Hemipelvectomy for the management of soft tissue tumors of the lower extremity

Hemipelvectomy e for the Management of Soft Tissue Tumors of the Lower Extremity JOHN T. PHELAN, M.D.,JAMES T. GRACE, JR.,M.D.AND GEORGE Bu$alo, New York

From tbe Department Department of Healtb, Buffalo, New York.

MOORE,

M.D., PH.D.,

anaIysis of tweIve consecutive hemipeIvectomies performed soIeIy for the management of maIignant soft tissue tumors invoIving the soft tissue parieties of the peIvis and Iower extremity. Each of the tweIve patients in this series was treated on the Soft Tissue Service at RosweII Park MemoriaI Institute, BuffaIo, New York, during the years 1956 to 1962 incIusive. There were no postoperative deaths in this series and a foIIow-up study was estabIished in each case.

of Surgery, New York State Rosweil Park Memorial Institute,

HE SURGICAL remova of a part or whoIe of the hemipeIvis aIong”with the contiguous Iower extremity has been practiced for over the fifty years. In recent surgica1 literature term, hemipeIvectomy, is commonIy used to describe this operative procedure; however, in the past the operation has been known by a variety of synonyms, such as hindquarter resection, transabdomina1 amputation, interinnomino-abdomina1 amputation and interpeIvic abdomina1 amputation [1,2,7,9--121. According to most authors, BiIIroth performed the first hemipeIvectomy in 1894, and PringIe of EngIand [7] in 1916 was the first surgeon to describe the operation in detai1 and report a series of successfu1 cases. During the earIy Igzo’s and 1930’s the operation was performed infrequentIy, mainIy because of the high operative mortaIity rate which in some coIIected series ran as high as 60 per cent [4], With the advent of bIood transfusions and improved chemotherapeutic and supportive measures, interest in hemipeIvectomy was renewed, and in 1942 Leighton [r;] recorded four consecutive hemipeIvectomies without a postoperative death. In the earIy 1950’s the surgica1 technic of hemipeIvectomy was further refined by Gordon-TayIor of EngIand [?I and Ravitch of the United States [8], and to these two authors much credit must be given for estabIishing the surgica1 procedure of hemipeIvectomy as we know it today. Because most authors have considered hemipeIvectomy as an operative procedure for the management of osseous or cartiIagenous tumor of the upper femur and peIvic bones, it is the purpose of this report to present a cIinica1

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American Journal of Surgery, Volume 107, April 1964

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MATERIAL TabIe I shows the age and sex of the patients, the site and histoIogic types of tumors and the clinica results. As will be noted, nine patients had mahgnant soft tissue tumors, and one patient had an unusua1 variety of recurrent juvenile fibromatosis with wide peIvic extension. Six tumors were considered recurrent Iesions since previous surgery had been empIoyed in their treatment. The types of malignant tumors varied considerabIy and included three rhabdomyosarcomas, two Iiposarcomas, two malignant synoviomas, one maIignant hemangioendotheIioma, one Ieiomyosarcoma, one uIcerative squamous ceI1 carcinoma of the groin and one neurofibrosarcoma. The postoperative compIications associated with hemipelvectomy in this series were as foIIows: Postoperative wound infection was the commonest major compIication, occurring in five patients. Postoperative urinary retention was noted in five however, this compIication cleared in patients; every patient prior to their discharge from the hospita1. One patient deveIoped transient urinary incontinence secondary to trauma of the bIadder neck during division of the pubic symphysis. Two patients experienced temporary feca1 incontinence. Al1 patients became ambuIatory earIy in the postoperative period with the aid of crutches. Four patients were fitted at a Iater date with a hemipelvectomy type of prosthesis; however, onIy two patients have successfuIIy mastered its use. Seven

604

HemipeIvectomy

for Soft TABLE

DATA

ON

TWELVE

PATIENTS

WITH

EXTREMITY

lge and Sex

Site of Tumor

Tumors

I

MALIGNANT TREATED

Tissue

SOFI’

