Couto et al.

World Journal of Surgical Oncology (2016) 14:255

DOI 10.1186/s12957-016-1001-7

RESEARCH Open Access

Survival rate and perioperative data

of patients who have undergone
hemipelvectomy: a retrospective case series
Alfredo Guilherme Haack Couto1* , Bruno Araújo2, Roberto André Torres de Vasconcelos3, Marcos José Renni4,
Clóvis Orlando Da Fonseca5 and Ismar Lima Cavalcanti1,6

Abstract
Background: Hemipelvectomy is a major orthopedic surgical procedure indicated in specific situations. Although
many studies discuss surgical techniques for hemipelvectomy, few studies have presented survival data, especially
in underdeveloped countries. Additionally, there is limited information on anesthesia for orthopedic oncologic
surgeries. The primary aim of this study was to determine the survival rate after hemipelvectomy, and the secondary
aims were to evaluate anesthesia and perioperative care associated with hemipelvectomy and determine the influence
of the surgical technique (external hemipelvectomy [amputation] or internal hemipelvectomy [limb sparing surgery])
on anesthesia and perioperative care in Brazil.
Methods: This retrospective case series collected data from 35 adult patients who underwent hemipelvectomy
between 2000 and 2013. Survival rates after surgery were determined, and group comparisons were performed using
the Kaplan–Meier method and the log-rank test. Mantel–Cox test and multiple linear regression analysis with stepwise
forward selection were performed for univariate and multivariate analyses, respectively.
Results: Mean survival time was 32.8 ± 4.6 months and 5-year survival rate was 27 %. Of the 35 patients, 23 patients
(65.7 %) underwent external hemipelvectomy and 12 patients (34.3 %) underwent internal hemipelvectomy. The
survival rate was significantly higher in patients with bone tumors than in those with soft tissue sarcomas (P = 0.024).
The 5-year cumulative probability of survival was significantly lower in patients who underwent external
hemipelvectomy than in those who underwent internal hemipelvectomy (P = 0.043). In the univariate and
multivariate analyses, only advanced disease stage (3 and 4) was identified as a significant independent
predictor of reduced survival (P = 0.0003). Balanced general anesthesia combined with epidural block was
the most frequent anesthesia technique. Median intraoperative crystalloid volume and red blood cell transfusions
were 3500 mL and 2 units, respectively.
Conclusions: Overall mean survival time after hemipelvectomy was 32.8 months. Advanced disease stage might be
independently associated with reduced survival. Smaller amounts of fluids and transfusions were administered and
time to discharge was shorter. Acute and chronic pain as well as wound complications are still important challenges
in hemipelvectomy.
Keywords: Anesthesia, Perioperative care, Cancer, Hemipelvectomy, Survival

* Correspondence: [email protected]
1
Department of Anesthesiology, Universidade Federal Fluminense, Niterói,
Brazil
Full list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Couto et al. World Journal of Surgical Oncology (2016) 14:255 Page 2 of 7

