Surgical classification of different types of en bloc resection for primary malignant sacral tumors

Is 3D-printed self-stabilizing endoprosthesis reconstruction without supplemental fixation following total sacrectomy a viable approach for sacral tumours?

PURPOSE

The spinopelvic reconstruction poses significant challenges following total sacrectomy in patients with malignant or aggressive benign bone tumours encompassing the entire sacrum. In this study, we aim to assess the functional outcomes and complications of an integrated 3D-printed sacral endoprostheses featuring a self-stabilizing design, eliminating the requirement for supplemental fixation.

METHODS

We retrospectively analyzed patients with sacral tumours who underwent total sacrectomy followed by reconstruction with 3D-printed self-stabilizing endoprosthesis. Clinically, we evaluated functional outcomes using the 1993 version of the musculoskeletal tumour society (MSTS-93) score. Perioperative and postoperative complications were also documented.

RESULTS

10 patients met final inclusion criteria. The median age was 49 years (range, 31-64 years). The median follow-up time was 26.5 months (range, 15-47 months). Median postoperative functional MSTS-93 was 22.5 (range, 13-25). The median operation time was 399.5 min (305-576 min), and the median intraoperative blood loss was and 3200 ml (2400-7800 ml). Complications include wound dehiscence in one patient, bowel, bladder, and sexual dysfunction in four patients, cerebrospinal fluid leak in one patient, and tumour recurrence in one patient. There were no mechanical complications related to the endoprosthesis at the last follow-up.

CONCLUSION

The utilization of 3D-printed self-stabilizing endoprosthesis proved to be a viable approach, yielding satisfactory short-term outcomes in patients undergoing total sacral reconstruction without supplemental fixation.

Current Concepts in the Treatment of Giant Cell Tumor of Bone: An Update

Curettage is recommended for the treatment of Campanacci stages 1-2 giant cell tumor of bone (GCTB) in the extremities, pelvis, sacrum, and spine, without preoperative denosumab treatment. In the distal femur, bone chips and plate fixation are utilized to reduce damage to the subchondral bone and prevent pathological fracture, respectively. For local recurrence, re-curettage may be utilized when feasible. En bloc resection is an option for very aggressive Campanacci stage 3 GCTB in the extremities, pelvis, sacrum, and spine, combined with 1-3 doses of preoperative denosumab treatment. Denosumab monotherapy once every 3 months is currently the standard strategy for inoperable patients and those with metastatic GCTB. However, in case of tumor growth, a possible malignant transformation should be considered. Zoledronic acid appears to be as effective as denosumab; nevertheless, it is a more cost-effective option. Therefore, zoledronic acid may be an alternative treatment option, particularly in developing countries. Surgery is the mainstay treatment for malignant GCTB.

Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor

BACKGROUND

The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome.

METHODS

A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups.

RESULTS

Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001).

CONCLUSIONS

This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.

Enhanced recovery after surgery (ERAS) in sacral tumour surgery and comprehensive description of a multidisciplinary program: a prospective study in a specialized hospital in China

PURPOSE

There were fewer data to guide the application of enhanced recovery after surgery (ERAS) theory into sacral tumour surgery. In the present study, we were aiming to describe a multidisciplinary program of ERAS and evaluate the availability in sacral tumour surgery.

METHODS

This was a prospective study of patients with sacral tumour between March 2021 and September 2021 at a single centre. We proposed a multidisciplinary program of ERAS for pre-admission, preoperative, intraoperative, postoperative, and post-discharge clinical care which positively influenced outcomes of patients with sacral tumour. All patients were prospectively assigned into two groups, ERAS group in which patients received ERAS protocols (n = 63), No-ERAS group in which patients had conventional clinical pathways (n = 62). Patient data were collected which included demographics, preoperative preparation, detailed information of surgical procedure, 60-day reoperation rate, 60-day readmission, postoperative length of stay (PLOS), time to first ambulation and flatus after surgery, time to removal of last drainage tube, and visual analogue scale (VAS) score at first ambulation and discharge. Complications referred to ones that occurred within 60 days after surgery. The above parameters were compared between ERAS group and No-ERAS group.

RESULTS

Time to first ambulation after surgery in ERAS group (mean 20.9 h) was significantly shorter than that in No-ERAS group (mean 104.3 ho). Meanwhile, time to first flatus after surgery in ERAS group (mean 26.7 h) was also significantly shorter than that in No-ERAS group (mean 37.3 h). Patients in ERAS group had statistically shorter PLOS (10.7 days) as compared to that in No-ERAS group (13.8 days). In ERAS group, 19 of 63 patients (30.2%) were discharged within seven days after surgery as compared to seven of 62 patients (11.3%) in No-ERAS group. VAS score at first ambulation in ERAS group was not obviously higher than that in No-ERAS group though the time of first ambulation in ERAS group was statistically earlier than one in No-ERAS group. Furthermore, VAS score at discharge in ERAS group was significantly lower than that in No-ERAS group. The rate of postoperative incision necrosis was 6.3% (4/63) in ERAS group and 8.1% (5/62) in No-ERAS group and all of these nine patients underwent reoperation before discharge. The difference was not statistically significant in the wound complication of incision necrosis and 60-day reoperation rate. Only one readmission occurred in No-ERAS group due to the surgical site infection and also there was no significant difference of 60-day readmission rate between these two groups. Furthermore, there was no statistical difference of complications of femoral artery thrombosis and rectal rupture between ERAS group and No-ERAS group.

CONCLUSIONS

Our proposed ERAS pathway for sacral tumour surgery and early walking facilitate safe and prompt discharge. ERAS protocols of sacral tumour surgery could decrease PLOS without significantly increasing postoperative complications, 60-day readmission rate and 60-day reoperation rate. The application of ERAS pathway in the field of sacral tumour surgery should have personalized feature with regard to resection type.

Modified Iliac Screw in Lumbopelvic Fixation After Sacral Tumor Resection: A Single-Center Case Series

BACKGROUND

Traditional iliac screw, S2-alar iliac screw, and modified iliac screw are the 3 common techniques for lumbopelvic fixation. The application of the modified iliac technique in sacral spinal tumors has been rarely reported.

OBJECTIVE

To report the feasibility and safety of modified iliac screws after sacral tumor resection and their preliminary clinical outcomes.

METHODS

Twenty-seven patients who underwent sacral tumor resection with modified iliac screw fixation between August 2017 and August 2021 at our center were clinically and radiographically evaluated.

RESULTS

A total of 59 iliac screws were inserted by freehand according to the anatomic landmarks. The mean operation time was 207 minutes (range, 140-435 minutes). The average estimated blood loss was 1396 mL (300-4200 mL). Computed tomography scans showed that 2 (3.4%) screws penetrated the iliac cortex, indicating a 96.6% implantation accuracy rate. There were no iatrogenic neurovascular or visceral structure complications observed. The mean minimal distances from the screw head to the skin were 24.9 and 25.8 mm on the left and right sides, respectively. The mean minimal distances from the screw head to the horizontal level of the posterior superior iliac spine were 7.9 and 8.3 mm on the left and right sides, respectively. Two patients (7.4%) underwent reoperation for wound infection. At the latest follow-up, no patient had complications of screw head prominence, pseudarthrosis, or instrument failure.

CONCLUSION

The modified iliac screw is characterized by its minimal invasiveness and simplicity of placement. It is an ideal alternative for lumbopelvic fixation after sacral tumor resection.