BY

TISSUE

TUMORS

OF

THE

LOU-ER

HEMIPELVECTOMY

-i-

T

Results

Histopathology

-j62,M 64,M 58,F 47,F 54.F z~,~M 12,M

62,F 68,M 61,F 61,M 57,M

Upper thigh IJpper thigh Upper thigh Upper thigh Upper thigh GIuteaI region GIuteaI region Upper thigh Lower leg Upper thigh Upper thigh Upper thigh

1

Malignant synovioma Rhabd omyosarcoma UIcerative squamous cel1 carcinoma Liposarcoma Liposarcoma Neurohbrosarcoma JuveniIe Iibromatosis MaIignant synovioma MaIignant hemangioendotheIioma Rhabdomyosarcoma Rhabdomyosarcoma Leiomyosarcoma

Living Living Living Living Dead Dead Living Dead Living Living Living Living

of groin

3 yr. 3 yr. 2 gr. 134 yr. in 2 yr. in I yr. 2 yr. in 13h yr. to mo. 234 gr. 2 mo. 2 mo.

-

-!-

of the tweIve patients experienced considerabIe phantom Iimb pain during their postoperative period and in every case symptoms have persisted during their period of follow-up study; however, these patients have been managed with mild anaIgesic agents. SELECTION

OF PATIENTS

From an anaIysis of these cases, certain opinions have been formuIated with respect to the use of hemipeIvectomy in the management of maIignant soft tissue tumors of the Iower extremity. They are as foIIows: Anatomic Site and Tumor Histology. From the standpoint of 3eIecting patients for hemipeIvectomy, we beIieve that Iarge, buIky, soft tissue maIignant tumors that arise from the soft tissues of the peIvis and upper thigh that are not amenabIe to wide IocaI excision shouId be given primary treatment by hemipeIvectomy. Because these tumors require wide excision for tota remova1, the choice of hemipeIvectomy is greatIy simpIified. In this series six patients had tumors of this type; however, two patients have succumbed from distant metastases during the period of foIIow-up study. (Fig. I.) There exists, however, a smaI1, but definite group of maIignant soft tissue tumors of the upper thigh by nature of their size, Iocation and reIationship to other structures, in which the indications for hemipeIvectomy are Iess specific. FrequentIy, their cIinica1 features pIace them in a “no man’s Iand” where the choice of hemipeIvectomy or hip joint disarticuIation is difi-

cuIt to make. As a guide to their surgica1 management we have directed our attention to seIecting the site of amputation from the known bioIogic and histoIogic behavior of the tumor in question. In this regard, we beIieve sufficient cIinicopathoIogic data have accumuIated to show that the IocaI invasive properties of malignant soft tissue tumors range over a wide spectrum and vary according to the tumor’s tissue of origin. Of the more common maIignant soft tissue tumors, Iow grade fibrosarcomas, Ieiomyosarcomas and we11 differentiated Iiposarcomas are characterized by a IocaI infiItrative growth that is not widespread; and, aIthough a

FIG. I. A bulky recurrent round ceI1 type of Iiposarcoma of the buttock. Recause of the tumor’s anatomic location, no other operative procedure short of a hemipelvectomy was feasible.

603

PheIan,

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and Moore

2

3

FIG. 2. A recurrent rhabdomyosarcoma of the upper thigh that was treated by hemipelvectomy. The arrows show the cIinica1 boundaries of the tumor. This tumor was amenabIe to hip disarticulation; however, because a rhabdomyosarcoma is characterized by extensive IocaI invasion of adjacent tissue pIanes, hemipelvectomy was performed. FIG. 3. A Iarge neurofibrosarcoma of the gIutea1 hemipeIvectomy. This patient was unable to lie on x-ray evidence of puImonary metastases. RemovaI peIvectomy greatly facihtated the nursing care of

area that was managed by his back, and also presented of the Iarge tumor by hemithis patiem.

