Chordoma makes up only 6% of all bone sarcoma diagnoses and most commonly affects adults in their 40’s and 50’s.
The majority of chordomas (50%) arise in the sacrum (the bottom of the spine); however, 30% arise at the base of the skull and the remaining 20% arise in other locations in the spine.
Signs and symptoms
Symptoms of bone sarcoma can vary depending on the size and location of your tumour.
- Bone pain, particularly occuring at night
- A mass or swelling
- Restricted movement in a joint
Symptoms can sometimes be confused with more common problems such as a sports injury or in children and young people, growing pains.
Types of diagnostic scans
Uses x-radiation to take images of dense tissuses inside the body such as bones or tumours.
The Computer Tomography (CT) scan takes a number of x-rays to make a 3D image of an affected area.
The Positron Emission Tomography (PET) scan shows up changes in tissues that use glucose as their main source of energy – for example, the brain or heart muscle. It involves an injection of a very small amount of a radioactive drug into the body. The drug travels to places where glucose is used for energy and shows up cancers because they use glucose in a different way from normal tissue.
Magnetic Resonance Imaging (MRI) uses magnets to create an image of the tissues of the body.
Uses radioactive chemicals called radionuclides which are injected, swallowed or breathed into the body, to take images of bones.
Examination of a tissue sample by a pathologist under a microscope to identify disease.
Laboratory analysis of a blood sample.
Understanding the diagnosis
A diagnosis of bone sarcoma usually starts with a visit to your GP who will refer you for an x-ray. If a bone sarcoma is suspected following the results of the x-ray your GP will refer you to a specialist bone sarcoma centre.
A specialist doctor will diagnose sarcoma through a series of tests. These may include:
- Physical examination
- A scan – taking pictures of the inside of the body using ultrasound, x-ray, CT, EUS, PET or MRI
- A biopsy – taking and testing a tissue sample
A diagnosis of bone sarcoma should be confirmed by a specialist sarcoma pathologist who will identify the type of sarcoma and the stage and grade of the tumour. Identifying the stage and grade of a cancer means your doctor can advise on the best course of treatment for you. It also describes the cancer in a common language which is useful when your doctor is discussing your case with other doctors or health professionals. The stage of a cancer is measured by how much it has grown or spread which can be seen on the results of your tests and scans. The results from a biopsy can tell the grade of the cancer.
Low-grade means that the cancer cells are slow-growing and look quite similar to normal cells. They are less aggressive and less likely to spread.
High-grade means the cancer cells are fast growing and look very abnormal. They are more aggressive and more likely to spread.
The cancer is low-grade and has not grown outside the bone. Stage 1 is further divided into:
- 1a The cancer is low-grade and is still completely within the bone it started in.
- 1b The cancer is low-grade and has grown through the bone wall.
The cancer is high-grade and has spread beyond the bone. Stage 2 is further divided into:
- 2a The cancer is high-grade and is still completely in the bone it started in.
- 2b The cancer is high-grade and has grown outside the bone wall.
The cancer may be any grade and has spread to another part of the body, such as the lungs.
The treatment for chordoma depends on the size and location of your tumour.
The National Institute for Health and Care Excellence (NICE) recommends that anyone with sarcoma should be referred to a specialist sarcoma team for diagnosis and treatment. There are five national bone sarcoma centres in England and Wales where all bone sarcoma patients should be treated. These are located in Newcastle, Manchester & Oswestry, Birmingham, Oxford and London.
People in Northern Ireland will usually travel to Birmingham for treatment. People in Scotland will be treated in Glasgow, Edinburgh, Aberdeen, Dundee and Inverness. This may mean you will have to travel some distance for your treatment. Some treatments like radiotherapy or chemotherapy may be given in your local hospital under the supervision of the specialist sarcoma centre.
Your case will be managed by a team of experts from a wide range of health care professions called a multidisciplinary team (MDT). Your MDT will include your key worker or sarcoma clinical nurse specialist, surgeon and other healthcare professionals involved in your care.
Types of treatment
The first treatment method for chordoma is surgery. The surgeon will remove the tumour and will aim to take out an area of normal tissue around it too; this is known as taking a margin. Sometimes surgery for chordoma cannot involve taking a margin of normal tissue due to the tumour’s location, so in these cases, the margins of the removed tissue will show tumour cells when viewed under a microscope.
Radiotherapy will be given after surgery to kill off any local cancer cells left in the area of your tumour, including those not visible microscopically. If there are nerves and arteries involved and they cannot be removed along with the tumour, then the aim of the surgeon will be to reduce the size of the tumour so radiotherapy treatment after surgery will be more successful. If your tumour cannot be operated on then radiotherapy alone will be the treatment of choice.
Some surgery for sarcoma may have some impact on your quality of life afterwards. Spinal surgery may affect how your bowel or bladder works or how your legs work. Surgery in the sacrum may involve the removal of nerves that work the bowel or bladder. This may lead to some people needing a colostomy or urostomy following surgery. You will be told of any potential risks involved before you have surgery.
The treatment you receive should take into account your individual situation and your doctor or clinical nurse specialist should talk you through all possible treatment alternatives. You should also have the opportunity to ask any questions you may have regarding the future implications of your surgery. Please speak to your doctor or sarcoma clinical nurse specialist if you have any concerns about your treatment.
