![Introduction
Outcomes after surgery in Chondrosarcomas arising
from the sacrum
Digant Shah
The School of Biomedical Informatics | The University of Texas Health Science Center at Houston
Methods
Results
Discussion
References
Acknowledgements
Conclusion
Tables and Figures
Please contact the author via email:
digant.b.shah@uth.tmc.edu
Chondrosarcoma is the second most common primary malignant tumor of bone with a prevalence of 1 in
200,000 and accounts for approximately 25% of all bone sarcomas [1]. The overall 5-year and 10-year
survival rates are 74.0% and 54.4%, respectively [2].
The gold standard for treatment of these lesions has been surgical resection, which is determined by the
tumor size, proximity to vital structures, and risk of compromising axial stability [3], and is affected by the
stage, grade, and location. The en bloc approach used by most experienced surgeons is one of the best
treatment modality but is the most technically challenging as compared to the intralesional approach
which is generally undertaken by inexperienced surgeons thus affecting the recurrence.
The area of focus in most of the studies on chondrosarcomas has been on oncological outcomes [4], but
not on survivorship which is the quality of life (QOL) and functional outcomes. Also, in the current
literature, there is no distinguishing between pelvic and sacral chondrosarcomas, and both have often
been grouped with chordomas.
[1] F. Bertoni, P. Bacchini and P. Hogendoorn, "Chondrosarcoma," World Health Organisation Classification
of Tumours.Pathology and Genetics of Tumours of Soft Tissue and Bone.IARC Press, Lyon, pp. 247-251,
2002.
[2] E. Konishi, Y. Nakashima, M. Mano, Y. Tomita, I. Nagasaki, T. Kubo, N. Araki, H. Haga, J. Toguchida and T.
Ueda, "Primary central chondrosarcoma of long bone, limb girdle and trunk: Analysis of 174 cases by
numerical scoring on histology," Pathol. Int., vol. 65, pp. 468-475, 2015.
[3] P. Bergh, B. Gunterberg, J. M. Meis‐Kindblom and L. Kindblom, "Prognostic factors and outcome of
pelvic, sacral, and spinal chondrosarcomas," Cancer, vol. 91, pp. 1201-1212, 2001.
[4] D. Andreou, S. Ruppin, S. Fehlberg, D. Pink, M. Werner and P. Tunn, "Survival and prognostic factors in
chondrosarcoma: results in 115 patients with long-term follow-up," Acta Orthopaedica, vol. 82, pp. 749-
755, 2011.
[5] Biagini, R., P. Ruggieri, M. Mercuri, R. Capanna, A. Briccoli, S. Perin, U. Orsini, S. Demitri, and S.
Arlecchini. "Neurologic deficit after resection of the sacrum." La Chirurgia degli organi di movimento 82,
no. 4: 357-372, 1996.
[6] A. W. Silberman, "Surgical debulking of tumors," Surg. Gynecol. Obstet., vol. 155, pp. 577-585, Oct,
1982.
[7] S. Canbay, A. E. Hasturk, I. Ustun, C. Bayram and G. Dilek, "Giant Sacral Chordoma: Radiographic
Features and Management," Neurosurgery Quarterly, vol. 22, pp. 12-15, 2012.
Patients with chondrosarcomas arising from the sacrum being treated at UT MD Anderson, Houston,
Texas between January 1, 1992, and March 1, 2014, were considered. A retrospective review of medical
records, imaging studies, pathology reports and clinical follow-up data was performed. Conventional
chondrosarcomas were graded using a three-tiered system (Grades 1 – Low grade, Grade 2 –
Intermediate grade, Grade 3 – High grade). Dedifferentiated chondrosarcomas and mesenchymal
chondrosarcomas were all categorized as Grade 4 tumors. Information on patient demographics, hospital
days, survival, local recurrences, metastases, and complication were obtained in all cases.
