Resection Of Sacral Chordoma Research Articles

Multidisciplinary surgical considerations for en bloc resection of sacral chordoma: review of recent advances and a contemporary single-center series.

Contemporary management of sacral chordomas requires maximizing the potential for recurrence-free and overall survival while minimizing treatment morbidity. En bloc resection can be performed at various levels of the sacrum, with tumor location and volume ultimately dictating the necessary extent of resection and subsequent tissue reconstruction. Because tumor resection involving the upper sacrum may be quite destabilizing, other pertinent considerations relate to instrumentation and subsequent tissue reconstruction. The primary aim of this study was to survey the surgical approaches used for managing primary sacral chordoma according to location of lumbosacral spine involvement, including a narrative review of the literature and examination of the authors' institutional case series. The authors performed a narrative review of pertinent literature regarding reconstruction and complication avoidance techniques following en bloc resection of primary sacral tumors, supplemented by a contemporary series of 11 cases from their cohort. Relevant surgical anatomy, advances in instrumentation and reconstruction techniques, intraoperative imaging and navigation, soft-tissue reconstruction, and wound complication avoidance are also discussed. The review of the literature identified several surgical approaches used for management of primary sacral chordoma localized to low sacral levels (mid-S2 and below), high sacral levels (involving upper S2 and above), and high sacral levels with lumbar involvement. In the contemporary case series, the majority of cases (8/11) presented as low sacral tumors that did not require instrumentation. A minority required more extensive instrumentation and reconstruction, with 2 tumors involving upper S2 and/or S1 levels and 1 tumor extending into the lower lumbar spine. En bloc resection was successfully achieved in 10 of 11 cases, with a colostomy required in 2 cases due to rectal involvement. All 11 cases underwent musculocutaneous flap wound closure by plastic surgery, with none experiencing wound complications requiring revision. The modern management of sacral chordoma involves a multidisciplinary team of surgeons and intraoperative technologies to minimize surgical morbidity while optimizing oncological outcomes through en bloc resection. Most cases present with lower sacral tumors not requiring instrumentation, but stabilizing instrumentation and lumbosacral reconstruction are often required in upper sacral and lumbosacral cases. Among efforts to minimize wound-related complications, musculocutaneous flap closure stands out as an evidence-based measure that may mitigate risk.

Clinical Outcome after Surgical Treatment of Sacral Chordomas: A Single-Center Retrospective Cohort of 27 Patients.

Introduction: The aims of our study were (1) to determine disease-specific and disease-free survival after the en-bloc resection of sacral chordomas and (2) to investigate potential risk factors for tumor recurrence and major postoperative wound-related complications. Methods: We retrospectively analyzed 27 consecutive patients with sacral chordomas who were surgically treated in our institution between 2004 and 2022. Three patients (11.1%) had a recurrent tumor and four patients (14.8%) had history of a second primary solid tumor prior to or after their sacral chordoma. A combined anterior and posterior approach, colostomy, plastic reconstruction, and spinopelvic instrumentation were necessitated in 51.9%, 29.6%, 37%, and 7.4% of cases, respectively. The mean duration of follow-up was 58 ± 41 months (range= 12-170). Death-related-to-disease, disease recurrence, and major surgical site complications were analyzed using Kaplan-Meier survival analysis, and investigation of the respective risk factors was performed with Cox hazard regression. Results: The estimated 5-year and 10-year disease-specific survival was 75.3% (95% CI = 49.1-87.5%) and 52.7% (95% CI = 31-73.8%), respectively. The estimated 1-year, 5-year, and 10-year disease-free survival regarding local and distant disease recurrence was 80.4% (95% CI = 60.9-91.1%), 53.9% (95% CI = 24.6-66.3%), and 38.5% (95% CI = 16.3-56.2%), respectively. The mean survival of the recurred patients was 61.7 ± 33.4 months after their tumor resection surgery. Conclusions: Despite the high relapse rates and perioperative morbidity, long-term patient survival is not severely impaired. Positive or less than 2 mm negative resection margins have a significant association with disease progression.