Background database of all patients who underwent hemipelvectomy

Hemipelvectomy is a major orthopedic surgical proced- at Instituto Nacional de Câncer, Brazil, between 2000
ure indicated in specific situations and regularly per- and 2013. Patients aged under 18 years were excluded
formed in highly complex tertiary centers [1, 2]. Primary from the search. The study was approved by the
bone and soft tissue pelvic sarcomas are the main indi- Research Ethics Committee of Instituto Nacional de
cations for hemipelvectomy [3], which has been used in Câncer José Alencar Gomes da Silva (reference number
specific critical pelvic trauma patients [4]. Since it was 82751/CAAE 05859312.9.0000.5274).
first performed by Billroth in 1891 [5], perioperative care The variables of interest were associated disorders, age,
has been a challenge for all health-care providers in- sex, weight, American Society of Anesthesiologists Phys-
volved in this aggressive procedure. ical Status classification, tobacco use, preoperative chemo-
Hemipelvectomy involves the following two different therapy and radiotherapy, tumor size and histology,
approaches: external approach (with limb amputation) disease stage, type of procedure, operation time, type of
and internal approach (with limb preservation) [5]. In anesthesia, neuroaxial opioid use, amount of crystalloids
the last few decades, the use of external hemipelvectomy and colloids infused, perioperative transfusion, and extu-
for the treatment of pelvic cancer has declined, and new bation. In addition, postoperative variables (acute and
surgical techniques and efforts for resection with limb chronic pain, surgical wound, and clinical complications)
preservation (internal hemipelvectomy) and reconstruc- and hospital length of stay were studied.
tion have been introduced [6–8]. As no specific guidelines were described in the database
Survival after hemipelvectomy might be related to sev- or medical charts, the choice of anesthesia technique as
eral different factors, such as tumor histopathology and well as transfusion triggers was based on individual criteria
size, disease stage, patient physical status, and resection of personal experience and subjective team evaluation.
type. In patients with soft tissue tumors, the 5-year sur- Pain was assessed using the visual analog scale (VAS)
vival rate might be as low as 10 %. Large tumors and and was considered severe if the VAS score was >7 and
bone and vascular involvement might be indicators of chronic if it persisted for over 12 weeks. Surgical wound
poor survival [8]. For bone tumor resection, the 5-year complications included infection, fistula, and dehiscence.
survival rate can be as high as 100 %, depending on the Information regarding follow-up and time to death was
resection type [9]. A large previous series reported a sur- retrieved from the Department of Cancer Information at
vival rate of 50 % after hemipelvectomy [10]. our institution. Patients who showed up in the last doctor
With regard to hemipelvectomy, anesthesia and peri- appointment were considered alive. All deceased patients
operative care may be considered challenging because of were registered in the database of the institution.
extensive tissue trauma related to the surgery, the use of External hemipelvectomy was indicated in cases where
preoperative adjuvant chemotherapy and radiotherapy, sig- adequate surgical margin could not be obtained with
nificant blood and fluid loss, bleeding disorders, and intense preservation of a viable and functioning limb. Also, it
postoperative pain [11]. In most cases, major neurovascular was indicated in large tumors with vascular involvement
dissection, large bone resection and reconstruction, and and ulcerated and great pelvic invasion. Bone recon-
skin flap rotation are needed [2]. Although many studies struction was not performed after internal hemipelvect-
have discussed surgical techniques for hemipelvectomy, few omy as it is not routine in this center.
studies [6, 7, 12] have presented survival data, especially in Pelvic resection in internal hemipelvectomy was classi-
underdeveloped countries [9]. Additionally, there is limited fied into the following: iliac (T1), acetabular (T2), pubis
information on anesthesia for orthopedic oncologic surger- or ischium (T3), and sacral (T4) [12]. Combinations of
ies [2]. We found only one paper that presented anesthetic procedures were also performed in association with high
and perioperative data specifically for hemipelvectomy. The femoral resection and/or sacral extension.
paper was published in 2007 [11]. Disease staging was performed retrospectively by an
The primary aim of this study was to determine the sur- orthopedic oncologic surgeon following the American
vival rate after hemipelvectomy, and the secondary aims Joint Committee on Cancer (AJCC) [13] for soft tissue
were to evaluate anesthesia and perioperative care associ- sarcomas and the Union for International Cancer Con-
ated with hemipelvectomy and determine the influence of trol (UICC) for cases involving the bone.
the surgical technique (external hemipelvectomy [amputa-
tion] or internal hemipelvectomy [limb sparing surgery]) Statistical analysis
on anesthesia and perioperative care in Brazil. Median, mean, standard deviation, and range were used
to summarize numerical data, and frequency (n) and
Methods percentage (%) were used for categorical data. The asso-
This retrospective case series collected data from the ciations between variables were analyzed using the
medical records and from the Department of Pathology Mann–Whitney U test for numerical data and the χ2 test
Couto et al. World Journal of Surgical Oncology (2016) 14:255 Page 3 of 7

