Review

Novel therapeutic targets

in chordoma
Mohamad Bydon, Kyriakos Papadimitriou, Timothy Witham,
1. Introduction Jean-Paul Wolinsky, Ali Bydon, Daniel Sciubba & Ziya Gokaslan†
†
The Johns Hopkins Hospital, Department of Neurological Surgery, Baltimore, MD, USA
2. Body
3. Expert opinion Introduction: Chordomas are malignant bone tumors arising from notochordal
remnants. They most commonly occur at the sacrum, skull base, and spine. The
gold standard treatment for these tumors is a combination of en-bloc resection
and radiation therapy.
Expert Opin. Ther. Targets Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14

Areas covered: Recent genomic studies have identified duplication of the

gene brachyury as a major susceptibility mutation in familial chordomas.
Studies on sporadic chordomas have identified several tumor markers, using
microRNAs and Comparative Genome Hybridization. In this article, we
highlight current advances in research on the molecular characterization
of chordomas.
Expert opinion: Scientific advances have allowed for the identification of
numerous tumor markers involved in chordoma pathogenesis. In the future,
chordoma cell lines will be produced that silence or over-express these
tumor markers. As we increase our understanding of the mechanism of
chordoma tumor proliferation, we can expect the development of targeted
For personal use only.

drug therapies.

Keywords: brachyury, CDKN2A, chordoma, imatinib, JHC7 chordoma cell line, met,
PTEN

Expert Opin. Ther. Targets (2012) 16(11):1139-1143

1. Introduction

Chordoma is a rare cancer that accounts for 1 -- 4% of all bone malignancies. It

usually arises from the osseous spine and skull base [1]. Chordoma is histologically
considered to be a low-grade tumor; however, it has a high recurrence rate and
can metastasize in up to 19% of cases [2,3]. These tumors are often resistant to tradi-
tional treatment protocols, with a median survival of approximately 6 years [4,5]. The
gold standard treatment for these tumors is en-bloc resection followed by post-
operative radiation therapy. Preoperative radiation has been recommended to
reduce tumor seeding during surgery [6].
Chordomas are often difficult to manage due to their locally destructive behavior
and predilection to grow in close proximity to critical neurovascular structures [4,7,8].
The invasive nature of this cancer makes complete resection challenging [4,9]. Surgi-
cal advancements have made en bloc excision of chordomas with negative margins
possible in both the cervical and sacral spine [4,8,10].
When they were first described, chordomas were thought to develop from
cartilage [2]. However, recent data suggests that they arise from the notochord, a
mesodermal structure involved in neuralation [2]. As opposed to chondroid tumors,
chordomas have been shown to express genes involved in the development of
cartilage [4,11].
The classic pathological features of chordomas include physaliferous cells, immu-
noreactivity to S-100, and the epithelial markers, epithelial membrane antigen
(MUC1) and cytokeratins [2]. Chordoid meningiomas and chondrosarcomas share
with chondroid chordomas the characteristic of S-100 immunoreactivity [2]. Recent

