The clinical effectiveness and safety of Zone III REBOA for resection of sacropelvic tumors in patients older than 70 years.

BACKGROUND: REBOA is a method used to manage bleeding during surgery involving sacropelvic tumors. Nevertheless, studies on the use of REBOA among elderly people are lacking. The aim of this research was to investigate the efficacy and safety of Zone III REBOA in patients aged more than 70 years. METHODS: A comparative study was conducted using case-control methods. A group of patients, referred to as Group A, who were younger than 70 years was identified and paired with a comparable group of patients, known as Group B, who were older than 70 years. Continuous monitoring of physiological parameters was conducted, and blood samples were collected at consistent intervals. RESULTS: Totally, 188 participants were enrolled and received REBOA. Among the 188 patients, seventeen were aged more than 70 years. By implementing REBOA, the average amount of blood loss was only 1427 ml. Experiments were also conducted to compare Group A and Group B. No notable differences were observed in terms of demographic variables, systolic blood pressure (SBP), arterial pH, lactate levels, blood creatinine levels, potassium levels, or calcium levels at baseline. Additionally, after the deflation of the REBOA, laboratory test results, which included arterial pH, lactate, potassium concentration, calcium concentration, and blood creatinine concentration, were not significantly different (P > 0.05). CONCLUSION: This study indicated that in selected patients aged more than 70 years can achieve satisfactory hemodynamic and metabolic stability with Zone III REBOA. LEVEL OF EVIDENCE: Therapeutic study, Level III.

[Analysis of factors influencing the efficacy and prognosis of surgical treatment for primary malignant pelvic bone tumors].

Objective: To analyze the prognostic factors and the influence of surgical margin to prognosis. Methods: A retrospective analysis was performed for 208 pelvic tumors who received surgical treatment from January 2000 to December 2017 in our instituition. Survival analysis was performed using the Kaplan-Meier method and Log rank test, and impact factor analysis was performed using Cox regression models. Results: There were 183 initial patients and 25 recurrent cases. According to Enneking staging, 110 cases were stage ⅠB and 98 cases were stage ⅡB. 19 lesions were in zone Ⅰ, 1 in zone Ⅱ, 15 in zone Ⅲ, 29 in zone Ⅰ+Ⅱ, 71 in zone Ⅱ+Ⅲ, 29 in zone Ⅰ+Ⅳ, 35 in zone Ⅰ+Ⅱ+Ⅲ, 3 in zone Ⅰ+Ⅱ+Ⅳ, and 6 in zone Ⅰ+Ⅱ+Ⅲ+Ⅳ. Surgical margins including Intralesional excision in 7 cases, contaminated margin in 21 cases, marginal resection in 67 cases, and wide resection in 113 cases. Local recurrence occurred in 37 cases (17.8%), 25 cases were performed by reoperation and 12 cases received amputation finally. The 5-year recurrence rate of marginal resection was higher than wide resection (P＜0.05), and the recurrence-free survival rate of marginal resection was lower than wide resection (P＜0.05). There was significant differences in recurrence rate and recurrence-free survival rate between R0 and R1 resection (P＜0.05). 92 cases were not reconstructed and 116 cases were reconstructed after pelvic surgery. At the last follow-up, 63 patients (30.3%) died, and the 5-year, 10-year and 15-year survival rates were 70.4%, 66.8% and 61.3%, respectively. The 5-year survival rate of stage ⅠB and ⅡB tumor was 90.4% and 46.8%, respectively. There were 29 cases had postoperative wound complications (13.8%), 1 case with pelvic organ injury. The final function was evaluated in 132 patients, with an average MSTS score of 25.1±3.6. Cox multivariate analysis showed that surgical staging, R0/R1 margin and metastasis were independent prognostic factors for pelvic tumors. Conclusions: The safe surgical margin is the key factor for recurrence-free of pelvic tumor. The survival rate of stage ⅡB pelvic tumors was significantly lower than that of stage ⅠB tumors. Wound infection is the main postoperative complication. Surgical staging, R0/R1 margin and metastasis were independent prognostic factors of pelvic tumors.

Variability in Surveillance Strategies Following Resection of Sacrococcygeal Teratoma.