or Fisher’s exact text for categorical data, as the Twelve patients presented soft tissue tumors and 23
Shapiro–Wilk normality test was rejected. had primary bone tumors. Classic chondrosarcoma was
The survival rate after surgery was calculated using the most frequent case (15 cases, 1 recurrence). Two
the Kaplan–Meier method, and the log-rank test was chondrosarcomas were classified as mesenchymal (bone,
used for comparisons. Survival curves compared groups 1; soft tissue [extra-skeletal], 1). Among the osteosar-
dichotomized by age (under 50 vs. 50 years or more), comas, 1 was fibroblastic, 1 was chondroblastic, 1 was
tumors (bone vs. soft tissue), and type of surgery small cell, and 3 were classic.
(internal vs. external). The other sarcomas included 1 clear cell, 2 pleo-
To identify factors that could independently influence morphic, 1 high-grade, 1 undifferentiated, and 1 fibro-
survival, univariate analysis was performed with Mantel– sarcoma. Of these 6 cases, 4 were recurrent. Malignant
Cox regression for each variable. The candidate variables fibrous histiocytoma was pleomorphic in 2 cases (1 re-
included sex, age, preoperative radiotherapy and chemo- current) and myxoid in 1 case. There were 2 cases of
therapy, transfusion, intraoperative fluid volume, and synovial cell sarcoma and 1 giant cell tumor.
disease stage. Multivariate analysis was performed using Of the 12 cases of soft tissue tumors, 5 were stage 3, 2
multiple linear regression with forward selection. were stage 4, and 5 were local recurrences. Of the 23
All analyses were performed using SAS® System 6.11 bone tumors, 13 were stage 2b, 8 were stage 1b, 1 was
(SAS Institute, Inc., Cary, NC). A P value <0.05 was con- stage 3, and 1 was local recurrence. Among the 12 pa-
sidered significant. tients with soft tissue tumors, 9 (75 %) had tumors
>10 cm; and among the patients with bone tumors, 19
Results (82.6 %) had tumors >8 cm.
Thirty-five cases were selected for analysis after database The surgical procedures are presented in Table 2.
searches. The 5-year survival rates after surgery are presented in
The preoperative data are presented in Table 1. Ambu- Fig. 1.
latory anesthesia preoperative evaluation was performed The mean survival time was 32.8 ± 4.6 months, and
2–3 weeks before hemipelvectomy in 12 patients, and 23 the survival rate after 5 years was 27 %. The survival rate
patients were visited by an anesthesiologist before sur- was higher among patients with bone tumors than
gery after hospital admission. Thirty-three procedures among those with soft tissue sarcomas (P = 0.024). Add-
were elective and 2 were considered emergency owing to itionally, the cumulative probability of survival at 5 years
tumor bleeding. was lower among patients who underwent external
hemipelvectomy than among those who underwent in-
Table 1 Preoperative data ternal hemipelvectomy (P = 0.043). Internal hemipelvect-
Variable Value omy patients presented a survival rate of 57 % in 5 years
Age, years (median and range) 40 (18–82) while external hemipelvectomy patients had only 11 %
Weight, kg (mean and range) 69.1 (43–106) in the same time interval. However, the survival rate dif-
Male/female (n) 24:11
ference was not statistically significant between patients
aged <50 at the time of the procedure and those aged
Preoperative radiotherapy (%) 28.6
≥50 at the time of the procedure (P = 0.083).
Preoperative chemotherapy (%) 17.1 In the univariate analysis, only advanced disease stage
ASA (n) (3 and 4) was found to be a significant independent fac-
1 14 tor for reduced survival among the variables tested (P =
2 13 0.0003, hazard ratio = 6.65, 95 % CI = 2.36–18.7).
3 8
Tobacco use (n) 15
Arterial hypertension (n) 9
Table 2 Surgical procedures
Type N
Diabetes (n) 2
Internal type I 5
Coronary disease (n) 1
Internal type I with sacral extension 1
Asthma (n) 1
Internal type II 2
Chronic renal failure (n) 1
Internal type III 1
Gastroesophageal reflux disease (n) 1
Internal types II and III 1
Pulmonary metastasis (n) 4
Internal types I, II, and III with high femoral resection 2
Depression (n) 2
External 23
ASA American Society of Anesthesiologists Physical Status Classification
Couto et al. World Journal of Surgical Oncology (2016) 14:255 Page 4 of 7

a b

c d

Fig. 1 Survival rate after surgery (n = 29). a Overall survival rate. b Survival rate of patients with bone tumors and those with soft tissue tumors.
c Survival rate of patients aged <50 and those aged ≥50. d Survival rate of patients who underwent internal hemipelvectomy and those who
underwent external hemipelvectomy

