Beyond Anatomical Resectability: A Hypermetabolic and Highly Aggressive Subtype of Spinal Chordoma Associated with Cancer-Specific Progression.

Authors

Zelin Yun, Yanchao Tang, Le Song, Shaomin Yang, Ben Wang, Panpan Hu, Yan Li, Xiao Liu, Fengliang Wu, Hua Zhou, Zhongjun Liu, Xiaoguang Liu, Feng Wei

Published in

The spine journal : official journal of the North American Spine Society. Sep 18, 2026. Epub Sep 18, 2026.

Abstract

Spinal chordoma demonstrates substantial biological heterogeneity, with a subset exhibiting highly aggressive behavior. However, existing isolated prognostic factors remain insufficient for reliable preoperative risk stratification.
To characterize a metabolically aggressive phenotype (MAP) of spinal chordoma associated with malignant events (MEs) and to develop a preliminary preoperative prognostic stratification score.
Retrospective single-center cohort study.
36 patients with newly diagnosed spinal chordoma who underwent preoperative PET/CT examination and comprehensive clinical, radiological, and pathological evaluation were finally included. The median follow-up was 78.5 months.
Primary outcomes were recurrence, metastasis, and cancer-specific death (CSD). The composite MEs endpoint comprised recurrence, metastasis, and CSD.
PET/CT-derived metabolic parameters together with clinical, imaging, pathological, and laboratory variables were analyzed to identify patients at increased risk of MEs. Model performance was evaluated using time-dependent ROC curves, calibration curves, decision curve analysis, and bootstrap validation.
Across analyses of the individual outcomes, higher PET/CT-derived metabolic tumor volume (MTV), total lesion glycolysis (TLG), Spinal Instability Neoplastic Score (SINS) >10, Enneking stage of IIB, elevated C-reactive protein levels, and hemorrhagic-necrotic pathology emerged as significant adverse features. In multivariable analysis, SINS score >10 (HR=4.685, P=0.026) and Enneking stage of IIB (HR=4.647, P=0.014) were significantly associated with MEs, whereas MTV >35 cm³ showed a borderline association (HR=2.242, P=0.053). The model demonstrated a C-index of 0.812 (bootstrap-corrected: 0.782), and time-dependent AUCs of 0.706, 0.899, and 0.918 at 12, 36, and 60 months. A preliminary MAP-associated MEs score was developed to stratify patients into low-, intermediate-, or high-risk groups.
The MAP in spinal chordoma is characterized by a triad of elevated PET/CT-derived MTV and/or TLG, hemorrhagic-necrotic pathology, and increased inflammatory activity. MAP is associated with MEs and demonstrates concordance with clinical and radiological indicators. The MAP-associated MEs score provides a biologically interpretable framework for risk stratification and may support individualized multidisciplinary treatment planning.

PMID:
42759847
Bibliographic data and abstract were imported from PubMed on 19 Sep 2026.

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