Wei Guo Francis J. Hornicek Franklin H. Sim Editors Surgery of the Pelvic and Sacral Tumor 123 Surgery of the Pelvic and Sacral Tumor Wei Guo • Francis J. Hornicek • Franklin H. Sim Editors Surgery of the Pelvic and Sacral Tumor Editors Wei Guo Francis J. Hornicek Musculoskeletal Tumor Center Orthopedic Surgery People’s Hospital Peking University David Geffen School of Medicine at UCLA Beijing Los Angeles, CA China USA Franklin H. Sim Orthopedics Mayo Clinic Rochester, MN USA ISBN 978-94-024-1943-6 ISBN 978-94-024-1945-0 (eBook) https://doi.org/10.1007/978-94-024-1945-0 © Springer Nature B.V. 2020 This work is subject to copyright. 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Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature B.V. The registered company address is: Van Godewijckstraat 30, 3311 GX Dordrecht, The Netherlands Contents Part I P elvic Tumors: The Fundamentals 1 Pelvis: General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Peter F. M. Choong 2 Anatomy and Physiology of the Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Robert Waldrop and Franklin H. Sim 3 Imaging Modalities and Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Matthew T. Houdek and Benjamin M. Howe 4 Tumors of the Pelvis: Pathologic Aspect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Matthew T. Houdek and Carrie Y. Inwards 5 Staging, Preoperative, and Surgical Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Lucas Eduardo Ritacco, Federico Edgardo Milano, Germán Luis Farfalli, Miguel Angel Ayerza, D. L. Muscolo, and Luis Alberto Aponte-Tinao Part II P elvic Tumors: Surgical Procedures 6 Overview on Pelvic Resections: Classification, Operative Considerations and Surgical Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Peter F. M. Choong 7 Resection of Periacetabular Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Howard Y. Park and Francis J. Hornicek 8 Pelvic Floor and Pubis Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Huayi Qu and Wei Guo 9 Combined Approach for Iliosacral Tumor Resection . . . . . . . . . . . . . . . . . . . . . . . 57 Tao Ji and Wei Guo 10 Surgical Treatment for Metastatic Lesions in Pelvis . . . . . . . . . . . . . . . . . . . . . . . . 61 Daniel A. Driscoll, Francis J. Hornicek, Joseph H. Schwab, and Santiago A. Lozano Calderon 11 External Hemipelvectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Dasen Li and Wei Guo Part III Pelvic Tumors: Pelvic Reconstruction 12 Reconstruction After Ilium Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Tao Ji and Wei Guo 13 Periacetabular Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Tao Ji and Wei Guo v vi Contents 14 Reconstruction of Pelvic Tumor with Sacrum Involved . . . . . . . . . . . . . . . . . . . . . 91 Yidan Zhang and Wei Guo Part IV Pelvic Tumors: Special Topics 15 Reconstruction with 3D-Printed Endoprosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . .107 Wei Guo 16 Navigation in Pelvic Tumour Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 J. G. Gerbers and P. C. Jutte 17 Pelvic Tumor Surgery in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 Rodolfo Zamora, Stephanie Punt, and Ernest U. Conrad III 18 Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141 Zhiye Du and Wei Guo 19 Complication Prevention and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147 Dasen Li and Wei Guo Part V Sacral Tumors: The Fundamentals 20 General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157 Yifei Wang and Wei Guo 21 Surgical Anatomy of the Sacrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165 Huayi Qu and Wei Guo 22 Diagnostic Imaging and Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .169 Yi Yang and Wei Guo 23 Tumors of the Sacrum: Pathologic Aspect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183 Yi Yang and Wei Guo 24 Preoperative Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195 Lu Xie and Wei Guo 25 Surgical Approaches to the Sacrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201 Taiqiang Yan and Wei Guo Part VI S acral Tumors: Procedures for Sacral Tumor 26 Two-Stage Total Sacrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207 Francis J. Hornicek 27 One-Stage Total Sacrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .219 Jie Zang and Wei Guo 28 Using 3D Printing Sacral Endoprosthesis for Spinopelvic Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225 Wei Guo 29 Resection of Hemisacrum Vertically and Sacroiliac Joint . . . . . . . . . . . . . . . . . . . .233 Dasen Li and Wei Guo Part VII Sacral Tumors: Special Topics 30 Lumbosacral Resection and Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .237 Matthew T. Houdek, Peter S. Rose, and Michael J. Yaszemski Contents vii 31 Surgical Strategy for Sacral