Additionally, in the multivariate analysis, only advanced Comparisons of perioperative data between external
disease stage (3 and 4) was found to be an independent hemipelvectomy and internal hemipelvectomy (without
risk factor for reduced survival. reconstruction) are presented in Table 5. There were no
Data on perioperative management are presented in significant differences in perioperative data between exter-
Table 3. The median volume of crystalloid infusion was nal hemipelvectomy and internal hemipelvectomy (with-
3500 mL, and 500-mL multiples were used for colloid out reconstruction), including time to hospital discharge.
administration quantification. Twenty patients received We compared surgical wound complications and the
red blood cell (RBC) concentrates intraoperatively and 4 incidence of chronic pain between external hemipelvect-
patients received other blood products in the operating omy and internal hemipelvectomy (without reconstruc-
room (OR). Thirty-three patients underwent tracheal tion) and found no significant differences (P = 0.095 and
extubation in the OR. In the perioperative period, a high P = 0.17, respectively). However, external hemipelvect-
number of patients presented at least one episode of se- omy was responsible for 8 of the 9 cases of surgical
vere hemodynamic instability (23 patients, 65.7 %). All wound complications. The number of patients with in-
these patients received fluid resuscitation, and vasopres- traoperative hemodynamic instability was higher among
sors (infusion, boluses, or both) were required in 12 of patients who underwent external hemipelvectomy than
these patients (52.17 %). Six patients presented persist- among patients who underwent internal hemipelvect-
ent bleeding disorders with associated abnormal coagu- omy (P = 0.003).
lation tests.
Postoperative data are presented in Table 4. Severe and
acute pain after the procedure was noticed in 31.4 % of the Discussion
cases and 40 % of the patients developed chronic pain. In this study, mean survival time was 32.8 ± 4.6 months.
Postoperative transfusion was performed in 17 patients. In a previous study, Penna et al. [9] demonstrated a
With regard to postoperative complications, 1 patient de- mean survival time of 43 ± 17 months. This difference
veloped acute renal failure, 2 had neurological disorders, 1 could be explained by the fact that a large number of pa-
had arrhythmia, and 9 developed surgical wound complica- tients had an advanced disease stage at the time of sur-
tions. Median hospital stay after surgery was 6 days. gery in this study.
Couto et al. World Journal of Surgical Oncology (2016) 14:255 Page 5 of 7

