Outcomes following attempted en bloc resection of cervical chordomas in the C-1 and C-2 region versus the subaxial region: a multiinstitutional experience

Clinical article

View More View Less
  • 1 Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland;
  • | 2 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 3 Department of Neurosurgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas; and
  • | 4 Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

Object

Chordomas involving the mobile spine are ideally managed via en bloc resection with reconstruction to optimize local control and possibly offer cure. In the cervical spine, local anatomy poses unique challenges, limiting the feasibility of aggressive resection. The authors present a multi-institutional series of 16 cases of cervical chordomas removed en bloc. Particular attention was paid to clinical outcome, complications, and recurrence. In addition, outcomes were assessed according to position of tumor at the C1–2 level versus the subaxial (SA) spine (C3–7).

Methods

The authors reviewed cases involving patients who underwent en bloc resection of cervical chordoma at 4 large spine centers. Patients were included if the lesion epicenter involved the C-1 to C-7 vertebral bodies. Demographic data and details of surgery, follow-up course, exposure to adjuvant therapy, and complications were obtained. Outcome was correlated with presence of tumor in C1–2 versus subaxial spine via a Student t-test.

Results

Sixteen patients were identified (mean age at presentation 55 ± 14 years). Seven cases (44%) cases involved C1–2, and 16 involved the subaxial spine. Median survival did not differ significantly different between the C1–2 (72 months) and SA (60 months) groups (p = 0.65). A combined (staged anteroposterior) approach was used in 81% of the cases. Use of the combined approach was significantly more common in treatment of subaxial than C1–2 tumors (100% vs 57%, p = 0.04). En bloc resection was attempted via an anterior approach in 6% of cases (C1–2: 14.3%; SA: 0%; p = 0.17) and a posterior approach in 13% of cases (C1–2: 29%; SA: 0%; p = 0.09). The most commonly reported margin classification was marginal (56% of cases), followed by violated (25%) and wide (19%). En bloc excision of subaxial tumors was significantly more likely to result in marginal margins than excision of C1–2 tumors (C1–2: 29%; SA: 78%; p = 0.03). C1–2 tumors were associated with significantly higher rates of postoperative complications (C1–2: 71%; SA: 22%; p = 0.03). Both local and distant tumor recurrence was greatest for C1–2 tumors (local C1–2: 29%; local SA: 11%; distant C1–2: 14%; distant SA: 0%). Statistical analysis of tumor recurrence based on tumor location was not possible due to the small number of cases. There was no between-groups difference in exposure to postoperative adjuvant radiotherapy. There was no difference in median survival between groups receiving proton beam radiotherapy or intensity-modulated radiotherapy versus no radiation therapy (p = 0.8).

Conclusions

Compared with en bloc resection of chordomas involving the subaxial cervical spine, en bloc resection of chordomas involving the upper cervical spine (C1–2) is associated with poorer outcomes, such as less favorable margins, higher rates of complications, and increased tumor recurrence. Data from this cohort do not support a statistically significant difference in survival for patients with C1–2 versus subaxial disease, but larger studies are needed to further study survival differences.

Abbreviations used in this paper:

IMRT = intensity-modulated radiotherapy; PBRT = proton beam radiotherapy; SA = subaxial; UCSF = University of California, San Francisco; USC = University of Southern California.

Spine - 1 year subscription bundle (Individuals Only)

USD  $376.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Bailey CS, , Fisher CG, , Boyd MC, & Dvorak MF: En bloc marginal excision of a multilevel cervical chordoma. Case report. J Neurosurg Spine 4:409414, 2006

    • Search Google Scholar
    • Export Citation
  • 2

    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

    • Search Google Scholar
    • Export Citation
  • 3

    Bas T, , Bas P, , Prieto M, , Ramos V, , Bas JL, & Espinosa C: A lumbar chordoma treated with a wide resection. Eur Spine J 3:115117, 1994

  • 4

    Bergh P, , Kindblom LG, , Gunterberg B, , Remotti F, , Ryd W, & Meis-Kindblom JM: Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients. Cancer 88:21222134, 2000

    • Search Google Scholar
    • Export Citation
  • 5

    Bjornsson J, , Wold LE, , Ebersold MJ, & Laws ER: Chordoma of the mobile spine. A clinicopathologic analysis of 40 patients. Cancer 71:735740, 1993

