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

Abstract

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.

Keywords: chordoma; recurrence; risk factors; sacrectomy; wound-related complications.

Figure 1

(A,B): T1-weighted axial and sagittal MRI of an S3 level sacral chordoma (male, 55 year), (C) post-en-bloc resection specimen (sagittal midline view), (D) postoperative progression-free MRI evaluation at 6 months after tumor resection surgery (contrast-enhanced T1-weighted sagittal view).

Figure 2

(A,B) T2-weighted with fat suppression and T2-weighted MRI sagittal views showing an S2 level sacral chordoma (male, 62 year), (C) postcontrast T1-weighted with fat suppression coronal MRI view showing dorsal soft tissue and gluteus maximus infiltration by the tumor (D,E) intraoperative photographs showing preparation and harvest of the VRAM flap, (F) photograph of the resected specimen showing en-bloc resection of the tumor with the skin and part of the rectum attached (combined approach), (G) restoration of the soft tissue defect with the VRAM flap, (H) satisfactory wound healing result without complications 1 year postoperatively, (I,J) T1-weighted coronal MRI view and T2-weighted with fat suppression sagittal MRI view, respectively, showing no local recurrence at 1 year postoperative follow-up.

Figure 3

(A,B) T2-weighted with fat suppression coronal and sagittal MRI views of an S1 level sacral chordoma (female, 58 year), (C,D) en-bloc total sacrectomy and spinopelvic fixation (combined approach), (E) restoration of the soft tissue defect with a VRAM flap, (F) en-bloc postresection specimen of the entire sacrum, (G) early postoperative AP plain radiograph of the lumbar spine and pelvis showing the lumbo-iliac fixation and reconstruction with a femoral allograft, (H) the patient underwent spinopelvic revision surgery due to instrumentation failure, (I,J) anteroposterior and lateral plain radiographs of lumbar spine, (K) postoperative 3D volume rendering CT image of the revised lumbo-iliac fixation, (L) satisfactory wound healing result 1 year postoperatively. The patient remains disease free at 14 years postoperatively.

Figure 4

Related-to-disease mortality after sacral chordoma resection. The estimated cumulative 5-year and 10-year disease-specific survival after Kaplan–Meier analysis was 75.3% (95% CI = 49.1–87.5%) and 52.7% (95% CI = 31–73.8%), respectively. All related-to-disease deaths occurred within 7 years after tumor resection surgery. The mean survival of the recurred patients was 61.7 ± 33.4 months after their tumor resection surgery.

Figure 5

Disease recurrence incidence after sacral chordoma resection. The estimated cumulative 1-year, 5-year, and 10-year disease-free survival regarding local and distant disease recurrence after Kaplan–Meier analysis 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. All recurrences occurred within 6 years after surgery. The mean time-to-recurrence for the recurred patients was 26.4 ± 22.5 months after tumor resection surgery.