Spinal cord stimulation for chronic pain treatment following sacral chordoma resection: illustrative case.

Cancer-related or postoperative pain can occur following sacral chordoma resection. Despite a lack of current recommendations for cancer pain treatment, spinal cord stimulation (SCS) has demonstrated effectiveness in addressing cancer-related pain. A 76-year-old female with a sacral chordoma underwent anterior osteotomies and partial en bloc sacrectomy. She subsequently presented with chronic pain affecting both buttocks and posterior thighs and legs, significantly impeding her daily activities. She underwent a staged epidural SCS paddle trial and permanent system placement using intraoperative neuromonitoring. The utilization of percutaneous leads was not viable because of her history of spinal fluid leakage, multiple lumbosacral surgeries, and previous complex plastic surgery closure. The patient reported a 62.5% improvement in her lower-extremity pain per the modified Quadruple Visual Analog Scale and a 50% improvement in the modified Pain and Sleep Questionnaire 3-item index during the SCS trial. Following permanent SCS system placement and removal of her externalized lead extenders, she had an uncomplicated postoperative course and reported notable improvements in her pain symptoms. This case provides a compelling illustration of the successful treatment of chronic pain using SCS following radical sacral chordoma resection. Surgeons may consider this treatment approach in patients presenting with refractory pain following spinal tumor resection.

Anatomical Considerations and Plastic Surgery Reconstruction Options of Sacral Chordoma Resection.

Introduction Chordomas are slow-growing malignant bone tumors arising from remnant embryonic notochord cells with predilection for the sacrum. They rarely metastasize, and early surgical resection with clear margins is the treatment of choice followed by plastic surgery reconstruction supplemented with adjuvant radiotherapy based on the local treatment protocol or in cases with a contaminated surgical field. Aim The aim of the present study is to present our experience in surgical management of sacral chordomas and propose a surgical reconstruction algorithmconsidering anatomical parameters after partial or total sacrectomy. Materials and methods Twenty-seven patients with sacral chordomas were treated in our Orthopaedic Surgery Department between January 1997 and September 2022, and 10 of them had plastic surgery reconstruction. Patients were divided into groups based on the type of sacrectomy, sacrum anatomical vascular or neural variations, partial or total, and the type of soft tissue reconstruction. The postoperative complications and the functional outcomes in each patient were assessed. Results Bilateral gluteal advancement flaps or gluteal perforator flaps are the first choice in patients with partial sacrectomy, intact gluteal vessels, and without preoperative radiotherapy followed by transpelvic vertical rectus abdominis myocutaneous flap or free flaps in those patients with near total sacrectomy and preoperative radiation therapy. Conclusion There are four reliable options for patients after sacral chordomaresection: direct closure, bilateral gluteal advancement flaps, transpelvic vertical rectus abdominis myocutaneous flaps,and free flaps. Each time, tumor-free margins and a good reconstructive plan according to the defect and patient characteristics are mandatory.

VP3: Pelvic Reconstruction After Large Sacral Chordoma Resection Using Acellular Dermal Matrix and Double Pedicled Gracilis Muscle Flap Combined with Gluteal Fasciocutaneous Rotation Flap