Trajectory of worst pain within the first two weeks following pelvic and sacral tumor surgery and long-term outcome: a pilot observational prospective cohort study

BACKGROUND

Pain management after pelvic and sacral tumor surgery is challenging and requires a multidisciplinary and multimodal approach. Few data on postoperative pain trajectories have been reported after pelvic and sacral tumor surgery. The aim of this pilot study was to determine pain trajectories within the first 2 weeks after surgery and explore the impact on long-term pain outcomes.

METHODS

Patients scheduled for pelvic and sacral tumor surgery were prospectively recruited. Worst/average pain scores were evaluated postoperatively using questions adapted from the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) until pain resolution was reached or up to 6 months after surgery. Pain trajectories over the first 2 weeks were compared using the k-means clustering algorithm. Whether pain trajectories were associated with long-term pain resolution and opioid cessation was assessed using Cox regression analysis.

RESULTS

A total of 59 patients were included. Two distinct groups of trajectories for worst and average pain scores over the first 2 weeks were generated. The median pain duration in the high vs low pain group was 120.0 (95% CI [25.0, 215.0]) days vs 60.0 (95% CI [38.6, 81.4]) days (log rank p = 0.037). The median time to opioid cessation in the high vs low pain group was 60.0 (95% CI [30.0, 90.0]) days vs 7.0 (95% CI [4.7, 9.3]) days (log rank p < 0.001). After adjusting for patient and surgical factors, the high pain group was independently associated with prolonged opioid cessation (hazard ratio [HR] 2.423, 95% CI [1.254, 4.681], p = 0.008) but not pain resolution (HR 1.557, 95% CI [0.748, 3.243], p = 0.237).

CONCLUSIONS

Postoperative pain is a significant problem among patients undergoing pelvic and sacral tumor surgery. High pain trajectories during the first 2 weeks after surgery were associated with delayed opioid cessation. Research is needed to explore interventions targeting pain trajectories and long-term pain outcomes.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov ( NCT03926858 , 25/04/2019).

Surgical Strategy and Application of Robotic-Assisted Benign Sacral Neurogenic Tumor Resection

BACKGROUND

Robotic surgery may be advantageous in neurogenic sacral tumor resection but only a few studies reported robotic-assisted neurogenic sacral tumor resection.

OBJECTIVE

To propose a new surgical strategy for robotic-assisted benign sacral neurogenic tumor resection and introduce the ultrasonic osteotomy surgical system in robotic surgery.

METHODS

Twelve patients who had robotic-assisted primary benign sacral neurogenic tumor resection between May 2015 and March 2021 were included. Our surgical strategy divides tumors into 4 types. Type I: Presacral tumors with diameter <10 cm. Type II: Narrow-base tumors involving the sacrum with diameter <10 cm. Type III: Broad-base tumors involving the sacrum with diameter <10 cm. Type IV: Tumors involving sacral nerve roots ≥2 levels and/or with diameter ≥10 cm.

RESULTS

Five type I, 5 type II, and 1 type III patients underwent tumor resection via an anterior approach, and 1 type IV patient via a combined approach. The median operation time, blood loss, and postoperative hospital stay of type I and II were much less than those of type IV. The ultrasonic osteotomy surgical system facilitated osteotomy in 2 type II and 1 type III patients. Eleven patients had total resections, and 1 type III patient had a partial resection. During the follow-up period of 7.9 to 70.9 months (median: 28.5 months), no local recurrences or deaths were noted.

CONCLUSION

With the largest single-center series to our knowledge, this surgical strategy helped to guide robotic-assisted benign sacral neurogenic tumor resection. The ultrasonic osteotomy surgical system was effective for type II and III.

The management of sacral tumours

Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours.

Cite this article: Bone Joint J 2022;104-B(12):1284–1291.

Association between intraoperative fluid overload and postoperative debridement in major sacrum tumor resection: A propensity score matching study

Intra-aortic balloon occlusion (IABO) is used to reduce intraoperative bleeding and facilitate successful sacrum tumor resection. Up to 20% of patients experience postoperative wound healing problems, but the risk factors related to this complication have not been clearly defined. The anesthetic database of Peking University People's Hospital, Beijing, China, was searched for all patients (aged 14-70 years old) who underwent sacrum tumor surgery with the application of IABO from 2014 to 2017. Data from 278 patients with an aortic occlusion duration of 72 ± 33 minutes were collected. Fifty-six patients required postoperative debridement because of wound infection. The independent risk factor identified by logistic regression was fluid excess (calculated as volume infused minus blood loss and urine output divided by body weight [kg]), and decision tree analysis revealed that the cutoff point for fluid excess was 38.5 mL/kg. Then patients were then divided into high fluid excess group (fluid excess > 38.5 mL/kg) and low fluid excess group (fluid excess ≤ 38.5 mL/kg) and 91 pairs of patients were generated through propensity score matching (PSM). Fluid excess was significantly higher in the high fluid excess group (46 vs 30 mL/kg, P < .001), and more patients required postoperative debridement than in the low fluid excess group (24 (26.3%) vs 12 (13.1%), P < .001). In this retrospective PSM study on sacrum tumor resection, fluid overload was related to postoperative debridement and further studies are needed to improve the clinical prognosis.

Evaluating the Optimal Management of Inoperable Giant Cell Tumors of the Spine: A Systematic Review and Meta-Analysis

Simple Summary

Spine giant cell tumors (SGCTs) are intermediate malignant bone tumors, sometimes aggressive and responsible for debilitating axial pain and sensorimotor impairments. Non-surgical therapies, including denosumab, radiotherapy, and selective arterial embolization (SAE), have shown promising results in the treatment of patients with inoperable SGCTs. In this systematic review, we aimed to comprehensively analyze the current literature on denosumab, radiotherapy, and SAE for inoperable SGCTs, comparing treatment outcomes and complications using a random-effect model meta-analysis. We found that all three treatments were equally effective in providing symptom improvement and radiological tumor response, also showing low and comparable rates of treatment-related complications. Patients treated with denosumab showed lower rates of local recurrences and distant metastases.

Abstract

Background: Surgical resection remains the preferred treatment in spine giant cell tumors (SGCTs), but it is not always feasible. Conservative strategies have been studied for inoperable cases. We systematically reviewed the literature on inoperable SGCTs treated with denosumab, radiotherapy or selective arterial embolization (SAE). Methods: PubMed, Scopus, Web-of-Science, Ovid-EMBASE, and Cochrane were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to include studies of inoperable SGCTs treated with denosumab, radiotherapy or SAE. Treatment outcomes were analyzed and compared with a random-effect model meta-analysis. Results: Among the 17 studies included, 128 patients received denosumab, 59 radiotherapy, and 43 SAE. No significant differences in baseline patient characteristics were found between the three groups. All strategies were equally effective in providing symptom improvement (p = 0.187, I² = 0%) and reduction in tumor volume (p = 0.738, I² = 56.8%). Rates of treatment-related complications were low (denosumab: 12.5%; radiotherapy: 8.5%; SAE: 18.6%) and comparable (p = 0.311, I² = 0%). Patients receiving denosumab had significantly lower rates of local tumor recurrence (10.9%) and distant metastases (0%) compared to patients receiving radiotherapy (30.5%; 8.5%) or SAE (35.6%; 7%) (p = 0.003, I² = 32%; p = 0.002, I² = 47%). Denosumab was also correlated with significantly higher overall survival rates at 18 months (99.2%) and 24 months (99.2%) compared to radiotherapy (91.5%; 89.6%) and SAE (92.5%; 89.4%) (p = 0.019, I² = 8%; p = 0.004, I² = 23%). Mortality was higher in patients receiving SAE (20.9%) or radiotherapy (13.6%) compared to denosumab (0.8%) (p < 0.001), but deaths mostly occurred for unrelated diseases. Conclusions: Denosumab, radiotherapy, and SAE are safe and effective for inoperable SGCTs. Clinical and radiological outcomes are mostly comparable, but denosumab may provide superior tumor control.

