CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 397, pp. 12–18
PELVIC SURGERY
Combined Posterior Pelvis and Lumbar
Spine Resection for Sarcoma
Bruno Fuchs, MD; Michael J. Yaszemski, MD, PhD;
and Franklin H. Sim, MD
The oncologic outcome in the treatment of pelvic
sarcomas is not comparable with that in the ex-
tremity. Particular problems arise when the tu-
mor involves the posterior pelvis and the sacrum
or even the lower lumbar spine. Because of the
difficulty in achieving local control and the ma-
jor functional deficits after extensive surgery,
some authors suggest conservative, nonsurgical
treatment for these patients. The purpose of the
current study was to analyze the oncologic out-
come of patients who were treated for a pelvic
sarcoma necessitating resection of the ilium,
part of the sacrum and part of the lower spine,
which is defined as extended hemipelvectomy.
Between 1979 and 1999, 11 males and seven fe-
males with a mean age of 34.5 years (range,
14–67 years) had an extended hemipelvectomy
for a sarcoma of the posterior pelvis. The tu-
mors included seven osteogenic sarcomas, six
chondrosarcomas, and five fibrosarcomas: 13
were classified as high-grade lesions. The mean
size of the tumor was 11
9
6 cm. In 11 pa-
tients, a hemivertebrectomy of L5 and in seven
From the Mayo Clinic, Department of Orthopedics,
Rochester, MN.
Reprint requests to F.H. Sim, MD, Chair, Division of Or-
thopedic Oncology, Department of Orthopedics, Mayo
Clinic, 200 First Street SW, Rochester, MN 55905.
12
© 2002 Lippincott Williams & Wilkins, Inc.
patients of L4 combined with L5 was done to
achieve an adequate margin. In four patients,
the resection was followed by reconstruction
with a vascularized fibula or autograft. At a
mean followup of 56 months (range, 3–220
months), 12 of 18 patients were alive and with-
out disease. Six patients died; four of these pa-
tients had metastasis to the lung at presentation.
The two remaining patients died of complica-
tions of adjuvant treatment. The authors con-
clude from this small series of patients that an
aggressive surgical resection for localized, non-
metastatic, high-grade sarcomas of the poste-
rior pelvis may be justified to provide local con-
trol and improve survival.
The treatment of patients with a sarcoma in the
pelvis represents one of the most challenging
problems for the orthopaedic oncologist. The
patient is confronted with one of the most mu-
tilating surgical procedures, particularly when
a hemipelvectomy is combined with amputa-
tion of its associated lower limb. Very often,
pelvic tumors tend to be large in diameter at
diagnosis,23 involving, or at least are in close
proximity to, the bladder, rectum, and neu-
rovascular structures. For these reasons, the
indication for such a procedure requires care-
Number 397
April, 2002 Posterior Pelvis and Lumbar Spine Resection 13

ful evaluation and thorough discussion with 14–67 years). There were seven osteogenic sarco-
the patient. mas, six chondrosarcomas, and five fibrosarcomas.
There are only a few reports in the literature In 13 patients, the lesion was defined as high-grade,
dealing with the oncologic outcome of pa- and in five patients, the lesion was defined as low-
grade. The average size of the tumor was 16
9

tients having a hemipelvectomy for sarco-
6 cm. Four patients presented with metastatic le-
mas.5,6,8,11,17,19,25 Analyzing the impact of the sions to the lung, and one patient had a metachro-
anatomic localization on the patient’s out- nous lesion (both in the pelvis). Eight of these 18
come, O’Connor and Sim15 reported on a local patients had an external hemipelvectomy (local re-
recurrence rate of 27% in 23 iliosacral lesions. section in combination with the amputation of the
Furthermore, patients with high-grade pelvic associated limb) and 10 patients had an internal
lesions had a significantly worse prognosis hemipelvectomy (local resection with preservation
than patients with low-grade pelvic lesions.18 of the associated limb). In seven patients, the prox-
The surgical margin is an additional factor imal resection included the hemivertebrae of L4–L5
considered to be of importance and influenc- and in 11 patients, the proximal resection included
ing the prognosis in patients with pelvic sar- the hemivertebra of L5. The margins obtained were
adequate in 17 patients and inadequate in one pa-
comas.11 All these factors have led some au-
tient. In this anatomic site with close proximity to
thors12 to consider nonoperative treatment in neurovascular structures, in most cases, it is not pos-
patients with large, high-grade sarcomas com- sible to obtain a traditional wide margin with a cuff
bined with a significant medial extension of of normal tissue. Therefore, in this location, the
tumor to the sacroiliac joint or sacrum, given standard system to classify margins is difficult to
the poor prognosis and high morbidity in these
patients. Based on the senior author’s (FHS)
earlier experience of a high rate of local recur-
rences mostly attributable to inadequate mar-
gins in such a patient group,15 which is sup-
ported by other reports,11,18 the authors think
that the recurrence rate may be decreased by
more aggressive resection to obtain adequate
margins, justifying a major surgery in selected
patients.
Therefore, the purpose of the current study
was to retrospectively analyze the oncologic
outcome of a selected group of patients with
such adverse prognostic factors, having a pos-
terior pelvic and partial lower lumbar spine re-
section for sarcoma.

