Sacral and presacral lesions: Cytopathologic analysis and clinical correlates

Comparison of free vascularized fibular flaps and allograft fibular strut grafts to supplement spinopelvic reconstruction for sacral malignancies

AIMS

Orthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques.

METHODS

We reviewed 44 patients (23 female, 21 male) with a mean age of 40 years (SD 17), who underwent en bloc sacrectomy for a malignant tumour of the sacrum with a reconstruction using a total (n = 20), subtotal (n = 2), or hemicathedral (n = 25) technique. The reconstructions were supplemented with a FVF in 25 patients (57%) and an AFS in 19 patients (43%). The mean length of the strut graft was 13 cm (SD 4). The mean follow-up was seven years (SD 5).

RESULTS

There was no difference in the mean age, sex, length of graft, size of the tumour, or the proportion of patients with a history of treatment with radiotherapy in the two groups. Reconstruction using an AFS was associated with nonunion (odds ratio 7.464 (95% confidence interval (CI) 1.77 to 31.36); p = 0.007) and a significantly longer mean time to union (12 months (SD 3) vs eight (SD 3); p = 0.001) compared with a reconstruction using a FVF. Revision for a pseudoarthrosis was more likely to occur in the AFS group compared with the FVF group (hazard ratio 3.84 (95% CI 0.74 to 19.80); p = 0.109); however, this was not significant. Following the procedure, 32 patients (78%) were mobile with a mean Musculoskeletal Tumor Society Score 93 of 52% (SD 24%). There was a significantly higher mean score in patients reconstructed with a FVF compared with an AFS (62% vs 42%; p = 0.003).

CONCLUSION

Supplementation of spinopelvic reconstruction with a FVF was associated with a shorter time to union and a trend towards a reduced risk of hardware failure secondary to nonunion compared with reconstruction using an AFS. Spinopelvic fixation supplemented with a FVF is our preferred technique for reconstruction following resection of a sacral tumour. Cite this article: Bone Joint J 2021;103-B(8):1414-1420.

Sinonasal Small Round Blue Cell Tumors: An Immunohistochemical Approach

Although clinical history and morphologic appearance should be the initial considerations when evaluating small round blue cell tumors of the sinonasal tract, the final diagnosis often hinges on immunohistochemical findings. Unfortunately, interpretation of stains in these tumors is fraught with numerous pitfalls and limitations. This article presents an approach to sinonasal small round blue cell tumors based on four common immunohistochemical patterns: cytokeratin positivity, squamous marker positivity, neuroendocrine marker positivity, and cytokeratin negativity.

Management approach and surgical strategies for retrorectal tumours: a systematic review

AIM

The management strategy for retrorectal tumours is complex. Due to their rarity, few surgeons have expertise in management.

METHOD

A systematic literature review was conducted using the PubMed database. English language publications in the years 2011-2015 that assessed preoperative management, surgical strategies and chemoradiotherapy for presacral tumours were included. Two hundred and fifty-one abstracts were screened of which 88 met the inclusion criteria. After review of the full text, this resulted in a final list of 42 studies eligible for review.

RESULTS

In all, 932 patients (63.2% female, 36.8% male; P < 0.01) with a retrorectal tumour were identified. Most were benign (65.9% vs. 33.7%, P < 0.01). Imaging distinguished benign from malignant lesions in 88.1% of cases; preoperative biopsy was superior to imaging in providing an accurate definitive diagnosis (91.3% vs. 61.4%, P < 0.05) with negligible seeding risk. Biopsy should be performed in solid tumours. It is useful in guiding neoadjuvant therapy for gastrointestinal stromal tumours, sarcomas and desmoid type fibromatosis and may alter the management strategy in cases of diffuse large B-cell lymphoma and metastases. Biopsies for cystic lesions are not recommended. The gold standard in imaging is MRI. The posterior Kraske procedure is the most common surgical approach. Overall, the reported recurrence rate was 19.7%.

CONCLUSION

This review evaluated the management strategies for retrorectal tumours. A preoperative biopsy should be performed for solid tumours. MRI is the most useful imaging modality. Surgery is the mainstay of treatment. There is limited information on robotic surgery, single-port surgery, transanal endoscopic microsurgery, chemoradiotherapy and reconstruction.

