Osteosarcoma of the pelvis

Internal hemipelvectomy: A single institution's learning curve and longitudinal experience

BACKGROUND AND OBJECTIVES

Wide margin resection for pelvic tumors via internal hemipelvectomy is among the most technically challenging procedures in orthopedic oncology. As such, surgeon experience and technique invariably affect patient outcomes. The aim of this clinical study was to assess how an individual surgeon's experiences and advancements in technology and techniques in the treatment of internal hemipelvectomy have impacted patient outcomes at our institution.

METHODS

This study retrospectively examined a single tertiary academic institution's consecutive longitudinal experience with internal hemipelvectomy for primary sarcoma or pelvic metastases over a 26-year period between the years 1994 and 2020. Outcomes were assessed using two separate techniques. The first stratified patients into cohorts based on the date of surgery with three distinct "eras" ("early," "middle," and "modern"), which reflect the implementation of new techniques, including three-dimensional (3D) computer navigation and cutting guide technology into our clinical practice. The second method of cohort selection grouped patients based on each surgeon's case experience with internal hemipelvectomy ("inexperienced," "developing," and "experienced"). Primary endpoints included margin status, complication profiles, and long-term oncologic outcomes. Whole group multivariate analysis was used to evaluate variables predicting blood loss, operative time, tumor-free survival, and mortality.

RESULTS

A total of 72 patients who underwent internal hemipelvectomy were identified. Of these patients, 24 had surgery between 1994 and 2007 (early), 28 between 2007 and 2015 (middle), and 20 between 2016 and 2020 (modern). Twenty-eight patients had surgery while the surgeon was still inexperienced, 24 while developing, and 20 when experienced. Evaluation by era demonstrated that a greater proportion of patients were indicated for surgery for oligometastatic disease in the modern era (0% vs. 14.3% vs. 35%, p = 0.022). Fewer modern cases utilized freehand resection (100% vs. 75% vs. 55%, p = 0.012), while instead opting for more frequent utilization of computer navigation (0% vs. 25% vs. 20%, p = 0.012), and customized 3D-printed cutting guides (0% vs. 0% vs. 25%, p =  0.002). Similarly, there was a decline in the rate of massive blood loss observed (72.2% vs. 30.8% vs. 35%, p = 0.016), and interdisciplinary collaboration with a general surgeon for pelvic dissection became more common (4.2% vs. 32.1% vs. 85%, p < 0.001). Local recurrence was less prevalent in patients treated in middle and modern eras (50% vs. 15.4% vs. 25%, p =  0.045). When stratifying by case experience, surgeries performed by experienced surgeons were less frequently complicated by massive blood loss (66.7% vs. 40% vs. 20%, p = 0.007) and more often involved a general surgeon for pelvic dissection (17.9% vs. 37.5% vs. 65%, p = 0.004). Whole group multivariate analysis demonstrated that the use of patient-specific instrumentation (PSI) predicted lower intraoperative blood loss (p = 0.040). However, surgeon experience had no significant effect on operative time (p = 0.125), tumor-free survival (p = 0.501), or overall patient survival (p = 0.735).

CONCLUSION

While our institution continues to utilize neoadjuvant and adjuvant therapies following current guideline-based care, we have noticed changing trends from early to modern periods. With the advent of new technologies, we have seen a decline in freehand resections for hemipelvectomy procedures, and a transition to utilizing more 3D navigation and customized 3D cutting guides. Furthermore, we have employed the use of an interdisciplinary team approach more regularly for these complicated cases. Although our results do not demonstrate a significant change in perioperative outcomes over the years, our institution's willingness to treat more complex cases likely obscures the benefits of surgeon experience and recent technological advances for patient outcomes.

A Planned Multidisciplinary Surgical Approach to Treat Primary Pelvic Malignancies

The pelvic anatomy poses great challenges to orthopedic surgeons. Sarcomas are often large in size and typically enclosed in the narrow confines of the pelvis with the close proximity of vital structures. The aim of this study is to report a systematic planned multidisciplinary surgical approach to treat pelvic sarcomas. Seventeen patients affected by bone and soft tissue sarcomas of the pelvis, treated using a planned multidisciplinary surgical approach, combining the expertise of orthopedic oncology and other surgeons (colleagues from urology, vascular surgery, abdominal surgery, gynecology and plastic surgery), were included. Seven patients were treated with hindquarter amputation; 10 patients underwent excision of the tumor. Reconstruction of bone defects was conducted in six patients with a custom-made 3D-printed pelvic prosthesis. Thirteen patients experienced at least one complication. Well-organized multidisciplinary collaborations between each subspecialty are the cornerstone for the management of patients affected by pelvic sarcomas, which should be conducted in specialized centers. A multidisciplinary surgical approach is of paramount importance in order to obtain the best successful surgical results and adequate margins for achieving acceptable outcomes.

Efficacy and safety of carbon ion radiotherapy for bone sarcomas: a systematic review and meta-analysis

Objective

This study aimed to systematically evaluate and conduct a meta-analysis of the efficacy and safety of carbon ion radiotherapy for bone sarcomas.

Methods

We searched for articles using the PubMed, Embase, Cochrane Library, and the Web of Science databases from their inception to January 12, 2022. Two researchers independently screened the literature and extracted data based on the inclusion and exclusion criteria. Statistical analyses were performed using STATA version 14.0.

Results

We searched for 4378 candidate articles, of which 12 studies were included in our study according to the inclusion and exclusion criteria. Of the 897 BSs patients who received carbon ion radiotherapy in the studies, 526 patients had chordoma, 255 patients had chondrosarcoma, 112 patients had osteosarcoma, and 4 patients had other sarcomas. The local control rate at 1, 2, 3, 4, 5, and 10 years in these studies were 98.5% (95% confidence interval [CI] = 0.961–1.009, I² = 0%), 85.8% (95% CI = 0.687–1.030, I² = 91%), 86% (95% CI = 0.763–0.957, I² = 85.3%), 91.1% (95% CI = 0.849–0.974), 74.3% (95% CI = 0.666–0.820, I² = 85.2%), and 64.7% (95% CI = 0.451–0.843, I² = 95.3%), respectively. The overall survival rate at 1, 2, 3, 4, 5, and 10 years in these studies were 99.9% (95% CI = 0.995–1.004, I² = 0%), 89.6% (95% CI = 0.811–0.980, I² = 96.6%), 85% (95% CI = 0.750–0.950, I² = 89.4%), 92.4% (95% CI = 0.866–0.982), 72.7% (95% CI = 0.609–0.844, I² = 95.3%), and 72.1% (95% CI = 0.661–0.781, I² = 46.5%), respectively. Across all studies, the incidence of acute and late toxicities was mainly grade 1 to grade 2, and grade 1 to grade 3, respectively.