we11pIanned radicaI surgica1 procedure is neceswas an aIternate possibIe choice. Of these five sary to insure their remova effectiveIy, a cerpatients, three are Iiving and we11 sixteen, tain degree of surgica1 conservation may be twenty-four and thirty-six months postoperempIoyed in seIecting a site of amputation. In ativeIy without evidence of disease. The other contrast, poorIy differentiated Iiposarcomas, two patients, one with maIignant hemangioparticuIarIy rhabdomyosarcomas, infiItrate conendotheIioma and the other with juveniIe tiguous tissues extensiveIy. FrequentIy, the fibromatosis have been foIIowed for onIy ten tumor process spreads between adjacent muscIe months and both are cIinicaIIy free of disease. Palliative Procedure. Certain patients with and fascia1 pIanes and is contained mainIy by the Iarge, buIky, painfu1, uIcerating tumors of the origin and insertion of these structures. SynoviaI upper thigh and peIvis and who present cIinica1 sarcomas, maIignant mesenchymomas and difevidence of distant spread may be made more ferent varieties of maIignant vascuIar tumors, comfortabIe by hemipeIvectomy. An exampIe such as hemangioendotheIiomas, behave much in which effective paIIiation was obtained from in the same fashion. Tumors of the Iatter types hemipeIvectomy is represented by the patient require a surgica1 procedure that incIudes in in Figure 3, who was in constant pain because the tumor fIeId not onIy a wide margin of norof neurofibrosarcoma that had invaded the ma1 tissue, but aIso the origin and insertion of sciatic nerve. From a nursing standpoint, the the muscIe and fascia1 pIanes that confine the patient was bedridden and incapabIe of mantumor IocaIIy. (Fig. 2.) In this series, one patient with a juveniIe aging his persona1 hygiene. PhysicaI examinanation reveaIed that hemipeIvectomy was fibromatosis, two patients with rhabdomyofeasibIe and wouId aIIow compIete remova of sarcomas, one with round ceI1 type Iiposarcoma the IocaI tumor; however, puImonary metasof the thigh and another with an infected tases were observed on chest x-ray. Because of hemangioendotheIioma of the Iower Ieg were the pain and nursing probIem associated with seIected for hemipeIvectomy mainIy on the the care of this patient, a hemipeIvectomy was basis of the tumor’s known growth characterperformed. The patient Iived five months after istics. In each of these cases, hip disarticuIation 606

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the operation and was abIe to Ieave the hospita1 and return to his home. The Iast months of his life were reIativeIy free of pain and he was abIe to manage his persona1 hygiene with a minima1 amount of nursing care. In reviewing hemipeIvectomy as a paIIiative procedure, considerabIe care must be empIoyed in the choice of patients for this operation. Of the many factors invoIved, the IocaI tumor findings and the known histoIogic behavior of the tumor appear to be most significant. In no instance should the procedure be carried out if gross tumor will be Ieft behind or if cIinica1 and histologic features indicate the tumor to be rapidly growing. Contraindications. The contraindications to hemipeIvectomy are dictated primariIy by the anatomic boundaries of the tumor and the presence of dista1 tumor spread. If necessary, the abdominal cavity shouId be expIored via a separate incision to determine the presence or absence of liver or other intra-abdominal metastases. Invasion by the tumor of the extrapeIvic structures, such as the rectum and bIadder, does not necessariIy ruIe out the possibiIity of treating a given tumor by hemipeIvectomy. In this series, one patient had partia1 resection of the bIadder and rectum performed in continuity with hemipeIvectomy. As indicated previously, the presence of distant metastases makes hemipeIvectomy inadvisabIe, except in those unusua1 cases in which the procedure is carried out as a paIIiative measure. Age and obesity per se are not contraindications tn hemipeIvectomy, but generaIIy these patients are poor candidates for hemipeIvectomy prosthesis.

