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EXTERNAL HEMIPELVECTOMY FOR TREATMENT OF THIGH SARCOMA: CASE REPORT
Apresentação do caso
A 34-year-old male sought care at our service in October 2020, reporting a fast-growing bulging in the left thigh that had appeared five months before. Patient denied having comorbidities. He underwent staging tests that identified thromboembolism in the lobar branch of the right pulmonary artery. The tests also showed a large expansive lesion affecting the anterior and medial muscles of the left thigh, having ill-defined contours, and extending to the region of the femoral periosteum. The lesion measured 15.7 x 17.5 x 22.4cm and caused lateral displacement of the vessels. Plus, a thrombus was identified in the left common femoral vein. Needle biopsy identified a lesion compatible with spindle cell sarcoma. Neoadjuvant chemoradiotherapy was indicated as well as anticoagulation due to venous thrombosis.
Despite the neoadjuvant treatment, the lesion grew, and a surgical approach was scheduled. Modified external hemipelvectomy was performed. Pathological examination showed pleomorphic rhabdomyosarcoma, grade 3, presenting invasion of the femoral vein and involvement of the femoral and iliac lymph nodes (pT4pN1).
Extensive tumors of the pelvic girdle region are difficult to treat conservatively. The external hemipelvectomy procedure has a considerable morbidity and is currently indicated for only a small fraction of pelvic tumors, when the size of the tumor makes it impossible to preserve the limb. In these cases, it may be the only alternative providing resection of such tumors within adequate margins and an acceptable disease-free interval.
Hemipelvectomy involves the following two different approaches: external approach (with limb amputation) and internal approach (with limb preservation). The modified hemipelvectomy, as performed in this case, may leave a small part of ilium, which makes the pelvic girdle more stable and fit for a lower limb prosthesis.
These procedures are mainly indicated for primary malignant tumors of the pelvis, but in rare cases they may be indicated for metastatic lesions, infection, or trauma. Reconstruction and surgical technique are dictated by: (a) extent of resection, (b) remaining structures, (c) histological grade of the tumor, and (d) location of the lesion. For that, a multidisciplinary team is required. Both patient and family should get counseling before surgery to discuss morbidity, mortality, rehabilitation process, and life expectancy.
sarcoma / external hemipelvectomy / thigh tumors
Couto, A.G.H., Araújo, B., Torres de Vasconcelos, R.A. et al. Survival rate and perioperative data of patients who have undergone hemipelvectomy: a retrospective case series. World J Surg Onc 14, 255 (2016). https://doi.org/10.1186/s12957-016-1001-7
Freitas RR, Crivellaro ALS, Mello GJP, Armani Neto M, Freitas Filho G, Silva LV. HEMIPELVECTOMIA: EXPERIÊNCIA DO HOSPITAL ERASTO GAERTNER COM 32 CASOS EM 10 ANOS . Rev Bras Ortop. 2010;45(4):413-9.
Mayerson JL, Wooldridge AN, Scharschmidt TJ. Pelvic resection: current concepts. J Am Acad Orthop Surg. 2014;22(4):214–22.
Wedemeyer C, Kauther MD. Hemipelvectomy: only a salvage therapy?. Orthop Rev (Pavia). 2011;3(1):e4. doi:10.4081/or.2011.e4
Sarcomas / tumores ósseos*
JUNIOR RODRIGUES SOARES, RENATO MORATO ZANATTO, GUSTAVO GARCIA FALCÃO