INTRODUCTION: Surveillance following sacrococcygeal teratoma (SCT) resection varies. The purpose of this study was to describe the clinical characteristics and outcomes of patients undergoing SCT resection and examine current institutional practices to detect recurrence. METHODS: A single-institution retrospective review of children who underwent resection of an SCT from January 1, 2010 to December 31, 2020 was performed. Data were summarized and surveillance strategies compared between histopathologic subtypes using nonparametric methods. RESULTS: Thirty six patients (75.0% female) underwent SCT removal at a median age of 8 d. Histopathology revealed 27 mature teratomas (75.0%), eight immature teratomas (22.2%), and one malignant germ cell tumor (2.8%). Median postoperative follow-up was 3.17 y (interquartile range [IQR]: 2.31-4.38 y). Patients had a median of 2.32 clinic visits per year (IQR: 2.00-2.70), alpha-fetoprotein levels were obtained at a median of 2.01 times per year (IQR: 0-1.66), and surveillance imaging was performed at a median of 2.31 times per year (IQR: 0-2.84). Patients with immature teratomas had alpha-fetoprotein laboratories obtained more frequently than patients with mature teratomas (3.10 times/year versus 0.93 times/year, P = 0.001). There was no significant difference in the number of imaging studies obtained between groups. Two patients (5.6%) developed recurrence, which were identified on magnetic resonance imaging at 191 and 104 d postresection, respectively. CONCLUSIONS: Postoperative surveillance practices varied widely. Recurrence was noted in a single malignant case in the first year following resection. Multi-institutional studies are needed to determine the optimal surveillance strategy to detect recurrence of SCT.

Uterine Leiomyosarcoma With Osteoclast-like Giant Cells: Report of 2 Cases and Review of Literature.

Leiomyosarcoma (LMS) with osteoclast-like giant cells (OLGCs) is a rare entity with only 18 reported cases thus far. It is not known whether these OLGCs are a reactive or malignant component of LMS. Herein we describe the clinical, histologic, and molecular characteristics of 2 cases of LMS with OLGCs and perform a brief literature review. In 2 of our cases, the OLGCs, marked with CD68, had a low proliferation index with Ki67 and did not show diffuse positivity for smooth muscle markers by immunohistochemistry. By next-generation sequencing, one case harbored a clinically significant TP53 mutation, which has been reported in a significant subset of conventional LMSs. In this case, based on immunohistochemistry, OLGCs showed different molecular alterations as compared with LMS. Although we did not show a distinct immunophenotype or molecular profile for LMS with OLGCs, this study provides additional data on this rare entity.

A prospective comparative study on bladder volume measurement with portable ultrasound scanner and CT simulator in pelvic tumor radiotherapy.

OBJECTIVE: The consistency of bladder volume is very important in pelvic tumor radiotherapy, and portable bladder scanner is a promising device to measure bladder volume. The purpose of this study was to investigate whether the bladder volume of patients with pelvic tumor treated with radiotherapy can be accurately measured using the Meike Palm Bladder Scanner PBSV3.2 manufactured in China and the accuracy of its measurement under different influencing factors. METHODS: A total of 165 patients with pelvic tumor undergoing radiotherapy were prospectively collected. The bladder volume was measured with PBSV3.2 before simulated localization. CT simulated localization was performed when the bladder volume was 200-400ml. The bladder volume was measured with PBSV3.2 immediately after localization and recorded. The bladder volume was then delineated on CT simulation images and recorded. To compare the consistency of CT simulation bladder volume and bladder volume measured by PBSV3.2. To investigate the accuracy of PBSV3.2 in different sex, age, treatment purpose, and bladder volume. RESULTS: There was a significant positive correlation with bladder volume on CT and PBSV3.2 (r = 0.874; p < 0.001). The mean difference between CT measured values and PBSV3.2 was (-0.14 ± 50.17) ml. The results of the different variables showed that the overall mean of PBSV3.2 and CT measurements were statistically different in the age ≥ 65 years, bladder volumes > 400ml and ≤ 400ml groups (p = 0.028, 0.002, 0.001). There was no statistical significance between the remaining variables. The volume difference between PBSV3.2 measurement and CT was 12.87ml in male patients, which was larger than that in female patients 3.27ml. Pearson correlation analysis showed that the correlation coefficient was 0.473 for bladder volume greater than 400ml and 0.868 for bladder volume less than 400ml; the correlation coefficient of the other variables ranged from 0.802 to 0.893. CONCLUSION: This is the first large-sample study to evaluate the accuracy of PBSV3.2 in a pelvic tumor radiotherapy population using the convenient bladder scanner PBSV3.2 made in China. PBSV3.2 provides an acceptable indicator for monitoring bladder volume in patients with pelvic radiotherapy. It is recommended to monitor bladder volume with PBSV3.2 when the planned bladder volume is 200-400ml. For male and patients ≥ 65 years old, at least two repeat measurements are required when using a bladder scanner and the volume should be corrected by using a modified feature to improve bladder volume consistency.