Conclusion

As an advanced radiotherapy, carbon ion radiotherapy is promising for patients with bone sarcomas that are unresectable or residual after incomplete surgery. The data indicated that carbon ion radiotherapy was safe and effective for bone sarcomas, showing promising results for local control, overall survival, and lower acute and late toxicity.

PROSPERO registration number

CRD42021258480.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-022-02089-0.

Management of pelvic sarcoma

Pelvic sarcomas are a rare and heterogenous group of tumors divided into two groups: soft tissue sarcomas and bone sarcomas. Soft tissue sarcomas of the pelvis include most commonly liposarcoma, leiomyosarcoma, gastrointestinal stromal tumors, malignant peripheral nerve sheath tumors, and solitary fibrous tumors. Bone sarcomas of the pelvis most commonly include osteosarcoma and chondrosarcoma. Multidisciplinary treatment at a center experienced in the treatment of sarcoma is essential. Management is dictated by histologic type and grade. Surgical resection with wide margins is the cornerstone of treatment for pelvic sarcomas, although this is often challenging due to anatomic constraints of the pelvis. Multimodal treatment is critical due to the high risk of local recurrence in the pelvis.

Timing of treatment in osteosarcoma: challenges and perspectives - a scoping review

BACKGROUND

The timing of events in the management of osteosarcoma may be critical for patient survivorship; however, the prognostic value of factors such as onset of symptoms or initiation of therapy in these patients has not been studied. This study sought to review the literature reporting treatment of osteosarcoma to determine the utility of event timing as a prognostic indicator. Due to significant heterogeneity in the literature, this study was conducted as a scoping review to assess the current state of the literature, identify strengths and weaknesses in current reporting practices, and to propose avenues for future improvement.

MAIN BODY

This review screened 312 peer-reviewed studies of osteosarcoma in any anatomic location published in an English journal for reporting of an event timing metric of any kind in a population of 6 or more. Thirty-seven studies met inclusion/exclusion criteria and were assessed for level of evidence, quality, and event timing metric. Reviewers also collated: publication year, population size, population age, tumor site, tumor type, surgical treatment, and adjuvant medical treatment. Extracted event timing data were further characterized using nine standardized categories to enable systematic analysis. The reporting of event timing in the treatment of osteosarcoma was incomplete and heterogenous. Only 37 of 312 (11.9%) screened studies reported event timing in any capacity. The period between patient-reported symptom initiation and definitive diagnosis was the most reported (17/37, 45.9%). Symptom duration was the second most reported period (10/37, 27.0%). Event timing was typically reported incidentally and was never rigorously incorporated into data analysis or discussion. No studies considered the impact of event timing on a primary outcome. The six largest studies were assessed in detail to identify pearls for future researchers. Notable shortcomings included the inadequate reporting of the definition of an event timing period and the pooling of patients into poorly defined timing groups.

CONCLUSIONS

Inconsistent reporting of event timing in osteosarcoma treatment prevents the development of clinically useful conclusions despite evidence to suggest event timing is a useful prognostic indicator. Consensus guidelines are necessary to improve uniformity and utility in the reporting of event timing.

Clinical characteristics of undifferentiated pleomorphic sarcoma of bone and the impact of adjuvant chemotherapy on the affected patients: a population-based cohort study

Background

Clinical characteristics of undifferentiated pleomorphic sarcoma of bone are not elucidated. Herein, we clarify its clinical features and analyze the efficacy of adjuvant chemotherapy in patients with undifferentiated pleomorphic sarcoma of bone.

Methods

Prognostic factors and estimated disease-specific survival in 247 patients with primary undifferentiated pleomorphic sarcoma of bone were identified from a registry in Japan. The effect of adjuvant chemotherapy was evaluated in localized resectable cases, and the characteristics of the two groups treated with or without chemotherapy were adjusted using propensity score matching.

Results

The 5-year disease-specific survival rates were 47.4% in the entire cohort and 56.4 and 16.9% in the M0 and M1 groups, respectively. Multivariate disease-specific survival analysis revealed that metastasis on initial presentation and age ≥ 65 years were poor prognostic factors. Overall, 132 localized and resectable primary lesions were extracted. Adjuvant chemotherapy administration was a favorable prognostic factor (hazard ratio: 0.43, P = 0.04), and it significantly prolonged disease-specific survival compared with no adjuvant chemotherapy (5-year disease-specific survival: 78.8% vs. 51.8%, P = 0.008). Adjuvant chemotherapy prolonged disease-specific survival in patients with tumor size &lt;8 cm (5-year disease-specific survival: 100% vs. 54.6%, P = 0.02); however, its efficacy decreased in those with tumor size ≥8 cm (5-year disease-specific survival: 68.7% vs. 42%, P = 0.09). After propensity score matching, adjuvant chemotherapy was significantly associated with good disease-specific survival (P = 0.02).

Conclusions

Metastasis in the initial presentation was the poorest prognostic factor. On evaluating localized and resectable cases only, adjuvant chemotherapy significantly improved disease-specific survival, although its effect decreased in cases with large tumors.

Osteosarcoma of the Pelvis: Clinical Presentation and Overall Survival

Introduction

Osteosarcoma is the most common sarcoma of bone. Pelvic osteosarcoma presents a significant therapeutic challenge due to potential late symptom onset, metastatic dissemination at diagnosis, and inherent difficulties of wide surgical resection secondary to the complex and critical anatomy of the pelvis. The rates of survival are well reported for osteosarcoma of the appendicular skeleton, but specific details regarding presentation and survival are less known for osteosarcoma of the pelvis.

Methods

The Surveillance, Epidemiology, and End Results (SEER) program was queried for primary osteosarcoma of the bony pelvis from 2004 to 2015. Cases with Collaborative Staging variables (available after 2004) were analyzed by grade, histologic subtype, surgical intervention, tumor size, tumor extension, and presence of metastasis at diagnosis. The 2-, 5-, and 10-year survival rates were assessed with respect to these variables. The SEER database was then queried for age, tumor size, surgical intervention, metastasis at time of presentation, and survivorship data for patients with primary osteosarcoma of the upper extremity, lower extremity, vertebrae, thorax, and face/skull, and rates for all anatomic locations were then compared to patients with primary pelvic osteosarcoma.

