Solitary plasmacytoma of the sacrum treated with microwave ablation in conjunction with high dose of dexamethasone: A case report and review of the literature

Background

Plasma cell neoplasms are characterized by the neoplastic proliferation of a single clone of plasma cells. Solitary plasmacytomas most often occur in bone, but they can also be found in soft tissues.

Case Description

A 53-year-old male presented with localized sacral pain and urinary incontinence. His radiographic studies showed a solitary sacral plasmacytoma (i.e., involving the bone). He was successfully managed with high-dose dexamethasone and microwave ablation (MWA).

Conclusion

Plasmacytomas of bone can be occasionally successfully managed with MWA, adjuvant cytoreduction therapy, and high doses of dexamethasone.

Characteristics, survivals and risk factors of surgical site infections after En Bloc sacrectomy for primary malignant sacral tumors at a single center

INTRODUCTION

For prolonged survival, primary malignant sacral tumors (PMST) are treated by En Bloc sacrectomy. Few studies analyzed specifically the surgical site infections (SSI) for this condition and whether they impact on the patients' survivals.

OBJECTIVES

The objectives were to (1) describe their characteristics; (2) compare the survivals of infected and non-infected patients; (3) identify patients- and surgery-related risk factors.

METHODS

We conducted a retrospective single center study on 51 consecutive patients with PMST who underwent an En Bloc sacrectomy. Mean follow-up was 89±68months (range, 13-256months). Histology consisted of 46 chordoma, 3 chondrosarcoma, 1 Ewing tumor, 1 malignant peripheral nerve sheet tumor. Mean age was 57.4±13.7years with 26 (51%) male. Approaches were mainly anterior-and-posterior with, for the anterior approach, 18 laparotomy and 32 laparoscopy. Other surgical characteristics included 39 (76%) sacrectomy above S3; 7 (14%) instrumented cases; 8 (16%) colostomy. A pedicled omental flap with artificial mesh was used for posterior wall reconstruction. Overall and disease-free survivals were compared between infected and non-infected patients using Kaplan-Meier curves and log-rank test.

RESULTS

A total of 29 (57%) patients developed a SSI (7 deep, 22 organ/space) at mean 13.2±7.7days. One patient had also an infected intraperitoneal hematoma at day 150. SSIs were polymicrobial in 26 (90%) cases with Enterococcus sp. (27%) and E. coli (24%) as predominant organisms. Overall and disease-free survivals were not statistically different between infected and non-infected patients. Factors associated with increased likelihood of SSI included age>65years (OR=3.64; 1.06-12.50; p=0.04) and an elevated ASA score (OR=3.28, 1.05-10.80; p=0.046). Neoadjuvant radiotherapy (OR=2.86; 0.97-9.37; p=0.08) demonstrated a trend towards increased risk of SSI. Tumor volume, sacrectomy level, operating time, laparoscopy, colostomy, instrumentation, bowel incontinence were not associated to an increased risk of SSI.

CONCLUSION

En Bloc sacrectomy for PMST led to frequent and early SSI which, however, did not seem to impact survivals. Preoperative frailty was the predominant risk factor found in this series. Further studies are required to identify protective measures.

LEVEL OF EVIDENCE

III, case-control study.

Sacroplasty Augmentation of Instrumented Pelvic Reconstruction After High Sacrectomy: A Technical Case Report

BACKGROUND AND IMPORTANCE

En bloc resection of sacral tumors is the most effective treatment to help prevent recurrence. Sacrectomy, however, can be destabilizing, depending on the extent of resection. Various surgical techniques for improving stability and enabling early ambulation have been proposed.

CLINICAL PRESENTATION

Here, we report a case in which we use PMMA (poly[methyl methacrylate]) to augment pelvic instrumentation to improve mechanical stability after sacrectomy for en bloc resection of a solitary fibrous tumor.

CONCLUSION

We highlight the use of sacroplasty augmentation of pelvic ring reconstruction to provide biomechanical stability without the need for fusion of any mobile spine segments, which allowed for early patient ambulation and no appreciable loss of range of motion or mobility.

Clinical manifestations, classification, and surgical management of sacral tumors and the need for personalized approach to sacrectomy

Background:

Although comprising 7% of all spinal tumors, sacral tumors present with a litany of issues due to their slow growth and difficulty in detection. As a result, sacral tumors can grow unperturbed for years until a patient presents for an incidental workup of an unassociated minor trauma or an offending primary tumor source that has metastasized to the sacrum; in most cases, this includes primary tumors of the breast, prostate, and lung. The goal of this review is to outline the pathophysiology underlying sacral tumors including the various tissues and structures that can be targeted for treatment, along with a discussion of the surgical approach to sacrectomy.