Pelvic-girdle reconstruction with three-dimensional-printed endoprostheses after limb-salvage surgery for pelvic sarcomas: current landscape.

Resection of pelvic bone tumors and the subsequent reconstruction of the pelvic girdle pose challenges due to complex anatomy, load-bearing demands, and significant defects. 3D-printed implants have revolutionized pelvic girdle reconstruction by offering customized solutions, porous surface structures for precise resection with custom guides, and improved integration. Many tertiary medical centers have adopted 3Dprinted hemipelvic endoprostheses, leading to enhanced outcomes. However, most studies are limited to single centers, with a small number of cases and short follow-up periods. Additionally, the design of these implants often relies heavily on individual experience, resulting in a lack of uniformity and significant variation. To provide a comprehensive assessment of this technology, we conducted an analysis of existing literature, encompassing tumor resection classification, various types of prosthesis design, reconstruction concepts, and post-reconstruction functional outcomes.

Pelvic exenteration for chronic fistulating pelvic sepsis after multimodal treatment of pelvic malignancy.

BACKGROUND: Chronic fistulating pelvic sepsis is an uncommon complication of multimodal treatment of visceral pelvic tumours. Radical multi-visceral resection is reserved for patients with persistent, debilitating symptoms despite less invasive treatments and for which there is minimal published data. This study aimed to report the rates of morbidity and long-term sepsis control after pelvic exenteration for chronic fistulating pelvic sepsis. METHODS: This retrospective cohort study was conducted at a high-volume pelvic exenteration referral centre. Patients who underwent pelvic exenteration for chronic fistulating pelvic sepsis between September 1994 and January 2023 after previous treatment for pelvic malignancy were included. Data relating to postoperative morbidity, mortality and the rate of recurrent pelvic sepsis or fistulae were retrospectively collected. RESULTS: 19 patients who underwent radical resection for chronic fistulating pelvic sepsis after previous pelvic cancer treatment were included. 11 patients were male (58 %) and median age was 62 years (range 42-79). Previously treated rectal (8 patients, 42 %), prostate (5, 26 %) and cervical cancer (5, 26 %) were most common. 18 patients (95 %) had previously received high-dose pelvic radiotherapy, and 14 (74 %) had required surgical resection. Total pelvic exenteration was performed in 47 % of patients, total cystectomy in 68 % and major pubic bone resection in 37 %. There was no intraoperative or postoperative mortality. Major complication rate was 32 %. 12-month readmission rate was 42 %. At last follow up, 74 % had no signs or symptoms of persisting pelvic sepsis. CONCLUSIONS: Pelvic exenteration for refractory pelvic sepsis following treatment of malignancy is safe and effective in selected patients.

Prognostic Impact of Tumor-Infiltrating Lymphocytes, Tertiary Lymphoid Structures, and Neutrophil-to-Lymphocyte Ratio in Pulmonary Metastases from Uterine Leiomyosarcoma.

