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

AIMS: Iliosacral sarcoma resections have been shown to have high rates of local recurrence (LR) and poor overall survival. There is also no universal classification for the resection of pelvic sarcomas invading the sacrum. This study proposes a novel classification system and analyzes the survival and risk of recurrence, when using this system. METHODS: This is a retrospective analysis of 151 patients (with median follow-up in survivors of 44 months (interquartile range 12 to 77)) who underwent hemipelvectomy with iliosacral resection at a single centre between 2007 and 2019. The proposed classification differentiates the extent of iliosacral resection and defines types S1 to S6 (S1 resection medial and parallel to the sacroiliac joint, S2 resection through the ipsilateral sacral lateral mass to the neuroforamina, S3 resection through the ipsilateral neuroforamina, S4 resection through ipsilateral the spinal canal, and S5 and S6 contralateral sacral resections). Descriptive statistics and the chi-squared test were used for categorical variables, and the Kaplan-Meier survival analysis were performed. RESULTS: Resections were S1 in 25/151 patients (17%), S2 in 70/151 (46%), S3 in 33/151 (22%), S4 in 77/151 (11%), S5 in 4/151 (3%), and S6 in 2/151 (1%). An internal hemipelvectomy was performed in 113/151 patients (75%), and 38/151 patients (25%) had an external hemipelvectomy. The predominant types of sarcoma were high-grade osteosarcoma in 48/151 patients (32%), chondrosarcoma in 41/151 (27%), Ewing sarcoma in 33/151 (22%), pleomorphic sarcoma in 17/151 (11%), and others in 2/151 (8%). LR was found in 24/151 patients (15%) with S3, S5, with S6 resections showing the highest rate of LR (p = 0.038). Overall, 19/151 patients (16%) had evidence of metastastic disease at the time of surgery and these patients showed poorer survival when compared to patients with no metastasis. CONCLUSION: The proposed classification can help to report and compare different surgical and reconstructive approaches in these difficult cases who are still have a considerable risk of LR. Cite this article: Bone Joint J 2022;104-B(2):290-296.

Anaesthesia for hemipelvectomy--a series of 49 cases.

We undertook an audit of 49 consecutive hemipelvectomies performed for primary or secondary malignancy. Combined epidural and general anaesthesia was used in 41 patients. The operations were long (range 90 to 600 minutes). The median crystalloid requirement was 8500 ml (range 1000 to 42000 ml) and a median of seven units of packed red blood cells were transfused (range 0 to 44 units). All measures of coagulation were normalised by the first postoperative day using fresh frozen plasma, platelets and cryoprecipitate. Warmed blood was administered at high flow rates using a custom designed system consisting of a roller pump and high capacity fluid warmer Thirty-five patients were managed postoperatively in the intensive care unit, of whom 31 remained intubated for postoperative ventilation. In 41 patients, postoperative pain management was by a continuous epidural infusion of local anaesthetic and opioid. The average duration of infusion was 4.25 days (range 3 to 6 days). One patient died during surgery from complications relating to massive blood loss, 14 had wound infections and one had an acute brain syndrome. There was significant utilisation of resources involving anaesthesia, surgery, intensive care and blood transfusion services. Anaesthesia for hemipelvectomy is challenging because of the extensive tissue trauma involved, the potential for massive blood loss and the potential for severe postoperative pain. The perioperative management necessitates care from a well coordinated, directed and focused healthcare team.