Results

A total of 292 cases of pelvic osteosarcoma were identified from 2004 to 2015 within the database, representing 9.8% of cases among all surveyed primary sites. The most common histologic subtype was osteoblastic osteosarcoma (69.9%), followed by chondroblastic osteosarcoma (22.3%). The majority of cases were high-grade tumors (94.3%), of size >8 cm (72.0%), and with extension beyond the originating bone (74.0%). For the entire pelvic osteosarcoma group, the 2-, 5-, 10-year survival rates were 45.6%, 26.5%, and 21.4%, respectively, which were the poorest among surveyed anatomic sites. The 5-year overall survival was an abysmal 5.3% for patients with metastatic disease at diagnosis, and 37.0% for non-metastatic pelvic osteosarcoma treated with surgery and chemotherapy. When compared to other locations, pelvic osteosarcoma had higher rates of metastatic disease at presentation (33.5%), larger median tumor size (11.0 cm), and older median age at diagnosis (47.5 years). While over 85% of patients with tumors at the extremities received surgery, only 47.4% of pelvic osteosarcomas in this cohort received surgical resection—likely influenced by larger tumor size, sacral involvement, frequency of metastasis, older age, or delayed referral to a sarcoma center.

Conclusion

This study clarifies presenting features and clinical outcomes of pelvic osteosarcomas, which often present with large, high-grade tumors with extracompartmental extension, high likelihood of metastatic disease at diagnosis, and a potential limited ability to be addressed surgically. The survival rates of primary osteosarcoma of the pelvis are poor and are lower than osteosarcomas from other anatomic locations. While acknowledging the influence of metastasis, tumor characteristics, and advanced age on the decision to undergo surgical excision of a pelvic osteosarcoma, the rates of surgical resection are low and highlight the importance of understanding appropriate conditions for oncologic resection of pelvic sarcomas.

Impact of Carbon Ion Radiotherapy on Inoperable Bone Sarcoma

Simple Summary

The standard treatment for bone sarcoma is surgery with or without additional chemotherapy; however, complete resection of the tumor might not be possible in patients with locally advanced lesions. Management of patients with bone sarcoma who are unsuitable for surgery is challenging. Carbon ion radiotherapy (C-ion RT) was initiated in 1994 for treating various cancers in Japan and is being considered to be an effective treatment for unresectable bone sarcoma. However, there is a limited number of reports on the clinical outcomes of C-ion RT for bone sarcoma. Here, we aimed to analyze the clinical outcomes and prognostic factors among patients with unresectable bone sarcoma who were treated with C-ion RT. We found that C-ion RT had favorable overall survival and local control with low toxicity rates compared to surgery. Therefore, our results suggest a potential role for C-ion RT in the radical treatment of inoperable bone sarcoma.

Abstract

Management of patients with bone sarcoma who are unsuitable for surgery is challenging. We aimed to analyze the clinical outcomes among such patients who were treated with carbon ion radiotherapy (C-ion RT). We reviewed the medical records of the patients treated with C-ion RT between April 2011 and February 2019 and analyzed the data of 53 patients. Toxicities were classified using the National Cancer Institute’s Common Terminology Criteria for Adverse Events (Version 4.0). The median follow-up duration for all patients was 36.9 months. Histologically, 32 patients had chordoma, 9 had chondrosarcoma, 8 had osteosarcoma, 3 had undifferentiated pleomorphic sarcoma, and 1 had sclerosing epithelioid fibrosarcoma. The estimated 3-year overall survival (OS), local control (LC), and progression-free survival (PFS) rates were 79.7%, 88.6%, and 68.9%, respectively. No patients developed grade 3 or higher acute toxicities. Three patients developed both grade 3 radiation dermatitis and osteomyelitis, one developed both grade 3 radiation dermatitis and soft tissue infection, and one developed rectum-sacrum-cutaneous fistula. C-ion RT showed favorable clinical outcomes in terms of OS, LC, and PFS and low rates of toxicity in bone sarcoma patients. These results suggest a potential role for C-ion RT in the management of this population.

Managing axial bone sarcomas in childhood

Introduction: Axial osteosarcoma and Ewing sarcoma are rare, aggressive neoplasms with a worse prognosis than with tumors involving the extremities because they are more likely to be associated with larger tumor volumes, older age, primary metastases, and a poor histological response to chemotherapy. The 5-year OS rates are reportedly in the range of 18-41% for axial osteosarcoma, and 46-64% for Ewing sarcoma.Area covered: The treatment of axial bone tumors is the same as for extremity bone tumors, and includes chemotherapy, surgery and/or radiotherapy.Expert opinion: Local treatment of axial tumors is particularly difficult due to their proximity to neurological and vascular structures, which often makes extensive and en bloc resections impossible without causing significant morbidity. The incidence of local relapse is consequently high, and this is the main issue in the treatment of these tumors. Radiotherapy is an option in the case of surgical resections with close or positive margins, as well as for inoperable tumors. Delivering high doses of RT to the spinal cord can be dangerous. Given the complexity and rarity of these tumors, it is essential for this subset of patients to be treated at selected reference institutions with specific expertise and multidisciplinary skills.

The pararectus approach-a versatile option in pelvic musculoskeletal tumor surgery

Background

Pelvic tumors are usually resected through the utilitarian pelvic incision, an extended ilioinguinal/iliofemoral approach. The pararectus approach, an intrapelvic anatomical approach with extraperitoneal access to the pelvis, has been established previously for the treatment of pelvic and acetabular fractures. However, it has not been used to address pelvic tumors. The study aimed at investigating the feasibility of this approach for pelvic tumor surgery and the possibilities of combining this approach with standard approaches to the hip joint.

Methods

Thirteen patients that underwent pelvic tumor resections were retrospectively reviewed. Tumor resections were performed through the pararectus (n = 10) or extended pararectus approach (n = 3). In six of those cases, the pararectus approach was combined with extrapelvic approaches including the modified Gibson (n = 4), the Kocher-Langenbeck (n = 1), and the trochanteric flip approach (n = 1). The mean follow-up was 32.6 ± 9.1 months.

Results

In all cases, the tumor resections were carried out according to the preoperative plan. In seven of 13 cases, wide resections were performed; six of 13 cases were planned close resections. Four cases of major complications were observed (vascular injury, deep infection, iliac vein thrombosis, total hip arthroplasty dislocation). Minor complications were observed in two cases. One tumor recurred locally. At the final follow-up, 10 patients were alive, eight of those without evidence of disease.