BACKGROUND: The presence of tumor-infiltrating lymphocytes (TILs) and tertiary lymphoid structures (TLSs) in tumor tissue has been related to the prognosis in various malignancies. Meanwhile, neutrophil-to-lymphocyte ratio (NLR) as a systemic inflammation marker also has been associated with the prognosis in them. However, few reports have investigated the relationship between pulmonary metastases from sarcoma and these biomarkers. METHODS: We retrospectively recruited 102 patients undergoing metastasectomy for pulmonary metastases from uterine leiomyosarcoma at Okayama University Hospital from January 2006 to December 2019. TILs and TLSs were evaluated by immunohistochemical staining of surgically resected specimens of pulmonary metastases using anti-CD3/CD8/CD103/Foxp3/CD20 antibodies. NLR was calculated from the blood examination immediately before the most recent pulmonary metastasectomy. We elucidated the relationship between the prognosis and these factors. Because we considered that the status of tumor tissue and systemic inflammation were equally valuable, we also assessed the impact of the combination of TILs or TLSs and NLR on the prognosis. RESULTS: As for TILs, CD3-positive cells and CD8-positive cells were correlated with the prognosis. The prognosis was significantly better in patients with CD3-high group, CD8-high group, TLSs-high group, and NLR-low group, respectively. The prognosis of CD8-high/NLR-low group and TLSs-high/NLR-low group was significantly better than that of CD8-low/NLR-high group and TLSs-low/NLR-high group, respectively. CONCLUSIONS: CD3-positive TILs, CD8-positive TILs, TLSs, and NLR are correlated with the prognosis, respectively. The combination of CD8-positive TILs or TLSs and NLR may be the indicators to predict the prognosis of patients with pulmonary metastases from uterine leiomyosarcoma.

Risk factors for 30-day soft tissue complications after pelvic sarcoma surgery: A National Surgical Quality Improvement Program study.

INTRODUCTION: Soft tissue (ST) complications after resection of bone and ST sarcomas of the pelvis occur more frequently than in appendicular tumors. We sought to identify risk factors for complications within 30 days of surgery. METHODS: The National Surgical Quality Improvement Program database was used for this study. Patients with sarcomas of bone and ST of the pelvis were retrieved using Current Procedural Terminology and International Classification of Diseases codes. Outcomes assessed were ST complications, overall complication rates, 30-day reoperation, and mortality. RESULTS: A total of 770 patients with pelvic bone and ST sarcoma were included. The ST complication rate was 12.6%, including 4.9% superficial and 4.7% deep surgical site infections. Higher ST complication rates were seen in patients >30 years, with partially dependent health status, hematocrit <30%, bone tumors, tumor >5 cm, amputation procedures, and longer operative times. ST complication rates were 1.5 and 3 times higher in pelvic sarcoma surgeries than in the lower and upper extremities, respectively. Age >30 years (odds ratio [OR] = 5.07), hematocrit <30% (OR = 1.84), operative time 1-3 h (OR = 2.97), and >3 h (OR = 4.89) were risk factors for ST complications. CONCLUSION: One in nine patients with pelvic sarcoma surgery will develop ST complications within 30 days. Risk factors for ST complications were age >30, hematocrit <30%, and longer operative time.

Comparing minimally invasive surgical and open approaches to pelvic exenteration for locally advanced or recurrent pelvic malignancies - Systematic review and meta-analysis.

INTRODUCTION: Pelvic exenteration (PE) is a complex multivisceral surgical procedure indicated for locally advanced or recurrent pelvic malignancies. It poses significant technical challenges which account for the high risk of morbidity and mortality associated with the procedure. Developments in minimally invasive surgical (MIS) approaches and enhanced peri-operative care have facilitated improved long term outcomes. However, the optimum approach to PE remains controversial. METHODS: A systematic literature search was conducted in accordance with PRISMA guidelines to identify studies comparing MIS (robotic or laparoscopic) approaches for PE versus the open approach for patients with locally advanced or recurrent pelvic malignancies. The methodological quality of the included studies was assessed systematically and a meta-analysis was conducted. RESULTS: 11 studies were identified, including 2009 patients, of whom 264 (13.1%) underwent MIS PE approaches. The MIS group displayed comparable R0 resections (Risk Ratio [RR] 1.02, 95% Confidence Interval [95% CI] 0.98, 1.07, p = 0.35)) and Lymph node yield (Weighted Mean Difference [WMD] 1.42, 95% CI -0.58, 3.43, p = 0.16), and although MIS had a trend towards improved towards improved survival and recurrence outcomes, this did not reach statistical significance. MIS was associated with prolonged operating times (WMD 67.93, 95% CI 4.43, 131.42, p < 0.00001) however, this correlated with less intra-operative blood loss, and a shorter length of post-operative stay (WMD -3.89, 955 CI -6.53, -1.25, p < 0.00001). Readmission rates were higher with MIS (RR 2.11, 95% CI 1.11, 4.02, p = 0.02), however, rates of pelvic abscess/sepsis were decreased (RR 0.45, 95% CI 0.21, 0.95, p = 0.04), and there was no difference in overall, major, or specific morbidity and mortality. CONCLUSION: MIS approaches are a safe and feasible option for PE, with no differences in survival or recurrence outcomes compared to the open approach. MIS also reduced the length of post-operative stay and decreased blood loss, offset by increased operating time.

