Combined Interventional Therapy With Imaging-Guided Drainage, Embolization, and Sclerotherapy of a Recurrent Sacral Chordoma

Abstract

We present the case of a 71-year-old female with recurrence of a large sacral chordoma and associated local spread. Symptoms consisted of bladder-bowel difficulties, pelvic pressure, and pelvic pain. Past therapies included partial surgical resection and radiation therapy. Myelography demonstrated the mass did not communicate with the thecal sac, making it safer for interventional therapy. Computed tomography (CT)-guided drainage and ethanol sclerosis of the mass was initially performed. However, the tumor size recurred within 6 weeks following initial drainage. Angiography demonstrated no significant vascular supply to the central lesion, with neovascularity of a left pelvic sidewall deposit of tumor embolized via polyvinyl alcohol particles. Originally planned cryoablation was not performed given the primary necrotic state of the tumor. Postembolization CT-guided drainage with tPA resulted in 900 mL serosanguinous-necrotic tumor, producing significant decrease in size. Sotradecol foam was injected into the residual tumor cavity for sclerosis. All procedures were performed under general anesthesia, with precise neural monitoring of bladder and bowel function. The patient did well following the procedures, with improvement in pelvic pain and pressure, and without recurrence for 3 months post procedure. Preexisting bladder and bowel dysfunction were without significant change. This case demonstrates how combined interventional therapy can be used to treat a recurrent necrotic sacral chordoma. 

Key words: sacral chordoma, embolization, drainage, sclerotherapy

As the number of therapeutic options in the field of interventional oncology continues to increase, so too does confusion in selecting which modalities are best served for the treatment of which patient. This issue is further complicated in the management of lesions in which concern regarding tumor rebound poses challenges for planning effective therapies. The following is our experience with treatment of a fastidious sacral chordoma via an interventional approach.

Patient Presentation

Our patient is a 71-year-old female who presented in May 2013 with a second recurrence of a large complex sacral chordoma. Initial treatment regimens included prior partial surgical resection and radiation therapy. Patient complaints included loss of autonomous bladder and bowel control, alterations in sacrogluteal sensation, pelvic heaviness, and superficial bleeding. 

Magnetic resonance imaging demonstrated a solid and cystic 14 cm x 12 cm x 16 cm mass resulting in destruction of the inferior sacrum (Figure 1). Myelographic lumbar CT examination was performed to assess sacral mass contiguity with the thecal sac. Myelographic contrast extended to the upper sacral spinal canal, without extension into the large sacral mass. Fluid seen within the mass did not communicate with the thecal sac (Figure 2). These parameters allowed for us to proceed with more aggressive interventional options.

Treatment

Computed tomography-guided drainage of the necrotic tumor cavity was performed. On initial needle aspiration of the central cavity, blood clots and serosanguinous products were slowly being drained. Given that the cavity consisted of mostly blood products, 5 mg of tPA (Genentech) in 50 mL of saline was instilled to further break up blood clots before additional drainage. This resulted in 800 mL of serosanguinous necrotic products being drained from the central tumor. This was followed by ethanol (Akorn Pharmaceuticals) sclerosis of the hollow cavity. The patient initially did very well, with improved pelvic pain and pressure (Figure 3). 

However, the patient’s symptoms recurred in 6 weeks, with imaging demonstrating the mass regained its initial volume (Figure 4). Given tumor recurrence within a short period of time, as well as presence of blood products within cavity on initial drainage, angiography was performed to determine if a vascular component of the tumor amenable to embolization existed.

During angiography, it was expected to selectively catheterize lateral and median sacral arterial branches as well as collateralized lumbar and iliac branches. The distal aorta, internal iliacs, and L5 lumbar arteries were selectively catheterized. In addition to the absence of the native median sacral arteries, tapered lateral sacral arteries and multiple other pelvic vessels were noted, probably secondary to prior radiation treatment. While the vast majority of the tumor was hypovascular, there was hypervascular tumor involving the left pelvic sidewall supplied by the left obturator artery. On confirmation that neurologic monitoring demonstrated no changes on injection of 3 mg sodium methohexital (generic, last supplied by JHP Pharmaceuticals), embolization of the tumor using 300- to 500-micron polyvinyl alcohol (PVA) particles (Boston Scientific) was performed. Postembolization angiography demonstrated diminished vascularity of the solid component of the tumor (Figure 5).

Next-day cryoablation using the Endocare Cryocare system (HealthTronics) was initially considered for further treatment of tumor. Ten-gauge bone biopsy needles serving as introducers were to be inserted into non-necrotic soft tissue components of the lesion. The 15-mm cyroablation probes (Percryo; HealthTronics) would have then been inserted through each introducer, taking care to avoid intact sacral foramina. Real-time temperature monitoring during cryoablation is accomplished with placement of an adjacent temperature probe. Once positioning is verified, a single freeze, thaw, and freeze cycle for 10, 8, and 10 minutes respectively is typically performed. This results in the formation of ovoid ice balls within the boundaries of the treated lesion, with freeze cycles capable of reducing tissue within the probe central zone down to -40°C. However, both angiography and next-day contrast enhanced CT showed that the bulk of the sacral mass did not demonstrate significant enhancement. Given its lack of enhancement, it was felt cryoablation ablation would not provide added therapeutic value. 

