience with chemotherapy. Cancer 74:12651269, 1994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Pedreira R, Abu-Bonsrah N, Karim Ahmed A, De la Garza-Ramos R, Goodwin CR, Gokaslan ZL, et al.: Hardware failure in patients with metastatic cancer to the spine. J Clin Neurosci 45:166171, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Pennicooke B, Laufer I, Sahgal A, Varga PP, Gokaslan ZL, Bilsky MH, et al.: Safety and local control of radiation therapy for chordoma of the spine and sacrum: a systematic review. Spine (Phila Pa 1976) 41 (Suppl 20):S186S192, 2016

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Rodallec MH, Feydy A, Larousserie F, Anract P, Campagna R, Babinet A, et al.: Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics 28:10191041, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Ropper AE, Cahill KS, Hanna JW, McCarthy EF, Gokaslan ZL, Chi JH: Primary vertebral tumors: a review of epidemiologic, histological and imaging findings, part II: locally aggressive and malignant tumors. Neurosurgery 70:211219, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Rovlias A, Balanika A, Nomikos A, Melissaris S: Primary myxoid liposarcoma of the upper thoracic spine in an elderly patient. J Neurosci Rural Pract 8 (Suppl 1):S120S122, 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Sanpakit S, Mansfield TL, Liebsch J: Role of onlay grafting with minimal internal fixation for occipitocervical fusion in oncologic patients. J Spinal Disord 13:382390, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Sundaresan N, Rosen G, Boriani S: Primary malignant tumors of the spine. Orthop Clin North Am 40:2136, v, 2009

  • 34

    Talac R, Yaszemski MJ, Currier BL, Fuchs B, Dekutoski MB, Kim CW, et al.: Relationship between surgical margins and local recurrence in sarcomas of the spine. Clin Orthop Relat Res (397):127132, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Tomita K, Kawahara N, Murakami H, Demura S: Total en bloc spondylectomy for spinal tumors: improvement of the technique and its associated basic background. J Orthop Sci 11:312, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Walcott BP, Nahed BV, Mohyeldin A, Coumans JV, Kahle KT, Ferreira MJ: Chordoma: current concepts, management, and future directions. Lancet Oncol 13:e69e76, 2012

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Xiao JR, Huang WD, Yang XH, Yan WJ, Song DW, Wei HF, et al.: En bloc resection of primary malignant bone tumor in the cervical spine based on 3-dimensional printing technology. Orthop Surg 8:171178, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Yamada Y, Laufer I, Cox BW, Lovelock DM, Maki RG, Zatcky JM, et al.: Preliminary results of high-dose single-fraction radiotherapy for the management of chordomas of the spine and sacrum. Neurosurgery 73:673680, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Zhang Y, Wen L, Zhang J, Yan G, Zhou Y, Huang B: Three-dimensional printing and computer navigation assisted hemipelvectomy for en bloc resection of osteochondroma: a case report. Medicine (Baltimore) 96:e6414, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1705 165 0
Full Text Views 388 126 42
PDF Downloads 333 80 12
EPUB Downloads 0 0 0