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Adjuvant Radiation Improves Local Control of Sacral Chordoma

Key findings

  • Among patients with sacral chondroma, overall survival at five and 10 years was not significantly different for those with primary tumors versus those with first-time local recurrent tumors
  • Increased tumor size predicted distant relapse, worse overall survival and worse distant relapse-free survival among patients with primary tumors, as well as worse local relapse-free survival among patients with first local recurrent tumors
  • Multivariate analysis demonstrated that in patients with primary tumors, adjuvant radiation therapy aided local control

Chordoma is a rare malignancy that occurs most frequently in the sacrum. Few high-quality studies have compared treatments for primary and first-time local recurrent tumors.

Researchers at Massachusetts General Hospital recently conducted a 35-year retrospective review of patients operated on for sacral chordoma. The results showed that adjuvant radiation improved local relapse-free survival in patients with primary tumors. The results were published in The Spine Journal.

Research Fellow Olivier D.R. van Wulfften Palthe, MD, and Francis J. Hornicek, MD, MSc, PhD, former chief of Orthopaedic Oncology Service, and colleagues studied 101 patients with sacral chordoma, without metastatic disease, who underwent surgery at Mass General between 1978 and 2013 and had at least 36 months of follow-up.

Most of the patients, 73 (72%), presented with a primary tumor and no prior treatment. Twenty-eight (28%) came to the center with a first local recurrent tumor after prior treatment elsewhere.

Overall survival at five and 10 years was not significantly different for patients with primary tumors and those with first local recurrent tumors (79%/59% and 65%/40%, respectively).

Unsurprisingly, the researchers note, primary tumors were significantly larger than first local recurrent tumors at presentation (median 158 cm3 vs. 39 cm3). Yet local relapse-free survival at five years was comparable for patients in the two groups (86% and 79%).

Among patients with primary tumors, increased tumor size was an independent predictor of worse overall and distant relapse-free survival. Among patients with first local recurrent tumors, tumor size was a predictor of worse local relapse-free survival.

Altogether, 27% of the patients with primary tumors eventually had a distant relapse, and tumor size was an independent predictor.

The biggest change during the long study period, the researchers say, was the increasing use of adjuvant radiation to treat chordoma at increasingly high doses. A significantly lower median total dose was delivered before January 2000 than after (50 vs 70 Gy), so that date was used as a cutoff.

Patients treated before January 2000 were more likely to have a recurrence, the researchers found. Among patients with primary tumors, not receiving radiation was an independent predictor of worse local relapse-free survival.

However, neoadjuvant and/or adjuvant radiation therapy was associated with an increased risk of deep infection in patients with first local recurrent tumors.

The authors caution that these results must be interpreted with care because they are based only on bivariate analysis (not multivariate analysis) due to small numbers of patients.

The authors emphasize that local control is the principal challenge in managing sacral chordoma. They advise close follow-up so that small local recurrences might be detected early, perhaps helping to extend local relapse-free survival.

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