CORRInsights®: What are the Conditional Survival and Functional Outcomes After Surgical Treatment of 115 Patients with Sacral Chordoma?

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The surgical management of sacral chordoma has evolved to more-aggressive resections, which seek to assure negative margins, since high local recurrence rates were reported with less-aggressive, subtotal resections. Locally recurrent or neglected tumors have proved to be nearly impossible to eradicate, and they lead to painfully slow deaths accompanied by loss of bowel, bladder, and sexual function. Over time, this emboldened surgeons to venture more ablative operations, which on the one hand improved local control, but on the other hand, altered the functions most of us take for granted.
Local control has traditionally been used as the primary outcome measure in studies of sacral chordoma. However, the associated loss of sacral nerve root function, which accompanies mid-to-high sacrectomy has long been subject of study including in vivo quantitative physiologic studies, surgeon-reported functional outcomes and, more recently, patient-reported outcomes [5-7, 10-12].
Prior work supports wide resection as a means to decrease local recurrence and it also documents the negative affect of mid to high sacrectomy on function [4, 10]. More recently, some centers have reported effective local control of sacral chordomas using high-dose proton or carbon-ion-based radiation without surgery [2, 8, 9]. The impact of high-dose radiation on the function of sacral nerve roots has not been well documented.
Ji and colleagues report on one institution's experience with sacral chordoma, emphasizing the oncologic and functional outcomes after operative management. The data present another clear indication that appropriate oncologic margins at the index operation offer the best chance of local control. They also shed light on how the risk of local failure changed over time, with most local recurrences occurring 3 to 4 years after surgery. The relative risk of local failure began to decrease 5 years after surgery. Additionally, they include functional outcomes, using a modification of a previously reported measure [1], which they use to demonstrate a direct relationship between function (pain, bladder, and bowel) and the level of sacral nerve root resected with the tumor.
Local control and functional outcomes appear to be at odds with one another, leaving clinicians and patients with difficult choices between better oncologic outcomes versus pain, and loss of bowel, bladder, and sexual function. This has stimulated the search for other seemingly less-ablative treatment modalities such as high-dose radiation therapy and targeted systemic therapy.
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