The treatment of a skull base chordoma is through a combination of surgery and radiotherapy. The principal of treatment is, therefore, to obtain maximal safe surgical resection followed by a specialised form of radiotherapy called proton beam radiotherapy.
The principal of maximal surgical resection is to remove as much tumour as is possible whilst minimising the risk of harm. Chordomas arise from the base of the skull through which are passing the cranial nerves supplying function to the head and neck, the spinal cord and the vessels supplying blood to the brain (arteries) and draining blood from the brain (veins and venous sinuses). The nature of this surgery is, therefore, technically challenging and requires a multi-disciplinary surgical team involving most commonly neurosurgeons with expertise in the condition and ENT surgeons (skull base neuro-otologists). Scott Rutherford and Andrew King have a large skull base practice which is the area of neurosurgery in which these tumours fall and have the appropriate expertise and experience to maximise the chance of effective surgical resection with minimal harm.
Invariably prior to the surgery, the surgical team (neurosurgery and ENT) will discuss with the radiotherapists the aims of surgery including what areas of the tumour can be removed and what cannot. The nature of a chordoma, invading the base of the skull, is that surgical resection, however successful, does not cure the condition and it is for this reason that post-operative radiotherapy is required to try and minimise the chance of recurrence.
In recent years, a specialised form of radiotherapy, proton beam radiotherapy, has become increasingly considered to be the gold standard form of radiotherapy. The reason why it is considered the gold standard is the nature of protons rather than the more usual photon radiotherapy. Protons have a much more rapid degree of degradation outside of the surgical field and effectively travel less far and, therefore, the risk of harm to the adjacent delicate neurological structures is considered to be less. At the present time, there is no proton beam radiotherapy centre in the UK. There is, however, a well-constructed system whereby patients with a diagnosis of chordoma are referred after their surgery to the National Proton Panel whereby arrangements can be made to send the patient to a proton beam centre elsewhere in the world, most typically in the USA or Switzerland. In appropriate cases, this is fully funded by the NHS. There are plans in place to build proton beam radiotherapy centres in the UK and the centres are planned are in Manchester and in London.