Management of Sacral Tumors Requiring Spino-Pelvic Reconstruction with Different Histopathologic Diagnosis: Evaluation with Four Cases

In this retrospective study, surgical results of four patients with sacral tumors having disparate pathologic diagnoses, who were treated with partial or total sacrectomy and lumbopelvic stabilization were abstracted. Two patients were treated with partial sacral resection and two patients were treated with total sacrectomy and spinopelvic fixation. Fixation methods included spinopelvic fixation with rods and screws in two cases, reconstruction plate in one case, and fresh frozen allografts in two cases. Fibular allografts used for reconstruction accelerated bony union and enhanced the stability in two cases. Addition of polymethyl methacrylate in the cavity in the case of a giant cell tumor had a positive stabilizing effect on fixation. As a result, we can conclude that mechanical instability after sacral resection can be stabilized securely with lumbopelvic fixation and polymethyl methacrylate application or addition of fresh frozen allografts between the rods can augment the stability of the reconstruction.

Interest of Laparoscopy for "En Bloc" Resection of Primary Malignant Sacral Tumors by Combined Approach: Comparative Study With Open Median Laparotomy

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To compare laparoscopy with open median laparotomy for anterior approach in "en bloc" resection of primary malignant sacral tumors (PMST) in combined approach strategy.

SUMMARY OF BACKGROUND DATA

Wide margin surgical resection is the "gold standard" treatment of PMST.

METHODS

Two groups of patients suffering from PMST and operated for "en bloc" resection by combined approach (anterior and posterior) only differencing for the anterior approach were constituted: "laparoscopy" group (n = 11) and "laparotomy" group (n = 22). Intraoperative morbidity (blood loss, red blood cell transfusion (RBC transfusion), surgical procedure duration) and postoperative morbidity (surgical-site infection (SSI), perineal dysfunctions, local recurrence) were analyzed. Surgical margins were studied. Data of both groups were compared using nonparametric Mann-Whitney test for continuous data and Fisher test for categorical data. Overall survival (OS) and Disease-free survival (DFS) were analyzed by Kaplan-Meier method.

RESULTS

Blood loss during anterior approach was less important in "laparoscopy" group 71.9 mL (range 0-400 mL) as compared with 2140 mL (range 0-9000 mL) for "laparotomy" group (P = 0.019). Blood loss during posterior approach was not different between the 2 groups. Total blood loss including anterior and posterior approach was inferior in "laparoscopy" group 2208 mL (range 230-4800 mL) versus 5385.7 mL (range 1400-11500 mL) for "laparotomy" group (P = 0.026). We reported significant difference on blood transfusion (3.7 RBC transfusions (range 0-8) for "laparoscopy group" versus 10.1 RBC transfusions (range 0-35) for "laparotomy" group (P = 0.025)). Surgical duration, quality of surgical margins, perineal dysfunctions and SSI were equivalent for both groups. At a follow-up of 36.6 months for "laparoscopy" group and 115.3 months for "laparotomy" group, OS and DFS were equivalent.

CONCLUSION

Use of laparoscopy for anterior approach decreases intraoperative blood loss and intraoperative RBC transfusion without increasing surgical duration, without altering the quality of surgical margins and without impairing long-term outcomes.

LEVEL OF EVIDENCE

4.

Lesions originating within the retrorectal space: a diverse group requiring individualized evaluation and surgery

BACKGROUND

Tumors occurring within the retrorectal space are rare and their low incidence has led to a paucity of literature regarding them.

METHODS

Adult patients with retrorectal tumors managed at this institution from 1981-2011 were identified. A retrospective chart review was conducted to obtain relevant data.

RESULTS

Retrorectal tumors were identified in 87 patients (67 female) with median age at diagnosis of 44 years (19-88), and median follow-up 8 months (0.1-225). Of the 25 different histologic tumors diagnosed, hamartomas were most common (32 %; n = 28) followed by epidermal cysts (11 %; n = 10), and teratomas (10 %; n = 9). Twenty-six percent (23/87) of all tumors were malignant. CT scans were obtained in 84 % (73/87) of patients, MRI in 59 % (51/87), and TRUS in 16 % (14/87). While 74 % (64/87) of tumors were at or below the S4 level, operative approach was strictly posterior in 73 % (46/63) of these tumors. Twenty-eight percent (24/87) of patients underwent diagnostic biopsy with no reported biopsy site recurrence. Thirty percent (7/23) of resected malignant (all recurrences: distant) and eleven percent (7/64) of benign tumors (all recurrences: local) recurred. Survival was 70 % (16/23) for malignant tumors and 98 % (63/64) for benign tumors.

CONCLUSIONS

Retrorectal tumors remain heterogeneous and a diagnostic challenge. Pre-operative imaging may help guide surgeons; however, malignancy portends worse outcomes. Despite preoperative biopsy site recurrence concerns, no patient in this study had biopsy site recurrence. As their natural history remains unclear, more studies are necessary to further characterize their behavior.

