J. A. Abraham, B. Kenneally, K. Amer, Rothman Institute, Philadelphia, PA, USA D. S. Geller, Montefiore Medical Center, New York, NY, USA J. A. Abraham, B. Kenneally, Thomas Jefferson University Hospital, Philadelphia, PA, USA This work was performed at Thomas Jefferson University Hospital, Philadelphia, PA, USA.
Clin Orthop Relat Res. 2018 Mar;476(3):499-508. doi: 10.1007/s11999.0000000000000064.
Navigation-assisted resection has been proposed as a useful adjunct to resection of malignant tumors in difficult anatomic sites such as the pelvis and sacrum where it is difficult to achieve tumor-free margins. Most of these studies are case reports or small case series, but these reports have been extremely promising. Very few reports, however, have documented benefits of navigation-assisted resection in series of pelvic and sacral primary tumors. Because this technology may add time and expense to the surgical procedure, it is important to determine whether navigation provides any such benefits or simply adds cost and time to an already complex procedure.
QUESTIONS/PURPOSES: (1) What proportion of pelvic and sacral bone sarcoma resections utilizing a computer-assisted resection technique achieves negative margins? (2) What are the oncologic outcomes associated with computer-assisted resection of pelvic and sacral bone sarcomas? (3) What complications are associated with navigation-assisted resection?
Between 2009 and 2015 we performed 24 navigation-assisted resections of primary tumors of the pelvis or sacrum. Of those, four were lost to followup after the 2-year postoperative visit. In one patient, however, there was a failure of navigation as a result of inadequate imaging, so nonnavigated resection was performed; the remaining 23 were accounted for and were studied here at a mean of 27 months after surgery (range, 12-52 months). During this period, we performed navigation-assisted resections in all patients presenting with a pelvis or sacral tumor; there was no selection process. No patients were treated for primary tumors in these locations without navigation during this time with the exception of the single patient in whom the navigation system failed. We retrospectively evaluated the records of these 23 patients and evaluated the margin status of these resections. We calculated the proportion of patients with local recurrence, development of metastases, and overall survival at an average 27-month followup (range, 12-52 months). We queried a longitudinally maintained surgical database for any complications and noted which, if any, could have been directly related to the use of the navigation-assisted technique.
In our series, 21 of 23 patients had a negative margin resection. In all patients the bone margin was negative, but two with sacral resections had positive soft tissue margins. Six of 23 patients experienced local recurrence within the study period. Three patients died during the study period. Seventeen patients demonstrated no evidence of disease at last recorded followup. We noted three intraoperative complications: one dural tear, one iliac vein laceration, and one bladder injury. Eight patients out of 23 had wound complications resulting in operative débridement. Two patients in the series developed transient postoperative femoral nerve palsy, which we believe were caused by stretch of the femoral nerve secondary to the placement of the reference array in the pubic ramus.
Navigation-assisted resection of pelvic and sacral tumors resulted in a high likelihood of negative margin resection in this series, and we observed relatively few complications related specifically to the navigation. We have no comparison group without navigation, and future studies should indeed compare navigated with nonnavigated resection approaches in these anatomic locations. We did identify a potential navigation-related complication of femoral nerve palsy in this series and suggest careful placement and observation of the reference array during the operative procedure to lessen the likelihood of this previously unreported complication. We suggest it is worthwhile to consider the use of navigation-assisted surgery in resection of tumors of the pelvis and sacrum, but further study will be needed to determine its precise impact, if any, on local recurrence and other oncologic outcomes.
Level IV, therapeutic study.
在骨盆和骶骨等难以达到无肿瘤边缘的解剖部位，导航辅助切除已被提议作为辅助切除恶性肿瘤的有用方法。这些研究大多是病例报告或小病例系列，但这些报告非常有希望。然而，很少有报道记录导航辅助切除骨盆和骶骨原发性肿瘤的系列中的益处。由于该技术可能会给手术过程增加时间和费用，因此重要的是要确定导航是否提供任何此类益处，或者是否只是在已经复杂的手术过程中增加了成本和时间。
问题/目的：（1）利用计算机辅助切除技术切除的骨盆和骶骨骨肉瘤中有多少比例达到阴性边缘？（2）计算机辅助切除骨盆和骶骨骨肉瘤的肿瘤学结果如何？（3）导航辅助切除相关的并发症有哪些？
在 2009 年至 2015 年间，我们对 24 例原发性骨盆或骶骨肿瘤进行了导航辅助切除术。其中 4 例在术后 2 年的随访中失访。然而，在一名患者中，由于成像不足，导航系统出现故障，因此进行了非导航切除；其余 23 例被记录下来，并在手术后平均 27 个月（范围 12-52 个月）进行了研究。在此期间，我们对所有出现骨盆或骶骨肿瘤的患者进行了导航辅助切除；没有选择过程。在此期间，没有患者未经导航治疗这些部位的原发性肿瘤，除了一名导航系统出现故障的患者。我们回顾性地评估了这 23 名患者的记录，并评估了这些切除的边缘状态。我们计算了在平均 27 个月（范围 12-52 个月）的随访中局部复发、转移发展和总体生存率的比例。我们纵向查询了一个手术数据库，以了解任何并发症，并指出哪些并发症可能与导航辅助技术的使用直接相关。
在我们的系列中，23 例患者中有 21 例达到了阴性边缘切除。所有患者的骨边缘均为阴性，但 2 例骶骨切除患者的软组织边缘阳性。23 例患者中有 6 例在研究期间发生局部复发。3 例患者在研究期间死亡。17 例患者在最后一次记录的随访中无疾病证据。我们注意到 3 例术中并发症：1 例硬脑膜撕裂、1 例髂静脉撕裂和 1 例膀胱损伤。23 例患者中有 8 例出现伤口并发症，导致手术清创。该系列中有 2 例患者出现短暂的术后股神经麻痹，我们认为这是由于耻骨支内参考阵列的放置导致股神经拉伸所致。
在本系列中，导航辅助切除骨盆和骶骨肿瘤导致阴性边缘切除的可能性很高，我们观察到与导航相关的并发症相对较少。我们没有没有导航的对照组，未来的研究确实应该在这些解剖部位比较导航与非导航切除方法。我们确实在本系列中发现了一个潜在的与导航相关的股神经麻痹并发症，并建议在手术过程中仔细放置和观察参考阵列，以减少这种以前未报告的并发症的可能性。我们建议在切除骨盆和骶骨肿瘤时考虑使用导航辅助手术，但需要进一步研究以确定其对局部复发和其他肿瘤学结果的精确影响。