Table 3 Perioperative data of more advanced disease such as failed neoadjuvant

Variable Value (n = 35) therapy, severe deep infection, sciatic nerve and femoral
Operating time (min)a 200 (90–460) vessel infiltration, local tumor recurrence, improvement
Type of anesthesia (n)
of the resection margin, and as a life-saving or palliative
procedure could possibly explain the higher chances of
General plus regional 31
survival in the internal hemipelvectomy group [2].
General alone 3 Although we did not notice any significant statistical
Regional alone 1 difference in survival when patient age (>50 or ≥50) was
Type of general anesthesia (n) considered (P = 0.083), Mankin et al. [10] demonstrated
Intravenous 3 a higher survival rate after hemipelvectomy in patients
Balanced 31
aged <50 than in those aged ≥50. Sample size may have
contributed to this difference.
Type of regional anesthesia (n)
Among the variables selected, only advanced disease stage
Spinal 4 was a significant predictor of reduced survival in both uni-
Epidural block 25 variate and multivariate analysis (P = 0.001), and this finding
Spinal plus epidural block 3 is consistent with the results of a previous study [10].
Intraoperative neuroaxial opioids (n) 32 All patients with soft tissue tumors died at 60 months
Intraoperative use of colloids, 0.5/1/1.5 L (n) 12/07/03
after the surgery in this study. However, Appfelstaedt et
al. [8] reported a 10 % survival rate at 5 years for cura-
Intraoperative crystalloid volume (mL)a 3500 (1000–8500)
tive surgery and 14 % for palliation. On evaluating the
Intraoperative albumin infusion (n) 6 data of patients with soft tissue tumors, we found that
Intraoperative transfusion (n) 20 almost all the patients had an advanced disease stage
Intraoperative red blood cells (units)a 2 (1–6) (grade 3 or 4), and this might explain the reduced
Intraoperative use of other blood products (n) survival.
Fresh frozen plasma 3
In the present series, 65.7 % of the procedures were
external hemipelvectomy, although limb savage surgeries
Cryoprecipitate 1
have been reported to be possible in most cases owing
Platelets 0 to medical advances [14]. Previous studies [9–12] have
Extubation in the operating room (n) 33 reported the predominance of internal hemipelvectomy
a
Median and range in the treatment of pelvic cancer. This difference may be
explained by the large tumor sizes in this study, and it
We found that the chance of survival was higher with reflects the high number of patients at an advanced dis-
internal hemipelvectomy than with external hemipel- ease stage assisted at Instituto Nacional de Câncer José
vectomy. This is consistent with the findings of a previ- Alencar Gomes da Silva.
ous study [9]. Therefore, if possible, limb preservation Intraoperatively, a median of 2 units (range, 1–6 units)
surgery is the first choice when hemipelvectomy is con- of RBCs were administered. Hemipelvectomy has been
sidered a possible approach. The fact that external hemi- shown to be associated with massive bleeding and sig-
pelvectomy is currently performed in specific situations nificant blood and fluid loss [15]. A previous study re-
ported the requirement of massive transfusions [1], and
Table 4 Postoperative data another reported that a median of 7 units (range, 0–
Variable Value 44 units) of RBCs were required intraoperatively [11].
Postoperative transfusion (n) 17 Moreover, intraoperatively, a median crystalloid volume
Severe acute pain after the procedure (VAS > 7) (n) 11 of 3500 mL (range, 1000–8500 mL) was infused, and the
volume administered was lower in this series than in the
Postoperative complications
study by Molnar et al. [11] (median, 8500 mL; range,
Acute renal failure (n) 1
1000–42,000 mL). Additionally, the operation time was
a
Neurological disorders (n) 2 shorter than in the study by Molnar et al. [11] (200 vs.
Arrhythmias (n) 1 300 min). These differences might be explained by the
Chronic pain 3 months after surgery (n) 14 fact that none of the patients who underwent internal
Surgical wound complications (n) 9 hemipelvectomy had bone reconstruction in this study,
while 19 of 49 patients underwent some form of recon-
Time to discharge (days)b 6 (3–27)
struction in the study by Molnar et al. [11].
VAS visual analog scale
a
Ischemia delirium and/or disorientation
Balanced general anesthesia combined with epidural
b
Median and range block was the most frequent choice of anesthesia for
Couto et al. World Journal of Surgical Oncology (2016) 14:255 Page 6 of 7

Table 5 Perioperative data (external hemipelvectomy vs. internal hemipelvectomy)

Internal (without reconstruction) External
Variable n Median Range n Median Range P value
Age (years) 12 40 32–46 23 45 29–55 0.39
Weight (kg) 12 75 64–81 23 63 52–83 0.15
Operation duration (min) 12 240 140–284 23 195 160–225 0.53
Intraoperative RBC transfusion (units) 6 4 1.8–6.0 14 2 2.0–3.0 0.13
Intraoperative crystalloid infusion (mL) 12 3750 2825–5000 23 3000 2500–4000 0.29
Postoperative RBC transfusion (units) 3 3 1.0–4.0 21 2 1.0–2.0 0.38
Total RBC transfusion (units) 7 4 1.0–8.0 14 3 2.0–4.0 0.4
Hospital stay after surgery (days) 12 6 5.0–7.0 23 6 4.0–8.0 0.68
RBC red blood cell