The value of preoperative biopsy in the management of solid presacral tumors

BACKGROUND

Surgical decision making and the use of neoadjuvant therapy in the management of solid presacral tumors rely greatly on an accurate preoperative diagnosis. The utility of preoperative biopsy has been questioned because of potential complications and the increasing accuracy of modern imaging.

OBJECTIVE

The aim of this study was to analyze biopsy-related morbidity and to compare the accuracy of imaging versus biopsy in making a preoperative diagnosis.

DESIGN

This study is a retrospective review of all patients who underwent biopsy of presacral tumors at Mayo Clinic Rochester between 1990 and 2010. The demographics, pathology, complications of biopsy, and imaging were reviewed. Biopsy results and radiologic findings were matched with the final pathology and analyzed.

SETTINGS

This study was conducted at a tertiary care center.

PATIENTS

Adult patients with solid presacral tumors who underwent preoperative biopsy were evaluated.

MAIN OUTCOME MEASURES

The primary outcomes measured were the biopsy-related complications and the accuracy of preoperative imaging and biopsy in comparison with final pathology.

RESULTS

Seventy-six biopsies were performed in 73 patients. Fifty-six patients underwent percutaneous biopsies, 14 underwent open biopsies, and 3 underwent both. Biopsy-specific complications included 2 hematomas (1 open, 1 percutaneous). Preoperative biopsy correlated with the postoperative pathologic diagnosis in 63 patients (91%). Of the 6 solid presacral tumors diagnosed incorrectly on biopsy, 1 was falsely reported as benign. Sensitivity, specificity, and positive and negative predictive values of biopsy to detect malignant disease was 96%, 100%, 100%, and 98%. Ten of 35 patients (29%) with a definitive imaging diagnosis were given incorrect diagnoses. Sensitivity, specificity, and positive and negative predictive values of imaging to diagnose malignant disease was 83%, 81%, 83%, and 81%.

LIMITATIONS

This investigation was designed as a retrospective study.

CONCLUSION

Preoperative biopsy of presacral tumors is safe and highly concordant with postoperative pathology in comparison with imaging. Given the significant differences in therapeutic approach for benign versus malignant solid presacral tumors, as well as the current limitations of imaging, a percutaneous preoperative biopsy should be obtained to guide management decisions.

Use of gluteus maximus adipomuscular sliding flaps in the reconstruction of sacral defects after tumor resection

Background

While performing sacrectomy from a posterior approach enables the en bloc resection of sacral tumors, it can result in deep posterior peritoneal defects and postoperative complications. We investigated whether defect reconstruction with gluteus maximus (GLM) adipomuscular sliding flaps would improve patient outcomes.

Methods

Between February 2007 and February 2012, 48 sacrectomies were performed at He Nan Cancer Hospital, Zhengzhou City, China. We retrospectively examined the medical records of each patient to obtain the following information: demographic characteristics, tumor location and pathology, oncological resection, postoperative drainage and complications. Based on the date of the operation, patients were assigned to two groups on the basis of closure type: simple midline closure (group 1) or GLM adipomuscular sliding reconstruction (group 2).

Results

We assessed 21 patients in group 1 and 27 in group 2. They did not differ with regards to gender, age, tumor location, pathology or size, or fixation methods. The mean time to last drainage was significantly longer in group 1 compared to group 2 (28.41 days (range 17–43 days) vs. 16.82 days (range 13–21 days, P < 0.05)) and the mean amount of fluid drained was higher (2,370 mL (range 2,000–4,000 mL) vs. 1,733 mL (range 1,500–2,800 mL)). The overall wound infection rate (eight (38.10%) vs. four (14.81%), P < 0.05) and dehiscence rate (four (19.05%)] vs. three (11.11%), P < 0.05) were significantly higher in group 1 than in group 2. The rate of wound margin necrosis was lower in group 1 than in group 2 (two (9.82%) vs. three (11.11%), P < 0.05).

Conclusions

The use of GLM adipomuscular sliding flaps for reconstruction after posterior sacrectomy can significantly reduce the risk of infection and improve outcomes.

Retrorectal tumors

Tumors that arise in the retrorectal (presacral) space are uncommon lesions that present with nonspecific signs and symptoms, which lead to difficult diagnoses. For complete evaluation of the lesion, cross-sectional imaging is required to determine the extent of resection and the appropriate surgical approach. Surgical removal leads to favorable outcomes for patients with benign purely cystic retrorectal tumors. Preoperative tissue diagnosis with transperineal and transsacral biopsies of solid or heterogeneous cystic lesions, are essential to determine the necessity of neoadjuvant therapy, which may decrease local recurrence after surgery and avoid an unnecessary delay in systemic therapy.