INTRODUCTION: Sacral chordomas are rare, malignant primary bone tumors. Surgical resection with wide margins, combined or not with radiotherapy, is the only effective treatment with near 50% remission at 10 years. Surgery results in large three dimensional defects, as total or subtotal sacrectomy is often required. The treatment is challenging and requires a multidisciplinary approach. Several reconstructive approaches have been described, classically including rectus abdominis or gluteus musculocutaneus flap and omental flap. We aim at presenting an innovative method of pelvic floor reconstruction using acellular dermal matrix and double pedicled Gracilis muscle flap combined with gluteal fasciocutaneous rotation flap. MATERIALS AND METHODS: We report the case of a 70 yo patient affected by locally invasive sacral chordoma. The oncological treatment included neuronavigation-assisted subtotal sacrectomy with en bloc resection at the level of S1-S2 intervertebral disc and laparoscopic abdomino-perineal amputation with terminal colostomy. After the R0 resection was confirmed, pelvic floor was reconstructed with an acellular dermal matrix and a double-breasted pedicled muscle Gracilis flap to avoid herniation of the abdominal cavity organs. The overlying soft tissue defect was reconstructed with an unilateral gluteal fasciocutaneous rotation flap partially deepitelialized to fill the dead space. The donor sites were closed directly. RESULTS: No surgical complications were observed, with flaps and donor sites healing uneventfully. After 3 days in intermediate intensive care and 22 days in plastic surgery department, he was transferred to rehabilitation center. Walking was reassumed after 2 weeks, sitting after 4 weeks. Satisfying outcomes both functionally and cosmetically for both patient and surgeons were observed at 3 months follow-up. CONCLUSION: Large sacral defect can successfully be reconstructed with double pedicled muscle Gracilis flap combined with gluteal rotation flap. The association with acellular dermal matrix is recommended to avoid abdominal cavity organs herniation. The oncological, functional results at 3 months are satisfying with minimal donor site morbidity. Presentation Type

Surgical and Functional Outcomes of En Bloc Resection of Sacral Chordoma: a Retrospective Analysis.

Conventional chordomas occur most commonly in the sacral region. Currently, wide local excision remains the only hope for a cure in this disease. However, given the substantial morbidity caused by sacrectomy, a delicate balance needs to be established. This study elaborates our experience in managing these complicated cases with the help of a multidisciplinary team approach and outlines the various surgical and functional outcomes of sacrectomy. This was aretrospective observationalstudy. Ten cases of biopsy proven sacral chordoma underwent en bloc resection by a posterior approach from 2011 to 2018 after multidisciplinary evaluation. Data collected and analyzed included demographics, extent of the disease, and operative parameters such as operative time, estimated blood loss, level of vertebral resection, level and number of the most caudal nerve roots preserved, surgical margins, soft tissue, or spinal reconstruction. Postoperative outcomes included time to recurrence and neurological function at 1 year. Mean size of the tumor was 116.1 mm. Three (30%) patients had positive margins. The median time to recurrence was 32 months. Four patients eventually succumbed to the disease due to local or distant recurrence. Bladder and bowel functions were excellent in those with preserved S3. Two patients remained wheelchair bound; the rest were able to walk with or without support. Management of sacral chordoma remains an onerous journey for both the treating surgeon and the patient. A multidisciplinary team approach, with careful preservation of sacral nerve roots, negative surgical margins, and excellent postoperative rehabilitation, can achieve optimum results.

Comparison of surgical invasiveness and morbidity of adult spinal deformity surgery to other major operations

Adult spinal deformity (ASD) surgeries are complex, involving long operative times and surgical morbidity. It is currently unclear how the invasiveness of ASD surgery compares to other major operations. To: (1) develop a quantitative score of surgical morbidity and invasiveness, and (2) compare this score between ASD surgery and other major operations. Retrospective review of prospectively collected data. A prospective surgical registry was used to identify all patients undergoing ASD surgery involving ≥ 7 segments. Seventeen additional procedures were included: coronary artery bypass grafting (CABG), pancreatectomy, and esophagectomy, among others. Perioperative factors (operative time, transfusions, ventilation) and complications were collected and combined with a previously validated Postoperative Morbidity Survey to create a Surgical Invasiveness and Morbidity Score (SIMS). Computed scores were compared across surgeries using Welch's t-test. Multiple linear regression modeling was used to compare the SIMS of major surgeries relative to ASD while controlling for patient demographics and comorbidities. A total of 1,245,282 surgical patients were included, 4,656 of which underwent ASD surgery. After multiple regression modeling controlling for patient demographics and comorbidities, ASD surgery ranked fourth in SIMS. ASD surgery had a significantly greater SIMS than 13 other major procedures including 6th esophagectomy (adjusted mean difference=-0.05, 95%CI -0.01-0.09, p<.001), 8th pancreatectomy (-0.40, 0.37-0.44, p<.001), 11th craniotomy for tumor (-1.01, 0.98-1.04, p<.001), and 12th sacral chordoma resection (-1.31, 1.26-1.37, p<.001). ASD surgery was associated with significantly greater SIMS than many other major operations, even when controlling for important perioperative factors. These data have implications for patient counseling, resource allocation, and informed consent.

