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Hemipelvectomy- Only a Salvage Therapy?

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Hemipelvectomy- Only a Salvage Therapy? Orthopedic Reviews 2011; volume 3:e4 Hemipelvectomy- only a salvage to resect. Therefore, pelvic tumors present a great challenge for orthopedic surgeons. Correspondence: Priv.-Doz. Dr. med Christian therapy? Basically, hemipelvectomy is divided into Wedemeyer, Department of Orthopaedic Surgery, external hemipelvectomy (amputation) and University of Duisburg-Essen, Hufelandstraße Christian Wedemeyer,1 internal hemipelvectomy with preservation of 55, 45147 Essen, Germany. Max Daniel Kauther2 the lower extremity. For many years external Tel. 49.201.723.3181 - Fax: +49.201.4089.2722. E-mail: [email protected] 1Department of Orthopedic Surgery, hemipelvectomy was the standard method of University Duisburg-Essen, Essen; treatment for locally aggressive and malignant Key words: hemipelvectomy, bone tumors, recon- 2Department of Trauma Surgery, bone tumors in the pelvis. Today, internal struction, oncological outcome. University Duisburg-Essen, Essen, hemipelvectomy presents an alternative in the 7,8 Acknowledgement: the authors would like to Germany struggle against pelvic tumors. Since an ade- quate and tumor free resection margin is of thank Kaye Schreyer, Dr. Anja Wedemeyer and Dr. great importance for the long-term oncological Cordula Kauther for editorial assistance with the manuscript. outcome, hemipelvectomy remains as a cura- tive approach.9-11 It is evident that not only sur- Abstract Conflict of interest: the authors report no con- gical technique but relevant development on flicts of interest. non-orthopaedic fields such as early diagnosis After the first hemipelvectomy in 1891 sig- and follow-ups by imaging, new chemotherapy Received for publication: 15 February 2011. nificant advances have been made in the fields Revision received: 3 March 2011. and/or radiation regimes, and innovative Accepted for publication: 4 March 2011. of preoperative diagnosis, surgical technique implants or bioengineering have lead to signif- and adjuvant treatment in patients with pelvic icant improvement in the management and This work is licensed under a Creative Commons tumors. The challenging surgical removal of success of hemipelvectomy. Modern imaging Attribution 3.0 License (by-nc 3.0). these rare malignant bone or soft tissue techniques allow early and accurate preopera- tumors accompanied by interdisciplinary ther- tive staging.12 Inoperable neoplasms become ©Copyright C. Wedemeyer and M.D.Kauther, 2011 apy is mostly the only chance of cure, but bares operable by neoadjuvant chemotherapy and Licensee PAGEPress, Italy Orthopedic Reviews 2011; 3:e4 the risk of intensive bleeding and infection. preoperative irradiation aiming to reduce the doi:10.4081/or.2011.e4 The reconstruction after hemipelvectomy is of tumor mass and increasing the chance to pre- importance for the later outcome and quality of serve the lower extremity.13 With adequate life for the patient. Here, plastic surgery with management internal hemipelvectomies do microvascular free flaps or local rotational not implement higher recurrence rates com- review presents the literature on the outcome flaps improved the reconstruction and reduced pared to amputations by external hemipelvec- after hemipelvectomy in dependency of infection rates. Average local recurrence rates tomy14 and, in contrast, lead to better function- defined reconstruction techniques during the of 14% demonstrate good surgical results, but al results in many cases.15 For reconstruction last thirty years. 5 year survival rates of only 50% are described of the hip and the hemipelvis after tumor for some tumor entities, showing the impor- resections various techniques have been Entities tance of a multimodal collaboration. On a basis developed to obtain a functional and cosmeti- Bone tumors can develop in all types of bone of a selective literature review the history, cally acceptable outcome, especially to prevent tissue and associated bone marrow cells. A indications, treatment options and outcome of from highshortening of the limb even after a tumor that originates in bone is called primary hemipelvectomies are presented. wide resection.16 bone cancer. Primary bone tumors only First, there is the possibility of solely resect- account for 1% of all solid tumors, and mostly ing the bone. In this procedure, fresh frozen affect patients under 20 years and between 40 allografts17 or autografts are frequently used - 50 years.26 The tumors most commonly occur- Introduction for bony reconstruction. Here, also re-implan- ring in the pelvis are chondrosarcoma, Ewing tion of devitalized autogenous bone16 was sarcoma, plasmocytoma and osteosarcoma. In The first hemipelvectomy was performed by reported. There are also options for