Tobert Daniel G, Kelly Sean P, Xiong Grace X, Chen Yen-Lin, MacDonald Shannon M, Bongers Michiel E, Lozano-Calderon Santiago A, Newman Erik T, Raskin Kevin A, Schwab Joseph H
Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Department of Orthopaedic Surgery, Pali Moma Medical Center, Honolulu, HI, USA.
Spine J. 2023 Jan;23(1):34-41. doi: 10.1016/j.spinee.2022.04.009. Epub 2022 Apr 22.
Local control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up.
The purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up.
STUDY DESIGN/SETTING: Retrospective, single-center, cohort study.
Patients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral.
The outcome measures were local recurrence-free interval (LRFI) and overall survival (OS).
Demographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method.
No funding was obtained for this work.
Seventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1-24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810).
Chordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence.
尽管手术技术和放射治疗（RT）方案有所进步，但脊索瘤的局部控制仍然是一个棘手的问题。现有研究显示不同治疗方式的局部控制率令人满意。然而，那些随访时间至少超过4年的研究表明局部失败率在上升。因此，随访时间少于4年的研究可能会无意中提高中期局部生存率。
本研究的目的是报告整块切除联合基于质子的放疗且随访时间至少5年的原发性脊柱脊索瘤的中期结果。
研究设计/地点：回顾性、单中心队列研究。
纳入1990年至2016年在单一机构接受脊柱或骶骨脊索瘤肿瘤初次手术切除的患者。如果患者在任何时候出现局部失败，或者至少有5年无局部失败的随访，则纳入研究。如果在转诊时已进行过先前的手术切除或存在转移，则排除患者。
观察指标为局部无复发生存期（LRFI）和总生存期（OS）。
使用Wilcoxon秩和检验或卡方检验比较人口统计学、临床、肿瘤学和手术变量，包括切缘状态，以及放射剂量和方案（新辅助、辅助或两者皆有）。目标放疗剂量为70格雷（总量），患者根据完成（C70）或接受未完成（I70）剂量进行分层。使用Kaplan-Meier方法计算总生存期（OS）和局部无复发生存期（LRFI）。
本研究未获得资金支持。
76例患者纳入最终分析。所有患者至少随访5年（中位9.3年，范围5.1 - 24.7年）。C70和I70放疗组之间无显著临床差异。C70放疗组的总生存期更长（5年总生存率82%对63%，p = 0.001）。切缘阳性组的总生存期相似（5年总生存率70%对61%，p = 0.266）。C70放疗组的局部无复发生存期更长（5年总生存率93%对78%，p = 0.017）。切缘阳性组的局部无复发生存期相似（5年总生存率90%对87%，p = 0.810）。
文献中脊索瘤的预后趋势是局部无复发生存率降低。在此我们报告了至少随访5年的原发性脊柱脊索瘤手术治疗的结果，手术切除联合C70放疗对总生存期和局部复发有获益。
