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Oncologic and Functional Outcome Following Sacrectomy for Sacral Chordoma

¹ Department of Orthopaedic Surgery, University of Miami, Ortho-Rehab Building (D-27) Room R303, Miami, FL 33101. E-mail address for C.A. Hulen: chulen{at}med.miami.edu. E-mail address for H.T. Temple: htemple{at}med.miami.edu. E-mail address for F.J. Eismont: feismont{at}med.miami.edu
² Francis Marion University, P.O. Box 100547, Florence, SC 29501. E-mail address: wfox{at}fmarion.edu
³ Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address: samaa{at}hss.edu
⁴ Department of Neurological Surgery, University of Miami, 1095 N.W. 14th Terrace, Miami, FL 33136. E-mail address: bgreen{at}med.miami.edu

Investigation performed at the Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, Miami, Florida

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from Miami Center for Orthopaedic Research and Education (Miami CORE). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

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.

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