Current Concepts in the Treatment of Giant Cell Tumors of Bone

Simple Summary

According to the 2020 World Health Organization classification, a giant cell tumor of bone is an intermediate malignant bone tumor. Denosumab treatment before curettage should be avoided due to the increased risk of local recurrence. Administration of denosumab before en bloc resection of the giant cell tumors of the pelvis and spine facilitates en bloc resection. Nerve-sparing surgery after embolization is a possible treatment for giant cell tumors of the sacrum. Denosumab therapy with or without embolization is indicated for inoperable giant cell tumors of the pelvis, spine, and sacrum. A wait-and-see approach is recommended for lung metastases at first, then denosumab should be administered to the growing lesions. Radiotherapy is not recommended owing to the risk of malignant transformation. Local recurrence after 2 years or more should be indicative of malignant transformation. This review summarizes the treatment approaches for non-malignant and malignant giant cell tumors of bone.

Abstract

The 2020 World Health Organization classification defined giant cell tumors of bone (GCTBs) as intermediate malignant tumors. Since the mutated H3F3A was found to be a specific marker for GCTB, it has become very useful in diagnosing GCTB. Curettage is the most common treatment for GCTBs. Preoperative administration of denosumab makes curettage difficult and increases the risk of local recurrence. Curettage is recommended to achieve good functional outcomes, even for local recurrence. For pathological fractures, joints should be preserved as much as possible and curettage should be attempted. Preoperative administration of denosumab for pelvic and spinal GCTBs reduces extraosseous lesions, hardens the tumor, and facilitates en bloc resection. Nerve-sparing surgery after embolization is a possible treatment for sacral GCTBS. Denosumab therapy with or without embolization is indicated for inoperable pelvic, spinal, and sacral GCTBs. It is recommended to first observe lung metastases, then administer denosumab for growing lesions. Radiotherapy is associated with a risk of malignant transformation and should be limited to cases where surgery is impossible and denosumab, zoledronic acid, or embolization is not available. Local recurrence after 2 years or more should be indicative of malignant transformation. This review summarizes the treatment approaches for non-malignant and malignant GCTBs.

Surgical Strategy of Pediatric Benign Sacral Tumors

BACKGROUND

Primary benign osseous tumors and tumor-like lesions at the sacrum are rare in the pediatric population and exact surgical strategy is still unclear. In this study, we evaluate the outcome for pediatric patients with benign tumors and tumor-like lesions at the sacrum who were receiving surgical treatment according to our proposed surgical strategy and classification.

METHODS

We analyzed 49 pediatric patients with sacral benign tumors or tumor-like lesions aged 18 years and below from 2005 to 2018. There were 23 men and 26 women with a mean age of 14.0±3.8 years. Nineteen patients had giant cell tumors (GCTs), 9 aneurysmal bone cysts, 5 osteoblastomas, 5 neurogenic tumors, 3 hemangiomas, 3 teratomas, 2 Langerhans cell histiocytosis, 1 chondroblastoma, 1 fibrous dysplasia, and 1 GCT of tendon sheath. We proposed our surgical plan and surgical classification for pediatric patients with sacral benign tumors or tumor-like lesions.

RESULTS

The mean follow-up duration was 6.2 years (range, 1.0 to 18.9 y). GCTs (39%, 19/49) and primary aneurysmal bone cysts (18%, 9/49) are the top 2 common histologic types. Preoperative selective arterial embolization (SAE) was performed in 12 cases and 24 patients received intraoperative aortic balloon occlusion (ABO) as the preoperative surgical plan. Furthermore, according to tumor location at the sacrum, we classified surgical excision of sacral benign tumors and tumor-like lesions into 3 types. Fourteen cases were classified as type I, 27 as type II, 3 as type III, and 5 patients with neurogenic tumors cannot be classified into this surgical classification. Ten patients had wound complications. Two had femoral artery thrombosis because of ABO application. One had mechanical failure. Rate of local recurrence was 16%. Seven patients with GCTs and 1 with neurogenic tumor had local recurrence. No patient died of disease at the last follow-up. For the assessment of neurological function, the rate of neurological dysfunction was 12% (6/49). Four cases had urinary incontinence, 3 fecal incontinence, and 3 had bowel obstruction. Next, univariate analysis for influence of preoperative SAE and intraoperative ABO on complications demonstrated that both of them exerted no significant influence on the occurrence of oncological and nononcological complications.

CONCLUSIONS

The proposed surgical strategy can provide an excellent therapeutic effect for pediatric benign tumors and tumor-like lesions at the sacrum. Preoperative SAE and intraoperative ABO can safeguard pediatric patients with high vascularity of benign tumor at the sacrum during the operation.

LEVEL OF EVIDENCE

Level IV.

Surgical Strategy for Sacral Tumor Resection

PURPOSE

This study aimed to present our experiences with a precise surgical strategy for sacrectomy.

MATERIALS AND METHODS

This study comprised a retrospective review of 16 patients (6 males and 10 females) who underwent sacrectomy from 2011 to 2019. The average age was 42.4 years old, and the mean follow-up period was 40.8 months. Clinical data, including age, sex, history, pathology, radiographs, surgical approaches, onset of recurrence, and prognosis, were analyzed.

RESULTS

The main preoperative symptom was non-specific local pain. Nine patients (56%) complained of bladder and bowel symptoms. All patients required spinopelvic reconstruction after sacrectomy. Three patients, one high, one middle, and one hemi-sacrectomy, underwent spinopelvic reconstruction. The pathology findings of tumors varied (chordoma, n=7; nerve sheath tumor, n=4; giant cell tumor, n=3, etc.). Adjuvant radiotherapy was performed for 5 patients, chemotherapy for three, and combined chemoradiotherapy for another three. Six patients (38%) reported postoperative motor weakness, and newly postoperative bladder and bowel symptoms occurred in 5 patients. Three patients (12%) experienced recurrence and expired.

CONCLUSION

In surgical resection of sacral tumors, the surgical approach depends on the size, location, extension, and pathology of the tumors. The recommended treatment option for sacral tumors is to remove as much of the tumor as possible. The level of root sacrifice is a predicting factor for postoperative neurologic functional impairment and the potential for morbidity. Pre-operative angiography and embolization are recommended to prevent excessive bleeding during surgery. Spinopelvic reconstruction must be considered following a total or high sacrectomy or sacroiliac joint removal.