MATERIALS AND METHODS

Between December 1979 and July 1999, 18 pa-
tients had an extended hemipelvectomy for a sar-
coma involving the sacroiliac joint.
An extended hemipelvectomy is defined as the re-
section of part of the lumbar spine (at least interver-
tebral disc between L5 and S1); part of the sacrum;
and part of (at least) the ilium, either combined with Fig 1. An anteroposterior radiograph of the pel-
external or internal hemipelvectomy (Fig 1). vis obtained postoperative shows the resection
At the time of the operation, the average age of of the right hemipelvis and the hemivertebrae L4
the 11 males and seven females was 35 years (range, and L5.

14 Fuchs et al.
apply.4 The authors suggest using the definition of
an adequate margin (including wide and marginal
resection) and an inadequate margin (including in-
tralesional resection) at this particular anatomic site.
Only in four patients was a reconstruction attempted,
either by a vascularized fibula (in three patients) or
a bone-graft from the anterior iliac crest (in one pa-
tient). Only one patient with an external extended
hemipelvectomy in this series had a primary recon-
struction with stabilization.
RESULTS
At an average followup of 56 months (range,
3–220 months), these 18 patients were re-
viewed retrospectively and data were obtained
from office records, hospital records, and from
the orthopaedic oncology files. At the time of
the data assessment for this report, 12 patients
were alive and six patients died (Table 1). The
overall 5-year survival rate was 72% (13 of 18
patients). Six patients died after a mean of 20
months after surgery. Four of these six pa-
tients had lung metastasis diagnosed at the ini-
tial presentation. Moreover, one patient died
of a cardiomyopathy subsequent to extensive
chemotherapy and the other patient died after
severe ischemia of the terminal ileum caused
by radiotherapy. The mean duration until death
(20 months) is in contrast to the followup of
those patients who still were alive at the time
of this assessment (73 months). However, four
of the 12 patients who currently are considered
disease-free are at high-risk for having pro-
gression of the disease. One patient is 6 months
after the resection of his third local recurrence.
A second patient had a craniotomy for a brain
metastasis of a histologically proven osteo-
genic sarcoma 7 months at the time of data col-
lection. A third patient is 3 years after a thora-
TABLE 1. Patient Status at Followup
Patient Status Number of Patients
Dead with disease
Dead without disease
Alive with disease
Alive without disease
Clinical Orthopaedics
and Related Research
cotomy for lung nodules, and a fourth patient
had the diagnosis of a metachronous multifocal
osteogenic sarcoma (calcaneus, pelvis, man-
dible). He now is 2 years after surgery, cur-
rently having samarium treatment.1
Three of 18 patients (15%) had a local recur-
rence. In one patient, the tumor recurred 4 years
after an inadequate (intralesional) resection of
an osteogenic sarcoma and in a second patient,
the tumor recurred 10 years after the resection
of a Grade 2 chondrosarcoma. A third patient
had an extended external hemipelvectomy in
November 1998, 13 months after an intrale-
sional internal hemipelvectomy for osteogenic
sarcoma at an outside institution. At the 1-year
followup, the patient worked full-time as a high
school teacher and ambulated with a prosthesis.
However, he required resection of a recurrent
mass in the ipsilateral flank (Fig 2).
Wound healing complications were com-
mon after these extensive resections, often re-
quiring multiple debridements and muscle