Instead, CT-guided drainage was again performed with insertion of a 14 Fr AP pigtail catheter (Boston Scientific). Given that prior drainage started slowly due to the presence of blood clots and serosanguinous material within the cavity, tPA (5 mg in 50 mL of saline) was infused into the tumor cavity prior to starting suction drainage. Computed tomography-guided drainage yielded 900 mL of serosanguinous-necrotic products. Post drainage scanning demonstrated that the mass had significantly reduced in size to 13 cm x 3 cm in axial dimensions. Cavity sclerosis was performed following drainage with 10 mL of 3% Sotradecol (Bioniche Pharma) mixed with 100 mL of room air to create a foam mixture. The Sotradecol foam was instilled into the tumor cavity (Figure 6).

The patient tolerated the procedures well with no postprocedure complications. There were no spinal monitoring changes throughout the procedures. The patient’s overall pelvic pain and pressure have since significantly decreased. There has been no change in pre-existing bladder and bowel dysfunction. The sacral mass has not recurred in 3 months.

Discussion

Chordomas are rare notochord-remnant-derived malignant tumors that classically produce significant osseous invasion and secondary destruction. Chordomas are typically more common in males, with a peak incidence between 50 and 60 years. Their microscopic and macroscopic appearances are similar, predominantly myxoid with intratumoral calcifications and areas of hemorrhage. Common locations are within the sacrum and pelvis (including the sacrococcygeal interface), at the spheno-occipital junction, and along the course of the mobile spine, with a roughly equal likelihood of development in any of these locations. They are notoriously longstanding, with recurrence upon resection and treatment frequently encountered.^1-3

En-bloc excision with wide margins and postoperative external beam radiation therapy is considered the gold standard of treatment.⁴ Cryoablation and preoperative arterial embolization to reduce tumor vascularity have been reported.⁵ However, recurrence is quite common after such isolated treatments.⁶ Additional resection is often not possible due to contiguous spread and potential resection of viable neurovascular structures. Given the lack of consensus regarding nonsurgical retreatment options, an interventional treatment plan was considered in the patient’s best interests. 

Recurrence in our patient was from a combination of neovascular mediated growth and progressive necrotic changes. The hypovascularity of the sacral lesion limited the applicability of planned cryoablative therapy, given the redundancy of inducing necrosis in an already necrotic mass. Potential damage of surrounding critical neurovascular structures from ablative therapy was also considered. 

The bulk of the tumor was hypovascular. However, there was solid hypervascular tumor along the left pelvic sidewall that was embolized with PVA particles. Tumor involving the left pelvic sidewall was not targeted by cryoablation, given its proximity to the ipsilateral sciatic nerve. 

Accumulation of necrotic tissue and blood products within the mass was felt most contributory to its quick recurrence. As such, particular emphasis was placed on repeat drainage of the mass. Given the utility of instilling tPA into the cavity during first drainage, tPA was instilled prior to initiation of second drainage to allow for adequate lysis of blood clots that could otherwise impede adequate drainage. The efficacy of this strategy was confirmed on drainage of 900 mL of serosanguinous necrotic material. Of the interventions performed on our patient, this second drainage resulted in the most significant mass reduction. 

To minimize future accumulation of necrotic products, foam sclerosis of the central cavity with Sotradecol was employed. Sotradecol is typically used in sclerosing varicose veins, with volumes instilled proportional to the needed sclerosant effect. Given the large size of the central necrotic cavity requiring sclerosis, 100 mL of air was mixed with 3% Sotradecol to create a large enough amount of foam to fill and sclerose the necrotic tumor cavity. 

The importance of neural monitoring during the course of procedures cannot be overemphasized. Given that these measures are employed to improve patient quality of life, further reduction in remaining nerve root function was not considered an acceptable treatment endpoint. To ensure sacral nerve root function was not compromised during angiography, low-dose Brevital Sodium (methohexital) was injected into candidate vasculature prior to PVA embolization to assess if temporary paralysis of sacral neural function was induced.⁷ If electromyography demonstrated tapering in either bowel or bladder function upon injection, the benefit vs. risk of potential nerve injury would have been strongly considered prior to any embolization. There were no changes in our patient’s spinal monitoring throughout the procedures.

Three-month follow-up demonstrated the patient’s symptoms of pelvic pain and pressure to have nearly resolved. However, preexisting bladder and bowel dysfunction was without significant change. A limitation of our study is that the time interval for post-procedural follow up is only 3 months. Follow-up assessment of this approach in a larger patient population is certainly needed to reaffirm its efficacy. However, the long-term applications of such treatments are promising, as we have previously reported the results of a similar combined interventional approach in treatment of a renal cell carcinoma sacral metastatic lesion having resulted in significant improvement in pain, patient symptoms, and overall quality of life.⁸

Neoplasms in the pelvis and sacrum can be difficult to plan treatment strategies for, given their potential for alteration in weight-bearing mechanics and invasion of adjacent neurovascular bundles. In our patient, the combination of embolizing visible areas of neovascularity, mass drainage, and central cavity sclerosis is expected to slow the rate of regrowth and allow for marked improvement in our patient’s quality of life.  

References

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Editor’s note: This article underwent peer review by one or more members of the Interventional Oncology 360 editorial board.

Address for correspondence: Sudipta Roychowdhury, MD, Robert Wood Johnson Medical School, Department of Radiology, MEB #404, P.O. Box 19, New Brunswick, NJ, 08903-0019. Email: sroychowdhury@univrad.com

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no disclosures related to the content of this manuscript.

Suggested citation: Sundararajan SH, Roychowdhury S, Nosher J. Combined interventional therapy with imaging-guided drainage, embolization, and sclerotherapy of a recurrent sacral chordoma. Intervent Oncol 360. 2013;1(3):E26-E33.