Conclusion

The study demonstrated the suitability of the pararectus approach for pelvic tumor resections. The possibility to combine the approach with standard approaches to the hip joint allowed for single-stage reconstructions of the pelvis and the hip joint without sacrificing surgical margins and function. The pararectus approach is a versatile option adding to the established approaches for musculoskeletal tumor surgery of the pelvis.

Are Limb-sparing Surgical Resections Comparable to Amputation for Patients With Pelvic Chondrosarcoma? A Case-control, Propensity Score-matched Analysis of the National Cancer Database

BACKGROUND

Chondrosarcoma is the second most frequent primary sarcoma of bone and frequently occurs in the pelvis. Surgical resection is the primary treatment with the two main operative modalities being limb-sparing resection and amputation. Contemporary management has trended toward limb-sparing procedures; however, whether this approach has an adverse effect on long-term survival is unclear.

QUESTIONS/PURPOSES

(1) What are the 5- and 10-year survival rates after limb-sparing surgery and amputation? (2) What factors are associated with survival after contemporary surgical management of pelvic chondrosarcoma?

METHODS

The 2004-2014 National Cancer Database, a nationwide registry that includes approximately 70% of all new cancers in the United States with requirement for 90% followup, was reviewed for patients diagnosed with pelvic chondrosarcoma who had undergone limb-sparing surgery or amputation. To compare survival, patient demographics, tumor attributes, and treatment characteristics were used to generate one-to-one propensity score-matched cohorts. Other factors associated with survival were determined through multivariable Cox regression. Three hundred eighty-five patients (75%) underwent limb-sparing surgery and 131 (25%) underwent amputation. Propensity score matching resulted in two balanced cohorts of 131 patients.

RESULTS

With the numbers available, we could not demonstrate a difference in overall survival between limb-sparing procedures and amputation. The 5-year survivorship was 70% (95% confidence interval [CI], 62%-79%) for limb-sparing surgery versus 70% (95% CI, 62%-79%) for amputation. The 10-year survivorship was 60% (95% CI, 48%-75%) for limb-sparing surgery versus 59% (95% CI, 48%-72%) for amputation. Kaplan-Meier survival analysis did not demonstrate a difference in survival (p = 0.9). Older age (hazard ratio [HR] = 1.029, p < 0.001), higher Charlson/Deyo comorbidity score (HR = 3.039, p = 0.004), higher grade (HR = 2.547, p = 0.005 for Grade 2; HR = 7.269, p < 0.001 for Grade 3; HR = 10.36, p < 0.001 for Grade 4), and positive surgical margins (HR = 1.61, p = 0.039) were associated with decreased survival.

CONCLUSIONS

Our findings support the trend toward increased use of limb-sparing surgery for patients with pelvic chondrosarcoma. Orthopaedic oncologists may use our results when counseling their patients regarding treatment options. However, the choice of limb-sparing surgery versus amputation for these challenging patients should still be a highly individualized decision with careful discussion between the patient and the surgeon.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Neoadjuvant Chemotherapy Followed by Delayed Surgery: Is it Necessary for All Patients With Nonmetastatic High-Grade Pelvic Osteosarcoma?

BACKGROUND

Neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy is the most-frequently employed strategy for patients with high-grade osteosarcoma. However, the contribution of neoadjuvant chemotherapy compared with postoperative adjuvant chemotherapy has not been tested rigorously in patients with nonmetastatic high-grade pelvic osteosarcoma.

QUESTIONS/PURPOSES

(1) Does neoadjuvant chemotherapy followed by delayed surgery offer a survival benefit to patients with nonmetastatic high-grade pelvic osteosarcoma compared with immediate surgery and adjuvant chemotherapy? (2) Is the timing of chemotherapy and surgery associated with a difference in the survivorship free from local recurrence and the risk of complications? (3) Is the threshold of 90% necrosis after neoadjuvant chemotherapy appropriate to distinguish responders from nonresponders in patients with pelvic osteosarcoma?

METHODS

Between 2000 and 2015, our center treated 112 patients with nonmetastatic high-grade primary pelvic osteosarcoma, of whom 93 underwent tumor resection with chemotherapy. Four patients (4%) were lost to followup before 24 months but were not known to have died; the remaining 89 patients were included in this retrospective study. Based on the timing of surgery and chemotherapy, patients were analyzed in two groups: (1) neoadjuvant chemotherapy followed by delayed surgery and adjuvant chemotherapy (n = 56; mean followup of 61 months, range 27-137 months), and (2) immediate surgery followed by adjuvant chemotherapy (n = 33; mean followup of 77 months, range 25-193 months). The total duration and intensity of chemotherapy was similar in both groups. During the period in question, we generally used neoadjuvant therapy followed by delayed surgery and adjuvant chemotherapy when patients received their biopsies in our center. We typically used immediate surgery with adjuvant chemotherapy when patients initially refused chemotherapy or when they had severe pain or poor walking function. Patients in the neoadjuvant chemotherapy group had a higher proportion of sacral infiltration; other factors such as sex, age and tumor size were well balanced between groups. We compared overall survival and local recurrence-free survival rates between the two groups. We completed univariate log-rank tests and multivariate Cox analyses in all patients to identify factors associated with survival and local recurrence using the Kaplan-Meier method.

RESULTS

No survival benefit was found in the patients treated with neoadjuvant chemotherapy followed by delayed surgery compared with the group treated with immediate surgery and adjuvant chemotherapy. At 5 years, the overall survival (OS) was 42% (95% CI, 33-52) for all patients in this study, 43% (95% CI, 30-56) for the neoadjuvant group, and 40% (95% CI, 25-55) for the immediate surgery group; p = 0.709. With the numbers available, there was no difference in the likelihood of successful limb salvage (five of 56 patients [89%] in the neoadjuvant chemotherapy group versus three of 33 patients [91%] in the immediate surgery group; p = 0.557). The 5-year local recurrence-free survival was 67% (95% CI, 59-76) with no difference between the two groups (68%; 95% CI, 57-78% versus 67%; 95% CI, 52-81; p = 0.595). With the numbers available, there was no difference in survival between patients whose tumors demonstrated more than 90% necrosis; however, only four of 56 patients in the neoadjuvant chemotherapy group demonstrated 90% necrosis.

CONCLUSIONS

We found no survival advantage with chemotherapy before surgery compared with immediate surgery in patients with nonmetastatic high-grade pelvic osteosarcoma. The decision on chemotherapy timing should be made for reasons other than survival. A prospective trial is needed to confirm this conclusion.

LEVEL OF EVIDENCE

Level III, therapeutic study.

