CHORDOMAS AND CHONDROSARCOMAS OF THE CRANIAL BASE - RESULTS AND FOLLOW-UP OF 60 PATIENTS

THE MANAGEMENT OF chordomas and chondrosarcomas involving the cranial base remains controversial. The options for therapy include biopsy, pa rtial resection, radical resection, and various forms of radiotherapy. In this article, we analyze the outcome of 60 patients with cranial b ase chordoma or chondrosarcoma treated with extensive surgical resecti on between 1984 and 1993. Forty-six patients had chordomas, and 14 had low-grade chondrosarcomas; 50% of these patients had been treated pre viously. Preoperative studies included computed tomography, magnetic r esonance imaging, cerebral angiography, and balloon occlusion test of the internal carotid artery, as indicated. Magnetic resonance imaging was performed on all patients during follow-up. The surgical approache s used for tumor resection were predominantly the following: subtempor al, transzygomatic, transcavernous, and transpetrous apex; subtemporal and infratemporal; extended frontal; and extreme lateral transcondyla r. Staged operations with a combination of approaches were used when n ecessary (52% of cases) to remove a tumor more completely. Statistical analysis was done by the chi(2) test and correlation matrix. Sixty-se ven percent of the patients had total or near-total resection. Twenty percent of the patients received postoperative radiotherapy. Eleven pa tients died during the postoperative follow-up period, nine with chord omas and two with chondrosarcomas. Three patients died because of syst emic complications within 3 months after surgery, five died because of tumor recurrence, one died from unrelated causes, and two died from l ate complications of radiotherapy. The recurrence-free survival rate f or all tumors was 80% at 3 years and 76% at 5 years. Chondrosarcomas h ad a better prognosis than chordomas (recurrence-free survival rates, 90% at 5 years and 65% at 5 years, respectively; P = 0.09). Patients w ho had undergone previous surgery had a greater risk of recurrence (5- year recurrence-free survival rate, 64%) than did patients who had not undergone previous surgery (5-year recurrence-free survival rate, 93% ; P < 0.05). Patients with total or near-total resection had a better 5-year recurrence-free survival rate (84%) than did patients with part ial or subtotal resection (64%) (P < 0.05). Postoperative leakage of c erebrospinal fluid was the most frequent complication (30% of patients ) and was found to increase the risk of permanent disability. Patients who had undergone previous radiotherapy had a greater risk of death i n the postoperative period (within 3 months of their operations) and d uring follow-up. However, total or near-total resection did not increa se the rate of postoperative disability. In suitable patients, total o r near-total surgical resection should be the preferred treatment for patients with chordomas and chondrosarcomas of the cranial base. Radio therapy with high-energy particles, or by focused radiation, is recomm ended if the tumor cannot be totally removed.