Giant Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .249 Wei Guo 32 Surgical Strategy for Sacral Neurogenic Tumors . . . . . . . . . . . . . . . . . . . . . . . . . .255 Wei Guo 33 Preoperative Embolization and Aortic Balloon . . . . . . . . . . . . . . . . . . . . . . . . . . . .259 Xiaodong Tang and Wei Guo 34 Complications After Sacrectomy and Pelvic Tumor Surgery . . . . . . . . . . . . . . . . .267 Dasen Li and Wei Guo 35 Rehabilitation After Sacrectomy and Pelvic Resection . . . . . . . . . . . . . . . . . . . . . .275 Jie Xu and Wei Guo Part I Pelvic Tumors: The Fundamentals Pelvis: General Considerations 1 Peter F. M. Choong Resections of tumours of the bony pelvis are highly morbid • Careful planning of the surgical approach together with and can challenge even the most expert of surgeons [1–5]. other specialist surgeons is critical for ensuring optimal Decisions regarding the surgery and the ultimate outcomes patient positioning and draping, for achieving the best of procedures are determined by the type and location of the view of the operative field and vital structures, for antici- tumour (bone or soft tissue) [4, 6–8], the operative approach pating the order of surgery when multiple specialties are [9], the reconstructive techniques utilised [1, 10–13] and the involved and for facilitating the use of specialised equip- amount and type of tissue sacrificed in the surgery. The mor- ment if required. bidity of pelvic reconstruction is high, and the intraoperative • Pelvic surgery often requires prolonged surgery that is demand on expertise, resources and personnel is such that frequently associated with episodes of haemodynamic pelvic tumour surgery is best practised in a multidisciplinary and respiratory instability. This requires an expert anaes- team setting with members who are familiar and expert in the thetic team capable of managing rapid transfusion require- intra- and perioperative care of such patients [9]. ments and invasive monitoring. Managing the physiologic upset during the procedure is an important consideration and requires a close working relationship with the anaes- 1.1 Important Considerations When thetic team. Planning Treatment of Pelvic Tumours • Understanding the aetiology of the tumour (benign, 1.2 Aetiology of Pelvic Tumours malignant, primary, metastatic) will allow engagement of the relevant clinical experts, determination of oncologic 1.2.1 Primary Tumours surgical margins and planning of durable reconstructions. Ten percent of primary tumours involve the pelvis, and of • Comprehensive pathologic, local and systemic staging is these, chondrosarcoma, Ewing’s sarcoma and osteosarcoma mandatory and part of the treatment strategy of these are the commonest [14]. These may be treated with curative complex tumours. or palliative intent and, other than chondrosarcoma, will • Classification systems help to define the location of the require adjuvant multimodal treatment. In either clinical tumour and the types of resections and reconstructions situation (curative, palliative), local control of disease to that may be required. minimise or negate tumour recurrence is the prime goal of • A careful study of the anatomy of the pelvis in relation to surgery. If vital structures are not at risk, then wide surgical the tumour and its planned resection allows anticipation margins are indicated and may be defined as at least 2 cm of and mitigation of intraoperative hazards. clear bone in the line of the bone and a cuff of normal tissue which is a named anatomic layer such as muscle or fascia P. F. M. Choong (*) that is parallel to the surface of the tumour [15]. Some Department of Orthopaedic Surgery, The University of Melbourne, authors have highlighted the importance of the quality of the St. Vincent’s Hospital Melbourne, Melbourne, VIC, Australia surgical margin and that this may vary between tissues that Department of Surgery, The University of Melbourne, St. Vincent’s comprise the margin [16]. In planned resections, which Hospital Melbourne, Melbourne, VIC, Australia involve adjuvant treatment, surgery is often preceded by Bone and Soft Tissue Sarcoma Service, Peter MacCallum Cancer neoadjuvant chemotherapy or radiotherapy. Chemotherapy Centre, Melbourne, VIC, Australia and radiotherapy aim to kill the tumour, reduce its size and e-mail: [email protected] © Springer Nature B.V. 2020 3 W. Guo et al. (eds.), Surgery of the Pelvic and Sacral Tumor, https://doi.org/10.1007/978-94-024-1945-0_1 4 P. F. M. Choong incite a fibrotic reaction around the tumour to create a true should be used and anchored in bone cement to enhance capsule which effectively enhances the surgical margin. The fixation and strength of the construct. If joint prostheses are extent of surgery including the resection of bone