Compassionate use of a custom 3D-printed sacral implant for revision of failing sacrectomy: case report

Reconstruction of the spinopelvic continuity after sacral resection for primary sacral tumors remains challenging. Complex anatomical and biomechanical factors of this transition zone may be addressed with the advancement of 3D-printed implants. Here, the authors report on a 67-year-old patient with a sacral chordoma who initially underwent total en bloc sacrectomy followed by standard spinopelvic reconstruction. Pseudarthrosis and instrumentation failure of the lumbosacral junction construct subsequently developed. A custom 3D-printed sacral prosthesis was created using high-resolution CT images. Emergency Food and Drug Administration approval was obtained, and the custom device was implanted as a salvage reconstruction surgery. Made of porous titanium mesh, the custom artificial sacrum was placed in the defect based on the anticipated osteotomic planes and was fixed with a screw-rod system along with a fibular bone strut graft. At the 18-month follow-up, the patient was disease free and walking short distances with assistance. CT revealed excellent bony incorporation into the graft.The use of a custom 3D-printed prosthesis in spinal reconstruction has been rarely reported, and its application in sacral reconstruction and long-term outcome are novel. While the implant was believed to be critical in endowing the region with enough biomechanical stability to promote healing, the procedure was difficult and several key learning points were discovered along the way.

Successful surgical resection of a rare case of a giant sacral chordoma: a multidisciplinary feat

We, here, report the case of a 72-year-old man who presented with a giant sacral chordoma without aggressive clinical and neurological course and confirmed with a CT guided biopsy. The patient underwent multidisciplinary, two-stage successful complete en bloc sacrectomy along with total gross tumour resection, followed by lumboiliac fusion and instrumentation in the second stage without any neurological deficit nor bladder or bowel-related complications.

Analysis of clinical outcome for adolescent patients undergoing conservative nerve-sparing surgery based on the proposed resection classification for sacral giant cell tumor

The most common of age distribution ranges from second to fourth decade of life and patients with giant cell tumors (GCT) aged less than 18 years is more uncommon. We are aiming to reveal what the conservative nerve-sparing surgery values for adolescent patients with sacral GCT. We retrospectively reviewed 15 adolescent patients with sacral GCT aged <eighteen years, who received the conservative nerve-sparing surgery at our center from 2007 to 2018. Four patients presented with tumor of Campanacci grade II and 11 patients with grade III. According to the location of tumor at the sacrum, we classified the surgical resection of sacral giant cell tumor into three types. In our adolescent cohort, nine had the aortic balloon occlusion and five received the selective arterial embolization. All patients were free of disease and no one had the pulmonary metastasis or died of disease. All five wound complications required the debridement. 6 out of 15 patients had the local recurrence that required surgery treatment. The average time to recurrence after initial surgery in the present adolescent cohort was 22.4 months. Two patients had the surgical site infection and three had the wound dehiscence. One had the femoral artery thrombosis due to the aortic balloon occlusion and received the surgical removal of thrombosis. With the help of preoperative selective embolization and intraoperative aortic balloon occlusion, adolescent patients undergoing conservative nerve-sparing surgery for giant cell tumor of sacrum based on the proposed surgical resection classification have an acceptable clinical outcome and neurologic function.

Preliminary investigation of bilateral internal iliac artery ligation and anterior tumor separation through laparoscopy before posterior resection of a giant sacral tumor

BACKGROUND

Surgical is the optimal therapeutic strategy for sacral tumors, and complete resection can effectively improve the recurrence and survival rates. However, the specialized anatomy, massive bleeding and adhesion to the anterior tissue, especially that caused by giant sacral tumors, makes complete resection difficult. The laparoscopic technique provides a new method to resect sacral tumors.

METHODS

34 patients with primary giant sacral tumors who underwent surgical resection were enrolled. After bilateral internal iliac artery ligation and anterior laparoscopic tumor separation, the sacral tumors were successfully resected posteriorly. The clinical, radiological and follow-up data were collected and analyzed.

RESULTS

The average operative time was 276.47 min and that for laparoscopy was 76.24 min. The average intraoperative blood loss was 1757.64 ml. No complications associated with laparoscopic surgery, such as intestinal, urinary tract, or vascular injuries, occurred. Ten patients (29.41%) had perioperative complications, including infection, unhealed wounds, and cerebrospinal fluid leaks in 10, 5 and 2 patients, respectively. Patients with complications had significantly longer total (55.00 ± 34.53 vs 25.13 ± 14.60, P = 0.001) and postoperative (39.10 ± 30.61 vs 14.83 ± 10.00, P = 0.002) hospitalization stays than patients without complications. Postoperatively, bowel and bladder dysfunction, intestinal obstruction, pain, and perianal numbness occurred in 21, 5, 8, and 2 patients, respectively. The recurrence rate was 11.76%.

CONCLUSIONS

Laparoscopically assisted sacral tumor resection is a technically feasible and effective surgical method to resect giant sacral tumors, with the advantages of reduced operative blood loss during internal iliac artery ligation and anterior tumor separation.

Assessment of patient experiences following total sacrectomy for primary malignant sacral tumors: A qualitative study

BACKGROUND AND OBJECTIVES

Few reports have investigated patient experiences following total en bloc sacrectomy. The aims of this study were to obtain a deeper understanding of patients' personal experiences, needs, and satisfaction with the treatment to reveal areas in which perioperative and long-term patient care can be improved.

METHODS

A qualitative design was applied to examine patient experiences and supportive care needs. Patients treated between 2007 and 2017 were identified from our institutional database.

RESULTS

A total of 28 survivors were interviewed (13 females, age 13-75 years). Eight themes were identified: the effect of surgery on patients' (a) daily lives, (b) social activities, (c) work or school activities, (d) and family lives; (e) acceptance of ostomy surgery; (f) need for guidance regarding long-term rehabilitation; (g) satisfaction with the medical services provided in the hospital; and (h) satisfaction with the treatment outcomes.

CONCLUSION

Total en bloc sacrectomy can yield satisfactory oncological outcomes; however, the procedure is a life-changing event for patients and their families. Physicians must provide long-term support and guidance after surgery to enable patients to fully understand and cope with the changes in their lives.

Reconstruction of the pelvic ring after total en bloc sacrectomy using a 3D-printed sacral endoprosthesis with re-establishment of spinopelvic stability: a retrospective comparative study

AIMS

The aim of this study was to describe the use of 3D-printed sacral endoprostheses to reconstruct the pelvic ring and re-establish spinopelvic stability after total en bloc sacrectomy (TES) and to review its outcome.

PATIENTS AND METHODS

We retrospectively reviewed 32 patients who underwent TES in our hospital between January 2015 and December 2017. We divided the patients into three groups on the basis of the method of reconstruction: an endoprosthesis group (n = 10); a combined reconstruction group (n = 14), who underwent non-endoprosthetic combined reconstruction, including anterior spinal column fixation; and a spinopelvic fixation (SPF) group (n = 8), who underwent only SPF. Spinopelvic stability, implant survival (IS), intraoperative haemorrhage rate, and perioperative complication rate in the endoprosthesis group were documented and compared with those of other two groups.

RESULTS

The mean overall follow-up was 22.1 months (9 to 44). In the endoprosthesis group, the mean intraoperative hemorrhage was 3530 ml (1600 to 8100). Perioperative complications occurred in two patients; both had problems with wound healing. After a mean follow-up of 17.7 months (12 to 38), 9/10 patients could walk without aids and 8/10 patients were not using analgesics. Imaging evidence of implant failure was found in three patients, all of whom had breakage of screws and/or rods. Only one of these, who had a local recurrence, underwent re-operation, at which solid bone-endoprosthetic osseointegration was found. The mean IS using re-operation as the endpoint was 32.5 months (95% confidence interval 23.2 to 41.8). Compared with the other two groups, the endoprosthesis group had significantly better spinopelvic stability and IS with no greater intraoperative haemorrhage or perioperative complications.

