Outcome of Sacropelvic Resection and Reconstruction Based on a Novel Classification System

Abstract

Background: Sacral tumor resections require a multidisciplinary approach to achieve a cure and a functional outcome. Currently, there is no accepted classification system that provides a means to communicate among the multidisciplinary teams in terms of approach, osseous resection, reconstruction, and acceptable functional outcome. The purpose of this study was to report the outcome of sacral tumor resection based on our classification system. Methods: In this study, 196 patients (71 female and 125 male) undergoing an oncologic en bloc sacrectomy were reviewed. The mean age (and standard deviation) was 49 ± 16 years, and the mean body mass index was 27.2 ± 6.4 kg/m2. The resections included 130 sarcomas (66%). The mean follow-up was 7 ± 5 years. Results: Resections included total sacrectomy (Type 1A: 20 patients [10%]) requiring reconstruction, subtotal sacrectomy (Type 1B: 5 patients [3%]) requiring reconstruction, subtotal sacrectomy (Type 1C: 104 patients [53%]) not requiring reconstruction, hemisacrectomy (Type 2: 29 patients [15%]), external hemipelvectomy and hemisacrectomy (Type 3: 32 patients [16%]), total sacrectomy and external hemipelvectomy (Type 4: 5 patients [3%]), and hemicorporectomy (Type 5: 1 patient [1%]). The disease-specific survival was 66% at 5 years and 52% at 10 years. Based on the classification, the 5-year disease-specific survival was 34% for Type 1A, 100% for Type 1B, 71% for Type 1C, 65% for Type 2, 57% for Type 3, 100% for Type 4, and 100% for Type 5 (p < 0.001). Tumor recurrence occurred in 67 patients, including isolated local recurrence (14 patients), isolated metastatic disease (31 patients), and combined local and metastatic disease (22 patients). At 5 years, the local recurrence-free survival was 77% and the metastasis-free survival was 68%. Complications occurred in 153 patients (78%), most commonly wound complications (95 patients [48%]). Following the procedure, 154 patients (79%) were ambulatory, and the mean Musculoskeletal Tumor Society (MSTS93) score was 60% ± 23%. Conclusions: Although resections of sacral malignancies are associated with complications, they can be curative in a majority of patients, with a majority of patients ambulatory with an acceptable functional outcome considering the extent of the resection. At our institution, this classification allows for communication between surgical teams and implies a surgical approach, staging, reconstruction, and potential functional outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of a novel classification system to predict local recurrence in sarcoma patients undergoing hemipelvectomy with iliosacral resection

“…While the tumour histology and percentage of patients with metastatic disease at the time of surgery are comparable, there was a poorer overall survival in our study. Given that ours is a retrospective study focusing on surgical outcome, we can only hypothesize that it is possible that there was a higher percentage of patients developing distant metastasis later on, although details on the treatment of LR and metastases are not available in either our study or that of Zhang et al 1 The study by Houdek et al 9 focused on oncological sacrectomy and defined resection types 1a to c, and two to five with types 2, 3, and 4 representing iliosacral resections. While their classification system included spinopelvic resection and reconstructions, including a great number of patients, those undergoing iliosacral resection were limited, and there was a certain heterogeneity as several patients with bone metastases were included.…”

“…2,8 Over the last few decades, more extensive resections of pelvic tumours invading the sacrum in conjunction with hemipelvectomies have been described. 1,2,[9][10][11] However, there is no universally accepted classification system. Zhang et al 1 have proposed a system that distinguishes three types of iliosacral resections and investigated patient survival in 141 patients using this approach.…”

“…They reported that 79% of their patients had adequate margins; however, 21% of their patients developed LR. In another study, Houdek et al 9 investigated oncological sacral resections in 196 patients with primary and metastatic tumours involving the sacrum and they proposed seven subtypes of resections, including 66 patients with iliosacral resections. They reported that there was 80% to 100% of LR-free survival in iliosacral resections.…”

Impact of preoperative sarcopenia in patients undergoing sacral tumor resection

“…Following institutional review board approval, we retrospectively reviewed 103 patients undergoing total or subtotal sacrectomy (Mayo Type 1) 2 for a malignant tumor from 2005 to 2017. Of this, 50 (49%) of patients had a preoperative CT scan which included the L4 vertebral level within 90‐days of surgery.…”

“…In patients with malignancies, including sarcoma, sarcopenia has been found to be an independent predictor of complications and survival 11–20 . As part of the clinical staging and work‐up of patients undergoing sacral tumor resection, a CT scan of the pelvis is often obtained, 2 and therefore sarcopenia may be easily assessed in this cohort. There is currently a paucity of data determining the impact of sarcopenia in patients undergoing sacral tumor resection.…”