Methods:

An extensive review of the published literature was conducted through PubMed database with articles simultaneously containing both search terms “sacral tumors” and “sacrectomy.” No date restrictions were used.

Results:

The search yielded 245 related articles. Cross-checking of articles was conducted to exclude of duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic.

Conclusion:

Once a sacral tumor has reached the point of diagnostic detection, invasive sacrectomy is typically utilized (through an anterior, posterior, or combination approach) to locally isolate and resect the tumor and minimize risk of future tumor growth and additional bone loss. While institutions have varying criteria for surgical approaches, a combination of anterior and posterior approach has traditionally been used in total and high sacrectomies due to the control it provides surgeons toward the rectum and vasculature anterior to the sacrum. A posterior-only approach can be performed for tumors that failed to invade pelvic organs or extend past the lumbosacral junction. Early detection with screenings can help avoid invasive sacrectomy by identifying the onset of tumor formation in the sacrum, particularly for highly metastatic cancers.

Prolonged balloon occlusion of the lower abdominal aorta during pelvic or sacral tumor resection

Background

To explore the efficacy of lower abdominal aorta balloon occlusion technology in pelvis and sacral tumor surgery and to assess the safety of prolonged balloon occlusion.

Methods

From January 2008 to January 2017, 81 patients were diagnosed with sacrum or pelvic tumor and underwent surgery in our institution. Balloon catheters were placed through the femoral artery to occlude the abdominal aorta of the pelvic tumor and sacrum region undergoing tumor resection. These patients were divided into two group based on single balloon blocking time. Group A had a balloon blocking time of 60 minutes or less, and group B had a balloon occlusion time greater than 60 minutes. The patients in the two groups were compared with regards to operation time, intraoperative blood loss, blood transfusion volume, average length of hospital stay, and postoperative complications.

Results

No balloon displacement or leakage of the abdominal aorta occurred during the operations. The difference in operation time between the two groups was statistically significant (P≤0.05), and the differences in intraoperative blood loss, blood transfusion volume, and average hospital stay between groups A and B were not significant (P>0.05). The incidence of postoperative complications was 12% in group A, and 22.6% in group B, with no statistically significant differences (P>0.05).

Conclusions

Prolonged balloon occlusion was safe and effective in the surgical treatment of complicated pelvic and sacral tumors. It did not increase the incidence of postoperative complications such as distal limb paralysis, arterial thrombosis, or ischemic necrosis.

Recurrence or neurological loss? Resection mode selection for patients with large sacral chordoma: an analysis of prognostic factors and quality of life

BACKGROUND

Surgical resection represents the main therapeutic method for sacral chordoma, but plans for resection mode must weigh neurological loss against complete tumor excision, a difficult balance to strike. The purpose of this study was to provide useful information contributing to surgical decision making in sacral chordoma.

METHODS

A retrospective review was performed on 47 patients with large sacral chordoma. Prognostic factors affecting recurrence-free survival (RFS) and overall survival (OS) were analyzed using the Kaplan-Meier method and Cox proportional hazards model. Quality of life was assessed by the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire and compared using Student's t test.

RESULTS

Resection mode was the independent prognostic factor affecting RFS, while independent prognostic factors affecting OS were resection mode and postoperative recurrence. As for quality of life, the en bloc resection group showed a higher score in emotional well-being, while the piecemeal resection group scored better in function well-being. No significant difference was identified in total the FACT-G score between two groups.

CONCLUSIONS

On the one hand, en bloc resection showed huge advantages in disease control for sacral chordoma. On the other hand, despite the unsatisfaction in functional well-being, en bloc resection did not sacrifice quality of life significantly in terms of the total FACT-G score.

Dual iliac screws in spinopelvic fixation: a systematic review

PURPOSE

The classical spinopelvic fixation includes 1 iliac screw on each side. The purpose of this study is to specify the indications of the "dual iliac screw" (DIS) construct, i.e., when to put 2 iliac screws on each side, to describe its biomechanical advantages, and to define its related technical aspects.

METHODS

A primary search on Medline through PubMed distribution was performed, with the use of the terms "pelvic fixation" or "spinopelvic" or "lumbo-iliac" and the terms "dual iliac screw" or "double iliac screw." English papers corresponding to the inclusion criteria were analyzed regarding the specific indications of the DIS construct and its surgical technique and advantages.