0 12 24 36 48 60 72 84 96 108 132 156 180
0.0
0.2
0.4
0.6
0.8
1.0
P-value= 0.369
Bilateral ( E / N = 4 / 5 )
Unilateral ( E / N = 10 / 17 )
Overall Survival by Nerve Root Scrificed Section
Time (months)
Probability
Overall Survival
Time (Months)
Probability
0 12 36 60 84 108 132 156 180
0.0
0.2
0.4
0.6
0.8
1.0
Statistical Analysis
1. Univariate analysis using Kaplan-Meier method with log-rank assessment to assess the prognostic
significance of individual risk factors.
2. Cox proportional hazards multivariate analysis to determine time-related to factors that affected
disease-free survival.
3. The long-term outcome determined by survival rate after treatment of local recurrence.
All statistical analyses were carried out using Statistical software SAS 9.3 (SAS, Cary, NC) and S-Plus 8.2
(TIBCO Software Inc., Palo Alto, CA). All tests were 2-sided and A p-value of less than 0.05 was considered
significant.
Table 1 provides a summary of the patient demographics and surgical details.
The analysis of the results shows that there was a significant effect of the type of surgery on the length of stay (p-
value = 0.0315), as seen in Table 2.
It was seen that there was a considerable amount of loss of motor, bowel, and bladder when an en bloc excision
was performed as compared an intralesional approach(Table 3), the results were not statistically significant.
The overall survival rates of the entire group at 5 and 10 years were 53% and 37.8%, respectively (Figure 1). It was
also seen that the overall survival rate was higher for a patient treated with unilateral nerve root resection as
compared to bilateral nerve root resection (Figure 2). However the results were not statistically significant.
Tumor related deaths
57% - sacrum (4/7)
25% - spine (3/12)
25% - pelvis (11/43)
ChondrosarcomaChordoma
Table 1 - Patient Demographics and
surgery details (n=27)
Age (Mean, 1st surgery) 46.04 years
Male
Female
18 (67%)
9 (33%)
Length of stay 40.23 days
Grade
1
2
3
4
1 (3.85%)
11 (42.31%)
10 (38.46%)
4 (15.38%)
Chemotherapy
Pre
Post
• 1 cycle
• 2 cycle
2 (7.41%)
5 (18.52%)
1 (3.7%)
XRT
Pre
Post
2 (7.69%)
3 (11.54%)
Alive
Dead
11 (40.74%)
16 (59.26%)
Metastasis 7 (25.93%)
Surgery Sequelae
Intralesional
En bloc
6 (22.22%)
21 (77.78%)
Reconstruction
Flap
VAG
Instrumentation
5 (33.35%)
8 (53.36%)
2 (13.34%)
Margins:
Negative
Positive
15 (15.56%)
12 (44.44%)
Recurrence 13 (50%)
Nerve Resection:
Unilateral
Bilateral
17 (77.27%)
5 (22.73%)
The purpose of this retrospective study is to assess the outcomes after surgery for chondrosarcomas
arising from the sacrum.
Objective
Grade: 1 – Low Grade, 2 – Intermediate Grade, 3 –
High Grade, 4 – Dedifferentiated/Mesenchymal,
VAG – Vascularized Auto Graph
Treatment course
Table 3 - Functional Outcomes (n = 27) [5]
Intralesional
(4)
HS
(2)
HSwHP
(17)
HSwEHP
(4)
Motor function 0 = 4 0 = 2 0 = 4, I = 10, II = 3 II = 4
Bowel function 0 = 4 0 = 2 0 = 9, I = 5, II = 3 0 = 2, I = 1, II = 1
Bladder function 0 = 4 0 = 2 0 = 10, I = 4, II = 3 0 = 1, II = 3
HS – Hemisectomy, HSwHP – Hemisectomy with Hemipelvectomy, HSwEHP – Hemisectomy with
External Hemipelvectomy,
In all tumors, the goal is to achieve full clearance of the cancerous growth which is achieved by en-
Bloc resection. However, at times, the tumor is too big or entwined with vital structures such as
major blood vessels or the axial skeleton that complete removal of the tumor would result in
immediate compromise of patient survival. In these cases, the surgeon compromises on clearance by
using the intralesional approach. This practice is called debulking and, is also called intralesional [6]
since much of the perimeter of resection is with the tumor, rather than outside the borders of the
tumor as seen in en-bloc. The reason why there seems to be a correlation between length of stay
and type of surgery is because the intralesional surgery is much less extensive/aggressive than an en-
bloc resection.