CONCLUSION

The use of 3D-printed endoprostheses for reconstruction after TES provides reliable spinopelvic stability and IS by facilitating osseointegration at the bone-implant interfaces, with acceptable levels of haemorrhage and complications. Cite this article: Bone Joint J 2019;101-B:880-888.

Rare case of neglected large sacral Chordoma in a young female treated by wide En bloc resection and Sacrectomy

BACKGROUND

Sacral chordoma is a locally aggressive malignant tumour originating from ectopic notochordal cells. The natural history of sacral chordoma is a slow growing tumour arising at the midline of the lower sacrum that can invade the sacrum and progressively increase in size expanding cranially and anteriorly. Metastasis is very rare even when the tumour is large. Sacral chordoma affects males more than females and is more commonly found in middle age and elderly patients.

CASE PRESENTATION

A 25 years old female had neglected an extremely large midline sacral mass for 2 years. On presentation to hospital, she had been bed bound for the past 2 years. The sacral mass was so large that it prevented her from lying down supine and sitting on the wheelchair comfortably. Clinical examination showed a 40 cm × 30 cm × 20 cm hard mass over the sacrum that involved both buttocks and the gluteal fold. Neurological exam of bilateral lower limb was normal. Computed Tomography Scan of the Pelvis showed a large destructive sacrococcygeal mass measuring 43 cm × 38 cm × 27 cm with extension into the presacral space resulting in anterior displacement of the rectum, urinary bladder and uterus; and posterior extension into the dorsal soft tissue with involvement of the gluteus, piriformis, and left erector spinae muscles. Biopsy taken confirmed Chordoma. This patient was managed by a multidisciplinary team in an Oncology referral centre. The patient had undergone Wide En Bloc Resection and Sacrectomy, a complex surgery that was associated with complications namely bleeding, surgical site infection and neurogenic bowel and bladder. Six months post operatively the patient was able to lie supine and sit on wheelchair comfortably. She required extensive rehabilitation to help her ambulate in future.

CONCLUSION

This is a rare case of neglected sacral chordoma in a young female treated with Wide En Bloc Resection and Sacrectomy associated with complications of this complex surgery. Nevertheless, surgery is still worthwhile to improve the quality of life and to prevent complications secondary to prolonged immobilization. A multidisciplinary approach is ideal and team members need to be prepared to address the complications once they arise.

Clinical results and quality of life after reconstruction following sacrectomy for primary bone malignancy

BACKGROUND

Sacrectomy is a rare and demanding surgical procedure that results in major soft tissue defects and spinopelvic discontinuity. No consensus is available on the optimal reconstruction algorithm. Therefore, the present study evaluated the results of sacrectomy reconstruction and its impact on patients' quality of life (QOL).

METHODS

A retrospective chart review was conducted for 21 patients who underwent sacrectomy for a primary bone tumour. Patients were divided into groups based on the timing of reconstruction as follows: no reconstruction, immediate reconstruction or delayed reconstruction. QOL was measured using the EQ-5D instrument before and after surgery in patients treated in the intensive care unit.

RESULTS

The mean patient age was 57 (range 22-81) years. The most common reconstruction was gluteal muscle flap (n = 9) and gluteal fasciocutaneous flap (n = 4). Four patients required free-tissue transfer, three latissimus dorsi flaps and one vascular fibula bone transfer. No free flap losses were noted. The need for unplanned re-operations did not differ between groups (p = 0.397), and no significant differences were found for pre- and post-operative QOL or any of its dimensions.

DISCUSSION

Free flap surgery is reliable for reconstructing the largest sacrectomy defects. Even in the most complex cases, surgery can be safely staged, and final reconstruction can be carried out within 1 week of resection surgery without increasing peri‑operative complications. Sacrectomy does not have an immoderate effect on the measured QOL.

Can Aortic Balloon Occlusion Reduce Blood Loss During Resection of Sacral Tumors That Extend Into the Lower Lumber Spine?

BACKGROUND

Although aortic balloon occlusion has been shown to reduce blood loss during sacral tumor resections, it has not been validated in larger sacral tumors involving the lower lumbar spine. If such an approach were shown to be associated with less blood loss, it might aid the tumor surgeon in resecting these difficult tumors.

QUESTIONS/PURPOSES

(1) Is the use of aortic balloon occlusion associated with reduced blood loss in sacral tumor resections when the lower lumbar spine is also involved? (2) Does the use of the aortic balloon prolong total operating time? (3) What complications are associated with the use of a balloon?

METHODS

We retrospectively studied all 56 patients diagnosed with sacral tumors involving the lower lumbar spine (L4, L5) who were treated surgically between 2004 and 2015 at our institute. During that time, 30 of the patients received aortic balloon occlusion therapy, whereas 26 of the patients did not. We generally used aortic balloon occlusion during procedures for hypervascular lesions (for example, giant cell tumors or metastatic renal cancers), primary malignant lesions, and recurrent lesions. We generally avoided use of aortic balloon occlusion in patients with anatomic defects of the aorta (aortic dissection or aneurysm was strictly contraindicated), renal artery bifurcation caudal to the L2 to L3 disc, age older than 70 years or younger than 12 years, history of Stage 2 hypertension [], history of balloon use in previous surgeries, and presence of unstable plaque on abdominal CT. The demographic data, intraoperative blood loss, transfusion volume, operating time, and postoperative wound drainage between the two groups were collected and analyzed. Balloon-related complications were identified. Followup in terms of balloon-related complications was conducted in all 56 patients for at least 6 months after surgery.

RESULTS

Intraoperative blood loss was determined to be less in patients treated with the balloon compared with those treated without the balloon (median volume, 2000 mL, range, 400-6000 mL versus 2650 mL, range, 550-6800 mL, respectively; median difference, 605 mL; 95% confidence interval [CI], 100-1500 mL; p = 0.035). Total operative time was not prolonged in the balloon group (including balloon insertion time) compared with those treated without it (median time, 215 minutes, range, 110-430 minutes versus 225 minutes, range, 115-340 minutes, respectively; median difference, 10 minutes; 95% CI, -40 to 30 minutes; p = 0.902). Balloon-related vascular complications included local hematoma at the puncture site in five patients, femoral artery spasm in three patients, lower limb ischemia in one patient, and femoral artery pseudoaneurysm in one patient. Acute kidney injury was found in two patients in the balloon group.

CONCLUSIONS

This study demonstrated that placement of the aortic balloon at a level just caudal to the renal artery bifurcation was associated with lower intraoperative blood loss and transfusion in lumbosacral tumor resections. However, procedure-specific complications were common and there was no benefit to total operative time. We suggest that the surgical procedures still need to be further refined to minimize complications. We also recommend that prospective studies be undertaken to confirm the efficacy of aortic balloon occlusion in surgery for lumbosacral tumors.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Single Stage Posterior Approach for Total Resection of Presacral Giant Schwannoma: A Technical Case Report

The neurogenic tumor of frequent occurrence in the presacral area is a schwannoma. Giant presacral schwannoma has a risk for anterior surgical approach because of its massive size and proximity to abundant vascularity of presacral region. We report a single stage posterior approach for total resection of a giant presacral schwannoma. A 40-year-old female patient experienced left buttock pain and tingling sensation at left S1 dermatome. Magnetic resonance imaging showed that the presacral huge mass at S1–3 level with osseous extension and structural remodeling in left sacral ala. The presacral mass was ranging in maximum diameter from 8.0 to 8.6 cm. S2 foramen laminectomy was performed to expose the mass. The tumor capsule and the root were carefully dissected away. The tumor was removed while preserving the capsule by dissecting the plane between the inner wall of the capsule and the tumor. The single stage posterior approach for presacral giant schwannoma is feasible, and it can be a good surgical alternative to prevent pelvic organ or vascular damage and anterior approach related dystocia and infertility.