RESULTS

Eleven papers were identified according to the research criteria and included in this review. Three main indications were identified for the DIS technique according to three types of pathologies: in adult deformities when a long construct is needed in an osteoporotic patient or when correction requires three-column osteotomy of the sacrum; in trauma when a U-shaped fracture-dislocation of the sacrum is involved; in sacral tumors when a sacrectomy is performed or when destructive metastatic lesions of the sacrum require palliative surgical treatment. Biomechanically, the DIS technique proved to have higher construct stiffness in terms of compression and torsion.

CONCLUSION

In specific cases, affecting different areas of spinal diseases, the DIS technique is more advantageous, when compared to the "single iliac screw" version, as it would provide a stronger and safer fixation at the base of the spinopelvic construct. These slides can be retrieved under Electronic Supplementary Material.

[A giant sacral chordoma resection and reconstruction with a gluteal perforator flap, a case report and literature review]

BACKGROUND

Sacral chordomas are rare primary bone tumors and represent more than half of all primary malignant sacral tumors. Surgical resection is the only treatment with close to 50% of remission at 10 years, with or without radiotherapy. This tissue removal can be very extensive and morbid, particularly for evolved tumors. The reconstruction mostly uses myocutaneous flaps, notably the gluteus maximus flap and the latissimus dorsi flap, increasing morbidity of the surgical procedure. To avoid a muscular sacrifice and reduce the post-surgical morbidity, we describe the case of a patient who underwent a giant sacral chordoma resection and a reconstruction with a superior gluteal artery perforator flap.

CASE REPORT

A 57-y.o. patient with a voluminous sacral chordoma had undergone a partial sacrectomy and abdomino-perineal resection. Firstly, a laparoscopy was realized to create a colostomy, to dissect an omental flap and to prepare the monobloc resection. In a prone position, the resection of the tumor was achieved and a de-epithelialized superior gluteal artery perforator flap was performed to fill the space and to support pelvic organs.

CONCLUSION

For resections of sacral chordomas, coelioscopy has considerably reduced the surgical morbidity. However, the majority of reconstructions use myocutaneous flaps, specifically gluteus maximus and latissimus dorsi, which their postural function is considerable. Muscular sacrifice can lead to functional impotence with difficulty walking and standing up and run contrary to the diminution morbidity initiated by oncologic surgeons.

Robot-assisted sacral tumor resection: a preliminary study

Background

Few studies have been done on robot-assisted sacral surgery. This study aims to evaluate the outcomes of seven patients with benign sacral or presacral tumors treated with a robotic surgical system at a single center.

Methods

All patients with benign sacral or presacral tumors who underwent transperitoneal resection (between June 2015 and June 2016) using the da Vinci Si HD robotic surgical system (Intuitive Surgical Inc.) were included in this retrospective study.

Results

Seven patients with a mean age of 43.8 years (range: 22- 62 years) were included in this study. The operation time ranged from 60 to 335 min. Five out of these seven patients with presacral tumor underwent complete tumor resection by the da Vinci robotic surgical system, with a median blood loss of 52 ml. The other patients underwent excision of the presacral tumor by the da Vinci robotic surgical system, followed by a posterior approach, with a median blood loss of 675 ml. The histological diagnosis was schwannoma of the sacral nerve in five cases (71.5%). The other two cases were chordoma and solitary fibroma of the sacrum, respectively. No perioperative or postoperative complications were encountered. The average hospitalization stay was 5.7 days. No recurrences were found at follow-up 24 to 31 months later.

Conclusion

Robot-assisted minimally invasive sacral surgery can provide precise dissection of the tissue under a perfect view. It is a technically feasible procedure that is associated with minimal blood loss, fewer injuries and short hospitalization. It is particularly suitable for presacral benign tumors.

[Development and current situation of reconstruction methods following total sacrectomy]

Objective

To review the development of the reconstruction methods following total sacrectomy, and to provide reference for finding a better reconstruction method following total sacrectomy.

Methods

The case reports and biomechanical and finite element studies of reconstruction following total sacrectomy at home and abroad were searched. Development and current situation were summarized.

Results

After developing for nearly 30 years, great progress has been made in the reconstruction concept and fixation techniques. The fixation methods can be summarized as the following three strategies: spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and anterior spinal column fixation (ASCF). SPF has undergone technical progress from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems. PPRF and ASCF could improve the stability of the reconstruction system.

Conclusion

Reconstruction following total sacrectomy remains a challenge. Reconstruction combining SPF, PPRF, and ASCF is the developmental direction to achieve mechanical stability. How to gain biological fixation to improve the long-term stability is an urgent problem to be solved.