CT cinematic rendering for pelvic primary tumor photorealistic visualization

Pelvic tumors can be both complicated and challenging, and computed tomography (CT) has played an important role in the diagnosis and treatment planning of these conditions. Cinematic rendering (CR) is a new method of 3D imaging using CT volumetric data. Unlike traditional 3D methods, CR uses the global illumination model to produce high-definition surface details and shadow effects to generate photorealistic images. In this pictorial review, a series of primary pelvic tumor cases are presented to demonstrate the potential value of CR relative to conventional volume rendering (VR). This technique holds great potential in disease diagnosis, preoperative planning, medical education and patient communication.

Is a Modular Pedicle-hemipelvic Endoprosthesis Durable at Short Term in Patients Undergoing Enneking Type I + II Tumor Resections With or Without Sacroiliac Involvement?

BACKGROUND

Functional reconstruction after Enneking Type I + II resections of the pelvis (those involving both the ilium and the acetabulum) is challenging, especially if resection of part of the sacrum is included. To assess the clinical outcomes of a newly designed modular pedicle-hemipelvic endoprosthesis, we performed a preliminary retrospective study on its clinical use in a small group of patients.

QUESTIONS/PURPOSES

The purposes of this study were (1) to evaluate in a small case series whether the new endoprosthesis restored lower limb function and lumbopelvic stability in the short term; (2) to identify the complications associated with use of the new prosthesis; and (3) to assess the 5-year cumulative survival, the cumulative incidence of a major postoperative event, and the cumulative incidence of implant failure in this group of patients.

METHODS

Between August 2012 and August 2014, our center performed 274 internal hemipelvectomies for oncologic indications. Among these, 20 were treated with the new endoprosthesis, which was designed for fixation both to the residual sacrum as well as the lumbar spine. An earlier version of the device had been removed from the market because of an unacceptable risk of serious complications. All of the 20 tumors were sarcomas necessitating en bloc resection. The implant is modular and can meet the different-sized defects in each patient. The general indication for use of the new implant was a total acetabular defect with extensive iliac involvement or total loss of the sacroiliac joint and/or hemisacrum. All 20 patients were followed up for a minimum of 24 months or until death in those patients who survived < 2 years (median, 36 months; range, 6-60 months). The clinical data were retrieved from the database and the study endpoints (function according to the Musculoskeletal Tumor Society [MSTS] score, complications, and survivorship of patients and implants) were ascertained by chart review. Lumbopelvic stability was defined as an excellent or good rating according to the International Society of Limb Salvage radiologic implant evaluation system. The cumulative survival of patients was estimated using the Kaplan-Meier approach. The cumulative incidence of major postoperative events including local recurrence, metastasis, and reoperation was estimated using a competing events analysis; the cumulative incidence of implant failure, including mechanical failure or deep infection, in patients who underwent reoperation was also estimated using a competing events analysis.

RESULTS

In the 16 patients who survived > 12 months, the median MSTS score was 19 of 30 (range, 5-26). Radiographic assessments demonstrated lumbopelvic stability in all of the 16 patients. Twelve of 20 patients developed postoperative complications, primarily including deep infection (one), hip dislocation (two), and local recurrence (three). Major revision surgery was performed in five of 20 patients. The estimated 5-year Kaplan-Meier patient survival rate was 69% (95% confidence interval [CI], 59%-79%), whereas the cumulative incidence of major postoperative events and implant failure using the competing risk estimator was 42% (95% CI, 23%-60%) and 15% (95% CI, 4%-34%) at 5 years, respectively.

CONCLUSIONS

Preliminary results with hemipelvic reconstruction using this new endoprosthesis achieved fair functional results and the complications that were observed appeared comparable to other reconstruction options at short-term followup. Longer-term surveillance is called for to see whether this implant will be durable compared with other available reconstructive alternatives such as a custom-made megaendoprosthesis or an autograft/allograft-prosthetic composite.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Osteosarcoma of the Pelvis: A Monoinstitutional Experience in Patients Younger than 41 Years

Aims and background

Information is scarce on systemic treatment of pelvic osteosarcoma because most chemotherapy protocols for osteosarcoma include patients with extremity tumors and aged up to 30–40 years.

Methods

Data on patients <41 years of age with high-grade pelvic osteosarcoma were prospectively collected. Patients received two chemotherapy protocols consisting of methotrexate, cisplatin, doxorubicin (MAP) and standard-dose or high-dose ifosfamide.

Results

Forty patients between 11 and 36 years were included. The most frequent histological subtype was osteoblastic followed by chondroblastic (37.5%). Complete surgical remission was achieved in 65% of patients. Eighteen patients had MAP/standard-dose ifosfamide, 22 MAP/high-dose ifosfamide. Primary chemotherapy was given to 25 patients and 6 (24%) of them had a good histological response. Median follow-up was 32 months (range, 4–134). Five-year overall survival was 27.5%: 33% in localized and 0 in metastatic patients (P = 0.02); 45% in patients with complete surgical remission and 0 for patients without complete surgical remission (P = 0.001). Local recurrence rate was 46%. In patients with complete surgical remission, 5-year overall survival was 32% with MAP/standard-dose ifosfamide and 59% with MAP/high-dose ifosfamide regimen (P = 0.3).

Conclusions

Local control is the major issue in the treatment of pelvic osteosarcoma. Poor pathological response and high incidence of chondroblastic variant indicate different characteristics between pelvic and extremity osteosarcoma. Chemotherapy with MAP and high-dose ifosfamide might be beneficial in patients with pelvic osteosarcoma and warrants further investigation.

Outcomes of internal hemipelvectomy for pelvic tumors: a developing country's prospective

Introduction

Previously, external hemipelvectomy was the mainstay of treatment for pelvic tumors. However, with technological advancements, limb salvage procedures such as internal hemipelvectomy have emerged as a viable alternative. However, there is limited literature available on long-term outcomes and complications of internal hemipelvectomy, especially from developing countries. Therefore, the objective of this study was to share our experience of internal hemipelvectomy at a tertiary care center in a developing country.

Materials and methods

A retrospective review was conducted in which all 24 patients undergoing internal hemipelvectomy from January 1, 2005 to December 31, 2015 at our institution were included. Medical record files were reviewed for intraoperative and early and late postoperative complications, and functional outcomes were assessed by contacting each patient on telephone.