hemipelvectomy in this series, and this finding is similar therapy in the operated area, and preoperative pain
to the finding of Molnar et al. [11]. Although some stud- (moderate to severe) for more than 1 month were
ies suggested that propofol anesthesia was superior to previously identified as risk factors for the develop-
volatile agents in cancer patients [16, 17], other studies ment of chronic postsurgical pain [24, 25], and all or
do not support this suggestion [18–20]. In a recent re- at least some of these factors may be present in
view, Heaney et al. [18] stated that there is no conclusive hemipelvectomy patients.
evidence to indicate that one anesthetic agent is better In this study, 25,7 % of cases developed surgical
than another agent in cancer patients. Therefore, there wound complications that included infection, fistula, and
is no reason to change the current practice. dehiscence. Previous studies by Higinbotham et al. [26]
We observed that efforts were made to deliver regional and Apffelstaedt et al. [27, 28] reported wound compli-
anesthetics in every case, and epidural or spinal local an- cation incidences of 75 and 47 %, respectively. Beck et
esthetics were delivered in 32 of the 35 patients. Usually, al. [22] reported a wound complication incidence of only
after the surgical plan was discussed, epidural catheters 4 %. Our findings are somewhat similar to the findings
were positioned in the lower thoracic or upper lumbar of these previous studies.
spine to avoid interference with the surgical field. A pre- The median postoperative length of hospital stay was
vious study reported that neuroaxial opioids were highly 6 days (range, 3–27 days), and there was no difference
effective at reducing postoperative pain [2]. However, as between patients who underwent external hemipelvect-
31.4 % of patients developed severe postoperative acute omy and those who underwent internal hemipelvectomy.
pain in our study, neuroaxial opioids were not able to The length of time was shorter than in the study by Beck
provide adequate postoperative analgesia. Nevertheless, et al. [22] (14 days for internal and 20 for external hemi-
Weinbroum [21] reported the superiority of epidural pelvectomy) and by Molnar et al. [11] (14 days). Team
over intravenous patient-controlled analgesia in ortho- efforts, institutional experience, and a low incidence of
pedic oncologic patients, and its use is recommended. clinical complications may explain the earlier hospital
Chronic pain was an important postoperative com- discharge in our study.
plication. A total of 14 patients experienced this com- This study did not focus on rehabilitation data. As a
plication, and among the 23 patients who underwent routine, all efforts were made to deliver early rehabilita-
external hemipelvectomy, 11 had persistent pain. Per- tion. Main goals were to sit in the first postoperative day
sistent postsurgical pain (pain that lasts for more than and stand up in the fourth and, at discharge, patients
1–2 months after surgery) has been reported to be were scheduled for ambulatory physiotherapy. Ampu-
present in more than 30 % of patients after proce- tated patients received focus on wound edges care and
dures, such as amputations, and its recognition is preparation for prostheses. Internal hemipelvectomy pa-
increasing [22]. Studies have shown that up to 90 % tients received ambulatory ambulation training, corporal
of patients may experience phantom pain after balance, and other mobility training such as gait aid.
hemipelvectomy-associated amputation, and although A retrospective case series approach is useful to study
the mechanisms of pain after this procedure are not rare diseases and infrequent procedures. However, several
fully understood, the pain can be debilitating and may limitations are associated with this approach. This study
impair rehabilitation and quality of life [22, 23]. was performed at a single center, and this might have re-
Neurotoxic chemotherapy, moderate-to-severe postop- sulted in bias. The large number of patients with advanced
erative pain, anxiety, younger age (adults), radiation disease stage, especially in the soft tissue sarcoma group,
Couto et al. World Journal of Surgical Oncology (2016) 14:255 Page 7 of 7

may have contributed to low sample survival as well as References

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Received: 6 May 2016 Accepted: 8 September 2016