    • Search Google Scholar
    • Export Citation
  • 6

    Bohlman HH, , Sachs BL, , Carter JR, , Riley L, & Robinson RA: Primary neoplasms of the cervical spine. Diagnosis and treatment of twenty-three patients. J Bone Joint Surg Am 68:483494, 1986

    • Search Google Scholar
    • Export Citation
  • 7

    Boriani S, , Chevalley F, , Weinstein JN, , Biagini R, , Campanacci L, & De Iure F, et al.: Chordoma of the spine above the sacrum. Treatment and outcome in 21 cases. Spine (Phila Pa 1976) 21:15691577, 1996

    • Search Google Scholar
    • Export Citation
  • 8

    Boriani S, , Weinstein JN, & Biagini R: Primary bone tumors of the spine. Terminology and surgical staging. Spine (Phila Pa 1976) 22:10361044, 1997

    • Search Google Scholar
    • Export Citation
  • 9

    Bosma JJ, , Pigott TJ, , Pennie BH, & Jaffray DC: En bloc removal of the lower lumbar vertebral body for chordoma. Report of two cases. J Neurosurg 94:2 Suppl 284291, 2001

    • Search Google Scholar
    • Export Citation
  • 10

    Chou D, , Acosta F Jr, , Cloyd JM, & Ames CP: Parasagittal osteotomy for en bloc resection of multilevel cervical chordomas. Technical note. J Neurosurg Spine 10:397403, 2009

    • Search Google Scholar
    • Export Citation
  • 11

    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

    • Search Google Scholar
    • Export Citation
  • 12

    Cohen ZR, , Fourney DR, , Marco RA, , Rhines LD, & Gokaslan ZL: Total cervical spondylectomy for primary osteogenic sarcoma. Case report and description of operative technique. J Neurosurg 97:3 Suppl 386392, 2002

    • Search Google Scholar
    • Export Citation
  • 13

    Currier BL, , Papagelopoulos PJ, , Krauss WE, , Unni KK, & Yaszemski MJ: Total en bloc spondylectomy of C5 vertebra for chordoma. Spine (Phila Pa 1976) 32:E294E299, 2007

    • Search Google Scholar
    • Export Citation
  • 14

    Ferraresi V, , Nuzzo C, , Zoccali C, , Marandino F, , Vidiri A, & Salducca N, et al.: Chordoma: clinical characteristics, management and prognosis of a case series of 25 patients. BMC Cancer 10:22, 2010

    • Search Google Scholar
    • Export Citation
  • 15

    Fourney DR, & Gokaslan ZL: Current management of sacral chordoma. Neurosurg Focus 15:2 E9, 2003

  • 16

    Fourney DR, , Rhines LD, , Hentschel SJ, , Skibber JM, , Wolinsky JP, & Weber KL, et al.: En bloc resection of primary sacral tumors: classification of surgical approaches and outcome. J Neurosurg Spine 3:111122, 2005

    • Search Google Scholar
    • Export Citation
  • 17

    Fuchs B, , Dickey ID, , Yaszemski MJ, , Inwards CY, & Sim FH: Operative management of sacral chordoma. J Bone Joint Surg Am 87:22112216, 2005

    • Search Google Scholar
    • Export Citation
  • 18

    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

    • Search Google Scholar
    • Export Citation
  • 19

    Heary RF, , Vaccaro AR, , Benevenia J, & Cotler JM: “En-bloc” vertebrectomy in the mobile lumbar spine. Surg Neurol 50:548556, 1998

  • 20

    Hee HT, , Majd ME, , Holt RT, , Whitecloud TS III, & Pienkowski D: Complications of multilevel cervical corpectomies and reconstruction with titanium cages and anterior plating. J Spinal Disord Tech 16:19, 2003

    • Search Google Scholar
    • Export Citation
  • 21

    Hsieh PC, , Galia GL, , Sciubba DM, , Bydon A, , Marco RA, & Rhines L, et al.: En-bloc excision of chordomas in the cervical spine: review of 5 consecutive cases with over 4-year follow-up. Spine (Phila Pa 1976) 36:E15811587, 2011