Results

Ewing sarcoma was found to be the most common diagnosis, followed by osteosarcoma as the second most common. The mean follow-up period was 18.7±13.9 months. Intraoperatively there were 4 cases of iatrogenic neurovascular injury and 2 cases each of urinary tract injury and dural tear. Four patients developed early wound infections, 7 developed late wound infections, and 2 developed flap necrosis. Three patients developed recurrence, whereas 7 patients developed metastasis postoperatively. The mean survival was calculated to be 28 months and the mean Musculoskeletal Tumor Society score was 19.3±5.2.

Conclusions

Outcomes and prevalence of complications shown in this study are comparable to those in the international literature, which suggests that hemipelvectomy is a viable option in developing countries also. However, more such studies are warranted to validate the findings and to identify the challenges and morbidities associated with hemipelvectomy in Asian and developing countries.

Surgical management of pelvic bone sarcoma with internal hemipelvectomy: Oncologic and Functional outcomes

INTRODUCTION

The management of pelvic sarcoma is challenging and goals of surgery are adequate oncologic local control, maintenance of optimum function with good quality of life.

METHODS

We have evaluated the results of internal hemipelvecotmy including age, type of resection, reconstruction, radiotherapy or chemotherapy. From 2010 to 2016, 23 patients with pelvic bone tumors (13 with Ewing's sarcoma, 9 with Osteosarcoma, 1 with chondrosarcoma) were treated by surgical resection.

RESULTS

The mean follow-up was 18 months (0.5-5) years. In 12 patients reconstruction was performed and 11 were without reconstruction. A total of 3 patients (13%) had an infection develop at a mean follow up of 1 month. Surgical debridement's and antibiotics in three patients led to complete recovery. One patient had sciatic nerve injury.One patient had injury to femoral vein; was treated with femoral vein reconstruction. Two patients (9%) developed a local recurrence and were treated with best supportive treatment. Distal pulmonary metastases were seen in four patients and treated with supportive treatment. Five-year disease-specific survival rates of all patients were 83%. The mean functional MSTS score was 18(14-24).

CONCLUSIONS

Proper selection of patients, preopertive planning and wide surgical margins with reconstruction provides good functional outcomes following internal hemipelvectomy. The surgical site infection and flap necrosis tend to be minor complication and can be managed leading to optimal outcomes and justifies the need for this complex surgery. The oncological and functional outcome after internal hemipelvectomy suggests that it's an effective method for treatment of patients with pelvic sarcomas.

Midurethral autologous fascial sling surgery with reconstruction of the lower abdominal wall using the tensor fascia lata muscle flap for post-hemipelvectomy stress urinary incontinence

Hemipelvectomy is surgery for pelvic bone neoplasms. In the case of pubic bone osteosarcoma, the distal end of the rectus abdominis muscle is severed from the pubic and ischium bones, and the pelvic floor muscles are resected en bloc with the bone, which leads to stress urinary incontinence. Cancer control is prioritized over complications, and stress urinary incontinence is generally disregarded. A 25-year-old woman presented with stress urinary incontinence. She had undergone a hemipelvectomy for left pubic bone osteosarcoma, and stress urinary incontinence appeared and persisted since the surgery. We carried out a reconstruction of the tissue deficit of the rectus abdominis using the tensor fascia lata muscle flap simultaneously with a midurethral autologous fascial sling anchoring to the tensor fascia lata flap. Stress incontinence was successfully improved without morbidity. This is the first reported case of midurethral suspension with reconstruction of the lower abdominal wall with the tensor fascia lata flap for post-hemipelvectomy stress urinary incontinence.

Biological reconstruction following the resection of malignant bone tumors of the pelvis

Background. Surgical treatment of malignant pelvic bone tumors can be very challenging. The objective of this retrospective study was to evaluate the oncological as well as the clinical and functional outcome after limb salvage surgery and biological reconstruction. Methods. The files of 27 patients with malignant pelvic bone tumors, who underwent surgical resection at our department between 2000 and 2011, were retrospectively analyzed (9 Ewing's sarcoma, 8 chondrosarcoma, 4 osteosarcoma, 1 synovial sarcoma, 1 malignant fibrous histiocytoma, and 4 carcinoma metastases). Results. After internal hemipelvectomy reconstruction was performed by hip transposition (n = 16), using autologous nonvascularised fibular graft (n = 5) or autologous iliac crest bone graft (n = 2). In one patient a proximal femor prothetis and in three patients a total hip prosthesis was implanted at the time of resection. The median follow-up was 33 months. Two- and five-year disease-specific survival rates of all patients were 86.1% and 57.7%, respectively. The mean functional MSTS score was 16.5 (~55%) for all patients. Conclusion. On the basis of the oncological as well as the clinical and functional outcome, biological reconstruction after internal hemipelvectomy seems to be a reliable technique for treating patients with a malignant pelvic bone tumor.

Outcome of surgical treatment of pelvic osteosarcoma: hospital universiti sains malaysia experience

We reviewed the surgical treatment and outcomes of 13 patients with pelvic osteosarcoma treated in our centre in the past decade. The study sample included 9 males and 4 females with a mean age of 28.1 years. Four patients had ileal lesions, five had acetabulum lesions, one had a ischiopubis lesion, and three had involvement of the whole hemipelvis. Seven patients presented with distant metastases at diagnosis. Limb salvage was performed in 6 patients and amputation in 7. In 60% of cases in the limb salvage surgery group, we attempted wide resection with positive microscopic margin compared to only 16.7% in the amputation group. Local recurrence was higher in the limb salvage group. Overall survival was 18 months for mean follow up of 14.8 months. Median survival was 19 months in the limb salvage group compared to 9 months in amputation group. The outcome of surgical treatment of pelvic osteosarcoma remains poor despite advancements in musculoskeletal oncology treatment.

A review of update clinical results of carbon ion radiotherapy

Among various types of ion species, carbon ions are considered to have the most balanced, optimal properties in terms of possessing physically and biologically effective dose localization in the body. This is due to the fact that when compared with photon beams, carbon ion beams offer improved dose distribution, leading to the concentration of the sufficient dose within a target volume while minimizing the dose in the surrounding normal tissues. In addition, carbon ions, being heavier than protons, provide a higher biological effectiveness, which increases with depth, reaching the maximum at the end of the beam's range. This is practically an ideal property from the standpoint of cancer radiotherapy. Clinical studies have been carried out in the world to confirm the efficacy of carbon ions against a variety of tumors as well as to develop effective techniques for delivering an efficient dose to the tumor. Through clinical experiences of carbon ion radiotherapy at the National Institute of Radiological Sciences and Gesellschaft für Schwerionenforschung, a significant reduction in the overall treatment time with acceptable toxicities has been obtained in almost all types of tumors. This means that carbon ion radiotherapy has meanwhile achieved for itself a solid place in general practice. This review describes clinical results of carbon ion radiotherapy together with physical, biological and technological aspects of carbon ions.