Surgical Treatment of Primary Osteosarcoma of the Sacrum: A Case Series of 26 Patients

STUDY DESIGN

Twenty-six patients were treated surgically for sacral osteosarcomas in our center. The oncological and functional results are analyzed.

OBJECTIVE

To describe the general characteristics and evaluate the outcome of surgical treatment of primary osteosarcoma of the sacrum.

SUMMARY OF BACKGROUND DATA

A very few reports have addressed the technique and outcome of surgical treatment of primary sacral osteosarcoma. The survival rate of such cases is low.

METHODS

The clinical data of 26 patients treated surgically for sacral osteosarcomas from June 2000 to December 2013 at our hospital were retrospectively reviewed.

RESULTS

There were 15 males and 11 females with a median age of 28 years (range, 12-68 years). Distal metastasis occurred in 13 patients (50%), and local recurrence occurred in 10 patients (38.5%, including 6 patients with additional distal metastasis). The 1-year and 5-year survival rates were 92.3% and 38.7%, respectively. Adequate and inadequate surgical margins were obtained in 16 and 10 cases, respectively. Patients with adequate margins had a significantly lower recurrence rate (P = 0.015) and higher event-free survival rate (P = 0.04) than those with inadequate margins. However, the overall survival rate did not differ significantly between patients with adequate and inadequate margins (P = 0.22). Only seven cases showed a good response based on necrosis rate (>90%). Patients with a better response to chemotherapy had better event-free and overall survival rates.

CONCLUSION

Adequate surgical margins are achievable in most cases of sacral osteosarcomas. Adequate margins can significantly improve the recurrence rate and event-free survival rate compared with inadequate margins. However, sacrectomy is still a challenging surgical technique. Adequate margins are also difficult to obtain in sacrectomy. In addition, only a few patients had a good response to chemotherapy. These reasons lead to a low 5-year survival rate in primary sacral osteosarcoma patients.

LEVEL OF EVIDENCE

4.

How Does the Level of Nerve Root Resection in En Bloc Sacrectomy Influence Patient-Reported Outcomes?

BACKGROUND

For patients with sacral tumors, who are well enough for surgery, en bloc resection is the preferred treatment. Survival, postoperative complications, and recurrent rates have been described, but patient-reported outcomes often are not included in these studies.

QUESTIONS/PURPOSES

The purposes of this study were (1) to compare patient-reported outcomes after en bloc sacrectomy, based on the level of sacral nerve root resection, in terms of mental health, physical health, bowel function, and sexual function; and (2) to assess differences in terms of mental health, physical health, and pain between patients with and without a colostomy.

METHODS

A total of 74 patients, of whom 58 (78%) were diagnosed with chordoma, were surveyed between February 2012 and October 2014. This represented 48% of patients with sacral chordoma who were alive and who had been treated with a transverse sacral resection between June 2000 and August 2013 at three institutions with a minimum followup of 6 months (mean, 59 months; range, 6-255 months). We chose 6 months because we believe that neurologic deficits generally are stable by this point and that patients generally have recovered from the operation by this time. Patients were divided into five groups based on the most caudal nerve root spared: L5 (N = 10), S1 (N = 22), S2 (N = 17), S3 (N = 18), and S4 (N = 7). Only postoperative outcomes were collected using the National institute of Health's Patient Reported Measurement Information System (PROMIS) Global Health survey, PROMIS Pain Interference survey, PROMIS Pain Intensity survey, PROMIS Sexual Function survey, and the Modified Obstruction and Defecation Score survey.

RESULTS

Differences between two adjacent levels were found in terms of mental health, physical health, and sexual function. Patients in whom the S2 nerve roots were spared had a lower mental health score (median = 44, interquartile range [IQR] = 41-51) than patients in whom the S3 nerve roots were spared (median = 53, IQR = 48-56, q = 0.049). Patients in whom the S2 nerve roots were spared had a slightly lower physical health score (median = 42, IQR = 40-51) than patients in whom the S3 nerve roots were spared (median = 47, IQR = 45-54, q = 0.043). Patients in whom the S1 roots were spared (median = 1.0, range = 1.0-1.0) had a lower orgasm score than patients in whom the S2 nerve roots were spared (median = 3, range = 2-5, q = 0.027). No differences in terms of mental health, physical health, or pain were found between the colostomy group and the no colostomy group.

CONCLUSIONS

The combination of our findings can be used to further educate patients and discuss expectations. In an operative setting, these data can be considered when deciding to place a colostomy.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Three-dimensional printing and computer navigation assisted hemipelvectomy for en bloc resection of osteochondroma: A case report

RATIONALE

Three-dimensional (3D) printed templates can be designed to match an individual's anatomy, allowing surgeons to refine preoperative planning. In addition, the use of computer navigation (NAV) is gaining popularity to improve surgical accuracy in the resection of pelvic tumors. However, its use in combination with 3D printing to assist complex pelvic tumor resection has not been reported.

PATIENT CONCERNS

A 36-year-old man presented with left-sided pelvic pain and a fast-growing mass. He also complained of a 3-month history of radiating pain and numbness in the lower left extremity.

DIAGNOSES

A biopsy revealed an osteochondroma with malignant potential. This osteochondroma arises from the ilium and involves the sacrum and lower lumbar vertebrae.

INTERVENTIONS

Here, we describe a novel combined application of 3D printing and intraoperative NAV systems to guide hemipelvectomy for en-bloc resection of the osteochondroma. The 3D printed template is analyzed during surgical planning and guides the initial intraoperative bone work to improve surgical accuracy and efficiency, while a computer NAV system provides real-time imaging during the tumor removal to achieve adequate resection margins and minimize the likelihood of injury to adjacent critical structures.

OUTCOMES

The tumor mass and the invaded spinal structures were removed en bloc.

LESSONS

The combined application of 3D printing and computer NAV may be useful for tumor targeting and safe osteotomies in pelvic tumor surgery.

Surgical Treatment of Sacral Neurogenic Tumor: A 10-year Experience with 64 Cases

OBJECTIVE

To explore the outcomes of surgical treatment of sacral neurogenic tumors

METHODS

Between 1 January 2003 and 31 December 2012, data on 64 patients with sacral neurogenic tumors treated with surgery were retrospectively analyzed. The mean age of the 64 cases (35 males and 29 females) was 37.2 years (range, 21-69 years); 38 had neurilemmomas and 26 neurofibromas. Thirty-four of the tumors involved S 1 and S 2 , 11 S 3 or lower, and 19 were single presacral soft tissue masses. Tumors were removed via anterior, posterior or combined anteroposterior approaches. Patients with unstable sacroiliac joints underwent iliolumbar fixation.