Another important consideration in this study has been the focus on chondrosarcomas and not
chordomas. Both are clinically and radiographically similar in nature, but are histologically and
immunohistologicaly different. Both chordomas and chondrosarcomas appear as a large expansile
mass in the sacrococcygeal region and present with symptoms such as pain, numbness, constipation,
weakness, and incontinence. Often vital structures such as the rectum, bladder, uterus, and adnexa
are displaced or completely surrounded by the tumor. Although chordomas tend to hemorrhage,
chondrosarcomas typically do not. However, Chondrosarcomas arise off midline and they consist of
both mineralized and non-mineralized Chondroid matrix [7]
Chondrosarcoma is a malignancy of bone that can present within the sacrum. The effective diagnosis
plays an essential role in the disease treatment. Currently, there is a huge gap in the literature on
chondrosarcomas arising from the sacrum. Focused studies on these lesions are required, which will
help to assess the functional outcomes and in turn help in improving patient quality of care and
outcome.
Table 2 – Type of Surgery vs Length of stay
Surgery type N Mean StD Min Q1 Median Q3 Max P-value
Intralesional 5 17 12.17 3 8 18 22 34 0.0315
En bloc 21 45.76 28.07 10 22 33 71 113
1. It is a retrospective analysis of patients treated over 22 years, diagnostic approaches and surgical
technical skills have changed.
2. Data was obtained from medical charts, which may not completely accurate.
3. Lack of patients due to rarity of the condition.
4. No information on the size of the lesion in the clinical notes.
Limitations
Figure 2 - Overall survival rate based on nerve root
sacrificed
Figure 1 -Overall survival rate
We thank Dr. Justin Bird for mentoring and supervising the project. Lei Feng for assisting in analyzing
the data and Sarah Rizvi for her contribution in writing the research protocol.](https://image.slidesharecdn.com/6265162c-9f30-43dc-b502-967e7c10206a-170124215448/85/Chondrosarcoma-1-320.jpg)
Chondrosarcoma
- 1. Introduction Outcomes after surgery in Chondrosarcomas arising from the sacrum Digant Shah The School of Biomedical Informatics | The University of Texas Health Science Center at Houston Methods Results Discussion References Acknowledgements Conclusion Tables and Figures Please contact the author via email: digant.b.shah@uth.tmc.edu Chondrosarcoma is the second most common primary malignant tumor of bone with a prevalence of 1 in 200,000 and accounts for approximately 25% of all bone sarcomas [1]. The overall 5-year and 10-year survival rates are 74.0% and 54.4%, respectively [2]. The gold standard for treatment of these lesions has been surgical resection, which is determined by the tumor size, proximity to vital structures, and risk of compromising axial stability [3], and is affected by the stage, grade, and location. The en bloc approach used by most experienced surgeons is one of the best treatment modality but is the most technically challenging as compared to the intralesional approach which is generally undertaken by inexperienced surgeons thus affecting the recurrence. The area of focus in most of the studies on chondrosarcomas has been on oncological outcomes [4], but not on survivorship which is the quality of life (QOL) and functional outcomes. Also, in the current literature, there is no distinguishing between pelvic and sacral chondrosarcomas, and both have often been grouped with chordomas. [1] F. Bertoni, P. Bacchini and P. Hogendoorn, "Chondrosarcoma," World Health Organisation Classification of Tumours.Pathology and Genetics of Tumours of Soft Tissue and Bone.IARC Press, Lyon, pp. 247-251, 2002. [2] E. Konishi, Y. Nakashima, M. Mano, Y. Tomita, I. Nagasaki, T. Kubo, N. Araki, H. Haga, J. Toguchida and