Prof Dr Harzem OzgerIstanbul University

Istanbul Faculty of MedicineDept. Of Orthopaedics and Traumatology

Orthopedic Oncologic Approach

in Sacrum Tumors

Epidemiology%1,4 – 4 of all musculoskeletal tumors

Benign aggressive > Malignant >>> Metastasis

Low grade >> High grade

• Benign ABC

GCT

• Malignant CS

Chordoma

EWS

Anatomical Considerations

Delayed diagnosis

Complicated radiotherapy

Demanding surgical technique

Increased perioperative morbidity / mortality

Poor prognosis

Anatomical Considerations

Bad prognostic anatomic siteDelayed

diagnosisCommon

pathologies are resistant to adjuvant treatments

Hard to achieve WIDE MARGINS

Perioperative morbidity / mortality

Patient

• Large intrapelvic volume retards

symptoms

Delayed diagnosis

Complicated radiotherapy

Demanding surgical technique

Increased perioperative morbidity / mortality

Poor prognosis

Anatomical Considerations

Bad prognostic anatomic siteDelayed

diagnosisCommon

pathologies are resistant to adjuvant treatments

Hard to achieve WIDE MARGINS

Perioperative morbidity / mortality

Delayed diagnosis

Complicated adjuvant treatment

Demanding surgical technique

Increased perioperative morbidity / mortality

Poor prognosis

Conventional RT

• Rectum, bladder, small bowel,

dural sac and sacral roots at risk

Anatomical Considerations

Bad prognostic anatomic siteDelayed

diagnosisCommon

pathologies are resistant to adjuvant treatments

Hard to achieve WIDE MARGINS

Perioperative morbidity / mortality

Delayed diagnosis

Complicated radiotherapy

Demanding surgical technique

Increased perioperative morbidity / mortality

Poor prognosis

• Difficult exposure

• Abundant hemorrhage

• Difficult 3D orientation

• Difficult reconstruction

Anatomical Considerations

Bad prognostic anatomic siteDelayed

diagnosisCommon

pathologies are resistant to adjuvant treatments

Hard to achieve WIDE MARGINS

Perioperative morbidity / mortality

Delayed diagnosis

Complicated radiotherapy

Demanding surgical technique

Increased perioperative morbidity / mortality

Poor prognosis

Anterior

Posterior

Anatomical Considerations

Bad prognostic anatomic siteDelayed

diagnosisCommon

pathologies are resistant to adjuvant treatments

Hard to achieve WIDE MARGINS

Perioperative morbidity / mortality

Delayed diagnosis

Complicated radiotherapy

Demanding surgical technique

Increased perioperative morbidity / mortality

Poor prognosis

Neighboring major

neurovascular

structures

Rectum,

bladder,

ureters

rectum

sacrum

Anatomical Considerations

Bad prognostic anatomic siteDelayed

diagnosisCommon

pathologies are resistant to adjuvant treatments

Hard to achieve WIDE MARGINS

Perioperative morbidity / mortality

Delayed diagnosis

Complicated radiotherapy

Demanding surgical technique

Increased perioperative morbidity / mortality

Poor prognosis

Loss of spinopelvic continuity

Biological Considerations

Surgeon

• Unfamiliar with the biology of sacral tumors

• Malignant behavior with benign histology in some cases!

• Late MET and AWD for years with low-grade malignant! (chordoma)

Psychological Considerations

Is the surgeon ready to sacrifice?

- Wide resection is the ONLY option for malignant tumors.

- Insufficient resection to avoid complication:

* Local recurrence which requires more morbid resection* Local recurrence which is inoperable* Metastasis

Psychological ConsiderationsIs the patient ready to sacrifice?

- Hard to convince a patient that he/she is going to / might have• Sexual dysfunction• Urinary incontinence• Anal incontinence - colostomy• Walking difficulties• Wound problems and prolonged hospitalization

after surgery and local recurrence is still possible.

- Palliative treatment is always an option.

BUT

- The patient MUST BE WELL INFORMED that these complications are inevitable even if no surgery is performed and the tumor will be unresectable by then.

• Preop assessment – Detailed MR imaging of sacral roots & margins and CT for osseous destruction

• RTx (especially IMRT – higher dose, less morbidity w/ 3D beam)

• CTx ???!!! (tumor-targeted CTx promising...)

• Preoperative embolisation (inform the interventional radiologist about the type of resection: intralesional / wide)

• Complex reconstructions (eg. lumbopelvic fixation – tumor surgeon cooperates w/ spine surgeon)

Principals of Management

• Team work beginning at biopsy

• Education of medical professionals: Prevention of wrong surgery !!!

