Musculoskeletal Tumours - Internal hemipelvectomy

Malignant pelvic bone tumours - surgical treatment

Malignant tumours located in the bones of the pelvis are relatively rare. However, when they do occur they are extremely difficult to treat. These tumours can be primary (e.g. osteosarcoma, chondrosarcoma, Ewing's sarcoma) i.e. tumours that originate in the pelvic bones or metastatic i.e. tumours that have occurred in another organ (e.g. lung, thyroid, breast, prostate etc.) and metastasise to the pelvic bones.

Treatment

The main treatment for tumours that occur in the bones is surgery, complemented by chemotherapy and/or radiotherapy. However, while both chemotherapy & radiotherapy have evolved significantly pelvic bone surgery lags behind not only in Greece but also in most foreign countries. Surgeries for pelvic bone tumors are extremely difficult and require highly skilled and experienced surgeons. Both the position of the bones in the body and the presence of important vessels and nerves as well as vital organs in the pelvis (e.g. ureters, spermatic cord, bowel) make the surgical environment unfamiliar and inaccessible for the orthopaedic surgeon.

Thus amputation or palliative rather than curative treatments are often applied to patients. The ability to go to specialist centres abroad is also very limited due to time (usually surgery has to be done at a specific time, 3-4 weeks after chemotherapy) so any time delay makes surgery ineffective or unfeasible either because of cost.

The cost for such an operation abroad and even in a specialized center is extremely high and the insurance funds, apart from the significant bureaucratic delay, usually cover part of the cost and only for young patients and mainly children. But even specialised centres rarely take on older patients. The patients who usually undergo such "limb salvage" pelvic surgery are patients relatively young in age up to 55 years.

Figure 1: pelvic osteosarcoma (OS)

Internal hemipyelectomy for the first time in Greece

In May 2020, we performed the first internal hemipylectomy in Greece at the "Agios Loukas" clinic. Such kind of interventions until now were performed only in very specialized centers abroad. The patient was a 72-year-old woman suffering from iliac-hip osteosarcoma that occurred after radiotherapy for localized non-Hodgkin's lymphoma (Figure 1,2).

Figure 2: Localisation of OA in the basin

The patient had previously been offered other surgical treatments of a palliative nature but without addressing the problem, focusing only on pain reduction and good functionality of the limb in the limited time of her life. Both the diagnosis and the treatment were carried out exclusively at the "St. Luke's" clinic.

Initially we proceeded with a needle biopsy under CT guidance to eliminate the risk of tumor spread. Based on the histological diagnosis, which was "high-malignant post-occlusive osteosarcoma", the patient was treated with chemotherapy in the oncology clinic. MRI scan after completion of the first cycle of chemotherapy showed a very good response of the tumor to chemotherapy with immediate disappearance of pain, resolution of symptoms and reduction in tumor size.

After the end of chemotherapy and after a new MRI scan, the surgery was digitally planned in a 3D plan (Digital 3D pre-operative analysis system). This operation belongs to the newest generation of surgical procedures in which we try to completely remove the tumour by salvaging the limbs (arms and legs) while avoiding amputation and is called by the international term "limb salvage surgery".

Figure 3: Pelvic osteotomy

We removed the iliac bone (bone) along with the hip joint and along with the muscles covering the tumor, in one piece (Figures 3,4).

Figure 4: Postoperative

Pathological anatomical examination showed that the tumour was very aggressive and was completely removed within healthy limits. The patient followed a smooth postoperative course, was discharged in very good condition much sooner than the average hospitalization for this type of surgery and is following a rehabilitation program. Both surgical time and blood loss were significantly better than the average presented by international studies. In addition, the age of the patient was significantly older than the average of the studies.

In the "St. Luke's" clinic we can treat any musculoskeletal tumor with excellent results.

Text:
Konstantinos Tsanidis
Orthopaedic Surgeon & Musculoskeletal Tumour Surgeon
TSANIDIS ORTHOPAEDIC CENTER ∙ TOC

Konstantinos Tsanidis is an orthopaedic surgeon specialising in the surgery of sarcomas and musculoskeletal tumours at the Royal National Orthopaedic Hospital Stanmore/London in the UK. He is the only orthopaedic surgeon who has worked as a senior attending surgeon at the "Theagenio" Anti-Cancer Hospital of Thessaloniki, he is a member of the International Society of Limb Salvage (ISOLS) and the first Greek member of the European Musculo-Skeletal Oncology Society (EMSOS).

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