Can computer navigation-assisted surgery reduce the risk of an intralesional margin and reduce the rate of local recurrence in patients with a tumour of the pelvis or sacrum?

Abstract

We hypothesised that the use of computer navigation-assisted surgery for pelvic and sacral tumours would reduce the risk of an intralesional margin. We reviewed 31 patients (18 men and 13 women) with a mean age of 52.9 years (13.5 to 77.2) in whom computer navigationassisted surgery had been carried out for a bone tumour of the pelvis or sacrum. There were 23 primary malignant bone tumours, four metastatic tumours and four locally advanced primary tumours of the rectum. The registration error when using computer navigation was < 1 mm in each case. There were no complications related to the navigation, which allowed the preservation of sacral nerve roots (n = 13), resection of otherwise inoperable disease (n = 4) and the avoidance of hindquarter amputation (n = 3). The intralesional resection rate for primary tumours of the pelvis and sacrum was 8.7% (n = 2): clear bone resection margins were achieved in all cases. At a mean follow-up of 13.1 months (3 to 34) three patients (13%) had developed a local recurrence. The mean time alive from diagnosis was 16.8 months (4 to 48).Computer navigation-assisted surgery is safe and has reduced our intralesional resection rate for primary tumours of the pelvis and sacrum. We recommend this technique as being worthy of further consideration for this group of patients. Cite this article: Bone Joint J 2013;95-B:1417-24.Resecting tumours of the pelvis and sacrum can be challenging because of their complex three-dimensional anatomy, the proximity of vital structures, the consistency of the tumour and the need to vary the position of the patient during the procedure. In patients with a musculoskeletal malignancy the aim is to perform a wide local resection with adequate disease-free margins. 1Cartiaux et al 2 reported that the probability of an experienced surgeon achieving a 1 cm surgical margin in all three planes on a simulated tumour model of the pelvis was only 52%. The importance of achieving adequate surgical margins is highlighted by the fact that there is a local recurrence rate of up to 70% after a marginal resection, and 92% after an intralesional resection. 3,4 In our previously reported series of 539 primary bone tumours of the pelvis resected using standard surgical techniques, the rate of intralesional resection was 29%, with a local recurrence rate of 27%; there were more major complications and significantly worse results than those achieved for primary bone tumours of the limbs.

What Is the Expected Learning Curve in Computer-assisted Navigation for Bone Tumor Resection?

“…The median registration error was 0.6 mm (range, 0.3-1.1 mm). This error is similar to that observed in previous publications [1,2,10,17,21,22]. In our study, the amount of registration error did not improve overtime (Fig.…”

“…Nevertheless, tumor operations are different from one patient to another because of the size and location of the tumor in each case. Therefore, the use of navigation assistance helps the surgeon provide anatomic detail about the surgical bed, adding accuracy and precision to the surgical resection [7,10]. We noted that in pelvic resections, the mean time for navigation was longer.…”

“…With the numbers we had we could not detect a difference between pelvic tumors and extremity tumors, but there may be a difference if we had a larger study. Several factors could be related to local recurrences [5], but in general, surgical margin is a major factor related to this problem [10]. Computer-assisted surgery has shown that it provides accuracy in oncological resection [15].…”

“…Therefore, surgeons cannot reproduce the preoperative planning with the degree of precision achieved in bone margins. Despite this technical limitation, a recent report suggests the utilization of this technology in pelvic tumors, because they found a lower incidence of local recurrences [10].…”

CORR Insights®: Reconstruction After Hemipelvectomy With the Ice-Cream Cone Prosthesis: What Are the Short-term Clinical Results?

“…They also have the worst functional outcomes. When resection methods (with and without reconstruction) are compared to one another, previously published studies [1,[4][5][6] do not agree about which approach is most likely to result in best functional outcomes. One review article likewise suggested that there is no clearly superior reconstructive approach for those patients who undergo internal hemipelvectomies for tumor [7].…”