and soft to be used, then consideration should be given for cement tissue often leaves the operative bed associated with a sub- fixation rather than cementless fixation, and for long- stantial dead space. Dead space is a potential source of com- stemmed prostheses rather than standard-length prostheses plications including haematoma, infection and wound for the femur, humerus and tibia for added protection. dehiscence, which may demand pre-emptive or corrective surgery. Early involvement of plastic and reconstructive sur- gical expertise in the surgical planning will optimise surgi- 1.3 Symptoms of Pelvic Tumours cal outcomes [17–19]. Because of the large intra-abdominal and intra-pelvic vol- ume, primary pelvic tumours may have an occult presenta- 1.2.2 Secondary Tumours tion, reaching large sizes before detection. Symptoms may vary between bone and soft tissue sarcomas with the former Metastatic bone disease following carcinoma is a common being associated with deep-seated and nocturnal pain, while occurrence [20, 21]. Common primary sites of carcinoma the latter often presenting without pain. Abdominal fullness which metastasise to the pelvis include breast, lung, prostate, may be a feature of the latter’s presentation. Irritation of the kidney and thyroid. Breast and prostate carcinoma metasta- bowel and bladder or compression of the ureter may lead to ses often present with mixed sclerotic-lytic disease. Lung obstructive symptoms, frequency or dissatisfied visceral carcinoma metastases often present with permeative and evacuation. Often, symptoms are vague and misinterpreted poorly circumscribed lesions. Thyroid and renal carcinoma for musculoskeletal injury or referred pain from the lumbar metastasise with cannonball lesions that are often hyper- spine. vascular and markedly lytic and may grow to considerable sizes. Metastases may also be associated with large soft tis- sue components, which present a similar complexity as large 1.4 Imaging Modalities primary tumours by obscuring or impinging on vital structures. Appropriate and adequate imaging is mandatory for surgery The management of primary bone malignancies differs about the pelvis [23–25]. When dealing with tumours, both from metastatic bone disease because primary tumours are anatomic and functional imaging can be very useful for often solitary, are amenable to wide surgical margins and are characterising the tumour and informing the planning of resected with as large a cuff or margin of normal tissue as is biopsy and surgical margins. Anatomic imaging includes possible. In contrast, the surgical management of metastatic plain radiography, computed tomography (CT) and mag- disease, which is diffuse, progressive and multifocal, aims netic resonance imaging (MRI). Functional imaging is used for conservative bone-preserving techniques that are durable to examine the metabolic activity of tumours and include and appropriate for what is often treatment with a palliative technetium bone scans, thallium scans and positron emis- intent [20, 22]. For the latter, curettage or the removal of only sion tomography. The results of functional scans can be macroscopically affected tissue is combined with recon- superimposed (co-registered) onto CT scans to provide the struction that is reinforced and not primarily dependent on exact location of metabolic activity in relation to the bone union or ingrowth. Rarely, truly solitary metastases patient’s anatomy. may be treated with wide resection like a primary tumour. More commonly, however, apparently solitary metastases are associated with micrometastatic lesions within the same 1.4.1 Plain Radiography bone, which eventually manifest their presence in the pas- sage of time. Careful scrutiny of well-performed anatomic Biplane and Judet views of the pelvis are simple and reliable and functional imaging investigations should be undertaken tests that allow assessment of the bony architecture of the before a decision is made to designate a tumour as solitary. pelvis. These are particularly important not only for charac- Progression of metastatic disease is the norm, and to avoid terising the primary tumour but also for delineating bone failure of the device from rapid recurrence of tumour, recon- destruction associated with metastatic disease. Digital imag- structions should be planned to achieve maximum durability ing is now available in most centres, and standardised views within the anticipated lifespan of the patient [20, 22]. For with appropriate scaling allow more accurate templating and example, internal fixation often reinforced by acrylic bone planning for acetabular or proximal femoral prostheses, as cement should span entire lengths of bones. Locking screws well as for selecting size-matched allografts.