RESULTS

Depending on the extent of tumor involvement, one of three surgical approaches was used: a single anterior approach (19 patients), single posterior approach (25 patients), or a combined anteroposterior approach (20 patients). The mean operation time was 3 h (range, 2-6 h) and the mean blood loss 878 mL (range, 400-3120 mL). The mean duration of follow-up was 58.2 months (range, 24-93 months). These surgeries had the following complications. Three patients had massive intraoperative hemorrhage and posterior back pain and discomfort postoperatively. One patient had intraoperative ureteral injuries requiring intraoperative ureteral catheterization. In two patients, the tumor involved the S 1 nerve roots bilaterally, necessitating their removal, which resulted in obvious lower limb motion and sphincteric dysfunction. In 13 patients with unilateral tumor involvement of the nerve roots of S 1 and lower spinal levels, only the contralateral nerve roots of the S1 and lower levels were preserved; eight of these patients had impaired bladder and bowel function. Posterior incisions failed to heal in 10 patients, secondary wound healing occurred in nine of them and one required a gluteus maximus myocutaneous flap. Three patients developed postoperative cerebrospinal fluid leaks that were and alleviated by waist belt compression bandaging and placing them in the Trendelenburg position. Eight patients developed tumor recurrences postoperatively; pathological examination of the tissue excised in the second surgeries revealed malignant changes in the three patients with neurilemmomas. There were no intraoperative deaths. Rod fractures occurred in three of the 18 patients requiring iliolumbar reconstruction.

CONCLUSIONS

The clinical characteristics of sacral neurogenic tumors make them easy to diagnose. The approach to resection should be determined by the location and size of the tumor. Patients with huge tumors may lose considerable blood intraoperatively and a have higher risk rate of postoperative complications.

One-step reconstruction with a 3D-printed, custom-made prosthesis after total en bloc sacrectomy: a technical note

BACKGROUND

Surgeries for primary malignancies involving upper sacrum require total en bloc sacrectomy followed by complex mechanical reconstruction, which might be simplified by application of the three-dimensional (3D) printing technique.

PURPOSES

To describe the design of a 3D-printed custom-made prosthesis for reconstruction after total en bloc sacrectomy, the surgical technique, and the clinical and functional outcome of a patient.

METHODS

A 62-year-old patient with recurrent sacral chordoma was admitted in our center. One-stage total en bloc sacrectomy through posterior approach was planned, and a 3D-printed sacral prosthesis was prepared for reconstruction according to the anticipated osteotomic planes.

RESULTS

The patient received one-stage total en bloc sacrectomy through posterior approach followed by reconstruction with the 3D-printed sacral prosthesis. The whole procedure took 5 h, and intra-operative blood loss was 3400 ml. The patient recovered uneventfully and started ambulation at 3 weeks after surgery. An asymptomatic instrument failure was found radiographically at 8-month follow-up. At 1 year after surgery, the patient was disease free and could walk over short distance with crutches without pain or any mechanical instability.

CONCLUSIONS

The advantages of our reconstruction method included: (1) the prosthesis provided an optimal reconstruction of lumbosacral and pelvic ring by integrating spinal pelvic fixation, posterior pelvic ring fixation, and anterior spinal column fixation in one step and (2) its porous surface could induce bone ingrowth and might enhance stability. Although there was an instrumental failure, we considered that it could be one reconstructive option. More research is warranted focusing on the modification of locations, diameters, and quantity of screws and biomechanical characteristics. The long-term functional and bone in-growth outcome will be followed to validate the use of the prosthesis.

Malignant Pelvic Tumors Involving the Sacrum: Surgical Approaches and Procedures Based on a New Classification

OBJECTIVE

To introduce a new classification of Enneking type IV pelvic tumors involving the sacrum and a corresponding system of standardized surgical approaches and procedures for resection of such tumors, and to investigate the feasibility and therapeutic effect of the new system.

METHODS

Data on 59 patients treated between February 2003 and February 2013 by standardized surgical approaches and procedures were retrospectively reviewed. The study subjects comprised 28 male and 31 female patients with a mean age at diagnosis of 36 years (range, 2-72 years). There are four subtypes in the new classification: (i) subtype IVa, neoplasms invading the ipsilateral sacral wing; (ii) subtype IVb, neoplasms invading the ipsilateral sacral foramina; (iii) subtype IVc, neoplasms invading the contralateral sacral foramina; and (iv) subtype IVd, neoplasms invading the whole of the sacrum. Standardized surgical approaches and procedures were devised for en-bloc resection for each subtype with adequate margins.

RESULTS

Adequate margins were achieved in 43/59 patients (72.9%). The mean operation time was 5.0 h and the mean intraoperative blood loss 2157 mL. At the final follow-up, 27/53 patients (50.9%) who had been followed up were alive and in complete remission. The mean Musculoskeletal Tumor Society 93 score was 17.4 (58%) of a possible 30 points. The mean functional score for patients who had undergone a pelvic zone II resection was 15.2, compared with 19.0 for those with an intact pelvic zone II.

CONCLUSIONS

The proposed standardized protocols should help orthopaedic surgeons to achieve adequate margins, manage risk, achieve better oncologic and functional outcomes, and minimize perioperative complications when treating massive pelvic tumors involving the sacrum.

Late local recurrence, at 19 and 17 years, of sacral chordoma treated by en bloc resection

Sacral chordoma (SC) is a malignant bone tumor with high risk of local recurrence (LR) even after en bloc resection, generally in the first 10 years after resection. We report two cases of late LR, at 17 and 19 years. Two male patients, aged 45 and 53 years, presented with large SC needing a combined approach for en bloc resection. Surgical margins were safe for the first patient and borderline for the second. The patients had yearly follow-up. The first patient developed LR on the posterior wall of the right acetabulum and the second developed LR in the right sciatic notch, at 17 and 19 years, respectively. These two cases of very late LR of SC advocate for yearly screening of patients even more than 20 years after resection.

LEVEL OF EVIDENCE

IV (case report).

Is total en bloc sacrectomy using a posterior-only approach feasible and safe for patients with malignant sacral tumors?

OBJECT In this study the authors' aim was to describe their experience with total en bloc sacrectomy using a posterioronly approach and to assess the outcome of patients with malignant sacral tumors who underwent this procedure at their center. METHODS The authors identified and retrospectively reviewed the records of 10 patients with malignant sacral tumors who underwent a total en bloc sacrectomy via a single posterior approach at their center. The pathological diagnosis was chordoma in 4 patients, chondrosarcoma in 1, osteosarcoma in 1, malignant schwannoma in 1, malignant giant cell tumor in 1, and Ewing's sarcoma in 2. Radiological examination revealed that the tumor involved S1-5 in 7 patients, S1-4 in 1, S1-3 in 1, and S1-2 in 1. RESULTS All 10 patients were stable during the perioperative period. The mean surgery duration was 282 minutes (range 250-310 minutes). The median estimated blood loss was 2595 ml (range 1500-3200 ml). All patients were followed up for 13-29 months (mean 22 months). Two patients had a local recurrence. Two patients died of disease, 1 patient was alive with disease, and 7 patients were alive without evidence of disease. Among the 8 surviving patients, 6 were able to walk without assistive devices, and 2 were able to walk with crutches. The total complication rate was 40% (4 of 10). Wound complications (deep infection and wound healing problems) occurred in 3 patients, and a distal deep vein thrombosis occurred in 1 patient. CONCLUSIONS Total en bloc sacrectomy using a posterior-only approach is feasible and safe in selected patients and is an important procedure for the treatment of primary malignant tumor involving the entire sacrum or only the top portion.

The small bowel in its hammock: how to avoid irradiation thanks to the sigmoid

BACKGROUND

High-dose irradiation is the cornerstone treatment of bone cancers of the pelvic rim. To protect the small bowel from irradiation and following consequences, we described the laparoscopic use of the sigmoid to perform a hammock.

