Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and...
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Transcript of Prof Dr Harzem Ozger Istanbul University Istanbul Faculty of Medicine Dept. Of Orthopaedics and...
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 !!!