Hemicorporectomy: a collective review

Hemicorporectomy or translumbar amputation has been described as the most revolutionary of all operative procedures. Frederick E. Kredel, who first voiced the concept of the operation in 1950, referred to it as halfectomy. Demonstration of his cadaver studies established the feasibility of the operation. Amputation is effected through the lower lumbar area of the body. Necessary life functions are preserved in the upper torso. Kredel envisioned hemicorporectomy as a curative operation for locally advanced cancer, limited to the pelvis, not encompassable by standard operative intervention. Additional indications are intractable decubitus ulcers with malignant change, particularly in paraplegics; pelvic organs, and bone infection with nonhealing fistulae; and crushing trauma to the pelvis. The first hemicorporectomy operation was reported in 1960. Thirty-four operations have been recorded in the world literature. Two heretofore unreported cases are added, raising the total to 36. Review of these 36 cases confirms the conviction that hemicorporectomy is a humane and ethical alternative to the suffering encumbered by advancing, painful, malodorous malignant disease not treatable by conventional means. While cure rates are not substantial, the best results are reported in paraplegics with intractable decubitus ulcers with or without malignancy. Rehabilitation is prolonged and costly. Most survivors have been restored to preoperative occupations or other gainful employment.     

Pelvic exenteration

Sixty-eight patients at the University of Illinois, Cook County, and the West Side Veterans Administration hospitals underwent pelvic exenteration for advanced pelvic malignancies during the 15-year period from 1969 to 1984. Thirty-two had colorectal cancers, eleven cervical, seven bladder, and six vulvar; in twelve the cancers were in miscellaneous pelvic sites. Forty-five exenterations were done with intent to cure, and twenty-three for palliation of patients with bulky, necrotic tumors that had caused symptomatic fistulae, local sepsis, chronic bleeding, or severe localized pain. The total 30-day postoperative mortality was 4.4% (3/68). The 5-year survival rate of patients who underwent curative exenteration was 33% (median 27 months). Pelvic exenteration appears to be a feasible surgical procedure for a variety of advanced malignancies as well as for palliation of severely symptomatic patients.     

Total pelvic exenteration with preservation of fecal continence

Total pelvic exenteration may be required in the management of locally advanced or recurrent pelvic malignancy. Although prolonged survival may be achieved, the morbidity of this procedure is substantial. Many of the complications associated with total pelvic exenteration are related to the perineal wound, the necessity for two cutaneous stomas, and the creation of a empty pelvis that often has been previously irradiated. In selected cases, perineal preservation with restoration of coloanal continuity may significantly reduce postoperative morbidity. We report four cases of recurrent pelvic malignancy treated by total pelvic exenteration with preservation of fecal continence. © 1993 Wiley-Liss, Inc.     

妇科盆腔手术保留盆腔神经丛的方式

盆腔植物神经丛由腹下神经和盆腔内脏神经组成。妇科肿瘤的盆腔手术经常遇切除主骶韧带或直肠系膜时损伤盆腔神经丛，而导致长时间保留尿管。保留盆腔植物神经（PANS）有利于尽快恢复膀胱排尿功能，子宫内膜癌行次广泛子宫切除者，Ⅰ型PANS多数患者可行，即完全保留盆腔神经丛，3天左右拔除尿管；一般意义上的子宫颈癌根治术，行Ⅱ型保留神经方式，即部分病例中保留大部分盆丛神经，7天左右拔除尿管；超根治性子宫切除手术，采用Ⅲ型PANS，即部分病例、大部分保留健侧神经，达到2～3周拔除尿管的目的。而在全阴道切除手术、Hartman手术、Dixon手术以及后盆腔脏器清除术中，部分病例可以选择Ⅱ型或Ⅲ型的神经保留手术。     

Pelvic exenteration and sphincter preservation: an analysis of 96 cases

BACKGROUND: Pelvic exenteration (PE) is characterized by its technical complexity and morbidity rate. Appropriate patient selection prior to the operation allows for more conservative surgeries, preserving sphincters, and continent reconstruction of the intestinal and urinary tract, contributing to better results. METHODS: Between 1980 and 2000, 96 PE were performed. Factors related to sphincter preservation as well as factors associated to prognosis were respectively analyzed. RESULTS: Of the 96 PE, at least one sphincter in 36 patients was preserved (37.5%). In the 1990s, the sphincter preservation rate was significantly higher than in the 1980s (47.6 vs. 18.2%) (P = 0.005). More serious complications happened in 19.8% of the patients and the post-operative mortality rate was 15.6%. The post-operative complication rate was not influenced by sphincter preservation (P = 0.276). In nine patients, the resection margins were compromised microscopically (R1) and in five patients, there were macroscopically compromised (R2). The resection margins were not influenced by the type of surgery (P = 0.104), nor by the preservation of sphincters (P = 0.881). Twenty-three patients experienced relapses, 13 being local, eight distant, and two local and distant. Disease free survival at 5 years was 40.5%, and the primary site of the tumor was a factor associated to differences in disease free survival (P = 0.027). Overall 5-year survival was 41.9% and was significantly associated to the number of organs compromised (P = 0.040) and sphincter preservation (P = 0.026). Patients who were submitted to R0 type resection had a median survival of 40.9 months, while R1 and R2 type resections had a median 21.2 month survival. CONCLUSIONS: The appropriate pre-operative selection of the patient and rigorous oncological criteria permit PE to be performed while preserving the sphincters in selected cases, without harming survival rates.     

