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Clinical and pathologic review of 34 cases of chordoma from the Massachusetts general hospital 1931–1977
MANAGEMENT OF PRIMARY SPINAL CORD TUMORS
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James G. Schwade, M.D., William M. Wara, M.D.,
Glenn E. Sheline, Ph.D., M.D., Stephen Sorgen, M.D., Charles B. Wilson, M.D.
University of California, San Francisco, Division of Radiation Oncology (JGS, WMW, GES) and Department of Neurosurgery (CBW) and Brooks Army Hospital, Radiation Therapy Department, San Antonio, Texas (SS)
Literature is scarce on surgical and/or radiotherapeutic management for primary neoplasms of the spinal cord, a rare form of tumor. We have retrospectively reviewed all cases of spinal cord tumors treated at the University of California, San Francisco, between 1950 and 1975, a total of 33 patients. Using megovoltage equipment, patients were treated to portals large enough to include the tumor with generous margins above and below the area of known disease. In 24 patients tumor histology was confirmed, while nine patients had nondiagnostic tissue diagnoses. All 11 patients who had ependymomas are alive without recurrence with a minimum follow-up of three years. Six patients had low grade astrocytomas and five of the six survived greater than three years. Five of the nine unbiopsied patients were alive with no evidence of disease, having minimum follow-up intervals of three years. Detailed analysis of dose, fractionation, and field size will be presented for all patients. Based upon our data, we currently recommend conservative surgery followed by irradiation as the optimal management for patients with spinal cord tumors.
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CLINICAL AND PATHOLOGIC REVIEW OF 34 CASES OF CHORDOMA FROM THE MASSACHUSETTS GENERAL HCSPITAL 1931-1977 Tyvin Rich, Alan L. Schiller, Herman D. Suit Department of Radiation Medicine, Massachusetts General Hospital, Boston, Massachusetts.
The clinical course and all available pathologic material were reviewed in 39 cases. Two cases were benign chordomas of the base of the skull discovered at autopsy and excluded. Three cases were excluded on the basis of review of the pathologic material. The remaining 34 cases were analyzed.
In this series the tumor occurred most frequently in the fifth decade; the sex distribution was 1:l. The sites involved were sacrococcygeal 44X, vertebral 35%, and base of skull 21%. The most frequent symptom at all locations was pain sometimes associated with a mass(26%) in the vertebral or sacrococcygeal regions. A history of trauma to the region of the primary tumor was found in only 2 cases. The pathology review showed only one correlation of histology with prognosis. Tumors containing chondroid elements were associated with better prognosis. There were three cases of "chondroid chordoma" of the base of skull that had a mean survival of 7.0 years. None received postoperative radiation therapy. 68
Two patients with non-chondroid chordomas at the same location survived an average of 2.2 years and both receieved postoperative radiation therapy. Mitotic figures were rarely found. Cellular pleomorphism was occasionally seen but was not of oroanostic value. Stainins for reticulin fibers was performed Reticulin form s a loose supporin 24 cases, and in all"24 reticulin was present. The presence of reticulin was helpful in tive network around individual cells. distinguishing chordoma from non-reticulin producing tumors, e.g. metastatic adenocarcinoma. This test was used to exclude two cases previous ly thought to be chordoma. Distant metastases developed in 8/32 (26%). The treatment consisted of surgery alone 14/34, surgery and radiation 18/34 and radiation alone 2/34. In the group treated with surgery alone, 8/14 had complete removal of tumor (all sacrococcygeal); in the remaining 6 cases (vertebral and base of skull) the surgeon thought that gross disease was still present. In these 6 cases more than one operation was performed. In the 18,cases treated with surgery and radiation, subtotal resection was followed by postoperative radiation in 16/18, subtotal resection with postoperative radiation later followed by radical resection in one, and one case of postoperative radiation after total gross removal. There were two cases treated with radiation alone after biopsy (1 vertebral and 1 sacrococcygeal). Most of the radiation doses were below 6000 rads; 8 patients received doses below 4500 rads, 9 patients received 4500-6000 rads and one patient received over 8000 rads with combination of external beam and an II25 implant. Survival was related to the site of disease and the feasbility of extirpation. The mo:st favorable location for complete removal was the sacrococcygeal. In the base of the skull"chondroid" tumors were associated with a longer survival than non-chondroid tumors.
34 Cases of Chordoma - Page 2
Radiation therapy has been used in selected cases after total removal but mainly in ,those cases of subtotal excision or recurrence. High doses of 6000 rads or greater have only been used in recent years. The patients who are surviving NED who have received postoperative radiation have had high dose; however, the followup is short (1.4-4.2 years). High dose radiation used postoperatively is likely to improve the local control and survival rates.