• Extremely specialized management – experienced team:

Oncologic orthopedic surgeon

Radiation oncologist

Medical oncologist

Radiologist

Spine surgeon

General surgeon

Plastic surgeon

Vascular surgeon

Urologist

Physiotherapist

Medical psychologist

Principals of Management

• Hemorrhage– A/V iliaca, corona mortis

– tumor itself

• Neurologic– Sacral roots

• Mechanic– Sacroiliac joint

• Neighbourhood– Anorectal complex

– Bladder, ureters

– Internal genitals

• Dead space

• ONCOLOGIC

Surgical Considerations

Minimising intraoperative bleeding 13 y, F

ABC of sacrum

Intralesional resection following embolisation

• Unilateral sacrif. causes mostly temporary palsies

• Bil. S3: Sexual dysfunction, urinary dysfunction

• Bil. S2: Anorectal dysfunction

• Bil. S1: Below knee extensor palsy

• For locomotion, quadriceps function is vital (try to protect L5)

Preservation of nerve roots

16 y, F

GCT of sacrum

Intralesional resection (curettage and phenolisation) only

NED at postop 4 yrs.

25 y, F

ABC of sacrum

Intralesional resection + phenolisation + PMMA

NED at postop 5 yrs.

%50 loss of SI joint causes vertical + rotational instability :

Lumbopelvic fixation !!

Mechanical support

21 y, F

LN of ABC of sacrum (curettage + PMMA in elsewhere hospital)

Preop embolisation + removal of PMMA + curettage + high-speed burr + phenolisation

Surgery had to be abandoned despite total spinopelvic discontinuity due to hemorrhage

1. stage

postop

2. stage

Posterior instrumentation performed after 2 wks for lumbopelvic fixation

42 y, M

Chondrosarcoma of R iliac wing

Loss of SI joint due to wide resection

Spinal instrumentation from posterolateral and augmentation with a second rod for lumbopelvic fixation + prolen mesh to avoid abdominal hernia

Early postop xrays

Postop 3 months

Management of Urogenital and Colorectal Complications

- 20 y/o F - GCT of sacrum- Neurogenic bladder at postop 4 wks.- Life-long intermittent urinary catheterization unavoidable in some patients

- 17 y, M with OS of right hemipelvis- double J-catheterization preop to avoid intraoperative ureter injury

65 y, M

Underwent surgery for sacrum chordoma

Permanent colostomy due to rectum resection (tumor invasion)

Temporary colostomy to avoid fecal contamination of the wound

- Dead space

- Avascular flaps

Management of Soft Tissue Complications

– Silicone prosthesis + Prolene Mesh– Live Tissue• Gluteus maximus flap– If the gluteal arteries are not injured!

• VRAM (Vertical Rectus Abdominis Muscle Flap)

VRAM

VR

AM

supine

prone

Adequate tumor resection

– Benign (Intralesional)

• Curettage

• High-speed burr

• Phenolisation (chemical tumor ablation)

• PMMA ( thermal tumor ablation)

– Malignant (Wide)

• No compromise on margins

• Adjuvant treatment can NEVER compensate for inadequate margins

65 y, M

Sacrum chordoma arising from S2-3-4 and extending proximally along the tract of previous intervention

Wide resection including the rectum + colostomy

Local recurrence at postop 1 yr - resected

Local recurrence at postop 3 yrs. - inoperable

All lessons learned!

Preoperative embolisation

- 30 y / F- Sacrum chordoma

1 2

3Before the resection of sacrum chordoma

- Colostomy is prepared,

- Vertical rectus abdominus myocutaneous

flap is prepared,

- VRAM flap is buried deep into the pelvis

and the patient is turned to prone position.

After wide resection of sacrum chordoma

and the rectum,VRAM flap is pulled out

from posterior to fill the dead space.

Clinical photos at 8 months postopPermanent colostomy (planned preoperatively)

NO complicationNO local recurrence at postop 50 months

Extreme reconstructions

- 16 y, F - osteosarcoma of right hemipelvis

- Internal hemipelvectomy (including partial sacrectomy) + hip transposition- Sciatic nerve was sacrified due to tumor invasion- Acetabular cup of uncemented total hip prosthesis was placed in L5& S1

Postop 5 months Postop 15 months

Ambulatory with a single crutch at 13 months postop

Life?Function?

Psychic health?

WrongOP

MorbidityPain

Quality of life Death comes late

Surgery with WIDE MARGINS

?

Urogenital & anorectal function

If the surgeon does not sacrifice these functions, the tumor will do it in time (with high mortality!)

ConclusionFor malignant sacral tumors,

• Marginal resection + Adjuvants do not provide safe margins.

• Intrapelvic recurrence is diffuse and mostly inoperable.

• Metastases appear late and the patient is usually Alive With

Disease for a long time and also full of morbidities !!!

• If the surgeon does not sacrifice the function (nerve roots), the

tumor does !!!

• The initial operation with WIDE MARGINS is the only chance for

cure !!!