Outcomes of Surgery for Sacral Chordoma and Impact of Complications: A Report of 50 Consecutive Patients With Long-Term Follow-Up.

Study Design:Retrospective case series.Objective:To determine predictive factors of overall survival (OS) and local recurrence (LR), report complications, and assess the impact of complications on survival, recurrence, and function in patients undergoing en bloc resection of sacral chordoma.Methods:This retrospective case series was obtained from a prospective database (1995-2016). All patients underwent en bloc resection of sacral chordoma. Demographic, perioperative, and complication data were collected. Outcomes included: overall survival(OS), local recurrence(LR), and complications. Survival analysis with multivariable cox regression was performed.Results:Among 50 patients, median follow-up was 5.3 years (range = 1.3-17.2). The majority (82%) underwent a negative margin resection. Survival: 17 patients died (34%) with a median OS of 10.0 years (range = 1.3-17.2). Multivariable cox regression revealed that a negative margin resection was not significantly associated with improved survival (HR = 3.35, 95%CI 0.87-12.80, P = .078). Recurrence: 20 patients (40%) experienced LR with a median time of 6.2 years (range = 0-16.9). Multivariable cox regression revealed that a negative margin resection was associated with a significant decreased risk of LR (HR = 4.96, 95%CI 1.84-13.34, P = 0.002,). A 62% overall complication rate was seen (42% major), with 26% reoperation rate. Of the reoperations, 54% were delayed (>6 weeks after the index surgery). Multivariable cox regression demonstrated that neither major complication nor reoperation significantly impacted OS (HR = 0.62, 95%CI 0.22-1.79, P = 0.380), LR (HR = 1.28, 95%CI 0.49-3.36, P = 0.611), or functional outcomes (OR = 2.94, 95%CI 0.25-34.8, P = 0.393).Conclusions:Negative margin resection was associated with decreased LR. Neither major complication nor reoperation significantly impacted OS, LR, or functional outcome. Though additional studies are needed, it appears that despite the morbidity associated with sacral chordoma resection, the long-term clinical outcomes are favorable.

Cervical chordomas: multicenter case series and meta-analysis.

En bloc spondylectomy is the gold standard for surgical resection of sacral chordomas (CHO), but the effect of extent of resection on recurrence and survival in patients with CHO of the cervical spine remains elusive. MEDLINE, Embase, Scopus, and Cochrane were systematically reviewed. Patients with cervical CHO treated at three tertiary-care academic institutions were reviewed for inclusion. We performed an individual participant data meta-analysis to assess the overall survival (OS) and progression free survival (PFS) after en bloc-gross total resection (GTR) and intralesional-GTR compared to subtotal resection (STR). We then performed an intention-to-treat analysis including all patients with attempted en bloc resection in the en bloc group, regardless of the surgical margins. There was a total of 13 series including 161 patients with cervical CHO, including our current series of 22 patients. GTR (en bloc-GTR + intralesional-GTR) was associated with a significant decrease in the risk of local progression (pooled hazard ratio (PHR) = 0.22; 95% CI 0.08-0.59; p = 0.003) and risk of death (PHR 0.31; 95%; CI 0.12-0.83; p = 0.020). A meta-regression analyses determined that intralesional-GTR improved PFS (PHR 0.35; 95% CI 0.16-0.76; p = 0.009) as well as OS (PHR 0.25; 95% CI 0.08-0.79; p = 0.019) when compared to STR. En bloc-GTR was associated with a significant reduction in the risk of local progression (PHR 0.06; 95% CI 0.01-0.77; p = 0.030), but not a decreased OS (PHR 0.50; 95% CI 0.19-1.27; p = 0.145). Our intention-to-treat analyses revealed a near significant improvement in OS for the en bloc group (PHR: 0.15; 95% CI 0.02-1.22; p = 0.054), and nearly identical improvement in PFS. Radiation data was not available for the studies included in the meta-analysis. This is the first and only meta-analysis of patients with cervical CHO. We found that both en bloc-GTR and intralesional-GTR resulted in improved local tumor control when compared to STR.