Hemicorporectomy

Translumbar amputation (hemicorporectomy) was first successfully performed in 1961 after cadaver feasibility dissections. It is useful for certain slow-growing malignancies of the pelvis and perineum and for patients with advanced sepsis involving pelvic bony structures. As indicated by our 20-year experience, the operation may be rewarded by control of a malignant process (two patients) and/or relief from chronic pelvic sepsis (four patients), survival and discharge from the hospital after lengthy rehabilitation (six patients).     

妇科盆腔肿瘤引起的慢性盆腔疼痛的中西医诊疗现状

在以卵巢癌、宫颈癌、子宫内膜癌为主的妇科盆腔肿瘤的发生发展以及治疗过程中,常出现以骨盆疼痛为主要表现的慢性盆腔疼痛,严重影响了女性盆腔肿瘤患者的身心健康与生活质量.目前,针对妇科盆腔肿瘤引起的慢性盆腔疼痛的相关研究较少,而且缺乏中医证候研究,故尚无针对性的诊治方案.本文将探讨慢性盆腔疼痛的相关概念、不同盆腔肿瘤引起的慢...     

Custom three-dimensional printed implants for reconstruction of oncologic pelvic defects

The use of three-dimensional printed implants in the field of orthopedic surgery has become increasingly popular and has potentiated hip reconstruction in the setting of oncologic resections of the pelvis and acetabulum. In this review, we examine and discuss the indications and technical considerations for custom implant reconstruction of pelvic defects.     

Technical aspects of resection of pelvic tumors

Tumors in the greater or lesser pelvis with lateral fixation present difficulties in their resection due to inadequate exposure distally. Two illustrative examples of such tumors, of a total of 26 pelvic tumors, suggest that resection of tumors in the pelvis with lateral fixation is facilitated with the use of the abdominoinguinal incision, ligation of one or both internal iliac arteries, and dissection at clean planes away from the tumor surface.     

Gastrointestinal Toxicity of Pelvic Radiotherapy: Are We Letting Women Down?

For all cancers there are four areas of importance: prevention, early diagnosis, optimising therapy and living with and beyond. For women diagnosed with gynaecological cancers, progress in these first three areas has been immense. However, living with and beyond has largely been ignored as a significant issue.As a group, patients treated for gynaecological cancer are more often young and more often suffer the most difficult long-term issues. Despite the growing number of long-term survivors, little has been done to ensure appropriate assessment and treatment of side-effects of cancer therapies, especially when radiotherapy has been used. For many affected patients their symptoms become part of everyday life, ‘normality’ is adjusted and these changes are tolerated even when severely limiting activities. Data show that even expert clinicians frequently do not appreciate the true impact of these problems and the focus of treatment and of follow-up remains fixed on 5-year survival and cancer recurrence, respectively. Many clinicians are unaware of what experts can do for toxicity and do not know where to refer their patients. However, rapid identification of patients with significant symptoms can lead to earlier diagnosis of treatable pathologies and improvement in patients' quality of life. In addition, the underlying pathophysiology of radiation-induced damage is potentially amenable to disease-modifying therapies. This review focuses on the factors that contribute to patients developing pelvic radiation disease, what can be done to mitigate the toxicity of treatment and highlights the challenges that must be addressed to reduce the gastrointestinal toxicity of pelvic radiotherapy.     

