Choosing the most effective surgical corridor to a deep seated and difficult lesion is crucial to improve the surgical outcome. In this issue, Hagihara and colleagues [1] present a novel approach to a giant multi-compartmental pediatric chordoma. This index case highlights several important issues as noted below. Chordoma is histologically a benign tumor but locally aggressive. These tumors have a bleak long-term outcome as shown by the most comprehensive survival analysis involving more than 400 cases, [2] which showed a median survival of 6.29 years. The issues that adversely affect the long-term outcome of these tumors include: the often large tumor burden at the time of diagnosis, spread along critical bony structures, encasement of important neurovascular structures, and poor margination all of which make both radical surgical resection and radiation therapy challenging.
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