Tissue

Tumors

any attempt to treat these tumors except by a surgica1 procedure that is pIanned and directed to tota tumor remova wiI1 invariabIy Iead to a IocaI tumor recurrence or faciIitate distant tumor spread. In the inteIIigent seIection of the proper surgica1 method of management, whether it be hemipeIvectomy, amputation or wide IocaI excision, due consideration must he given the cIinica1 appearance of the tumor, its &c, Iocation and reIation to other structures; in addition, equa1 consideration must aIso be given to the known biologic behavior of the tumor as interpreted from the biopsy specimen. In our opinion, this Iatter factor has not received the surgica1 attention which is due. In our group of patients, there were five instances in which the known bioIogic characteristics of the tumor were the decisive factor that made us perform a hemipeIvectomy. Sufice it to say, a hemipeIvectomy resuIts in a severe physica handicap. However, with the ingenious methods of rehabiIitation now avaiIabIe, many of these patients are abIe to lead a most gainfu1 Iife. SUMMARY I. A cIinicostudy of tweIve cases of maIignant soft tissue tumors of the Iower extremity and peIvis treated by hemipeIvectomy has been presented. 2. It is concIuded that hemipeIvectomy is an effective and safe operation for the surgica1 management of soft tissue maIignant tumors of the thigh and peIvis. Other than tumor size and position, emphasis is directed to the utilization of the tumor’s histoIogic and biologic behavior as a criterion for seIecting patients for hemipeIvectomy.

COMMENTS REFERENCES

In our opinion, hemipeIvectomy has extended the possibiIity of cure to patients with maIignant soft tissue tumors of the upper thigh and peIvis. Because of its magnitude, there is a certain degree of reIuctance to empIoy this operation as the primary procedure unIess the tumor is huge in size. In addition, hemipeIvectomy is frequentIy Iooked upon as a Iast resort to be used onIy after repeated IocaI excisions have faiIed to remove the tumor. Because of these misconceptions, we wish to point out that most maIignant soft tissue tumors are IocaI invasive Iesions and frequentIy infiItrate beyond their paIpabIe confines, and

I. GORDON-TAYLOR, G. and WILES, P. Interinnominoabdomimd (hindquarter) amputation. hit. J. Surg., 22: 671, 1935. 2. GORDON-TAYLOR, G. A further review of the interinnomino-abdominal operation. &it. J. Surg., 27: 643, 1940. 3. GORDOK-TAYLOR, G. and MONRO, R. The technique and management of the hindquarter amputation. Brit. J. Surg., 39: 536, 1952. 4. LEE, C. M. and ALT, L. P. HemipeIvectomy and hip disarticulation for malignant tumors of the p&is and lower extremity. Ann. Surg., 137: 704. 1953. 5. LEIGHTON, W. E. IntrapeIvicoabdominaI amputation. Arch. Surg., 4~: 613, 1942. 6. PACK, G. I., EI-IRLICH, H. E. and GENTIL, F. Radica1 amputations of the extremities in the treat-

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PheIan, Grace and Moore IO. SPEED, K. HemipeIvectomy. Ann. Surg., 95: 167, ‘932. I I. SUGARBAKER,E. D. and ACKERMAN,L. DisarticuIation of the innominate bone for maIignant tumors of the pelvic parieties and upper thigh. Surg. Gynec. &‘ Obst., 81: 36, 1945. 12. TAYLOR, G. and ROGERS, W. Hindquarter amputation. New England J. Med., 249: 963,

ment of cancer. Surg. Gynec. CY Obst., 84: 1105, ‘947. 7. PRINGLE, J. H. The interpeIvic-abdomina1 amputation. Brit. J. Surg., 4: 283, 1916. 8. RAVITCH, M. HemipeIvectomy. Surgery, 26: Igg, ‘949. g. JAVIT, J. H. The hindquarter (interinnominoabdomina1) amputation. Am. J. Surg., 80: 142,

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