A case-control study of computer navigation assisted resection of primary sacral chordoma above sacrum 3 level

BackgroundThe operation of sacral chordoma resection is difficult especial in the tumor above sacrum 3 level and the local recurrence rate was high. The purpose of this study is to analyze the effect of computer navigation aided technology in primary sacral chordoma resection above sacrum 3 level through a case-control study, which including perioperative safety, surgical margin, postoperative recurrence and function results. MethodsThis is a retrospective case-control study. The clinical data of 25 patients received initial computer-assisted resection of sacral chordoma above the level of sacrum 3 from 2009 to 2016 were analyzed; the patients underwent non-navigation assisted resection of tumor above the level of sacrum 3 in the same period were matched and 25 patients were selected randomly. There was no significant difference between these two groups in gender (P = 0.370), age (P = 0.554), tumor transverse diameter (P = 0.836). The average maximum diameter of tumor in navigation group was significant bigger than that in non-navigation group (P = 0.005). The intraoperative safety results, surgical margin, postoperative complications, recurrence rate and function were compared between these groups. ResultsThere was no significant difference between navigation and non-navigation group in operative time (P = 0.105) and intraoperative blood loss (P = 0.537). There were 18 wide resections, 4 marginal resections and 3 intracapsular resections in navigation group; there were 6 wide resections, 12 marginal resections and 7 intracapsular resections in non-navigation group; the surgical margins of two groups were significant different (P = 0.003). There were 5 cases (20%) and 6 cases (24%) with wound complication in navigation group and non-navigation group (P = 0.733). The average follow-up was 49.6 (16–102) months in navigation group and 51.3 (12–110) months in non-navigation group. Three cases (12%) showed recurrence in navigation group and six cases showed recurrence (24%) in non-navigation group. The surgical margin was significantly related with tumor recurrence (P = 0.000). The average MSTS score was 27.3 (19–30) and 26.5 (20–29) in navigation group and non-navigation group (P = 0.374). ConclusionThe computer navigation aided technology can improve the accuracy of primary sacral chordoma resection, and make more cases achieve safe surgical margin. Compared with the traditional operation, the application of computer navigation in the larger tumor resection does not increase the operation time and intraoperative blood loss, which shows good safety.

Predictive Value of Preoperative Magnetic Resonance Imaging Findings for Survival and Local Recurrence in Patients Undergoing En Bloc Resection of Sacral Chordomas.

