Could recent advances improve the survival times and quality of life for sacral and mobile spine chordomas? A systematic review and meta-analysis

Purpose: This systematic review and meta-analysis evaluated whether recent advances have improved survival outcomes for sacral and mobile spine chordomas, examining the necessity of radical surgical resection, efficacy of modern radiotherapy techniques, and potential for biomarkers to predict outcomes. Methods: We systematically searched English-language literature from 2004 to 2024, and of the 202 initially identified studies, 39 met the inclusion criteria for meta-analysis. We performed Z-test analysis and meta-analysis of overall survival (OS) and progression-free survival (PFS) at 5 and 10 years across three domains: treatment modalities (n = 31), surgical margins (n = 26), and radiotherapy modalities (n = 18). Results: Five-year OS rates were 79 % for surgery alone, 82 % for radiotherapy alone, and 80 % for combined therapy. Negative margins were associated with lower local recurrence rates; however, overall survival did not differ significantly between negative and positive margins (83 % vs. 74 % five-year OS). Extensive resections for negative margins resulted in higher complication rates and negatively impacted quality of life. Proton beam therapy showed superior survival rates compared to conventional radiotherapy (85 % vs. 70 %, p = 0.012), although 10-year data remain unavailable. Biomarker and histopathological prediction methods, as well as chemotherapy approaches, lack standardization. Conclusions: Recent advances in chordoma management have improved survival outcomes, with radiotherapy, particularly proton beam therapy, emerging as an effective primary or adjuvant treatment. Surgical margins do not significantly impact overall survival, which raises questions about the necessity of radical resections and their associated morbidity. While promising biomarkers and targeted therapies are under investigation, standardized protocols for predicting outcomes and administering systemic therapy remain to be established.