MATERIALS AND METHODS

Three patients were diagnosed with metastatic Ewing's sarcoma, localized malignant peripheral nerve sheath tumor, and localized BCOR-CCNB3 (Ewing-like) sarcoma of the pelvic rim at 13.1, 5.7, and 12.9 years, respectively. After neoadjuvant chemotherapy, the 2 female patients underwent a hemisacrectomy under S2 only by the posterior approach, whereas no orthopedic surgery was required for the male patient because of excellent local response to chemotherapy. A 54-Gy intensity-modulated radiotherapy of the posterior part of the pelvis was intended for all patients.

RESULTS

The laparoscopic procedure consisted in the fixation of the sigmoid loop to the anterior parietal wall on a transverse line just below the umbilicus, associated with a colostomy in the right iliac fossa. The anterior transposition of the two ovaries, uterus, and rectum and the dissection of left iliac vessels to move them anteriorly were added in female patients. Stomas were closed around 6 months after completion of the radiotherapy course, associated with the repositioning of the uterus, ovaries, and colon. With a mean follow-up of 22 months, all patients are alive without any recurrences or radiation-related symptoms.

CONCLUSIONS

The laparoscopic "hammock technique" both protects the small bowel from irradiation and secures the orthopedic procedure by displacing the abdominal organs forward.

Preservation of the contralateral sacral nerves during hemisacrectomy for sacral malignancies

PURPOSE

This study aimed to evaluate the oncologic and functional outcome of the cases treated with hemisacrectomy through a sagittal plane in the sacrum and simultaneous en bloc resection together with the ipsilateral sacroiliac joint without sacrificing the contralateral sacral nerves and summarize tumor resection techniques and reconstruction strategy.

METHODS

En bloc resection of a sacral malignancy with ipsilateral sacroiliac joint and preservation of the contralateral sacral nerves by sagittal hemisacrectomy had been performed in 15 patients. An intra-abdominal aortic balloon was used in all these cases and a combined posterior-anterior approach was adopted. A modified Galveston technique was used to reestablish spinopelvic stability and a nonvascularized fibula autograft was used in selected cases.

RESULTS

Contralateral sacral nerves were preserved in all 15 patients. Adequate margins (wide and marginal margin) were accomplished in 10 patients. Local recurrence occurred in seven (47%) patients, and four of these had an inadequate margin. There was no perioperative death. Four (27%) patients had wound problems. No mechanical breakdown occurred until the last follow-up. All the patients were able to walk without the use of a walking aid. Sphincter function was partially preserved in all these patients. At the last follow-up, seven (47%) patients survived without evidence of disease, two (13%) patients lived with disease, and six (40%) patients had died of disease.

CONCLUSIONS

This procedure has an oncologic outcome that is similar to that of other high sacrectomy and a much better function outcome. Although demanding, it is indicated in selected patients.

Sacrococcygeal sinus angle: as a new anatomic landmark for the posterior approach of presacral lesions

PURPOSE

We have discussed the importance of sacrococcygeal sinus angle (SSA), which is a new anatomical landmark in the surgery of presacral lesions. Because of its anatomical structure, the sacrum limits the surgical exposure like a compact barrier for the posterior surgical approach. The main aim of this paper is to explain the anatomical description and clinical importance of SSA in the surgery of presacral lesions.

METHODS

Three groups were designated, consisting of ten patients in each group, as early childhood (group 1), late childhood (group 2) and adulthood (group 3). Patients were selected randomly. The degree of SSA measurement was performed between the line tangent to the anterior margin of the first sacral vertebra and the line from the promontorium to the tip of the coccyx. The measurement of SSA was performed on patients' lumbosacral magnetic resonance images. When the SSA forms a triangle via a parallel line starting from the inferior tip of the sacrum and running parallel to the ground, the area of the triangle also covers the field of view of the presacral region. In addition, the sacral region needed to be resected for maximum exposure is also within this area.

RESULTS

The mean SSA was measured to be 53.9 ± 11.4° in group 1, 77.8 ± 11.2° in group 2 and 74.5 ± 12.5° in group 3. Intergroup comparisons revealed a significant difference between group 1 and the other two groups statistically. It was found that the SSA was 20° less in group 1 as compared to the other age groups (p = 0.0005). The area of a triangle is calculated using the sine area formula, and according to this formula the area of a triangle increases when the degree of the angle increases, thus comprising larger part of the sacrum. This condition requires more and wide sacral resection to obtain maximum exposure in the presacral zone.

CONCLUSIONS

We have observed that the SSA is significantly smaller during early childhood compared with the other age groups. This feature provides an anatomical superiority in this age group for the posterior approach in the surgical treatment of presacral masses.

Experience with wound complications after surgery for sacral tumors

PURPOSE

The aim of this article is to summarize our experience in treating sacral wound complications after sacrectomy. We focus, in particular, on factors associated with wound complications, including surgical site infection (SSI) and wound dehiscence.

METHODS

The definition of SSI devised by Horgan et al. was applied. Wound dehiscence was defined as a wound showing breakdown in the absence of clinical signs meeting the diagnostic standard for SSI. Between September 1997 and August 2009, 387 patients with a sacral tumor underwent sacrectomy performed by the same team of surgeons and were followed up for ≥ 12 months. Potential risk factors were evaluated for univariate associations with SSI and wound complications. Multivariable conditional logistic regression was used to identify the combined effects of several risk factors.

RESULTS

Of the 387 wounds studied, 274 healed uneventfully, and 113 (29.2 %) broke down because of infection or dehiscence. Fifty-one (13.2 %) patients developed a postoperative SSI, and 62 (16.0 %) patients developed wound dehiscence. Gram-negative bacteria grew in 45 cultures (91.8 %) and included 38 cases of Escherichia coli. Previous radiation, rectum rupture, longer duration of surgery, and cerebrospinal fluid leakage were significantly associated with increased likelihood of developing an SSI. Previous radiation, rectum rupture, age <40 years, history of diabetes mellitus, maximum tumor diameter ≥ 10 cm, and instrumentation used were risk factors for wound complications.

CONCLUSIONS

The incidence of wound complications is not so high at a musculoskeletal tumor center with surgeons experienced in treating sacral tumors. Controlling for these risk factors when possible may improve clinical outcomes.

Blood Loss and Massive Transfusion in Patients Undergoing Major Oncological Surgery: What Do We Know?

Patients with solid malignancies who were not candidates for tumor resections in the past are now presenting for extensive oncological resections. Cancer patients are at risk for thromboembolic complications due to an underlying hypercoagulable state; however, some patients may have an increased risk for bleeding due to the effects of chemotherapy, the administration of anticoagulant drugs, tumor-related fibrinolysis, tumor location, tumor vascularity, and extent of disease. A common potential complication of all complex oncological surgeries is massive intra- and postoperative hemorrhage and the subsequent risk for massive blood transfusion. This can be anticipated or unexpected. Several surgical and anesthesia interventions including preoperative tumor embolization, major vessel occlusion, hemodynamic manipulation, and perioperative antifibrinolytic therapy have been used to prevent or control blood loss with varying success. The exact incidence of massive blood transfusion in oncological surgery is largely unknown and/or underreported. The current literature mostly consists of purely descriptive observational studies. Thus, recommendation regarding specific perioperative intervention cannot be made at this point, and more research is warranted.