flaps. In addition, there was a lower quadrant
hernia, a compartment syndrome of the hand,
and a resection of an ischemic terminal ileum.
Comparing the oncologic outcome of pa-
tients having an internal extended hemipelvec-
tomy with patients having an external extended
hemipelvectomy, no major difference was de-
tected between these two patient groups ex-
cept for the longer followup of the patients
with the limb salvage procedure. Both patients
who died of unrelated causes had an external
hemipelvectomy (Table 2).
DISCUSSION
Patients who present with a primary pelvic
sarcoma present a complex treatment problem
Followup (months)
4 21 (range, 6–62)
2 18 (3 and 34)
0 —
12 73 (range, 3–220)
Number 397
April, 2002
Fig 2. A computed tomography scan of a 33-
year-old patient shows a paravertebral recur-
rence in the flank which developed proximal to
the prior resected tumor bed 1 year after the pa-
tient had an extended hemipelvectomy.
with an increased risk for failure, and compro-
mised survival. Although refined techniques
for pelvic surgery have evolved during the
past decades,2,7,9,15,20,22 allowing partial pelvic
resection with limb sparing surgery, the indi-
cation for resection of a tumor localized to the
sacroiliac joint or sacrum still is controver-
sial.12 Shin et al18 reported that patients with
high-grade sarcomas in the pelvis continue to
have a bad prognosis. Fifteen of the 17 pa-
tients (88%) survived with low-grade tumors
compared with six of 24 patients (25%) with
high-grade tumors. Kawai et al,11 analyzing
102 patients with localized pelvic sarcomas
who had surgical excision, reported that an in-
adequate surgical margin was a negative pre-
TABLE 2. Comparison of Patients Having Internal Versus
External Extended Hemipelvectomy
Hemipelvectomy
Number
Dead (entire series)
Alive (entire series)
Alive without disease
Grade of tumor
High-grade (Grades III and IV)
Low-grade (Grades I and II)
Size of tumor (cm)
Mean followup (months)
Posterior Pelvis and Lumbar Spine Resection 15
dictor of survival in this patient group. The pa-
tients analyzed in the current report represent
a selected group with the adverse prognostic
factors in view of the anatomically difficult lo-
calization, and the majority of tumors being
high-grade. The current study shows that an
adequate surgical margin can be obtained even
when the tumor is localized in the posterior
pelvis, and extends into the sacrum or along
the lumbar spine. Obtaining an adequate re-
section margin has improved the outcome
with an overall survival of 72%. However, one
has to take into account that four patients had
treatment for progression of disease and cur-
rently are considered disease-free. When con-
sidering the failure rate in the current series, it
is noteworthy that four of six patients who
died initially presented with lung metastasis.
This suggests that this extensive surgery may
be best reserved for patients with localized
disease. Careful planning and a multidiscipli-
nary surgical approach may provide an ade-
quate margin at this anatomic site, which has
been a significant factor for the overall sur-
vival.11 Local recurrence at this location re-
mains problematic, with three local failures in
this series. This may be explained by an inad-
equate resection in two patients, but one tumor
recurred despite obtaining adequate margins.
Because the tumor in this particular patient re-
curred proximally to the prior tumor bed, it is
assumed that this represents a tumor cell seed-
ing that occurred during the prior surgeries.
Therefore, doing an extended hemipelvec-
External Internal
8 10
3 3
5 7
4 7
6 7
2 3
12/8/7 11/9/6
35 67