Few studies have assessed the prognostic importance of preoperative magnetic resonance imaging (MRI) scan findings in patients undergoing en bloc resection of sacral chordomas. To (1) report in-depth imaging characteristics of sacral chordomas, (2) describe the patterns of local and distant recurrence, and (3) determine imaging predictors of overall survival (OS) and local recurrence (LR). This retrospective case series was obtained from a prospectively maintained spine database from 1995 to 2016. All patients underwent en bloc resection of sacral chordomas. Detailed demographic, outcome, and MRI data were collected. A survival analysis was completed with multivariable cox regression to assess the impact of MRI findings on OS and LR. A total of 41 patients underwent en bloc resection of sacral chordoma with preoperative MRI scans. Tumor characteristics included lobulated: (93%) and soft tissue tail (54%). The following areas had tumor invasion lobulated: sacroiliac (SI) joint (15%), ilium (5%), piriformis (61%), gluteus (46%), subcutaneous fat (32%), and lumbosacral venous plexus (22%). After multivariable analysis, only subcutaneous fat extension was an independent predictor of decreased OS (hazard ratio 5.30, 95% confidence interval 1.47-19.19, P=.011). Though not significant after multivariable analysis, the following factors were significant predictors of LR after univariate logrank testing: above the L5/S1 disc space (P=.004), SI joint invasion (P=.036), and piriformis extension (P=.022). The presence of subcutaneous fat extension was an independent predictor of decreased OS. Other MRI findings with potential for future evaluation include size, presence of soft tissue tail, extension above L5/S1, and SI joint and piriformis invasion.

Association between patient age and the risk of mortality following local recurrence of a sacral chordoma.

Local recurrence (LR) of sacral chordoma is a difficult problem and the mortality risk associated with LR remains poorly described. The purpose of this study was to evaluate the risk of mortality in patients with LR and determine if patient age is associated with mortality. A total of 218 patients (144 male, 69 female; mean age 59 ± 15 years) with sacrococcygeal chordomas were reviewed. Cumulative incidence functions and competing risks for death due to disease and nondisease mortality were employed to analyze mortality trends following LR. The 10-year overall survival (OS) was 55%. Patients with LR had 44% 10-year OS, similar to patients without (59%; P = .38). The 10-year OS between those less than 55 compared with ≥55 years were similar (69% vs 48%; P = .52). The 10-year death due to disease was worse in patients with LR compared with those without (44% vs 84%; P < .001). In patients without LR, patients ≥55 years were 1.6-fold more likely to experience death due to other causes. Patients with an LR are more likely to die due to disease. Advanced patient age was associated with higher all-cause mortality following resection of sacral chordoma. LR of chordoma was associated with increased disease-specific mortality, regardless of age.

The use of preoperative imaging in the treatment of sacral chordomas.

We greatly appreciate the thoughtful response by Munger and colleagues (1) to our original article on the predictive value of magnetic resonance imaging (MRI) findings on outcomes after en bloc resection of sacral chordomas (2). While we caution against over-interpretation given our sample size, we humbly believe that the preoperative imaging factors elucidated in our study may have prognostic implications that are important for both patients and surgeons.

Maximizing Sacral Chordoma Resection by Precise 3-Dimensional Tumor Modeling in the Operating Room Using Intraoperative Computed Tomography Registration with Preoperative Magnetic Resonance Imaging Fusion and Intraoperative Neuronavigation: A Case Series

The primary treatment for patients with sacral chordoma is en bloc surgical resection with negative margins, which has been shown to reduce local recurrence and tumor-related morbidity. Here we describe the use of intraoperative neuronavigation using preoperative spine magnetic resonance imaging fused to intraoperative computed tomography (CT) to create 3-dimensional tumor reconstructions in the operating room for intraoperative identification of bone and soft-tissue margins for maximal safe tumor resection. A single-institution retrospective chart review was completed to encompass our experience of 6 consecutive patients who had sacral chordoma resections using our described navigation protocol. We collected data on patient demographics, previous surgeries, radiation therapy, preoperative examination, spinal levels involved, dural involvement, estimated blood loss, surgery time, tissue diagnosis, follow-up, postoperative examination, complications, and recurrence. Primary outcome was en bloc resection with negative margins as planned preoperatively. Negative surgical margins were achieved in 5 of 5 patients, who were preoperatively planned for en bloc resection with negative margins. The most common levels involved were S4-S5. All patients had a stable or improved neurologic examination after en bloc surgical resection. The average follow-up was 5.4 months ± 84.6 days. No patient had residual or recurrent tumor at last follow-up. Magnetic resonance imaging-CT fusion and 3-dimensional reconstruction techniques using an intraoperative CT scanner with image-guided navigation to aid preoperative planning and surgical resection of sacral chordomas are not well represented in the literature. This technique can be used for planning en bloc surgical resections and for more precisely identifying tumor margins intraoperatively.