recon- rare cases, histiocytoma, lymphoma, rhab- Billroth in 1891. The patient survived only a few struction by means of allograft or autograft domyosarcoma and fibrosarcoma are located hours. In 1893, Jabulay operated on a patient interposition in combination with a total in the pelvis.27 Osteosarcomas are considered who died immediately after the procedure. The hip15,18,19 or even pelvis prosthesis,20 by transpo- to be the most common primary malignant first successful hemipelvectomy in terms of sur- sition of the hip joint or by arthrodesis21,22 and bone tumors with 150 cases per year in vival was performed by Girard in 1895. In 1902, hindfoot rotationplasty. Furthermore, there Germany.28 While this tumor type is mainly there were reports on 13 hemipelvectomies has been an attempt to reconstruct the pelvis located in the metaphysis of long bones, the with a mortality rate of 60%.1,2 The most com- with polymethylmethacrylate (PMMA) com- incidence rate in the pelvis is only 6.4-8% of all mon indications for hemipelvectomy are bined with screws or nails.23 However, the lat- osteosarcomas and thus comparatively rare.29 malignant or locally aggressive/ destructive ter techniques only appropriate for palliative Chondrosarcomas are the second most com- bone and soft tissue tumors of the pelvis and situations or temporary reconstruction. There mon malignant bone tumors.30 They are usual- the adjacent muscles, especially osteosarcoma, is no standard procedure and little information ly located close to the trunk and the pelvic chondrosarcoma and Ewing's sarcoma. In is available about the results although many skeleton. This differs from the osteosarcoma, some rare cases hemipelvectomy is also neces- different options exist for reconstruction after which is found in the pelvis only in exception- sary because of trauma3 or osteomyelitis.4 The internal hemipelvectomy. It is also much al cases.30,31 Chondrosarcomas have to be treat- overall prognosis for patients with malignant debate about which approach is appropriate for ed primarily by surgical therapy, because bone tumors is poor.5,6 Due to the location and each single patient.12,24 The decision regarding chemotherapy and radiation therapy are most- extension of these lesions but also to the com- surgical strategy takes into account the age of ly not effective.8 Here, a wide surgical resec- plex anatomy and the aim to achieve a good the patient,15 the required extent of resection tion margin is crucial for successful treatment. functional outcome, these tumors are difficult and the experience of the surgeons.12,25 This A further 10% of malignant bone tumors are [page 12] [Orthopedic Reviews 2011; 3:e4] Article Ewing sarcomas with an annual incidence of removal is often quiet technical difficult and 0.6/million in the population.30 In children and embare a high complication risk, these opera- young adults they are the second most com- tions should not be performed as a purely pal- mon primary bone tumors.30 Recent studies liative procedure.37 Indications for palliative suggested that Ewing sarcomas probably origi- radical amputation are the involvement of nate from undifferentiated mesenchymal cells nerve structures in the pelvis causing uncon- of the bone marrow and are mainly located in trollable pain and failed local control of the metaphysis and diaphysis and in the metastatic disease. However, such cases are pelvis. Other authors believed that Ewing sar- rare. Severe trauma38 or osteomyelitis4 of the comas belong to the primitive neuroectoder- pelvis may also indicate hemipelvectomy in mal tumors, derived from the neural crest and defined cases. Amputation is recommended if are characterized by ews/ets translocation. the tumor has infiltrated the sciatic nerve and However, the exact origin of Ewing sarcoma therefore relevant function of the lower family is unknown.32,33 Seven percent of all extremity is not to be expected.39 bone tumors are primary non-Hodgkin's lym- Figure 1. Subtypes of hemipelvic resection phoma.34 Like the Ewing sarcoma, this rare Surgical, anatomical and patient methods, Eneking and Dunham 1978, tumor affects the metaphysis of long bones related aspects of hemipelvectomy Figure redrawn.44 Type I: resection includes and the pelvis.34 only the ilium. Type IA: resection of the Detailed descriptions of surgical approaches ilium and the gluteal muscles. Type I/S: are found in literature.40 Prior to biopsy the Resection of the ilium with a portion of the Indications for hemipelvectomy surgeon needs to have detailed information of sacrum. Type II: Resection of the periac- Tumors of the pelvis are often recognized at tumor’s extent and, in case of malignancy, of etabular region. Type IIA: Resection of the a late stage because they can extend without the tumor resection to be performed later in periacetabular region
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