treatment of sacral chordoma treatment of skullbase chordoma alternative approaches

sacral chordoma: surgery-based treatment

Studies agree that a radical removal of the tumor provides the best prospects for prognosis [3,5,11]. The chordoma is neither particularly sensitive to radiation therapy nor does a chemotherapy exist that is considered effective and has been approved for treatment. An exception is radiation therapy with protons; however, to date it has only been used for skullbase chordoma for which surgery is more difficult.

The size of the tumor boundaries is crucial in all surgery-based treatment. Large boundaries allow for removal from within healthy tissue and provides the best premise for cure. In this case, sacretomy removes that part of the sacral bone that is infested by the tumor. This may imply removal or impairment of nerval structures, resulting in possible functional shortfalls. For example, surgery above S3 (partially) disconnects the sacral micturition center (S2-S4), leading to urological conditions. If both S2 roots are removed, fecal incontinence is to be expected in addition. Further consequences may be sensory losses in the buttocks, retral upper and lower thighs and, in case of removal of S1, in the feet. Moreover, inability to reach orgasm for women and erectile dysfunction for men may result. If S1 has been removed, movement disorders have also to be expected; and walking may only be possible with specific assistance to the tibialis anterior muscle.

These shortfalls are rather numerous and affect quality of life but are consequence of the only treatment option with a prospect for cure. However, recrudescence of chordoma often occurs. Moreover, metastases later occur in 5%-40% of all cases [12], mostly in the lung and more rarely in the liver or intraspinally.


sacral chordoma: chemotherapy

Generally, chordoma is considered insensitive to chemotherapy but recent approaches suggest a relatively good effectiveness of Imatinib (Glivec®), a tyrosine kinase inhibitor [13,14]. There are, however, several reports on patients who did not respond to Imatinib. In that case, use of Sunitinib (Sutent®) may be considered. It has been approved for tumors that are resistent against Imatinib in the US [15] and is a kind of "second generation tyrosine-kinase inhibitor". A corresponding study has been conducted in the US but the results have not yet been published.


sacral chordoma: radiation therapy

Generally chordoma is considered insensitive to radiation. Opinions differ, however, on whether radiation therapy should be administered after surgery and correspondingly treatment centers follow different strategies. Due to the slow growth of chordoma which results in a low sensititivity to radiation, high radiation doses (more than 70Gy up to 90Gy) are required. Moreover, radiation therapy is complicated, in particular in case of skullbase chordoma, by the localization close to vitally and functionally important structures which may be impaired. For skullbase chordoma, so-called proton beam radiation therapy has recently been introduced (see below).


skullbase chordoma: surgery-based treatment

Due to their proximity to vitale structures, skullbase chordoma usually cannot completely be removed by surgery [10]. Correspondingly, large surgical boundaries can most often not be maintained. Therefore skullbase chordomae typically are treated with radiation therapy, using similarly high doses as for sacral chordomae (see below).


skullbase chordoma: chemotherapy

Recent research [16] indicates a certain growth factor (PDGFA/PDGFB), similar to that for sacral chordoma, to be activated. This suggests application of Imatinib (Glivec®). Conventional chemotherapy turned out to be ineffective.


skullbase chordoma: radiation therapy

Since skullbase chordomae can typically not be treated by curative surgery, radiation therapy is the treatment option most often used. Both standard photon radiation as well as proton radiation are employed. To date, the latter is available in only a few centers in Germany. Rather high doses (60-70Gy) are required [17].
centers offering proton therapy


alternative approaches: mistletoe

An approach which is a good supplement of "standard treatments" is treatment with an aqueous solution of various forms of viscum (appletree, pine, etc). The idea is that mistletoe as a plant cell is a foreign cell for our body and will be "identified" as foreign. This will trigger an immune reaction which diagnoses and destroys the foreign substances; that is, the immune system is activated by this form of therapy. This is important since cancer cells are also foreign and shall be recognized as such to be destroyed. Taking of mistletoe itself is not noxious. It is important, however, that a doctor administers the treatment who knows of suitable medicinal products.
A good overview is provided by the following site on mistletoe therapy.
http://www.mistel-therapie.de


alternative approaches: hyperthermia

Hyperthermia corresponds to the targeted heating of single bodily parts or the whole body to 40°C-43°C. The idea is to improve blood flow, including in the tumor, by heating such that these areas will become more sensitive to radiation therapy, chemotherapy, immunotherapy, gene therapy etc, improving the prospects for these treatment methods. Moreover, increase of the body temperature, acting like an artificial purexia induction, shall initiate immune reaction. The goal is for the body itself to identify and fight foreign cells, similarly to mistletoe therapy. Currently, there are not yet many scientific results on effectiveness of hyperthermia but work is in progress. Although this form of cancer therapy is known to be quite successful for some tumors, so far treatment costs are not covered by statutory health insurance.
A short introduction on hyperthermia is provided by the German Cancer Research Center .