10.1517/14728222.2012.714772 © 2012 Informa UK, Ltd. ISSN 1472-8222 1139

All rights reserved: reproduction in whole or in part not permitted
 M. Bydon et al.
Article highlights.
. Chordomas are malignant bone tumors with high
recurrence rates.
. Studies on familial chordomas have identified brachyury
expression as a factor in tumor proliferation.
.
Studies on sporadic chordomas have implicated the
proto-oncogene Met as well as the tumor suppressor
genes PTEN and CDKN2A.
. MicroRNAs and Comparative Genome Hybridization
have led to advances in the molecular characterization
of chordomas.
.
The development of chemotherapeutic targets for
chordomas holds potential for increasing the remission
rates for patients.
Expert Opin. Ther. Targets Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14
This box summarizes key points contained in the article.
studies have focused on finding additional biomarkers
specific for chordomas, including cytogenetic and proteomic
profiling. These studies have led to the identification of
brachyury and keratin [12].
2. Body
For personal use only.
Recently, there have been studies focusing on the genetic basis
of familial chordoma [2,13]. Comparative genomic hybridization
of eight families with heritable chordoma has implicated a
transcription factor involved in notochord development called
brachyury (6q27) [2,4,13,14]. Studies indicate that brachyury is
expressed in up to 90% of chordoma tumors [4,11]. The mech-
anism of action for brachyury in chordomas has not been
described; however, this protein appears to be involved in
tumor pathogenesis [4]. Brachyury has recently been implicated
in promoting epithelial--mesenchymal transition in various
human malignancies [15]. There are reports that brachyury is
expressed in 41% of primary lung carcinomas [16].
MicroRNAs (miRNAs) are a newly discovered class
of small RNA molecules that down-regulate messenger RNA
(mRNA) expression [17,18]. MicroRNAs can act as either
oncogenes or tumor suppressors, thereby affecting tumor
formation [18]. While the function of miRNAs in chordoma
tumors has not been defined, chordoma tissues and cell lines
revealed significant differences in miRNA expression when
compared to control (p < 0.01) [17]. Duan et al. found that
expression of miRNA-1, miRNA-206, and miRNA-133 was
significantly reduced in chordomas [17]. Overall, the authors
discovered 17 miRNAs that were down-regulated and four
miRNAs that were up-regulated in chordoma tissues and
cell lines [17].
While much remains to be learned about the role of
miRNA-1 in oncogenesis, this microRNA is believed to con-
tribute to the formation of liver and lung cancer [17-19].
Indeed, the proto-oncogene Met, which is over-expressed in
many human cancers, has two conserved miRNA-1 sites [19].
This proto-oncogene is expressed in almost all chordomas
1140 Expert Opin. Ther. Targets (2012) 16(11)
(94.4%) as well as many chondrosarcomas (54.2%) and
osteosarcomas (23.3%) [20].
Several studies have utilized Comparative Genomic
Hybridization (CGH) to investigate the role of chromosomal
imbalance in chordoma [21,22]. A study by Scheil and collea-
gues revealed loss of DNA sequences at 3p and 1p [22]. In
the same study, copy number gains of DNA sequence
occurred at 7q, 20, 5q, and 12q, with 7q36 harboring the
most frequently detected gain of chromosomal material [21,22].
Certain genes on 7q36 are known to be expressed in the noto-
chord, including the homeobox-containing gene HLXB9 and
sonic hedgehog gene (SHH) [23].
By utilizing the Agilent 244K genome-wide CGH microar-
ray, Le et al. found numerous “recurrent and remarkably stereo-
typic chromosomal abnormalities in sporadic chordomas” [23].
The authors consistently found deletions in chromosomes 1p
and 9p in chordoma tumors [23]. Chromosome 9 harbors
the tumor suppressor gene CDKN2A, which inhibits the
cdk4- and cdk6-cyclin D complexes involved in the regulation
of retinoblastoma protein (pRb) [24]. As a result, CDKN2A
inhibition can result in uncontrolled cellular proliferation [23].
Le et al. also report deletions of the 10q23.3 region in 16 of
20 (80%) sporadic chordoma cases [23]. This region houses
the PTEN tumor suppressor gene, leading the authors to con-
clude that CDKN2A and PTEN are key regulators of sporadic
chordomas [23,24].
The lack of adequate in vivo models for human chordoma
prompted many scientists to seek new lines in order to inves-
tigate signaling pathways [25]. Recently, several chordoma cell
lines have been established. These cell lines include U-CH1
from a recurrent sacral chordoma, CH8 from a recurrent
chordoma of the lumbar vertebrae, CCL-3 and JHC7 derived
from a primary sacral chordoma, EACH-1 from a scapular
tumor, MUG-Chor1 from a recurrent sacrococcygeal chordo-
mas, and CH22 from a recurrent sacral chordoma [4,22,25-29].
To date, only JHC7, EACH-1, and U-CH1 have been tested
in xenografts [25].
Yang et al., in a well-designed study, characterized three chor-
doma cell lines: CH 8, GB 60, and U-CH1 [26]. The authors
also managed to grow chordoma cells in a three-dimensional
culture system. These cells are thought to more closely resemble
chordomas in “cell surface receptor expression, cell density, met-
abolic functions, and extracellular matrix synthesis,” allowing
for a more accurate analysis of carninogenesis [26].
Hsu et al. described the generation of the JHC7 cell line [4].
In order to investigate the role of brachyury in cultured
chordoma cells, JHC7 cells were transduced with various
shRNA vectors against brachyury, resulting in knockdown
of the gene [4]. A 20 -- 25% reduction of cell viability and
complete arrest of growth was observed following brachyury
knockdown, with a significant decrease in average cell dia-
meter size with nearly complete loss of cytoplasmic vacuoles.
Chordoma cells with knockdown of brachyury did not
contain physaliferous features; rather, these cells contained a
differentiated stellate appearance [4].