16 Fuchs et al.
tomy in a patient who had prior surgeries at the
same site may represent an increased risk.
There still is an ongoing debate whether to
do an external or internal hemipelvectomy for
pelvic tumors. Kawai et al11 found an external
hemipelvectomy to be a negative predictor of
survival. However, the patients in their study
who had an external hemipelvectomy also
tended to have the largest and most advanced
tumors. Therefore, they recommend an external
hemipelvectomy particularly when there is
sacral involvement. The results of the current
study do not additionally assist in making the
decision of when to do an external or internal
hemipelvectomy. Comparing these two patient
groups (Table 2), no difference was detected
between survival, disease status, margins ob-
tained during surgery, size and grade of the tu-
mor, and recurrence rate. Interestingly, patients
having an internal extended hemipelvectomy
had the longer followup, which cannot be ex-
plained by the aforementioned parameters. The
current authors think that patients with these tu-
mors should be treated by a multidisciplinary
approach with involvement of colorectal, uro-
logic, neurosurgical, and plastic surgical teams.
If attempts at limb salvage would sacrifice
neural structures producing limb anesthesia,
paralysis, or excessive shortening, or if the pre-
operative investigations showed that adequate
margins could not be envisaged, then external
hemipelvectomy is indicated. A vascular re-
construction after tumor resection in the pelvis
was not necessary in this series.
In the current series, there was a high number
of revision surgeries because of wound compli-
cations. The greatest risk factors for having a
wound problem develop is the inability to pre-
serve the internal iliac vessels and the necessity
to do a sacral osteotomy.12 Even though some
think10 that preservation of the internal iliac ves-
sels has no influence on posterior flap necrosis,
it has to be considered that a sacral osteotomy
decreases the blood supply to a posterior flap by
detaching the sacral attachment of the gluteus
maximus and increases the potential dead space
under the flap, compromising wound healing. At
the authors’ institution, there currently is a very
Clinical Orthopaedics
and Related Research
low threshold to place a myocutaneous rectus
flap16,22 or even a free muscle transfer from the
lower leg in the case of an external hemipelvec-
tomy24 to avoid these complications.
Achieving a good oncologic outcome in
limb salvage procedures of the pelvis remains
challenging. Moreover, the issue of recon-
struction after resection at this anatomic site
remains unclear. Skeletal reconstruction is not
necessary after resection of the anterior pelvis
because pelvic stability is maintained. Re-
construction after periacetabular resection is
extremely challenging with the options of il-
iofemoral arthrodeses or pseudarthrosis, mas-
sive allograft or autoclaved autograft with hip
arthroplasty, and pelvic or saddle prosthesis.
For patients with resection of the ilium and
loss of pelvis stability, iliosacral arthrodeses
provide good function.14 However, particular
problems arise regarding reconstruction in pa-
tients with extended hemipelvectomy as pre-
sented in the current study. Although some au-
thors are not enthusiastic to reconstruct defects
after sacroiliac resections because the func-
tional results are not predictable,13 others de-
scribe using vascularized and nonvascularized
fibular iliosacral arthrodeses.3,21 In the current
series, four patients having an internal ex-
tended hemipelvectomy had reconstruction
with a fibular graft. One patient had a second
postirradiation osteosarcoma develop in the
opposite left sacroiliac region 2.5 years after
sacroiliac joint resection on the right side. Af-
ter the extended internal hemipelvectomy on
the left side, the patient had reconstruction
with a fibular graft. Although this reconstruc-
tion failed with graft fractures, the patient was
able to walk with crutches and with an ankle-
foot-orthosis (Fig 3). The issue of spinal insta-
bility after extended hemipelvectomy must be
considered. Reconstructive options include
fixation with pedicle screws to the remaining
sacrum and ilium combined with rods.21 Al-
though only one patient in the current series
having an external extended hemipelvectomy
had primary reconstruction, this may be nec-
essary as a later secondary procedure. Progres-
sive scoliosis could be documented as shown
Number 397
April, 2002 Posterior Pelvis and Lumbar Spine Resection 17

A B

Fig 3A–C. (A) A 22-year-old patient had a right in-

ternal hemipelvectomy for a radiation-induced os-
teosarcoma, 2.5 years before having a second os-
teosarcoma develop at the left sacroiliac joint. (B)
He had a left extended internal hemipelvectomy
and reconstruction with a vascularized fibula. (C)
Twenty months after the last surgery, the recon-
struction failed, but the patient was able to walk
C
with two crutches and an ankle-foot orthosis.

in Figure 4. Two years after the extended ex-

ternal hemipelvectomy, this patient had a 38
scoliosis develop, and complained of mechan-
ical pain with increased activity. This patient
may require reconstruction in the future. The
question remains as to what is the best type of
reconstruction in this setting. Based on the re-
sults of the current study, these issues may
need to be confronted as the survival in this
patient group increases. Additional investiga-
tion into development of biomechanically sound
stabilization procedures is warranted.
It is concluded from the current study that
the resection of high-grade sarcomas located
in the posterior pelvis is justified because local
control can be achieved in combination with a
multimodality treatment. However, this type
of surgery is not indicated in patients with
metastatic disease at onset or with other se- Fig 4. A radiograph of a 14-year-old patient
verely compromising medical factors at initial shows a progressive scoliosis which developed 2
presentation. years after an external extended hemipelvectomy.

18 Fuchs et al.
Acknowledgment
Dr. Bruno Fuchs was supported by a scholarship from
the Schweizerische Gesellschaft für Orthopädie.
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