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Prognostic factors for long-term outcome of patients with surgical resection of skull base chordomas—106 cases review in one institution

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Abstract

Skull base chordoma are still challenging. Between May 1993 and June 2005, 106 consecutive patients with skull base chordoma underwent surgical removal at Skull Base Division of Neurosurgery, Beijing Tiantan Hospital, China. Retrospective analysis included medical charts and images. The age of the patients ranged from 7 to 65 years old, with an average age of 35.6 years. Sixty patients were male; the other 46 were female (1.3:1). Follow up data were available in 79 cases ranging from 10 to 158 months (average 63.9 months) after operation. The prognostic factors for recurrence and survival were analyzed with Kaplan‐Meier, Cox regression and t‐test. Overall, 1, 3, 5 and 10 years survival rates were 87.2%, 79.4%, 67.6%and 59.5% respectively. One, 3, 5 and 10 year recurrent rates were 19.1%, 34.7%, 52.9% and 88.3%, respectively. The long term outcome of the skull base chordomas is poor. The previous radiotherapy or surgery, dedifferentiated pathology, and less tumor resection are risk factors for longterm survival and recurrence (p < 0.05). Although there is no statistic significant role of tumor adherent to vital structure for outcome (p = 0.051), it can not exclude its importance for favorable outcome. Gender, age, tumor size and staging are not independent risk factors for outcome. Surgical technique leading to radical tumor resection with less morbidity is advocatory and beneficial for patients with skull base chordoma with long term outcome, if the tumor could be exposed and resected completely, the recurrence rate was very low for most benign chordomas.

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Correspondence to Junting Zhang.

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Comments

Luis A. B. Borba, Curitiba, Brazil

We read with great interest the paper entitled “Prognostic factors for long-term outcome of patients with surgical resection of skull base chordomas—106 cases review in one institution” by Wu Zhen et al.

In this article, the authors reported their large experience in the treatment of this challenging tumor. They follow 79 patients with a mean follow-up of 63.9 months. The recurrence rates at 1, 3, 5, and 10 years were 19.1%, 34.7%, 52.9%, and 88.3%, respectively. The degree of surgical resection, pathology type, prior surgical removal, and RT were directly related with tumor control.

We disagree with the authors in a few topics.

Chordoma is an extradural tumor and should be attacked from the extradural compartment to the intradural. In our series, the incidence of intradural invasion is around 45% of the cases, and it is not the main concern because usually the tumor has a good plan with the CNS except in cases of recurrence or prior RT. A rare situation of pial invasion can be found, however it is not a place for recurrent tumor.

For us, chordomas should be understood and approached from these perspectives:

(a) The tumor comes from the bone.

(b) The free-time recurrence is directly related with the extension of surgical removal.

(c) Sometimes more than one surgical procedures need to get a radical removal.

(d) The tumor is extradural with or without intradural extension; therefore, approach it from an extradural fashion.

(e) Chordoma is different than chondrosarcoma; the cytokeratin and EMA staining are essential to the diagnosis. The old reported “chondroid chordoma” may be a low-grade chondrosarcoma which has a better prognosis.

(f) The tumor will recur (it’s a matter of time). Islands of residual tumor occur away from the main tumor mass, inside the bone of skull base.

(g) A radical bony removal is mandatory; however, the time to stop to do it is the most challenging part in the surgical procedure.

(h) A radical removal does not mean a high surgical morbidity. Tumor extension to the cavernous sinus, petroclival region, occipital condyles, etc., can be easily removed without adding surgical morbidity or mortality.

(i) The role of high dosage of radiation treatment with proton beam is the best additional therapy. The capacity to deliver a high dose protecting the adjacent tissue (Braga peak effect) is the main point to indicate it.

We would like to congratulate the authors for the excellent work in the management of these truly challenging tumors.

Anil Nanda, Shreveport, USA

Zhen et al. reviewed retrospectively one of the largest series reported to date on skull base chordomas. The authors report the outcomes of 106 consecutive cases of chordomas operated between 1993 and 2005. Follow-up data obtained on 79 patients showed overall survival rates and recurrence rates over 1, 3, 5, and 10 years. They report a 60% survival over 10 years and recurrence rate of 88%. Conventional radiation therapy was administered as an adjuvant. Pathology and extent of surgical excision (and previous treatment) were significant risk factors for both survival and recurrence. Tumor size and grading were not independent risk factors for outcome. The authors need to be congratulated for their superb management of these difficult tumors.

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Wu, Z., Zhang, J., Zhang, L. et al. Prognostic factors for long-term outcome of patients with surgical resection of skull base chordomas—106 cases review in one institution. Neurosurg Rev 33, 451–456 (2010). https://doi.org/10.1007/s10143-010-0273-6

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