Elsevier

The Spine Journal

Volume 9, Issue 12, December 2009, Pages 972-980
The Spine Journal

Clinical Study
Analysis of risk factors for recurrence after the resection of sacral chordoma combined with embolization

https://doi.org/10.1016/j.spinee.2009.08.447Get rights and content

Abstract

Background context

Although several authors have already reported on the high local recurrence rate of sacral chordomas after surgical resection, there are no reports on the risk factors for recurrence after resection when combined with preoperative tumor-related blood vessel embolism by digital subtraction angiography (DSA) technique.

Purpose

To investigate the factors related to the continuous disease-free survival time (CDFS) after the resection of sacral chordomas combined with embolization.

Study design/setting

Retrospective review of the signs, images, and immunohistochemical data of patients with sacral chordomas treated with an initial operation combined with transcatheter arterial embolization.

Patient sample

Twenty-two patients with sacral chordomas received initial resection combined with transcatheter arterial embolization.

Outcome measures

Recurrence, proliferating cell nuclear antigen (PCNA) expression, basic fibroblast growth factor (bFGF) expression, CDFS.

Methods

All cases were selected and followed for an average of 39.2 months. The roles of gender, age, tumor size, tumor location, surgical method, radiation therapy, PCNA expression, and bFGF expression in local recurrence were analyzed using the log-rank test.

Results

Sacral chordomas recurred in eight of 22 cases. The CDFS was significantly greater in tumors located below S3 as compared with those above S3. When evaluating PCNA and bFGF expression levels, the CDFS was greater in low expressions rather than high expressions. It was determined that the surgical method used was of prognostic significance to the CDFS.

Conclusions

Higher tumor location and higher expressions of PCNA and bFGF will lead to a shorter CDFS. Resecting the tumor as completely as possible will decrease the chances of local recurrence of sacral chordomas.

Introduction

Evidence & Methods

Risk factors for local recurrence of sacral chordomas following combined surgical resection and preoperative embolization are poorly understood.

In this retrospective series, the authors found three factors associated with recurrence: tumors located cephalad to S3; tumors with high expression of PCNA and bFGF; and tumors treated operatively by intralesional resection.

This article provides useful prognostic information for patients with these rare tumors.

The Editors

Sacral chordoma is a rare slow-growing malignant neoplasm arising from cellular remnants of the notochord. Because of its insidious onset and ambiguous symptoms, by the time the tumor has been detected, it is often already large in size and invading the sacral nerves. Radiotherapy and chemotherapy are ineffective, making surgery the main treatment for sacral chordomas. Because of the anatomic characteristics of the region, removing a sacral tumor was once regarded as a difficult procedure with massive blood loss and severe surgical injury [1], [2], [3], [4], [5]. If the primary tumor is not completely resected, controlling the disease becomes more difficult, increasing the risk of recurrence.

Although the local recurrence rate of sacral chordomas after surgical resections has been discussed in several studies [4], [6], [7], [8], [9], the present authors have not found any reports on the risk of recurrence after resection with preoperative tumor-related blood vessel embolism by digital subtraction angiography (DSA) technique. The present study reviewed initial operations, combined with transcatheter arterial embolization (TAE), of 22 sacral chordomas from January 1994 to September 2006. Significant improvements in outcome were made when using this method. Symptoms, signs, images, and immunohistochemical data were collected to investigate the factors related to the continuous disease-free survival time (CDFS) after the resection of sacral chordoma.

Section snippets

Patient selection and data collection

There were a total of 22 patients (10 men and 12 women) in the present study. The average age was 47.1±13.7 years (range: 22–76 years). Between 1994 and 2006, they were diagnosed and treated, selected for the present study, and their patient charts were reviewed. Original paraffin specimens were available from 16 of the 22 patients. These were immunohistochemically prepared for the detection of basic fibroblast growth factor (bFGF) and proliferating cell nuclear antigen (PCNA).

Age at the time

General data

Intraoperative blood loss ranged from 200 to 4,500 mL (mean: 1,200 mL). The average follow-up time was 38.2±32.0 months (range: 6–144 months). Eight of the 22 cases experienced local recurrence (36.4%).

Postoperative neurologic function

In 17 patients, the sacral nerve root was reserved bilaterally at and above S3, and the sphincter muscle function of the bladder and bowel was normal. In two cases, the nerve root was reserved unilaterally at and above S3, resulting in a partial dysfunction of the bladder and bowel. The function of

Discussion

The bilateral internal iliac artery and the median sacral artery are the blood supply of the sacrum with numerous collateral branches between these arteries and the superior gluteal artery. Because of the short distance between the sacral tumor and the main vessels, severe blood loss often occurs intraoperatively. This can be significantly reduced with TAE. In the present study, intraoperative blood loss ranged from 200 to 4,500 mL (mean: 1,200 mL). Previously published studies that did not use

Conclusions

Patients treated with radical resections had a significantly longer CDFS than patients treated with perilesional and intralesional resections. In the present study, a trend was discovered in which the higher the location of the tumor, the shorter the CDFS. In addition, greater expressions of PCNA and bFGF led to a shorter CDFS. Patient's age at the time of diagnosis, gender, tumor size, and radiation therapy were found to have no statistical significance on the CDFS.

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