Laparoscopic ovarian transposition prior to pelvic radiation in young women with anorectal malignancies: a systematic review and meta-analysis of prevalence.

AIM: Young women undergoing radiotherapy (RT) for pelvic malignancies are at risk of developing premature ovarian insufficiency. Ovarian transposition (OT) aims to preserve ovarian function in these patients. However, its role in anorectal malignancy has yet to be firmly established. The aim of this review was to determine the effectiveness of laparoscopic OT in preserving ovarian function in premenopausal women undergoing neoadjuvant pelvic RT for anorectal malignancies. METHODS: MEDLINE, Embase and CENTRAL were systematically searched from inception through to May 2022. Articles were included if they evaluated ovarian function after OT in women with anorectal malignancies undergoing pelvic RT. The primary outcome was ovarian function preservation. The secondary outcome was 30-day postoperative morbidity following OT. RESULTS: From 207 citations, 10 studies with 133 patients with rectal or anal cancer who underwent OT prior to RT were included. Meta-analysis of pooled proportions of preserved ovarian function demonstrated an incidence of 66.9% (95% CI 55.0-79.0%, I2 = 43%). The 30-day postoperative morbidity rate was 1.2% (n = 1). There was heterogeneity in interventions and outcome reporting. CONCLUSIONS: Laparoscopic OT in premenopausal patients undergoing pelvic radiation for anorectal malignancies might be an effective technique at reducing ovarian exposure to RT. The meta-analyses must be interpreted within the context of clinical heterogeneity of the included studies. Further studies are required to fully investigate the outcomes of OT in patients undergoing pelvic radiation for anorectal malignancies.

Clinical algorithm for the management of advanced pelvic tumours involving the aortoiliac axis.

Pelvic exenteration offers potentially curative treatment for locally advanced and recurrent pelvic tumours. Laterally infiltrating tumours involving the pelvic sidewall have historically been considered unresectable. Highly specialised exenteration units have accumulated experience with en bloc resection of part or all of the iliac vascular system for tumours with major vessel involvement. These approaches involve complex vascular dissection and reconstructive techniques requiring collaboration with the vascular surgery unit. Adding to the complexity is the paucity of evidence on oncovascular techniques in the pelvis given its developing nature. An algorithm for the workup to determine resectability and the vascular reconstruction approach for advanced pelvic tumours involving the aortoiliac axis is suggested based on current literature and personal experience from the authors' unit.

Study of the efficacy of 3D-printed prosthetic reconstruction after pelvic tumour resection.

The purpose of this study is to explore the effect of using 3D printed pelvic prosthesis to reconstruct bone defect after pelvic tumor resection. From June 2018 to October 2021, a total of 10 patients with pelvic tumors underwent pelvic tumor resection and 3D printed customized hemipelvic prosthesis reconstruction in our hospital. Enneking pelvic surgery subdivision method was used to determine the degree of tumor invasion and the site of prosthesis reconstruction. 2 cases in Zone I, 2 cases in Zone II, 3 cases in Zone I + II, 2 cases in Zone II + III and 1 case in Zone I + II + III. Patients had preoperative VAS scores of 6.5 ± 1.3, postoperative VAS scores of 2.2 ± 0.9, preoperative MSTS-93 scores of 9.4 ± 5.3 and postoperative 19.4 ± 5.9(p < 0.05), all patients had improvement in pain after surgery; Postoperative complications included joint dislocation in 2 cases, myasthenia caused by Guillain-Barre syndrome in 1 case, delayed wound healing in 3 cases and wound infection in 2 cases. Postoperative wound-related complications and dislocations were associated with the extent of the tumor. Patients with tumor invasion of the iliopsoas and gluteus medius muscles had higher complication rates and worse postoperative MSTS scores (p < 0.05). The patients were followed up for 8 ∼ 28 months. During the follow-up period, 1 case recurred, 4 cases metastasized and 1 case died. All pelvic CTs reviewed 3-6 months after surgery showed good alignment between the 3D printed prosthesis and the bone contact, and tomography showed the growth of trabecular structures into the bone. Overall pain scores decreased and functional scores improved in patients after 3D printed prosthesis replacement for pelvic tumor resection. Long-term bone ingrowth could be seen on the prosthesis-bone contact surface with good stability.