Marginal Resection of Sacral Chordoma through Posterior Approach: Study of 18 Cases

The study was carried out to report the results of marginal resection in sacral chordoma using a posterior midline approach. The study was carried out between July 2008 to June 2016, there were 21 patients who underwent the operation. Fourteen patients were male and seven were female and age ranging from 28 and 76 years. All most of the patients presented with pain, sacral mass and neurological deficit. Total sacrectomy and bone reconstruction were carried out in 11 patients. Subtotal sacrectomy was carried out in the remaining ten patients. Patients were followed up for at least seven years. Recovery after the operation was good. Duration of operation ranged between three to six hours. Three to five units blood was transfused in all patients after operation .Bowel and bladder dysfunction were almost all patients. After surgery following local complications including infection and wound disruption occurs in three patients and seroma occurs in two patients. Three patients (14%) had tumor recurrence and one patient expired three years after operation. 18 patients were still tumor-free at long term (seven years) follow-up. Marginal resection of sacral chordoma through posterior approachcan be a management plan for sacral chordoma with acceptable results.TAJ 2017; 30(1): 21-26

Chordome géant du sacrum et reconstruction par lambeau perforant glutéal supérieur, à propos d’un cas clinique et revue de la littérature

Sacral chordomas are rare primary bone tumors and represent more than half of all primary malignant sacral tumors. Surgical resection is the only treatment with close to 50% of remission at 10 years, with or without radiotherapy. This tissue removal can be very extensive and morbid, particularly for evolved tumors. The reconstruction mostly uses myocutaneous flaps, notably the gluteus maximus flap and the latissimus dorsi flap, increasing morbidity of the surgical procedure. To avoid a muscular sacrifice and reduce the post-surgical morbidity, we describe the case of a patient who underwent a giant sacral chordoma resection and a reconstruction with a superior gluteal artery perforator flap. A 57-y.o. patient with a voluminous sacral chordoma had undergone a partial sacrectomy and abdomino-perineal resection. Firstly, a laparoscopy was realized to create a colostomy, to dissect an omental flap and to prepare the monobloc resection. In a prone position, the resection of the tumor was achieved and a de-epithelialized superior gluteal artery perforator flap was performed to fill the space and to support pelvic organs. For resections of sacral chordomas, coelioscopy has considerably reduced the surgical morbidity. However, the majority of reconstructions use myocutaneous flaps, specifically gluteus maximus and latissimus dorsi, which their postural function is considerable. Muscular sacrifice can lead to functional impotence with difficulty walking and standing up and run contrary to the diminution morbidity initiated by oncologic surgeons.

Computer Navigation-aided Resection of Sacral Chordomas.

