Subtotal Sacrectomy followed by Maximally Tolerated 3D Conformal Radiation for High-Level Chordomas with Neural Integrity: Technique and Outcome

Abstract

Background data: Chordomas are the most common sacral tumors, usually treated by wide resections with free margins. Radical resections are likely followed by significant neurological deficits that may not be accepted for some patients who presented with preserved neural functions. Purpose: To present local institutional experience in the technique and outcome of subtotal sacrectomy followed by maximally tolerated radiation therapy in a cohort of patients having high sacral (S1-S2) chordomas who presented with intact neurological functions and were not previously treated. Study design: Retrospective case series. Patients and Methods: This is a retrospective case series conducted over 7 years, including 14 consecutive patients with high-level sacral chordomas who refused radical resection and underwent subtotal sacrectomy aiming to preserve as many neural structures as possible, followed by 3D conformal radiotherapy given at a maximum dose tolerated by the surrounding viscera. The surgical resection, perioperative management, including radiotherapy techniques, and their functional and oncologic outcomes were reviewed. Results: The mean age was 44.6 ± 4.7 years, and 10 cases (71.4%) were males. Patients complained of sacral pain for 2–9 months before diagnosis, and all were continent with no gross sensorimotor deficits. Resections were performed through posterior-only approaches using T-shaped or inverted U-shaped incisions. Surgeries went uneventful, with two incisions indicated for further plastic management. Negative margins were achieved in 1 case. Bladder/bowel functions were lost postoperatively in 28.6% of cases. Ten cases had disease progression at a mean duration of 62.4 ± 27.9 months. The median survival was 99 months. The 5-year absolute survival rate was 78.6% and the 5-year disease progression was 42.9%. The overall survival in this study was found to be 35.7%, with a median follow-up of 6.3 years. Conclusion: Despite the promising outcomes at 5 years, the used strategy was associated with sphincteric dysfunctions in a substantial proportion of patients and failed to achieve an adequate overall survival. We recommend radical resections for young patients to improve survival. Subtotal sacrectomy followed by 3D conformal radiation can be a valid alternative for older patients with shorter life expectancy. (2021ESJ250)