The 'Pelvic exenteration lexicon': Creating a common language for complex pelvic cancer surgery.

AIM: Pelvic exenteration surgery is an umbrella term for a multitude of operative techniques for locally advanced and recurrent pelvic malignancy. Currently, there is heterogeneity in the operative description that limits the interpretation of patient outcome and collaboration between units through standardized data collection. Our study aims to develop a consensus lexicon to describe the operative components of extended and exenteration pelvic surgery. METHOD: This study adopted a mixed-methods approach using semi-structured interviews, questionnaires, focus groups and validation exercises involving pelvic exenteration experts from centres in the UK. Qualitative data were collected, and descriptive statistics are presented. RESULTS: We identified eight headings with 32 subheadings that encompass all components of the extent of the potential surgery. The lexicon was validated by 15 UK specialists. A 'high-complexity pelvic exenteration' was defined as encompassing 'conventional pelvic exenteration' with the extension of surgery to remove bony structures or the structures in the pelvic sidewall. Pelvic sidewall structures include major vessels, sciatic nerves and/or bone. Bony structures include the sacrum and/or pubic bones. CONCLUSION: This pelvic exenteration lexicon will permit classification of the surgical approach used that will improve data synthesis, allow more accurate activity recording for audit and ultimately improved outcomes for patients.

A Planned Multidisciplinary Surgical Approach to Treat Primary Pelvic Malignancies.

The pelvic anatomy poses great challenges to orthopedic surgeons. Sarcomas are often large in size and typically enclosed in the narrow confines of the pelvis with the close proximity of vital structures. The aim of this study is to report a systematic planned multidisciplinary surgical approach to treat pelvic sarcomas. Seventeen patients affected by bone and soft tissue sarcomas of the pelvis, treated using a planned multidisciplinary surgical approach, combining the expertise of orthopedic oncology and other surgeons (colleagues from urology, vascular surgery, abdominal surgery, gynecology and plastic surgery), were included. Seven patients were treated with hindquarter amputation; 10 patients underwent excision of the tumor. Reconstruction of bone defects was conducted in six patients with a custom-made 3D-printed pelvic prosthesis. Thirteen patients experienced at least one complication. Well-organized multidisciplinary collaborations between each subspecialty are the cornerstone for the management of patients affected by pelvic sarcomas, which should be conducted in specialized centers. A multidisciplinary surgical approach is of paramount importance in order to obtain the best successful surgical results and adequate margins for achieving acceptable outcomes.

Clinical efficacy and safety analysis of CT-guided 125I implantation in the treatment of recurrent or metastatic pelvic malignant tumor.

PURPOSE: This study was conducted to evaluate the clinical efficacy and safety of computed tomography (CT)-guided 125I implantation in the treatment of recurrent or metastatic pelvic malignant tumor. METHODS AND MATERIALS: This retrospective study analyzed the data of 30 patients with recurrent and metastatic pelvic malignant tumor who were treated with CT-guided 125I implantation between January 2016 and December 2020. Disease control rate, objective remission rate, overall survival (OS), pain relief rate, quality of life score, and complications were evaluated after the followup. RESULTS: Median followup was 20.1 (7-30) months. Disease control rate was 86.67% at 6 months. Objective response rates at 1, 3, and 6 months were 36.67%, 60%, and 56.67%, respectively. OS rates at 12 and 24 months were 76.67% (23/30) and 33.33% (10/30), respectively. Progression-free survival rates at 12 and 24 months were 63.33% (19/30) and 33.33% (10/30), respectively. Postoperative pain relief rate was 86.67% (26/30). There were no major bleeding, pelvic abscess, intestinal fistula, intestinal perforation, and other serious complications. CONCLUSIONS: CT-guided 125I seed implantation in the treatment of patients with pelvic malignant tumor is a simple operation and less traumatic and can improve patients' quality of life and reduce tumor load.