title: The unresolved case of sacral chordoma: from misdiagnosis to challenging surgery and medical therapy resistance.
abstract: OBJECTIVE
  A sacral chordoma is a rare, slow-growing, primary bone tumor, arising from embryonic notochordal remnants. Radical surgery is the only hope for cure. The aim of our present study is to analyse our experience with the challenging treatment of this rare tumor, to review current treatment modalities and to assess the outcome based on R status.
  
  
  METHODS
  Eight patients were treated in our institution between 2001 and 2011. All patients were discussed by a multidisciplinary tumor board, and an en bloc surgical resection by posterior perineal access only or by combined anterior/posterior accesses was planned based on tumor extension.
  
  
  RESULTS
  Seven patients underwent radical surgery, and one was treated by using local cryotherapy alone due to low performance status. Three misdiagnosed patients had primary surgery at another hospital with R1 margins. Reresection margins in our institution were R1 in two and R0 in one, and all three recurred. Four patients were primarily operated on at our institution and had en bloc surgery with R0 resection margins. One had local recurrence after 18 months. The overall morbidity rate was 86% (6/7 patients) and was mostly related to the perineal wound. Overall, 3 out of 7 resected patients were disease-free at a median follow-up of 2.9 years (range, 1.6-8.0 years).
  
  
  CONCLUSIONS
  Our experience confirms the importance of early correct diagnosis and of an R0 resection for a sacral chordoma invading pelvic structures. It is a rare disease that requires a challenging multidisciplinary treatment, which should ideally be performed in a tertiary referral center.
authors.affiliation: Department of Surgery, Intercantonal Hospital Broye, Payerne, Switzerland. ; Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
authors.forename: Fabio
authors.initials: F
authors.lastname: Garofalo
authors.affiliation: Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland. ; Department of Surgery, Hospital Civico, Lugano, Switzerland.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Christoforidis
authors.affiliation: Department of Plastic and Reconstructive Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
authors.forename: Pietro G
authors.initials: PG
authors.lastname: di Summa
authors.affiliation: Department of Oncology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
authors.forename: Béatrice
authors.initials: B
authors.lastname: Gay
authors.affiliation: Department of Orthopedics, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Cherix
authors.affiliation: Department of Plastic and Reconstructive Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
authors.forename: Wassim
authors.initials: W
authors.lastname: Raffoul
authors.affiliation: Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Demartines
authors.affiliation: Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
authors.forename: Maurice
authors.initials: M
authors.lastname: Matter
keywords: Chordoma; Sacrum; perineum