Surgical Margins and Local Control in Resection of Sacral Chordomas

Abstract

Background The treatment of choice in sacral chordoma is surgical resection, although the risk of local recurrence and metastasis remains high. The quality of surgical margins obtained at initial surgery is the primary factor to improve survival reducing the risk of local recurrence, but proximal sacral resections are associated with substantial perioperative morbidity. Questions/purposes We considered survivorship related to local recurrence in terms of surgical margins, level of resection, and previous surgery. Methods We retrospectively reviewed 56 patients with sacral chordomas treated with surgical resection. Thirtyseven were resected above S3 by a combined anterior and posterior approach and 19 at or below S3 by a posterior approach. Nine of these had had previous intralesional surgery elsewhere. The minimum followup was 3 years (mean, 9.5 years; range, 3-28 years). Results Overall survival was 97% at 5 years, 71% at 10 years, and 47% at 15 years. Survivorship to local recurrence was 65% at 5 years and 52% at 10 years. Thirty percent of patients developed metastases. Wide margins were associated with increased survivorship to local recurrence. We found no differences in local recurrence between wide and wide-contaminated margins (that is, if the tumor or its pseudocapsule was exposed intraoperatively, but further tissue was removed to achieve wide margins). Previous intralesional surgery was associated with an increased local recurrence rate. We observed no differences in the recurrence rate in resections above S3 or at and below S3. Conclusions Surgical margins affect the risk of local recurrence. Previous intralesional surgery was associated with a higher rate of local recurrence. Intraoperative contamination did not affect the risk of local recurrence when wide margins were subsequently attained.

What Are the Conditional Survival and Functional Outcomes After Surgical Treatment of 115 Patients With Sacral Chordoma?

“…The conditional 5-year survival of patients who received an inadequate margin resection showed the lowest survival probability during the third and fourth years postoperatively, which indicated that the effect of the surgical margin on conditional 5-year survival was the greatest between 3 and 4 years after surgery. Despite a similar trend of the surgical margin and previous surgery in conditional survival over time, an inadequate margin and previous surgery before referral continued to have a lower 5-year conditional survival, which is consistent with previous studies demonstrating that the surgical margin is an important predictor of survival [9,23,26,34,38,42]. The surgical margin is the main predictor factor for local control and disease-free survival [3,11,24,44].…”

How Does the Level of Nerve Root Resection in En Bloc Sacrectomy Influence Patient-Reported Outcomes?

“…Currently, there is a paucity of studies reporting on patientreported outcomes after treatment for sacral tumors. Studies that do address these outcomes use different tools and use tools that are not completed by the patient, making institutional comparisons increasingly difficult [13,14,19,23,25]. We found that, when comparing patient-reported outcomes based on the sacral nerve roots that were sacrificed, mental and physical health decreased when S3 was bilaterally sacrificed.…”

“…Most studies focus on the crucial oncological outcomes but only briefly address the results of, often objective, functional outcome measures [13,14,23]. Patient-reported outcomes are becoming increasingly important in the determination of treatment success.…”

CORR ® Tumor Board: Sacral Insufficiency Fractures are Common After High-dose Radiation for Sacral Chordomas Treated With or Without Surgery

“…This study reveals a higher-than-expected risk of sacral insufficiency fracture following radiotherapy when compared to past studies with fracture rates of 6% to 8% [2,11]. Nearly half of the patients in the study developed insufficiency fractures, and the proportion was even higher in patients with high sacrectomy.…”

“…Since the authors were specifically searching for insufficiency fractures, they likely discovered more patients with this complication than did earlier reports that relied on the initial radiology report [2,11]. It is important for radiologists and surgeons to be aware of this complication in order to interpret the imaging scans correctly, which can guide the correct treatment.…”