Poor survival for osteosarcoma of the pelvis: a report from the Children's Oncology Group

BACKGROUND

The pelvis is an infrequent site of osteosarcoma and treatment requires surgery plus systemic chemotherapy. Poor survival has been reported, but has not been confirmed previously by the Children's Oncology Group (COG). In addition, survival of patients with pelvic osteosarcomas has not been compared directly with that of patients with nonpelvic disease treated on the same clinical trials.

QUESTIONS/PURPOSES

First, we assessed the event-free (EFS) and overall survival (OS) of patients with pelvic osteosarcoma treated on COG clinical trials. We then asked whether patient survival compared with that of patients treated on the same clinical trials with nonpelvic disease. Finally, we asked whether patients with metastatic disease at initial diagnosis had worse survival.

METHODS

We retrospectively reviewed data from 1054 patients with osteosarcoma treated in four studies between 1993 and 2005. Twenty-six of the 1054 patients (2.5%) had a primary tumor of the pelvis. At diagnosis, nine patients had metastatic disease. The minimum followup was 2 months (mean, 34 months; range, 2-102 months).

RESULTS

Two of the nine patients with metastatic disease at diagnosis and five of the 17 with localized disease were alive at last contact. Estimates of the 5-year EFS for localized versus metastatic disease of the pelvis were 22% versus 23%. OS for patients with localized versus metastatic disease was 47% versus 22%. Patients with osteosarcoma in all other locations had a 5-year EFS of 57% and OS of 69%.

CONCLUSIONS

Our analysis confirms poor survival for patients with pelvic osteosarcoma. Survival with metastatic disease in the absence of a pelvic primary tumor is similar to that for localized or metastatic pelvic osteosarcoma. Improved surgical or medical therapy is needed, and patients with pelvic osteosarcoma may warrant alternate or experimental therapy.

The role of radical amputations for extremity tumors: a single institution experience and review of the literature

BACKGROUND

Major amputations are indicated for advanced tumors when limb-preservation techniques have been exhausted. Radical surgery can result in significant palliation and possible cure.

METHODS

We identified 40 patients who underwent forequarter (FQ) or hindquarter (HQ) amputations between May 2000 and January 2011. Patient demographics, tumor-related factors, and outcomes were reviewed.

RESULTS

There were 30 FQ and 10 HQ amputations. The most common diagnoses were sarcoma (55%) and squamous cell carcinoma (25%). Patients presented with primary tumors (35%), regional recurrence (57.5%), or unresectable limb metastatic disease (7.5%). Presenting symptoms included fungating wounds (35%), intractable pain (78%), and limb dysfunction (65%). Operations were performed with curative intent (10%), curative/palliative intent (70%), or palliation alone (20%). Wound complications occurred in 35%. Pain was improved in 78% of patients following surgery. Despite a 91% negative margin rate, 79% of patients recurred either locally or distantly. Median overall survival was 10.9, 13.2, and 3.4 months in the curative, curative/palliative, and palliative groups, respectively.

CONCLUSIONS

In the absence of conservative options, major amputations are indicated for the management of advanced tumors. These operations can be performed safely, resulting in effective palliation of debilitating symptoms. While recurrence rates remain high, some patients can achieve prolonged survival.

Hemipelvectomy- only a salvage therapy?

After the first hemipelvectomy in 1891 significant advances have been made in the fields of preoperative diagnosis, surgical technique and adjuvant treatment in patients with pelvic tumors. The challenging surgical removal of these rare malignant bone or soft tissue tumors accompanied by interdisciplinary therapy is mostly the only chance of cure, but bares the risk of intensive bleeding and infection. The reconstruction after hemipelvectomy is of importance for the later outcome and quality of life for the patient. Here, plastic surgery with microvascular free flaps or local rotational flaps improved the reconstruction and reduced infection rates. Average local recurrence rates of 14% demonstrate good surgical results, but 5 year survival rates of only 50% are described for some tumor entities, showing the importance of a multimodal collaboration. On a basis of a selective literature review the history, indications, treatment options and outcome of hemipelvectomies are presented.

Malignant sarcoma of the pelvic bones: treatment outcomes and prognostic factors vary by histopathology

BACKGROUND

Treatment of malignant sarcomas of the pelvis poses a challenge for local disease control and oncologic outcome. Many reports have described the dismal outcomes. Most studies are retrospective series coming out of single centers, thus biased toward patient selection and are of limited statistical power.

METHODS

The authors used the Surveillance, Epidemiology, and End Results database to analyze 1185 pelvic sarcoma cases from 1987 to 2006. Kaplan-Meier and Cox regression were used to analyze the significance of prognostic factors. The analysis was repeated for different histopathological subtypes to determine specific prognostic factors in each case.

RESULTS

Incidence of pelvic sarcoma in 2006 was 89 per 100,000 persons; it has significantly increased since 1973 (P < .05). The overall 5-year survival for all the patients with pelvic sarcoma was 47%, with osteosarcoma having the worst 5-year survival at 19% and patients with chordoma having the best 5-year survival at 60%. Independent prognostic factors included age, stage, grade, size of primary lesion, histopathology, and treatment-related factors. Comparing the patients only with high-grade lesions, patients with Ewing sarcoma have the best prognosis.

CONCLUSIONS

This is an analysis of patients with pelvic sarcomas derived from a population-based registry. Survival and prognostics vary with histopathological diagnoses. Although surgical resection was associated with superior outcomes for osteosarcoma and chondrosarcoma, there was no significant difference in outcomes of patients with Ewing sarcoma treated with surgery and/or radiotherapy.