Background:Resection of sacral chordomas is challenging. The anatomy is complex, and there are often no bony landmarks to guide the resection. Achieving adequate surgical margins is, therefore, difficult, and the recurrence rate is high. Use of computer navigation may allow optimal preoperative planning and improve precision in tumor resection. The purpose of this study was to evaluate the safety and feasibility of computer navigation-aided resection of sacral chordomas.Methods:Between 2007 and 2013, a total of 26 patients with sacral chordoma underwent computer navigation-aided surgery were included and followed for a minimum of 18 months. There were 21 primary cases and 5 recurrent cases, with a mean age of 55.8 years old (range: 35–84 years old). Tumors were located above the level of the S3 neural foramen in 23 patients and below the level of the S3 neural foramen in 3 patients. Three-dimensional images were reconstructed with a computed tomography-based navigation system combined with the magnetic resonance images using the navigation software. Tumors were resected via a posterior approach assisted by the computer navigation. Mean follow-up was 38.6 months (range: 18–84 months).Results:Mean operative time was 307 min. Mean intraoperative blood loss was 3065 ml. For computer navigation, the mean registration deviation during surgery was 1.7 mm. There were 18 wide resections, 4 marginal resections, and 4 intralesional resections. All patients were alive at the final follow-up, with 2 (7.7%) exhibiting tumor recurrence. The other 24 patients were tumor-free. The mean Musculoskeletal Tumor Society Score was 27.3 (range: 19–30).Conclusions:Computer-assisted navigation can be safely applied to the resection of the sacral chordomas, allowing execution of preoperative plans, and achieving good oncological outcomes. Nevertheless, this needs to be accomplished by surgeons with adequate experience and skill.

Wide Resection of Sacral Chordoma Including Gluteus Maximus Muscles via Posterior Approach

Wide Resection of Sacral Chordoma Including Gluteus Maximus Muscles via Posterior Approach

En bloc resection of middle-lower sacral chordomas under the microscope: a clinical study

Objective To investigate the application value of microneurosurgery in combination with en-bloc idea in the resection of middle-lower sacral chordomas. Methods The chordomas only involving under S3 (including S3) are known as the middle-lower sacral chordomas. Eleven patients with middle-lower sacral chordoma were treated surgically from October 2007 to December 2012. The en-bloc resection concept was used as a guiding principle during the operation; osteotomy, nerve anatomy, and tumor separation were performed by using microneurosurgical technique in the specific removal process. The effect of operation and complications were observed. Results In the case of keeping the capsule intact, the sacral chordomas were totally removed. The mean time of operation was 141 min, and the mean blood loss was 420 ml. The nerves were clearly identified under the microscope. The anterior nerve roots above bilateral S3 were retained completely in 9 cases, and the anterior nerve roots of the unilateral S3 were retained completely in 2 cases. The bowel and bladder functions were preserved completely in 10 cases at 6 months after procedure, and partially preserved in one case. The patients were followed up for a mean of 3.7 years. Two patients had local recurrence. Conclusions In the middle-lower sacral chordoma surgery, en-bloc resection in combination with microneurosurgery technique is conducive to en-bloc resection of sacral chordomas and protection of neurological function, and reduction of introperative blood loss. The recurrence rate is low. Key words: Chordoma; Sacrococcygeal region; Microsurgery; En bloc resection

Prognostic factors in surgical resection of sacral chordoma.

The best treatment of sacral chordoma is surgical resection, nowadays associated with optimized radiation therapy. We analysed 1) the oncologic outcome in a large series; 2) the effect of previous intralesional surgery, resection level, tumor volume and margins on survivorship to local recurrence (LR) and 3) the complication rate. We reviewed 71 patients with sacral chordomas. Forty-eight resections were proximal to S3. Mean tumor volume was 535 cm3. Eleven received previous intralesional surgery elsewhere. Margins were wide in 44 resections, wide-contaminated in 11, marginal in 9 and intralesional in 7. Overall survival was 92%, 65% and 44% at 5, 10 and 15 years. At a mean of 9.5 years 37 were NED (54.4%), 23 died with disease (33.8%) and 8 were alive with disease (11.7%). Relapses included 15 LRs, 6 distant metastases, 17 both. LR rate was significantly higher in patients with previous surgery (p=0.0217), with inadequate margins (p= 0.0339) and large tumors(p<0.01), whereas resection level was not significant. Multivariate analysis confirmed the role of tumor volume. Complication rate was high (80.9%) with an infection rate of 41.2%. The most prominent adverse factor for LR was previous intralesional surgery. LR rate was related with inadequate margins and tumor volume.