Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and...
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![Page 1: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/1.jpg)
Prof Dr Harzem OzgerIstanbul University
Istanbul Faculty of MedicineDept. Of Orthopaedics and Traumatology
Orthopedic Oncologic Approach
in Sacrum Tumors
![Page 2: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/2.jpg)
Epidemiology%1,4 – 4 of all musculoskeletal tumors
Benign aggressive > Malignant >>> Metastasis
Low grade >> High grade
• Benign ABC
GCT
• Malignant CS
Chordoma
EWS
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Anatomical Considerations
Delayed diagnosis
Complicated radiotherapy
Demanding surgical technique
Increased perioperative morbidity / mortality
Poor prognosis
![Page 4: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/4.jpg)
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
![Page 5: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/5.jpg)
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
![Page 6: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/6.jpg)
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
![Page 7: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/7.jpg)
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
![Page 8: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/8.jpg)
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
![Page 9: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/9.jpg)
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
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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)
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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
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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.
![Page 13: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/13.jpg)
• 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
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• 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
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• 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
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Minimising intraoperative bleeding 13 y, F
ABC of sacrum
Intralesional resection following embolisation
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• 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
![Page 18: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/18.jpg)
16 y, F
GCT of sacrum
Intralesional resection (curettage and phenolisation) only
NED at postop 4 yrs.
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25 y, F
ABC of sacrum
Intralesional resection + phenolisation + PMMA
NED at postop 5 yrs.
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%50 loss of SI joint causes vertical + rotational instability :
Lumbopelvic fixation !!
Mechanical support
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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
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2. stage
Posterior instrumentation performed after 2 wks for lumbopelvic fixation
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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
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Early postop xrays
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Postop 3 months
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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
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- 17 y, M with OS of right hemipelvis- double J-catheterization preop to avoid intraoperative ureter injury
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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
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- Dead space
- Avascular flaps
Management of Soft Tissue Complications
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– 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
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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
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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
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Local recurrence at postop 1 yr - resected
![Page 34: Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and Traumatology Orthopedic Oncologic Approach in Sacrum Tumors.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649c9c5503460f9495a550/html5/thumbnails/34.jpg)
Local recurrence at postop 3 yrs. - inoperable
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All lessons learned!
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Preoperative embolisation
- 30 y / F- Sacrum chordoma
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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.
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After wide resection of sacrum chordoma
and the rectum,VRAM flap is pulled out
from posterior to fill the dead space.
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Clinical photos at 8 months postopPermanent colostomy (planned preoperatively)
NO complicationNO local recurrence at postop 50 months
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Extreme reconstructions
- 16 y, F - osteosarcoma of right hemipelvis
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- 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
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Postop 5 months Postop 15 months
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Ambulatory with a single crutch at 13 months postop
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Life?Function?
Psychic health?
WrongOP
MorbidityPain
Quality of life Death comes late
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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!)
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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 !!!