title: Outcomes following attempted en bloc resection of cervical chordomas in the C-1 and C-2 region versus the subaxial region: a multiinstitutional experience.
abstract: OBJECTIVE
  Chordomas involving the mobile spine are ideally managed via en bloc resection with reconstruction to optimize local control and possibly offer cure. In the cervical spine, local anatomy poses unique challenges, limiting the feasibility of aggressive resection. The authors present a multi-institutional series of 16 cases of cervical chordomas removed en bloc. Particular attention was paid to clinical outcome, complications, and recurrence. In addition, outcomes were assessed according to position of tumor at the C1-2 level versus the subaxial (SA) spine (C3-7).
  
  
  METHODS
  The authors reviewed cases involving patients who underwent en bloc resection of cervical chordoma at 4 large spine centers. Patients were included if the lesion epicenter involved the C-1 to C-7 vertebral bodies. Demographic data and details of surgery, follow-up course, exposure to adjuvant therapy, and complications were obtained. Outcome was correlated with presence of tumor in C1-2 versus subaxial spine via a Student t-test.
  
  
  RESULTS
  Sixteen patients were identified (mean age at presentation 55 ± 14 years). Seven cases (44%) cases involved C1-2, and 16 involved the subaxial spine. Median survival did not differ significantly different between the C1-2 (72 months) and SA (60 months) groups (p = 0.65). A combined (staged anteroposterior) approach was used in 81% of the cases. Use of the combined approach was significantly more common in treatment of subaxial than C1-2 tumors (100% vs 57%, p = 0.04). En bloc resection was attempted via an anterior approach in 6% of cases (C1-2: 14.3%; SA: 0%; p = 0.17) and a posterior approach in 13% of cases (C1-2: 29%; SA: 0%; p = 0.09). The most commonly reported margin classification was marginal (56% of cases), followed by violated (25%) and wide (19%). En bloc excision of subaxial tumors was significantly more likely to result in marginal margins than excision of C1-2 tumors (C1-2: 29%; SA: 78%; p = 0.03). C1-2 tumors were associated with significantly higher rates of postoperative complications (C1-2: 71%; SA: 22%; p = 0.03). Both local and distant tumor recurrence was greatest for C1-2 tumors (local C1-2: 29%; local SA: 11%; distant C1-2: 14%; distant SA: 0%). Statistical analysis of tumor recurrence based on tumor location was not possible due to the small number of cases. There was no between-groups difference in exposure to postoperative adjuvant radiotherapy. There was no difference in median survival between groups receiving proton beam radiotherapy or intensity-modulated radiotherapy versus no radiation therapy (p = 0.8).
  
  
  CONCLUSIONS
  Compared with en bloc resection of chordomas involving the subaxial cervical spine, en bloc resection of chordomas involving the upper cervical spine (C1-2) is associated with poorer outcomes, such as less favorable margins, higher rates of complications, and increased tumor recurrence. Data from this cohort do not support a statistically significant difference in survival for patients with C1-2 versus subaxial disease, but larger studies are needed to further study survival differences.
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland;
authors.forename: Camilo A
authors.initials: CA
authors.lastname: Molina
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Ames
authors.forename: Dean
authors.initials: D
authors.lastname: Chou
authors.forename: Laurence D
authors.initials: LD
authors.lastname: Rhines
authors.forename: Patrick C
authors.initials: PC
authors.lastname: Hsieh
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Zadnik
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Wolinsky
authors.forename: Ziya L
authors.initials: ZL
authors.lastname: Gokaslan
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Sciubba
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002574:Cervical Vertebrae / Q000473:pathology / Q000601:surgery*; D002817:Chordoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D010027:Osteotomy / Q000379:methods* / Q000401:mortality; D011183:Postoperative Complications; D013125:Spinal Neoplasms / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate; D016896:Treatment Outcome
keywords: IMRT = intensity-modulated radiotherapy; PBRT = proton beam radiotherapy; SA = subaxial; UCSF = University of California, San Francisco; USC = University of Southern California; chordoma; en bloc; oncology; spine; surgery; tumor