Title: Fractionated Stereotactic Radiotherapy in Recurrent Clival Chordoma: A Case Report
Authors: Dr Saritha Sunny Pullan, MBBS, Dr Siddanna R Palled, MD, DNB, Dr RA Sunil, MD, Dr Lokesh Viswanath, MD
DOI: https://dx.doi.org/10.18535/jmscr/v9i10.27
Abstract
Clival chordomas are a rare type of clinically malignant tumour, arising from the undifferentiated remnants of the notochord, which are slow-growing, usually radioresistant, locally aggressive and infiltrative, with high rates of recurrence and a poor prognosis. Hence, the role of radiotherapy post maximal resection in clival chordoma is undoubtedly significant, especially stereotactic radiotherapy which helps deliver higher doses with minimal dose to critical organs.
Here we are preseting the history of a 22-year-old female who had undergone multiple surgical decompressions (5 times) for recurrent clival chordoma, who presented with a history of weakness of the right upper and lower limb, difficulty of speech, and difficulty in swallowing within 6 months of last surgery. Imaging with MRI scan revealed a large, irregular lesion, arising from the superior part of the clivus, with severe mass effect on the brainstem. She was diagnosed to have a recurrence of the clival chordoma and she underwent left temporal craniotomy and decompression of lesion, immediately followed by radiation therapy with fractionated stereotactic radiotherapy to a dose of 3900cGy in 13 fractions over 3 weeks. Further dose escalation was not considered given the OARs dose constraint and the large volume of residual disease. She had neurological improvement, with 50% improvement in dysarthria and also the ability to walk with support during her last visit.
The role of radiotherapy, post maximal resection in clival chordoma is undoubtedly significant in terms of local control. It helps avoid multiple surgical interventions in the brain, like in this patient. Even a large residual tumour volume, post-surgical debulking, can be controlled with high-dose photon radiotherapy, especially when delivered by newer radiation techniques like stereotactic radiotherapy. This case study elucidates the need for use of sophisticated stereotactic fractionated radiotherapy in skull base chordomas. It also reinforces the need for adjuvant radiotherapy, for neurological and clinical improvement in large volume tumours, as it shrinks the residual tumour and also helps control local recurrence.
Keywords: Recurrent clival chordoma, Fractionated radiotherapy, Stereotactic radiotherapy, Palliative radiotherapy, FSRT, Clival chordoma. Case report.
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