T. Ueda, "Primary central chondrosarcoma of long bone, limb girdle and trunk: Analysis of 174 cases by numerical scoring on histology," Pathol. Int., vol. 65, pp. 468-475, 2015. [3] P. Bergh, B. Gunterberg, J. M. Meis‐Kindblom and L. Kindblom, "Prognostic factors and outcome of pelvic, sacral, and spinal chondrosarcomas," Cancer, vol. 91, pp. 1201-1212, 2001. [4] D. Andreou, S. Ruppin, S. Fehlberg, D. Pink, M. Werner and P. Tunn, "Survival and prognostic factors in chondrosarcoma: results in 115 patients with long-term follow-up," Acta Orthopaedica, vol. 82, pp. 749- 755, 2011. [5] Biagini, R., P. Ruggieri, M. Mercuri, R. Capanna, A. Briccoli, S. Perin, U. Orsini, S. Demitri, and S. Arlecchini. "Neurologic deficit after resection of the sacrum." La Chirurgia degli organi di movimento 82, no. 4: 357-372, 1996. [6] A. W. Silberman, "Surgical debulking of tumors," Surg. Gynecol. Obstet., vol. 155, pp. 577-585, Oct, 1982. [7] S. Canbay, A. E. Hasturk, I. Ustun, C. Bayram and G. Dilek, "Giant Sacral Chordoma: Radiographic Features and Management," Neurosurgery Quarterly, vol. 22, pp. 12-15, 2012. Patients with chondrosarcomas arising from the sacrum being treated at UT MD Anderson, Houston, Texas between January 1, 1992, and March 1, 2014, were considered. A retrospective review of medical records, imaging studies, pathology reports and clinical follow-up data was performed. Conventional chondrosarcomas were graded using a three-tiered system (Grades 1 – Low grade, Grade 2 – Intermediate grade, Grade 3 – High grade). Dedifferentiated chondrosarcomas and mesenchymal chondrosarcomas were all categorized as Grade 4 tumors. Information on patient demographics, hospital days, survival, local recurrences, metastases, and complication were obtained in all cases. 0 12 24 36 48 60 72 84 96 108 132 156 180 0.0 0.2 0.4 0.6 0.8 1.0 P-value= 0.369 Bilateral ( E / N = 4 / 5 ) Unilateral ( E / N = 10 / 17 ) Overall Survival by Nerve Root Scrificed Section Time (months) Probability Overall Survival Time (Months) Probability 0 12 36 60 84 108 132 156 180 0.0 0.2 0.4 0.6 0.8 1.0 Statistical Analysis 1. Univariate analysis using Kaplan-Meier method with log-rank assessment to assess the prognostic significance of individual risk factors. 2. Cox proportional hazards multivariate analysis to determine time-related to factors that affected disease-free survival. 3. The long-term outcome determined by survival rate after treatment of local recurrence. All statistical analyses were carried out using Statistical software SAS 9.3 (SAS, Cary, NC) and S-Plus 8.2 (TIBCO Software Inc., Palo Alto, CA). All tests were 2-sided and A p-value of less than 0.05 was considered significant. Table 1 provides a summary of the patient demographics and surgical details. The analysis of the results shows that there was a significant effect of the type of surgery on the length of stay (p- value = 0.0315), as seen in Table 2. It was seen that there was a considerable amount of loss of motor, bowel, and bladder when an en bloc excision was performed as compared an intralesional approach(Table 3), the results were not statistically significant. The overall survival rates of the entire group at 5 and 10 years were 53% and 37.8%, respectively (Figure 1). It was also seen that the overall survival rate was higher for a patient treated with unilateral nerve root resection as compared to bilateral nerve root resection (Figure 2). However the results were not statistically significant. Tumor related deaths 57% - sacrum (4/7) 25% - spine (3/12) 25% - pelvis (11/43) ChondrosarcomaChordoma Table 1 - Patient Demographics and surgery details (n=27) Age (Mean, 1st surgery) 46.04 years Male Female 18 (67%) 9 (33%) Length of stay 40.23 days Grade 1 2 3 4 1 (3.85%) 11 (42.31%) 10 (38.46%) 4 (15.38%) Chemotherapy Pre Post • 1 cycle • 2 cycle 2 (7.41%) 5 (18.52%) 1 (3.7%) XRT Pre Post 2 (7.69%) 3 (11.54%) Alive Dead 11 (40.74%) 16 (59.26%) Metastasis 7 (25.93%) Surgery Sequelae Intralesional En bloc 6 (22.22%) 21 (77.78%) Reconstruction Flap VAG Instrumentation 5 (33.35%) 8 (53.36%) 2 (13.34%) Margins: Negative Positive 15 (15.56%) 12 (44.44%) Recurrence 13 (50%) Nerve Resection: Unilateral Bilateral 17 (77.27%) 5 (22.73%) The purpose of this retrospective study is to assess the outcomes after surgery for chondrosarcomas arising from the sacrum. Objective Grade: 1 – Low Grade, 2 – Intermediate Grade, 3 – High Grade, 4 – Dedifferentiated/Mesenchymal, VAG – Vascularized Auto Graph Treatment course Table 3 - Functional Outcomes (n = 27) [5] Intralesional (4) HS (2) HSwHP (17) HSwEHP (4) Motor function 0 = 4 0 = 2 0 = 4, I = 10, II = 3 II = 4 Bowel function 0 = 4 0 = 2 0 = 9, I = 5, II = 3 0 = 2, I = 1, II = 1 Bladder function 0 = 4 0 = 2 0 = 10, I = 4, II = 3 0 = 1, II = 3 HS – Hemisectomy, HSwHP – Hemisectomy with Hemipelvectomy, HSwEHP – Hemisectomy with External Hemipelvectomy, In all tumors, the goal is to achieve full clearance of the cancerous growth which is achieved by en- Bloc resection. However, at times, the tumor is too big or entwined with vital structures such as major blood vessels or the axial skeleton that complete removal of the tumor would result in immediate compromise of patient survival. In these cases, the surgeon compromises on clearance by using the intralesional approach. This practice is called debulking and, is also called intralesional [6] since much of the perimeter of resection is with the tumor, rather than outside the borders of the tumor as seen in en-bloc. The reason why there seems to be a correlation between length of stay and type of surgery is because the intralesional surgery is much less extensive/aggressive than an en- bloc resection. Another important consideration in this study has been the focus on chondrosarcomas and not chordomas. Both are clinically and radiographically similar in nature, but are histologically and immunohistologicaly different. Both chordomas and chondrosarcomas appear as a large expansile mass in the sacrococcygeal region and present with symptoms such as pain, numbness, constipation, weakness, and incontinence. Often vital structures such as the rectum, bladder, uterus, and adnexa are displaced or completely surrounded by the tumor. Although chordomas tend to hemorrhage, chondrosarcomas typically do not. However, Chondrosarcomas arise off midline and they consist of both mineralized and non-mineralized Chondroid matrix [7] Chondrosarcoma is a malignancy of bone that can present within the sacrum. The effective diagnosis plays an essential role in the disease treatment. Currently, there is a huge gap in the literature on chondrosarcomas arising from the sacrum. Focused studies on these lesions are required, which will help to assess the functional outcomes and in turn help in improving patient quality of care and outcome. Table 2 – Type of Surgery vs Length of stay Surgery type N Mean StD Min Q1 Median Q3 Max P-value Intralesional 5 17 12.17 3 8 18 22 34 0.0315 En bloc 21 45.76 28.07 10 22 33 71 113 1. It is a retrospective analysis of patients treated over 22 years, diagnostic approaches and surgical technical skills have changed. 2. Data was obtained from medical charts, which may not completely accurate. 3. Lack of patients due to rarity of the condition. 4. No information on the size of the lesion in the clinical notes. Limitations Figure 2 - Overall survival rate based on nerve root sacrificed Figure 1 -Overall survival rate We thank Dr. Justin Bird for mentoring and supervising the project. Lei Feng for assisting in analyzing the data and Sarah Rizvi for her contribution in writing the research protocol.