Internal hemipelvectomy for pelvic sarcomas using a T-incision surgical approach

Internal hemipelvectomy is performed for pelvic sarcomas when the tumor can be safely resected without sacrificing the entire extremity. Wide exposure and awareness of major neurovascular structures are crucial to the success of this surgery. Various modifications on the standard utilitarian approach have been used to best achieve these goals. We reviewed our experience using the T-incision technique for 30 pelvic sarcoma resections. The minimum followup was 3.6 months (mean, 55 months; range, 3.6-185.4 months). Postoperative complications included minor complications (requiring no surgery or a simple incision and drainage with primary closure) in 27% of patients and major complications (involving a deep infection or more extensive surgical treatment) in 17%. Ninety-two percent of wound complications healed uneventfully with antibiotics and incision and drainage. The 2-, 5-, and 10-year patient survival rates were 67%, 59%, and 53%. The 2-, 5-, and 10-year disease-free survival rates were 68%, 42%, and 42%. The mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Scores were 69% and 86%, respectively. We believe the T-incision technique for internal hemipelvectomy is an effective surgical approach for pelvic sarcomas when limb salvage is possible.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Osteosarcoma of the pelvis: outcome analysis of surgical treatment

Risk factors to explain the poor survival of patients with osteosarcoma of the pelvis are poorly understood. Therefore, we attempted to identify factors affecting survival and development of local recurrence and metastasis. We retrospectively reviewed 43 patients who had high-grade pelvic tumors and were treated surgically. Twenty lesions were chondroblastic, 10 fibroblastic, 11 osteoblastic, and one each was giant cell-rich and small cell osteosarcomas. At a median of 3.5 years (range, 0.3-21 years) postoperatively, 13 patients were alive with no evidence of disease. The overall and disease-free 5-year survival rates were 38% and 29%, respectively, at 5 years. Anatomic location, tumor size, and margin predicted survival. Fifteen patients (35%) had local recurrence. The 5-year cumulative incidence of recurrence with death as a competing risk factor was 34%. Location in the ilium and size of the tumor predicted local recurrence. Twenty-one (49%) of 43 patients had metastases develop. The cumulative incidence of metastasis with death as a competing risk factor was 48% at 5 years. Six patients who presented with metastasis had a worse survival than patients who had no evidence of metastasis at presentation (2-year survival, 33% versus 76%). If distant metastasis is diagnosed subsequent to primary treatment, aggressive therapy may be justified.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Pelvic reconstruction with a structural pelvic allograft after resection of a malignant bone tumor

BACKGROUND

Reconstruction of the pelvic arch after resection of a malignant pelvic tumor remains a major surgical challenge because of the high rate of associated complications. The purpose of this investigation was to assess the functional outcome and complication rate following treatment with a bone allograft to reconstruct the pelvis.

METHODS

Twenty-four consecutive patients underwent excision of a malignant pelvic bone tumor and reconstruction with a pelvic bone allograft. The living patients were followed for a minimum of twenty-four months. There were nineteen primary malignant bone tumors, sixteen of which were high-grade sarcomas, and there were five isolated metastases. Patients were examined clinically and radiographically and were assessed functionally with the Musculoskeletal Tumor Society score.

RESULTS

The mean age of the patients at the time of the index surgery was thirty-four years, and the mean duration of follow-up was forty-one months. Eighteen of the twenty-four resections involved the periacetabular area and were followed by reconstruction either with a hip prosthesis (thirteen) or with an osteochondral allograft alone (five). The six other resections involved the iliac bone. All patients received a massive bone allograft that had been sterilely procured without secondary irradiation. At the time of our last evaluation, eight patients were alive and free of disease. Seven patients had a local recurrence. Neurological deficits were present in six patients, and three had a deep infection. Nonunion of three of the sixteen allografts that could be evaluated was observed. Neither graft fracture nor lysis was observed. Eleven patients underwent surgical revision, with nine of these revisions related to the reconstruction. The average Musculoskeletal Tumor Society score at the time of the latest follow-up was 73% of the maximal possible score. The average score was 82% for the eleven patients with an age of less than twenty years at the time of the index procedure and 65% for the thirteen older patients. Ten patients walked without any assistive device, and five of them had normal function with no or only a slight limp.

CONCLUSIONS

Pelvic reconstruction after a limb-sparing resection is associated with a high risk of surgical complications and usually should be reserved for patients with a primary bone sarcoma. A pelvic allograft can restore the anatomy and provide good functional results, especially in young patients. Nonunion was the most common allograft-related complication.

Intra-arterial chemotherapy for limb preservation in patients with osteosarcoma: nursing implications

Osteosarcoma is an aggressive tumor found in children and young adults, originating primarily in the legs or arms. The high-grade tumor grows in a circular, ball-like mass in the bone tissue. Before the 1970s and the advent of chemotherapy use in osteosarcoma, treatment consisted solely of amputation. More recently, a preoperative regimen of intra-arterial (IA) cisplatin and infusional doxorubicin with limb-sparing procedures has provided an effective treatment option and improved survival for many patients with osteosarcoma. IA chemotherapy is administered through a small, temporary, external catheter that rests in the arterial vessel that supplies the tumor. The primary advantage of IA chemotherapy administration is the delivery of a higher chemotherapy concentration directly to the tumor site, Nursing management of patients with IA chemotherapy requires knowledge of treatment side effects and procedure-related assessments. Further implications for practice include instructing patients and families before and after the insertion of the IA line and giving discharge and long-term follow-up education. Oncology nurses are well positioned to assist children and young adult patients through difficulties with adjustment after treatment is completed and a response has been achieved, owing to advanced communication skills and knowledge of developmental stages and survivorship issues,

Research: Is resection of tumours involving the pelvic ring justified? : A review of 49 consecutive cases

Introduction

Pelvic surgery is challenging and impacts significantly on limb and visceral function, thus, raising the question "is heroic surgery justifiable". This study assessed the functional, oncologic and surgical outcomes following pelvis tumour resections.

Methods

Between 1996–2003, 49 patients (mean age 43 years) underwent pelvic tumour resections- 38 primary malignant tumours, 5 secondary tumours and 6 benign tumours. Bone tumours comprised 5 osteosarcomas, 5 Ewings sarcomas, and 12 chondrosarcomas. Of the soft tumours, 9 were of neural origin. Tumours involved the ilium, acetabulum, pubic bones, sacrum or a combination of these. Functional assessment was performed and no patient had metastases at presentation.

Results

There were 41 limb sparing resections and 8 hindquarter amputations. Surgical margins were intralesional (1), marginal (13), wide (26), and radical (3). Of limb sparing surgery, prosthetic reconstructions were performed in 10 patients, biologic reconstructions in 6, a combination of these in 3 and no reconstruction in others. There was 1 intraoperative death, 7 local recurrences and 19 metastases. Death from disease occurred at a mean of 14.2 months with a mean followup of 27 (1–96) months. Amputation and periacetabular resections had worse functional outcomes. Emotional acceptance was surprisingly high.

Conclusion

Pelvic resections are complex. Functional outcome is significantly affected by surgery. Disease control is similar to limb tumours. Emotional acceptance of surgery in survivors was surprisingly high. Major pelvic resection for malignancy appears justified.