Prognosis-Related Analysis of Renal Pelvic Cancer

Objective  To promote the diagnosis and therapeutic results for renal pelvic cancer. Methods  The prognosis-related factors in 47 cases with renal pelvic cancer were analyzed retrospectively. Results  The overall 3 and 5-year survival rates for renal pelvic cancer patients were 65.9% (31/47) and 51.1% (24/47), respectively. The 5-year survival was 55% (23/40) in organ-confined cancer and 26.7% (2/7) with coexisting muiti -organ involvement (P>0.05). The 5-year survival was 38.7%( 12/31) in cases with a tumor >2.5 cm and 75%(12/16) in the cases with tumor ≤2.5 cm (P<0 05). The 5-year survival was 37.9% (11/29) in cases with serious hydronephrosis, which was significantly lower than the 72.2% (13/18) found in those with slight hydronephrosis (P <0.05). According to the histologicsl grade, the 5-year survival was 100% (6/6) in patients with a G1 tumor, 65.2% (15/23) with G2, and 16.7% (3/18) with G3 (P<0.01 ). Based on the pathologic stage, the 5-year survival of cases was 84.6% (11/13) with T1 tumors, 60% (12/20) with T2, and 7.1% (1/14) with T3-T4 (P<0.01). Patients with a G2T2 or higher staging tumor, who underwent radical nephroureterectomy with partial bladder resection by a transabdominal approach had a significantly higher 5-year survival than those; who underwent nephrectomy or nephroureterectomy with partial bladder resection via a lumbar approach (P <0.05). There was no significant difference between the 5 -year survival of patients with recurrence of bladder carcinoma compared to patients without recurrence (P>0.05). Conclusion  The tumor grade and stage are the key points for prognosis. Radical nephroureterectomy with partial bladder resection is an effective method to improve the prognosis of patients with a high grade and high stage tumor.     

Prognosis-related analysis of renal pelvic cancer

Objective To promote the diagnosis and therapeutic results for renal pelvic cancer. Methods The prognosis-related factors in 47 cases with renal pelvic cancer were analyzed retrospectively. Results The overall 3 and 5-year survival rates for renal pelvic cancer patients were 65.9% (31/47) and 51.1% (24/47), respectively. The 5-year survival was 55% (23/40) in organ-confined cancer and 26.7% (2/7) with coexisting muiti -organ involvement (P>0.05). The 5-year survival was 38.7%( 12/31) in cases with a tumor >2.5 cm and 75%(12/16) in the cases with tumor ≤2.5 cm (P<0 05). The 5-year survival was 37.9% (11/29) in cases with serious hydronephrosis, which was significantly lower than the 72.2% (13/18) found in those with slight hydronephrosis (P <0.05). According to the histologicsl grade, the 5-year survival was 100% (6/6) in patients with a G1 tumor, 65.2% (15/23) with G2, and 16.7% (3/18) with G3 (P<0.01 ). Based on the pathologic stage, the 5-year survival of cases was 84.6% (11/13) with T1 tumors, 60% (12/20) with T2, and 7.1% (1/14) with T3-T4 (P<0.01). Patients with a G2T2 or higher staging tumor, who underwent radical nephroureterectomy with partial bladder resection by a transabdominal approach had a significantly higher 5-year survival than those; who underwent nephrectomy or nephroureterectomy with partial bladder resection via a lumbar approach (P <0.05). There was no significant difference between the 5 -year survival of patients with recurrence of bladder carcinoma compared to patients without recurrence (P>0.05). Conclusion The tumor grade and stage are the key points for prognosis. Radical nephroureterectomy with partial bladder resection is an effective method to improve the prognosis of patients with a high grade and high stage tumor.     

MRI检查方案对子宫及卵巢肿瘤诊断价值分析

目的;分析和探讨MRI不同成像序列及扫描位置对显示正常女性盆腔结构和诊断盆腔肿瘤的价值,并进一步确定诊断子宫及卵巢肿瘤的最佳MRI检查方案。方法：对20例正常女性贫腔和40例经手术病理证实的子宫或卵巢肿瘤患者的盆腔磁共振成像检查资料进行了定量及定性分析。所有检查均采用SE T1WI及FSE T2WI序列,分别行横断、矢状及冠状面扫描。在20例患有子宫肿瘤的患者中,11例加做了与子宫腔长轴平行的冠斜位T1WI和T2WI序列扫描。结果：对于正常子宫及直肠的辨别能力,FSE T2WI图像明显好于SE T1WI图像,两者之间有显著性统计学差异。对于子宫肿瘤患者,分析子宫肿瘤与正常子宫结合带的CNR值,结果表明T2WI图像明显高于T1WI图像且两者之间有显著性统计学差异;联合应用T1WI及T2WI扫描序列在横断、矢状及冠状位对子宫肿瘤的检出准确性分别为64.3%,96.4%,53.6%,且矢状与横断及冠状位之间差异有显著性统计学意义。在11例加做与子宫腔长轴平行的冠斜位患者中,对肿瘤检出及定位,定性的诊断准确性方面,8例（73.0%)显示明显优于其他3种位置。对于卵巢肿瘤的观察结果表明：3种扫描位置的检出能力无明显显著性差异,横断,矢状及冠状位的准确性分别为100％,95％,100％,但对于恶性肿瘤是否伴有髂血管区淋巴结转移及盆壁是否侵犯的观察,横断及冠状面显示最佳。结论：T2WI序列矢状位为诊断子宫肿瘤的首选MRI检查方法,必要时辅以与子宫腔长轴平行的冠斜位;而观察卵巢肿瘤及盆壁情况,横断及冠状位为必备检查位置。     

Pelvic neoplasms causing pain.

