In evaluation of the tumor magnetic resonance imaging

In evaluation of the tumor, magnetic resonance imaging examination was performed before surgery and showed a mass of about 3cm in diameter without joint space involvement (Fig. 3). This was considered to be a periacetabular metastatic tumor, which required wide excision including hip joint. However, the patient had undergone major gynecologic surgery and series of chemotherapy within 6 months, which made her weak and depressed, probably unsuitable for further major surgeries. After discussion with the patient, she interleukins agreed to undergo intralesional curettage with hip preservation, instead of a Type II resection of the pelvic bone. In a lateral position, the operation was performed through a posterolateral approach with a wound about 10 centimeters in length. At the lateral side of the acetabulum, we made a burr hole of 2cm in diameter and executed adequate intralesional curettage. The cavity was irrigated with a large amount of normal saline, and the free margin was cauterized by phenol. One package of cement (40mg) (Howmedica, Mahwah, NJ, USA) was blended with cisplatin (50mg/100ml). As humidity lengthened the setup time from the liquid to the doughy phase, we added cisplatin drop by drop with persistent stirring from the liquid phase. The capacity of 40mg cement is equivalent to about 30ml of cisplatin (50mg/100ml). It took 10 minutes to reach the doughy phase and another 5–7 minutes to the solid phase. The progress was prolonged and yet smooth. In the doughy phase, the cisplatin-loaded cement filled the bone cavity created by curettage of the tumor. The neurovascular structures were left intact after surgery, without injuring the articular space. The skin-to-skin operative time was 80 minutes with a blood loss of less than 200ml. After the surgery, the pain at the hip was significantly relieved and, after 2 days, the patient recovered to complete weightbearing status, free of walking aids. Her general condition and wound condition were good and she was discharged on Postoperative Day 4. The adjuvant radiotherapy for local treatment with the total dose of 45Gy in 28 fractions began 3 weeks later. Then, she was reviewed with surveillance radiographs every 3 months in the following 2 years (Fig. 4). Serial radiographs and clinical examination showed no signs of recurrence of disease (Fig. 5A and B). At her last follow-up on May 10, 2011, more than 2 years after the surgery, she had no residual pain and had a normal gait without the use of walking aids.
Discussion There are three general principles for surgical treatment of metastatic bone disease: tumor removal, filling of the resultant bone defect, and bypass of the defect. For pelvic tumor, either primary or metastasis, surgical management is challenging. The complexity of acetabular, pelvic bone anatomy, and the proximity of neurovascular structures can complicate the surgery. Type II periacetabular lesions are particularly difficult to treat, and their reconstruction results in a high incidence of mechanical complications. Besides, the reconstruction of the acetabulum is a major surgical procedure with a significant risk of complications. A retrospective review of surgical procedures for periacetabular metastasis shows that the average blood loss during the operation was 1600ml in 43 patients and the bleeding exceeded 3000ml in three patients with renal carcinomas. The complications of periarticular reconstruction included deep infections, superficial infections, wound complications, local recurrence, fracture, dislocations, rotational deformity, and even intraoperative mortality. The study also documented that the complication rate related to implants was 21.7%. A prospective multicenter study revealed that periacetabular endoprosthetic replacement was associated with acceptable functional and oncological outcome but a high complication rate owing, predominantly, to infection. The indication for hemipelvic prosthesis in patients with a metastatic disease must be considered seriously.