Chordomas can be treated with a chemotherapy regimen
that includes anthracycline, cisplatin, alkylating agents, and
camptothecin analogues [30]. While previous studies have
demonstrated chordomas to be insensitive to conventional
chemotherapy [31], recent evidence has shown promising results
using imatinib, a tyrosine-kinase inhibitor (TKI) specific for
the kinase domain of platelet-derived growth factor receptor
(PDGFR) and kit receptors [32,33]. A prospective study investi-
gated the antitumor activity of imatinib in 56 patients with
chordomas that express platelet-derived growth factor b
(PDGFB)/PDGF receptor b (PDGFRB). Ten of 26 patients
receiving imatinib (39%) achieved a ‡ 25% decrease in
standard uptake value on Positron Emission Tomography
Expert Opin. Ther. Targets Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14
(PET) after 3 months of treatment when compared to the
pretreatment baseline [32].
In another trial, a series of 12 patients with chordoma
revealed strong expression of epidermal growth factor receptor
(EGFR) and c-MET [34]. Based on this finding, Hof et al.
successfully utilized cetuximab and gefitinib, two well-known
drugs that inhibit the EGFR pathway, in the treatment of sacral
chordoma [35]. An analysis of 70 chordoma tissue specimens
showed activation of the phosphorylated signal transducer
and activator of transcription 3 (STAT3), a transcription factor
associated with poor prognosis in several human cancers [36].
For personal use only.
Strong suppression of cell growth and proliferation with the
use of STAT3 inhibitors has been demonstrated in chordoma
cell lines [37].
3. Expert opinion
Chordomas are malignant bone tumors arising from
notochordal remnants. They most commonly occur at the
sacrum, skull base, and spine. The gold standard treatment
for these tumors is a combination of en-bloc resection and
radiation therapy. Despite aggressive surgical approaches and
high-dose radiation therapy, many chordomas will recur or
progress. Surgical advancement has allowed for successful
en bloc resection of chordomas in many cases. In the coming
years, chemotherapeutic advancement will continue to
provide encouraging results in the development of adjuvant
therapies for chordoma.
Historically, our understanding of chordoma tumors has
been highlighted by their classic pathological features and
immunoreactivity to S-100 [12]. Recent advances have led to
the identification of several promising tumor markers, using
both familial and sporadic chordoma cases. Studies on
familial chordoma have revealed the important association
of chordoma proliferation with brachyury expression [2,4,12].
Recently, a Johns Hopkins University research group
Expert Opin. Ther. Targets (2012) 16(11)
Novel therapeutic targets in chordoma
generated the JHC7 chordoma cell line. Brachyrury silencing
using this cell line resulted in decreased progression of
chordoma tumor cells in vitro [4]. In addition to brachyury
inhibitors, tyrosine-kinase inhibitors may prove to be potent
therapies for the treatment of chordoma [32,33,38]. While these
findings are promising, it should be noted that most chor-
doma cases are sporadic and brachyury is commonly expressed
in other tumors [2,4].
The advent of miRNAs and CGH has led to significant
advances in our understanding of chordoma pathogenesis.
Studies on sporadic chordomas have implicated the proto-
oncogene Met, as well as the tumor suppressor genes PTEN
and CDKN2A [21,24]. In the future, chordoma cell lines will
be produced that silence or over-express these tumor markers.
As we increase our understanding of the mechanism of chor-
doma tumor proliferation, we can expect the development of
targeted drug therapies.
In the US, Phase I (NCT01407198) and Phase II
(NCT00464620) clinical trials that investigate the effective-
ness of targeted drug therapies----nilotinib and dasatinib,
respectively----have begun enrolling patients [2]. Moreover,
another multi-center study (NCT01175109) is being con-
ducted in order to investigate the effectiveness of imatinib
and LBH589 (panobinostat) in patients with newly diagnosed
and recurrent chordoma. Similarly in Europe, a Phase II study
of imatinib in combination with RAD001 (everolimus) and a
Phase II study of lapatinib in EGFR/HER2-positive advanced
chordoma are being undertaken. Continued research is
necessary in order to identify further therapeutic targets for
the treatment of chordomas.
The ultimate goal of this research is to produce a new treat-
ment paradigm for patients afflicted with chordomas. The
exciting development of three-dimensional cell lines [26] in
combination with the use of miRNAs and CGH in order to
identify tumor markers will continue to advance the field in
the coming years [26]. This will result in more targeted clinical
therapies that will serve as a chemotherapeutic regimen to
augment current standards of treatment. Along with advances
in surgical technique and radiation therapy, clinical trials that
investigate the various drug targets will provide higher rates of
remission and cure for patients suffering from chordomas.
Declaration of interest
The lead author has received funding from DePuy Spine,
Medtronic, the Neurosurgery Research and Education Foun-
dation (NREF), Integra LifeSci, Fellowship support from
AOSpine North America. Two of the authors are associated
with DePuy Spine.
1141
 M. Bydon et al.
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Expert Opin. Ther. Targets (2012) 16(11)
Novel therapeutic targets in chordoma
Affiliation
Mohamad Bydon MD,
Kyriakos Papadimitriou MD,
Timothy Witham MD, Jean-Paul Wolinsky MD,
Ali Bydon MD, Daniel Sciubba MD &
Ziya Gokaslan† MD
†
Author for correspondence
The Johns Hopkins Hospital,
Department of Neurological Surgery,
600 N Wolfe St, Meyer 7-109,
Baltimore, MD 21287, USA
E-mail: zgokas1@jhmi.edu
1143