    • Search Google Scholar
    • Export Citation
  • 22

    Hsieh PC, , Xu R, , Sciubba DM, , McGirt MJ, , Nelson C, & Witham TF, et al.: Long-term clinical outcomes following en bloc resections for sacral chordomas and chondrosarcomas: a series of twenty consecutive patients. Spine (Phila Pa 1976) 34:22332239, 2009

    • Search Google Scholar
    • Export Citation
  • 23

    Hsu KY, , Zucherman JF, , Mortensen N, , Johnston JO, & Gartland J: Follow-up evaluation of resected lumbar vertebral chordoma over 11 years: a case report. Spine (Phila Pa 1976) 25:25372540, 2000

    • Search Google Scholar
    • Export Citation
  • 24

    Hsu W, , Kosztowski TA, , Zaidi HA, , Gokaslan ZL, & Wolinsky JP: Image-guided, endoscopic, transcervical resection of cervical chordoma. Technical note. J Neurosurg Spine 12:431435, 2010

    • Search Google Scholar
    • Export Citation
  • 25

    Huang W, , Cao D, , Ma J, , Yang X, , Xiao J, & Zheng W, et al.: Solitary plasmacytoma of cervical spine: treatment and prognosis in patients with neurological lesions and spinal instability. Spine (Phila Pa 1976) 35:E278E284, 2010

    • Search Google Scholar
    • Export Citation
  • 26

    Kelley SP, , Ashford RU, , Rao AS, & Dickson RA: Primary bone tumours of the spine: a 42-year survey from the Leeds Regional Bone Tumour Registry. Eur Spine J 16:405409, 2007

    • Search Google Scholar
    • Export Citation
  • 27

    Leitner Y, , Shabat S, , Boriani L, & Boriani S: En bloc resection of a C4 chordoma: surgical technique. Eur Spine J 16:22382242, 2007

  • 28

    McMaster ML, , Goldstein AM, , Bromley CM, , Ishibe N, & Parry DM: Chordoma: incidence and survival patterns in the United States, 1973–1995. Cancer Causes Control 12:111, 2001

    • Search Google Scholar
    • Export Citation
  • 29

    Rhines LD, , Fourney DR, , Siadati A, , Suk I, & Gokaslan ZL: En bloc resection of multilevel cervical chordoma with C-2 involvement. Case report and description of operative technique. J Neurosurg Spine 2:199205, 2005

    • Search Google Scholar
    • Export Citation
  • 30

    Sciubba DM, , Chi JH, , Rhines LD, & Gokaslan ZL: Chordoma of the spinal column. Neurosurg Clin N Am 19:515, 2008

  • 31

    Štulík J, , Kozák J, , Šebesta P, , Vyskočil T, , Kryl J, & Klezl Z: Total spondylectomy of C2: report of three cases and review of the literature. J Spinal Disord Tech 23:e53e58, 2010

    • Search Google Scholar
    • Export Citation
  • 32

    Suchomel P, , Buchvald P, , Barsa P, , Froehlich R, , Choutka O, & Krejzar Z, et al.: Single-stage total C-2 intralesional spondylectomy for chordoma with three-column reconstruction. Technical note. J Neurosurg Spine 6:611618, 2007

    • Search Google Scholar
    • Export Citation
  • 33

    Sundaresan N, , Steinberger AA, , Moore F, , Sachdev VP, , Krol G, & Hough L, et al.: Indications and results of combined anteriorposterior approaches for spine tumor surgery. J Neurosurg 85:438446, 1996

    • Search Google Scholar
    • Export Citation
  • 34

    Vassal F, , Dumas B, & Nuti C: Margin-free, en bloc resection of a multilevel cervical chordoma with C-2 involvement: case report with 2-year follow-up and description of operative technique. Br J Neurosurg 26:929931, 2012

    • Search Google Scholar
    • Export Citation
  • 35

    York JE, , Kaczaraj A, , Abi-Said D, , Fuller GN, , Skibber JM, & Janjan NA, et al.: Sacral chordoma: 40-year experience at a major cancer center. Neurosurgery 44:7480, 1999

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 524 198 6
Full Text Views 598 44 1
PDF Downloads 315 33 1
EPUB Downloads 0 0 0