Letter: Factors Predicting Recurrence after Resection of Clival Chordoma Using Variable Surgical Approaches and Radiation Modalities
Letter: Factors Predicting Recurrence after Resection of Clival Chordoma Using Variable Surgical Approaches and Radiation Modalities
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DOI：
10.1093/neuros/nyx136
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发表时间：
2015-02
期刊：
影响因子：
4.8
通讯作者：
Arman Jahangiri;A. Chin;J. Wagner;S. Kunwar;C. Ames;D. Chou;I. Barani;A. Parsa;M. McDermott
中科院分区：
文献类型：
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作者：
Arman Jahangiri;A. Chin;J. Wagner;S. Kunwar;C. Ames;D. Chou;I. Barani;A. Parsa;M. McDermott
背景斜坡脊索瘤因其位置和侵袭性而经常复发。目的探讨与斜坡脊索瘤复发相关的临床、手术和解剖因素。方法回顾性分析我院1993 ~ 2013年收治的斜坡脊索瘤病例。结果新诊断为平均直径3.3 cm （1.5 ~ 6.7 cm）的斜坡脊索瘤患者50例（56%男性），年龄中位数为59岁（范围8 ~ 76岁）。症状包括头痛（38%）、复视（36%）和吞咽困难（14%）。手术包括经蝶（n=34）、经口（n=4）、开颅（n=5）和分阶段入路（n=7）。总切除（GTR）率为52%，平均体积减少83%，随着时间的推移，这些数值有所提高。斜坡下三分之一是最不可能存在肿瘤的上下端（上三分之一=72%/中三分之一=82%/下三分之一=42%），但最常存在残留肿瘤（上三分之一=33%/中三分之一=38%/下三分之一=63%；P< 0.05）。复视和头痛的症状改善率分别为61%和53%。术后放疗包括质子束（n=19）、射波刀（n=7）、调强放疗（n=6）、外置放疗（n=10）和无放疗（n=4）。最后随访47例患者，23例（49%）无病或肿瘤稳定残留。下三分之一的斜坡在GTR后进展最多（上/中/下三分之一=32%/41%/75%）。在多因素Cox比例风险模型中，男性（风险比[HR]=1.2/P=.03）、次全切除（HR=5.0/P=.02）和术前斜坡中三分之一（HR=1.2/P=.02）和下三分之一（HR=1.8/P=.02）肿瘤的存在增加了进一步的生长或再生长，而放疗方式没有。结论：我们的研究结果强调了GTR减少脊索瘤复发的长期支持。尽管分阶段入路可提供中外侧（经颅+鼻内）或上下侧（鼻内+经口）宽度，但斜坡的下三分之一经常有残留或复发的肿瘤。基于质子的辐射与基于光子的辐射没有任何优势，这与传统的假设相矛盾。
BACKGROUND Clival chordomas frequently recur because of their location and invasiveness. OBJECTIVE To investigate clinical, operative, and anatomic factors associated with clival chordoma recurrence. METHODS Retrospective review of clival chordomas treated at our center from 1993 to 2013. RESULTS Fifty patients (56% male) with median age of 59 years (range, 8-76) were newly diagnosed with clival chordoma of mean diameter 3.3 cm (range, 1.5-6.7). Symptoms included headaches (38%), diplopia (36%), and dysphagia (14%). Procedures included transsphenoidal (n=34), transoral (n=4), craniotomy (n=5), and staged approaches (n=7). Gross total resection (GTR) rate was 52%, with 83% mean volumetric reduction, values that improved over time. While the lower third of the clivus was the least likely superoinferior zone to contain tumor (upper third=72%/middle third=82%/lower third=42%), it most frequently contained residual tumor (upper third=33%/middle third=38%/lower third=63%; P<.05). Symptom improvement rates were 61% (diplopia) and 53% (headache). Postoperative radiation included proton beam (n=19), cyberknife (n=7), intensity-modulated radiation therapy (n=6), external beam (n=10), and none (n=4). At last follow-up of 47 patients, 23 (49%) remain disease-free or have stable residual tumor. Lower third of clivus progressed most after GTR (upper/mid/lower third=32%/41%/75%). In a multivariate Cox proportional hazards model, male gender (hazard ratio [HR]=1.2/P=.03), subtotal resection (HR=5.0/P=.02), and the preoperative presence of tumor in the middle third (HR=1.2/P=.02) and lower third (HR=1.8/P=.02) of the clivus increased further growth or regrowth, while radiation modality did not. CONCLUSION Our findings underscore long-standing support for GTR as reducing chordoma recurrence. The lower third of the clivus frequently harbored residual or recurrent tumor, despite staged approaches providing mediolateral (transcranial+endonasal) or superoinferior (endonasal+transoral) breadth. There was no benefit of proton-based over photon-based radiation, contradicting conventional presumptions.