The following is a discussion of dyspareunia and its role as an aid to diagnosing pelvic neoplasms. The great majority of cases of dysparenia are psychosomatic in origin, and in a large proportion of the remaining cases, painful coitus is an indicator of benign problems. Nevertheless, painful coitus is a symptom which requires careful pelvic examination to rule out the possibility of pelvic neoplasm and to discover treatable causes of dyspareunia.     

Sacral chordoma: A case study and review

Chordomas are a low grade, tenacious, but eventually lethal neoplasm for which little improvement in outcome has been reported. A current review of the literature and a case report are provided to support this position. The reported sacral chordoma did respond temporarily to chemotherapy. Its rare occurrence precludes controlled studies chordoma; therefore, any response merits reporting. The authors observed that hyperthermic chemotherapy was feasible for treating some chordomas but has not yet been reported. It was evaluated for the patient in this report.     

Bilateral abdominoinguinal incision

A successful removal of a very vascular pelvic sarcoma through a bilateral abdominoinguinal incision is presented. The advantages of the incision are that it provides good exposure of the iliac vessels and aids in dissecting the tumor from these vessels. Catheter embolization of the branches supplying the tumor during angiogram helps to decrease vascularity of very vascular tumors.     

Defining the optimal lymphadenectomy cut-off value in epithelial ovarian cancer staging surgery utilizing a mathematical model of validation

Objective

Since 1985 International Federation of Gynecology and Obstetrics includes pelvic and aortic lymphadenectomy as part of the surgical staging in epithelial ovarian cancer (EOC). There is no consensus on the overall number of nodes needed in a systematic lymphadenectomy. The aim of this study is to calculate the optimal cut-off value using a mathematical modeling approach.

Methods

Data was collected retrospectively, from 1996 to 2000, of 120 consecutive Mayo Clinic patients with EOC and positive nodes. All patients was underwent pelvic and/or aortic lymphadnectomy during surgical staging.To mathematically predict the probability of a positive node in EOC patients we used a predictive mathematical model (PMM). The mathematical analysis consisted: creation of a new PMM according to our purposes, application of PMM to describe the experimental data in order to build the polynomial regression curves in each lymphatic area and determine the optimal point for each curve.

Results

The mean number of lymph nodes and metastatic nodes removed were 35 and 7.8, respectively; the mean percentage of positive nodes was 28.3%. The optimal point of each fitting curves were: 7 nodes for unilateral aortic nodal sampling (at least 3 infrarenal or 5 inframesenteric) and 15 nodes for unilateral pelvic lymphadenectomy (at least 5 external iliac).

Conclusions

We can mathematically predict the probability to obtain a positive node in EOC surgical staging. Our results have shown the need to obtain at least 22 lymph nodes between pelvic and aortic lymphadenectomy.     

The use of CT derived solid modelling of the pelvis in planning cancer resections

Clinical problem

Resection of malignant tumors of the pelvis is demanding. To avoid disabling hemipelvectomies, years ago internal hemipelvectomy combined with partial pelvic replacements had become a surgical procedure. To achieve adequate reconstructions custom-made replacements were recommended. In early stages of the surgical procedure using megaprostheses, individual pelvic models were manufactured.

Aim of the study

Since little is known about the accuracy of such models we analysed the charts of 24 patients (25 models) for whom an individual model of the osseous pelvis had been manufactured.

Results

Two patients refused surgery. In 23 patients partial resection of the bony pelvis was performed followed by a partial pelvic replacement (13×), hip transposition procedure (5×), ilio-sacral resection (4×), or revision surgery.In all patients who received a partial pelvic replacement, the fit of the replacement was optimal. No major unplanned resection was necessary. The same was observed in patients who received a hip transposition procedure or an ilio-sacral resection.Oncologically, in most of the patients we achieved wide resection margins (14×). In 5 patients the margins were marginal (4×) or intralesional (1×). In two cases the aim was a palliative resection because of a metastatic disease (1×) or benign entity (1×).

Conclusion

Pelvic models are helpful tools to planning the manufacture of partial pelvic replacements and ensuring optimal osseous resection of the involved bone. Further attempts have to be made to evaluate the aim of navigational techniques regarding the accuracy of the osseous and soft-tissue resection.