SKULL BASE CHORDOMAS - A MANAGEMENT CHALLENGE

Because of their critical location, invasive nature, and aggressive re currence, skull base chordomas are challenging and, at times, frustrat ing tumors to treat. Both radical surgical removal and high-dose radia tion therapy, particularly proton beam therapy, reportedly are effecti ve in tumor control and improve survival rates. The authors posit that these tumors are best treated with radical surgery and proton-photon beam therapy. During the last 5 years, they treated 25 patients (15 fe males and 10 males) who harbored pathologically diagnosed skull base c hordomas. The mean age of the patients was 38.4 years (range 8-61 year s). Previous surgery or radiation therapy was performed at other insti tutions in seven and two patients, respectively. The authors performed 33 surgical procedures on 23 patients. Radical removal (defined as ab sence of residual tumor on operative inspection and postoperative imag ing) was achieved in 10 patients; subtotal resection (defined as resec tion of > 90% of the tumor) was achieved in 11 patients; and partial r esection (defined as resection of < 90% of the tumor) was achieved in two patients. Radical surgical removal included not only the excision of soft-tumor tissue. but also extensive drilling of the adjacent bone . Adjuvant therapy consisted of postoperative combined proton-photon b eam therapy (given to 17 patients and planned for one patient) and con ventional radiation therapy (two patients); three patients received no adjunct therapy. To date, four patients have died. One patient who ha d undergone previous surgery and sacrifice of the internal carotid art ery died postoperatively from a massive stroke; one patient died from adenocarcinoma of the pancreas without evidence of recurrence; and two patients died at 25 and 39 months of recurrent tumor. Permanent neuro logical complications included third cranial nerve palsy (one patient) and hemianopsia (one patient), radiation necrosis occurred in three p atients. OF the 21 patients followed for mere than 3 months after surg ery, 16 have had no evidence of recurrence and five (including the two mortalities noted above) have had recurrent tumors (four diagnosed cl inically and one radiologically). The mean disease-free interval was 1 4.4 months. A longer follow-up period will, hopefully, support the ear ly indication that radical surgical removal and postoperative proton-p hoton beam therapy is an efficacious treatment. The use of skull base approaches based on the tumor classification introduced in this paper is associated with low mortality and morbidity rates.