Sacral chordoma : A review of literature

Chordoma is a rare malignant tumor with predilection for the sacrum. A favorable outcome depends on early diagnosis and surgical excision with tumor free margins.

Aim

To review the incidence and prevalence of sacral chordoma and the appropriate surgical management and formulate a criteria for early diagnosis.

Materials and methods

Thirty eight articles on the subject of sacral chordoma and extrapolated data of clinical and surgical significance.

Results

The commonest presenting feature in patients with sacral chordoma was lower back pain which was worse on sitting and up to a third of these patients had associated urinary tract infections, constipation or symptoms of disc herniation. The hallmark of sacral chordoma is lower back pain with poor response to non-steroidal anti-inflammatory drugs.Disease free eradication in chordoma is rare and not without neurological deficit. The common sacral levels involved ie. S2,3 have to be sacrificed to achieve adequate margins4. Whilst wide excision via posterior surgery shows a decrease in recurrence, the overall survival still remains low.

Prognosis and Risk Factors Influencing Recurrence in Surgery-treated Patients with Primary Sacral Tumors

BACKGROUND

We aimed to explore the prognosis and risk factors influencing tumor recurrence in surgery-treated patients with primary sacral tumors.

METHODS

Fifty-six patients between February 2011 and December 2016 in Yishui Central Hospital with primary sacral tumors were selected and treated with radical surgeries. The perioperative outcomes and postoperative neurological functions were observed. After postoperative follow-up, the overall survival time (OS), disease-free survival time (DFS), and recurrence were recorded to analyze the potential risk factors influencing tumor recurrence.

RESULTS

The average surgical duration and intraoperative hemorrhagic volume were 3.92 ± 1.46 h and 2, 348.21 ± 813.67 ml, respectively. The postoperative short-term complications included three patients with infection from obstructed drainage and two with skin flap necrosis-induced infection, who recovered after anti-infection therapies; nine with incision-edge necrosis; two with calf muscle venous thrombosis; and one with an endorhachis cerebrospinal fluid fistula, who recovered after conventional treatment. Among patients, the 1-, 2- and 3-year survival rates were 91.07% (51/56), 82.14% (46/56), and 75.00% (42/56) while the 1-, 2- and 3-year DFS rates were 89.29% (50/56), 78.57% (44/56) and 71.43% (40/56), respectively. Of the 56 patients, 16 had recurrence after surgery, with recurrence rate of 28.57%. It was predicated that surgical methods and local infiltration were the independent risk factors influencing tumor recurrence (P<0.01).

CONCLUSION

The reservation of bilateral S₃ or > unilateral S₃ nerves can improve quality of life of patients. Surgical methods and local infiltration are the independent risk factors influencing tumor recurrence, and extensive resection can effectively control the recurrence rate.

Technique and surgical outcome of total resection of lower sacral tumor

OBJECTIVE

To summarize the technique and surgical outcome for total resection of lower sacral tumor.

METHODS

This retrospective study included 12 cases of total resection of lower sacral tumor (involving S3 and the below) from January 2010 to February 2013. Seven patients underwent en bloc resection and five cases accepted intralesional curettage. We used extraperitoneal approach to ligature the bilateral internal iliac artery, separated the tumor, and used transverse incision to separate the sacrum from surrounding ligaments and muscles. We then separated the sacrum to S2-S3 junction and ligatured the dural sac, cut off the sacrum at the S2-S3 junction, and remove the tumor out of the envelope. The other five patients underwent posterior surgery, which directly revealed lesions. Curettes were used under direct vision to scrape the tumor tissue.

RESULTS

All patients underwent the operation successfully without perioperative death or serious complication. The blood loss ranged from 300-650 mL (460 mL in average) in en bloc resection group. The blood loss ranged from 350-2800 mL (1595 mL in average) in curettage group. One case of transient enteroplegia and one case of transient gatism were respectively reported in en bloc resection group and one case of chronic pain in sacral was reported in curettage group. The postoperative pathological results revealed that there were 4 chordomas, 2 giant cell tumor and 1 metastatic tumor in en bloc resection group. All patients were followed up for 4-36 months (13.6 in average). At the final follow-up there was no recurrence reported. Two cases of local recurrence (40%) in curettage group were reported.

CONCLUSION

The surgery combined with anterior-posterior approach helped remove the lower sacral tumor totally, with uncomplicated surgical operations and obviously reduced recurrence rate. The recurrence rate was significantly reduced using curettage method.