Background: Sacral chordoma is a rare, low to intermediate-grade
tumor that poses substantial challenges in terms of timely diagnosis and
adequate treatment. Few studies have examined the oncologic and functional
outcomes of patients treated for sacral chordoma.
Methods: The clinical records of sixteen patients who had undergone
sacrectomy for chordoma between 1985 and 2001 were evaluated retrospectively.
All patients underwent resection by means of a sequential combined anterior
and posterior approach. Patients were followed clinically at six-month
intervals following recovery from the index surgical procedure. The disease
onset, treatment, hospital stay, recurrence rates, survival, adjuvant therapy,
functional outcome measures, and complications were evaluated.
Results: The average age at the time of diagnosis was sixty-one
years. The mean tumor size was 15.2 cm in diameter, and all patients had a
resection involving S1 or S2. The mean duration of follow-up was sixty-six
months, and the tumor recurred in twelve of the sixteen patients. The mean
time to metastasis was fifty months. Four patients were clinically
disease-free at a mean follow-up of 94.5 months, while five patients died as a
result of progressive local or metastatic disease at a mean follow-up of 31.4
months. Only one patient had normal bowel and bladder control postoperatively,
and only three were able to walk without assistive devices. Eight patients had
wound complications, and one patient had a deep-vein thrombosis. With the
numbers available, neither negative margins at the time of initial tumor
resection nor adjuvant radiation therapy had a significant impact on survival
or local recurrence. More cephalad levels of resection were associated with
significantly worse bowel (p = 0.01) and bladder (p = 0.01) control.
Complications were frequent and were more common with a larger tumor size at
the time of presentation (p = 0.034).
Conclusions: The treatment of sacral chordoma is an arduous clinical
undertaking that requires a multidisciplinary approach and attention to detail
from the outset. Despite aggressive well-planned surgical management and
adherence to strict surveillance protocols, frequent recurrence and the late
onset of metastatic disease are to be expected in a substantial proportion of
patients, especially those with a very large chordoma or one at a more
cephalad level. Adequate surgical treatment results in substantial functional
impairment and numerous complications; however, it does offer the possibility
of long-term disease-free survival. We advocate an attempt at complete
resection, when there is still a possibility of cure, and aggressive treatment
of local recurrences.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.