Radiotherapy uses high-energy radiation beams to destroy cancer cells. It is used in the treatment of chordoma after surgery to kill off any local cancer cells that are left in the area. It will also be used after surgery if your tumour has only been partially removed. If your tumour cannot be operated on then radiotherapy alone will be the treatment of choice.
There are newer methods of radiotherapy that are sometime used to treat chordoma. Stereotactic radiotherapy, image-guided radiotherapy (IGRT) and intensity-modulated radiotherapy (IMRT) all allow doctors to direct higher doses of radiation more accurately at the tumour and minimise the side effects of treatment.
Proton beam therapy can be effective in treating chordoma. It is a different type of radiotherapy that uses high-energy protons rather than high-energy radiation to deliver a dose of radiotherapy. Proton beam therapy can be more effective than regular radiotherapy as it can be delivered precisely to where it is needed. This reduces the risk of damage to the surrounding tissue or vital organs. It is not currently available in the UK; however, the NHS will pay for selected patients (including some sarcoma patients) to receive this type of treatment overseas (in the USA or Europe).
Chemotherapy uses anti-cancer drugs to destroy cancer cells. It has not been shown to be effective in treating chordoma; however, it is sometimes used to control chordoma that
has come back after initial treatment (recurred) or spread to another part of the body (metastasised).
After treatment for sarcoma you may benefit from rehabilitation services. They can offer specialist advice and treatment that aids your recovery and helps you to deal with the effects of cancer and its treatment.
Rehabilitation services include:
Occupational therapists assess your ability to carry out daily living activities such as washing, dressing and meal preparation. They can also help you return to normal daily activities such as work, parenting, and leisure activities.
Physiotherapists help you return to as active a lifestyle as possible. They will help you strengthen your muscles and ensure your joints regain as much mobility as they can.
This may involve designing a special exercise programme, providing advice about managing tiredness or teaching you to use equipment to help you walk or to support your joints.
Dieticians assess whether you need any special diet and can advise on the most appropriate nutritional support to help you before, during and after treatment.
Orthotics and prosthetics
After surgery for bone sarcoma you may need aids to help you. For example, an orthotist can help by providing you with supports or splints. If you have had an amputation, a prosthetist can assess and fit an artificial limb.
Rehabilitation usually starts after treatment. However, with bone sarcoma you may find that it helps to start rehabilitation earlier. Ask your sarcoma clinical nurse specialist or doctor to refer you to the rehabilitation team. You may find that you are not automatically offered a referral to rehabilitation services by your medical team, so it is important to ask at the earliest opportunity for a referral.
A recurrence of cancer may appear in other parts of the body. This is called a metastasis or secondary cancer. In people with bone sarcoma, these secondary cancers may appear in the lungs. A chest x-ray is taken at follow-up appointments to look for secondary cancers in the lung.
Treatment for secondary cancers may involve surgery, radiotherapy or chemotherapy as appropriate; your treatment will be assessed on an individual basis.
Emotional and practical support
TALKING ABOUT IT
There is no right or wrong way to feel or react to diagnosis; you may feel angry, sad or anxious about the future. You may also have concerns for how the news will affect your loved ones. You may find comfort in talking about your concerns with family members or friends.
TALKING TO OTHERS AFFECTED BY SARCOMA
If you do not feel comfortable discussing your concerns with family or friends, it may help to talk to other people who have been affected by sarcoma. There are a number of sarcoma support groups supported by Sarcoma UK around the country. These offer valuable support and information to patients, carers and family members, and provide the opportunity to meet with other people in the same situation.
Most groups are run by patients and carers working together with local sarcoma clinical nurse specialists or doctors. A typical meeting may include a talk from an invited speaker on a related topic, discussion and questions, informal chat with other group members, and refreshments.
There is also online support available for people affected by all types of sarcoma. Online support provides members with the opportunity to get in touch with other sarcoma patients or carers to discuss their concerns over a new diagnosis, treatment options or worries about the future.
Club HQ is a national support network for sarcoma patients who have had a hindquarter amputation. They offer information, mentoring, support, a private Facebook group and annual get-togethers to share and discuss experiences. New members are welcome to send their name, address, telephone and email to Club HQ, c/o Bone Cancer Research Trust, 10 Feast Field, Horsforth, Leeds LS18 4TJ. Tel: 0113 258 5934 Email: firstname.lastname@example.org
TALKING TO A PROFESSIONAL
You may find it helpful to talk to your sarcoma clinical nurse specialist or doctor about your diagnosis; they will be able to answer any questions you may have about your condition. They may also be able to put you in touch with a counsellor for additional support, providing you with a safe, confidential place to talk about your concerns. Your GP will have access to local counselling services who can provide support to people with cancer.
Patients who are being treated for cancer can apply for a medical exemption (MedEx) certificate which will allow you to get free prescriptions. You can get an application form from your doctor and it will need to be countersigned by your GP or consultant. Prescriptions are free for all patients in Scotland, Wales and Northern Ireland.
Your sarcoma clinical nurse specialist should be able to advise you on the types of benefits you can claim or any special funding you can apply for. Your local Citizens Advice Bureau can also give you benefits information and many branches can help you fill out application forms. Macmillan Cancer Support have a number of benefit advisors who offer financial advice and support to cancer patients including advice about returning to work following cancer treatment.