69
(31)
James G. Schwade, M.D., William M. Wara, M.D.,
Glenn E. Sheline, Ph.D., M.D., Stephen Sorgen, M.D., Charles B. Wilson, M.D.
University of California, San Francisco, Division of Radiation Oncology (JGS, WMW, GES) and Department of Neurosurgery (CBW) and Brooks Army Hospital, Radiation Therapy Department, San Antonio, Texas (SS)
Literature is scarce on surgical and/or radiotherapeutic management for primary neoplasms of the spinal cord, a rare form of tumor. We have retrospectively reviewed all cases of spinal cord tumors treated at the University of California, San Francisco, between 1950 and 1975, a total of 33 patients. Using megovoltage equipment, patients were treated to portals large enough to include the tumor with generous margins above and below the area of known disease. In 24 patients tumor histology was confirmed, while nine patients had nondiagnostic tissue diagnoses. All 11 patients who had ependymomas are alive without recurrence with a minimum follow-up of three years. Six patients had low grade astrocytomas and five of the six survived greater than three years. Five of the nine unbiopsied patients were alive with no evidence of disease, having minimum follow-up intervals of three years. Detailed analysis of dose, fractionation, and field size will be presented for all patients. Based upon our data, we currently recommend conservative surgery followed by irradiation as the optimal management for patients with spinal cord tumors.
(32)
CLINICAL AND PATHOLOGIC REVIEW OF 34 CASES OF CHORDOMA FROM THE MASSACHUSETTS GENERAL HCSPITAL 1931-1977 Tyvin Rich, Alan L. Schiller, Herman D. Suit Department of Radiation Medicine, Massachusetts General Hospital, Boston, Massachusetts.
The clinical course and all available pathologic material were reviewed in 39 cases. Two cases were benign chordomas of the base of the skull discovered at autopsy and excluded. Three cases were excluded on the basis of review of the pathologic material. The remaining 34 cases were analyzed.
In this series the tumor occurred most frequently in the fifth decade; the sex distribution was 1:l. The sites involved were sacrococcygeal 44X, vertebral 35%, and base of skull 21%. The most frequent symptom at all locations was pain sometimes associated with a mass(26%) in the vertebral or sacrococcygeal regions. A history of trauma to the region of the primary tumor was found in only 2 cases. The pathology review showed only one correlation of histology with prognosis. Tumors containing chondroid elements were associated with better prognosis. There were three cases of "chondroid chordoma" of the base of skull that had a mean survival of 7.0 years. None received postoperative radiation therapy. 68
Two patients with non-chondroid chordomas at the same location survived an average of 2.2 years and both receieved postoperative radiation therapy. Mitotic figures were rarely found. Cellular pleomorphism was occasionally seen but was not of oroanostic value. Stainins for reticulin fibers was performed Reticulin form s a loose supporin 24 cases, and in all"24 reticulin was present. The presence of reticulin was helpful in tive network around individual cells. distinguishing chordoma from non-reticulin producing tumors, e.g. metastatic adenocarcinoma. This test was used to exclude two cases previous ly thought to be chordoma. Distant metastases developed in 8/32 (26%). The treatment consisted of surgery alone 14/34, surgery and radiation 18/34 and radiation alone 2/34. In the group treated with surgery alone, 8/14 had complete removal of tumor (all sacrococcygeal); in the remaining 6 cases (vertebral and base of skull) the surgeon thought that gross disease was still present. In these 6 cases more than one operation was performed. In the 18,cases treated with surgery and radiation, subtotal resection was followed by postoperative radiation in 16/18, subtotal resection with postoperative radiation later followed by radical resection in one, and one case of postoperative radiation after total gross removal. There were two cases treated with radiation alone after biopsy (1 vertebral and 1 sacrococcygeal). Most of the radiation doses were below 6000 rads; 8 patients received doses below 4500 rads, 9 patients received 4500-6000 rads and one patient received over 8000 rads with combination of external beam and an II25 implant. Survival was related to the site of disease and the feasbility of extirpation. The mo:st favorable location for complete removal was the sacrococcygeal. In the base of the skull"chondroid" tumors were associated with a longer survival than non-chondroid tumors.
34 Cases of Chordoma - Page 2
Radiation therapy has been used in selected cases after total removal but mainly in ,those cases of subtotal excision or recurrence. High doses of 6000 rads or greater have only been used in recent years. The patients who are surviving NED who have received postoperative radiation have had high dose; however, the followup is short (1.4-4.2 years). High dose radiation used postoperatively is likely to improve the local control and survival rates.
69