As Radical as Technically Feasible-Surgical Treatment for Mobile Spine Chordoma

Purpose: In this retrospective study, we compared the impact of en bloc resection with negative margins to that of intralesional resection followed by adjuvant radiotherapy on local control (LC) and overall survival (OS) in patients with mobile spine chordomas. Secondary endpoints included mechanical complication rates, associated risk factors, and quality of life outcomes. Methods: Between June 2008 and March 2025, 26 patients aged ≥ 15 years with mobile spine (C1-L5) chordomas underwent surgical treatment at our institution. Patients were divided into en bloc resection (=Enneking appropriate (EA)) and intralesional resection (=Enneking inappropriate (EI)) plus HT groups. Clinical, oncologic, and surgical data were collected and analyzed to determine outcomes. Results: The EA group demonstrated a clear trend toward improved local recurrence-free survival (LRFS, EA median 35 months vs. EI resection median 14 months) and OS. Adjuvant therapy led to better LRFS and OS independently of the extent of resection. Clinical outcomes and quality of life were favorable in both groups, with no statistically significant differences in short-term, as well as long-term complications (27%). No specific risk factors for long-term complications were identified. Conclusions: En bloc resection remains the gold standard for mobile spine chordoma resection whenever feasible. Nevertheless, Enneking-appropriate resection is often limited by anatomical constraints. In such cases, every effort should still be made to achieve the most complete tumor resection possible prior to initiating adjuvant therapy. Due to the rarity of spinal chordomas and their surgical complexity, these procedures should be performed in specialized spine centers with multidisciplinary expertise.