Elsevier

The Spine Journal

Volume 9, Issue 5, May 2009, Pages 396-403
The Spine Journal

Clinical Study
Decision making in primary sacral tumors

https://doi.org/10.1016/j.spinee.2008.10.001Get rights and content

Abstract

Background context

Primary tumors of the sacrum are extremely rare lesions. Their management is governed by an interplay of complex factors. Appropriate decision making is crucial to obtain the best possible outcome in terms of maximizing disease control while attempting to minimize neurological dysfunction.

Purpose

Our study presents the results of a group of patients with primary tumors of the sacrum who were surgically treated by the same multidisciplinary team at a specialist oncology center over a relatively short period of time (5 years).

Study design/setting

Patients were identified by a retrospective review from a prospectively maintained database.

Patient sample

Between January 2000 and December 2005, 17 primary sacral tumors were surgically treated at our institution, a referral center for oncology.

Outcome measures

We evaluated the outcome in terms of local disease control, residual neurological dysfunction, and complications as a result of surgical intervention.

Methods

There were 12 males and 5 females. The diagnosis included chordoma in six patients, giant cell tumor in seven patients, aneurysmal bone cyst in two patients, and a chondrosarcoma and an osteoblastoma in one patient each. Sixteen of these patients were analyzed. Four lesions had their upper extent at S1, six lesions had their upper extent at S2, four lesions had their upper extent at S3, and two lesions were below S3. Ten cases were treated with wide excision and underwent partial sacral amputations. Five cases had a midline sacral amputation through S1, three through S2, and two through S3. Six benign lesions were treated with curettage. None of the patients received chemotherapy. Four cases received postoperative radiation. The follow-up duration ranged from 18 to 44 months with a mean of 31 months.

Results

None of the six patients who presented with loss of bladder and bowel control regained it after surgery. Of the 10 patients who had intact bladder and bowel control preoperatively only 4 retained bladder and bowel control postoperatively. Of the six patients who lost bladder and bowel control postoperatively, four patients had a wide excision where bilateral S2 roots were sacrificed. The other two cases in whom the disease extended up to S1 had curettage. Local recurrence occurred in 4 of the 10 lesions treated with wide excision. All the patients who had inadequate margins recurred. Local recurrence occurred in two of the six lesions treated with curettage. Three of the four cases who received postoperative irradiation developed recurrence. Our wound complication rate was 13%.

Conclusion

Wide resection with adequate margins gives the best chance of local control and should be the surgery of choice for all malignant primary sacral tumors and in benign lesions involving lower segments when preservation of both S3 roots is possible. Intralesional curettage has a higher risk of local recurrence without providing the certainty of retaining neurological function. To retain bladder and bowel control and minimize neurological dysfunction, it may be worthwhile managing benign sacral tumors that extend above S3 with serial embolization. The administration of parentral bisphosphonates may prove beneficial in cases of giant cell tumor managed with serial embolization.

Introduction

Evidence & Methods

Sacral tumors are rare and challenging. This paper presents a series of cases from one institution.

In this retrospective review of sixteen available cases with variable pathologically, six patients presenting with loss of bladder and bowel function failed to recover, and four more lost function post-operatively. A 33% recurrence was noted with curettage, 40% with wide excision and 100% with inadequate margins using the authors' technique.

That many patients with primary sacral tumors have poor outcomes is well known. The behavior of tumors arising in the sacrum is problematic, and the anatomic considerations add significantly to the difficulties in treatment. The take-home point is that sacral tumors are not for the “occasional”" tumor surgeon and often require a team approach, including urological, colorectal and medical oncology support. When available, referral to an orthopedic oncologist having experience with these tumors is strongly preferred. The general spine surgeon's role may be limited to assisting with reconstruction.

—The Editors

Primary tumors of the sacrum are extremely rare lesions. These tumors are usually diagnosed late in the disease course and might reach huge sizes. The complexity of the sacral neuro anatomy and its close relationship with vital organs adds additional challenges in their treatment. Their management is governed by an interplay of complex factors, which includes their pathology, the extent of the disease, and presenting neurological symptoms. Their treatment entails interaction between multiple disciplines involving orthopedic oncologists, urosurgeons, colorectal surgeons, pathologists, interventional radiologists, and radiotherapists among others. Appropriate decision making is crucial to obtain the best possible outcome in terms of maximizing disease control while attempting to minimize neurological dysfunction.

Our study presents the results of a group of patients with primary tumors of the sacrum who were surgically treated by the same multidisciplinary team at a specialist oncology center over a relatively short period of time (5 years). We evaluated the outcome in terms of local disease control, residual neurological dysfunction, and complications as a result of surgical intervention. Based on our experience and current literature, we suggest a treatment strategy that may be of assistance when contemplating surgical management of these uncommon and challenging lesions.

Section snippets

Patients and methods

Between January 2000 and December 2005, 17 primary sacral tumors were surgically treated at our institution, a referral center for oncology. These patients were identified by a retrospective review from a prospectively maintained database. The medical records, radiographs, and pathology data were reviewed. There were 12 males and 5 females. The diagnosis included chordoma in six patients, giant cell tumor in seven patients, aneurysmal bone cyst in two patients, and a chondrosarcoma and an

Results

In patients undergoing curettage blood loss during surgery ranged from 5.5 to 30 L (mean 10.5 L). In patients with wide excision, blood loss during surgery ranged from 0.2 to 6.8 L (mean 4.8 L). The duration of the surgical procedure for the curettage group ranged from 4 to 8 hours (mean 6.5 hours) and for patients with wide excision ranged from 2.4 to 13.5 hours (mean 7.7 hours).

Of the 10 lesions treated with wide excision, margins were adequate in six patients. Two patients of chordoma had

Discussion

Primary sacral tumors are a rarity [1], [2]. This was evident in our practice too as only 1% of primary bone tumors (17 of approximately 1,750) operated between January 2000 and December 2005 were sacral lesions.

Decision making in these lesions depends on a variety of factors. To offer the best chance of cure, an accurate diagnosis is vital. Though some authors have recommended an open biopsy for diagnosis, we have been satisfied with the adequacy of material and accuracy of diagnosis obtained

Conclusion

Wide resection with adequate margins gives the best chance of local control and should be the surgery of choice for all malignant primary sacral tumors and in benign lesions involving lower segments when preservation of both S3 roots is possible. Intralesional curettage has a higher risk of local recurrence without providing the certainty of retaining neurological function. To retain bladder and bowel control and minimize neurological dysfunction, it may be worthwhile managing benign sacral

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