Hemipelvectomy, a surgical procedure involving resection of either the pelvis or innominate bone, is an established therapeutic procedure for the management of primary bone and soft tissue sarcomas. This procedure is associated with significant morbidity, functional impairment, and alterations in quality of life and body image.1 A thorough pre- and postoperative nursing assessment of the hemipelvectomy candidate is essential to promoting enhanced physiologic and quality-of-life outcomes for these patients. In addition, proactive discharge planning can be critical to preparing patients and their family caregivers for transition to the outpatient setting. Hemipelvectomy is usually performed in highly specialized tertiary/quaternary medical centers by a comprehensive surgical oncology team. Approximately 30 to 50 hemipelvectomy surgeries are completed annually at the University of Texas MD Anderson Cancer Center.
SARCOMA
Sarcomas are broadly defined as a heterogeneous group of rare and solid tumors that originate in the connective tissue or bone, including¾but not limited to¾muscle, fat, blood vessels, or supporting tissues of the body.2 Soft-tissue sarcomas are the most frequently diagnosed sarcomas in adults, with an estimated 12,020 cases in the United States in 2014. Fifty percent of these tumors arise in the mesodermal tissues of the extremities, 40% in the trunk and retroperitoneum, and 10% in the head or neck.3 The American Cancer Society estimates that 4,740 deaths will be attributed to soft-tissue sarcomas in 2014.3 Soft-tissue sarcomas are classified according to the originating soft tissue, with the grade reflecting the metastatic potential of the tumor.3 Staging of soft tissue sarcomas, which is determined by tumor size, histologic grade, and lymph node or distant site involvement, is essential to determining the most effective treatment.3 Multimodal treatment of soft tissue sarcoma is the most common approach and includes pre- and post-operative radiation in combination with surgical resection.3
Primary bone tumors are extremely rare in adults. In the United States, they account for fewer than 0.2% of all cancers and have an annual incidence of approximately 2,500 cases and an annual mortality of 1,400.2 Osteosarcomas are the most common primary bone tumors in the pelvis and account for 35% of cases.4 Osteosarcoma is diagnosed predominantly in adolescents and young adults and accounts for an estimated 450 new cases in the United States each year among persons age birth to 24 years.5 Osteosarcoma is classified as either central (medullary) or surface (peripheral). Its staging is determined by tumor grade and size and by the presence of discontinuous tumors in the primary bone site or distant metastases.5 Osteosarcoma is treated with systemic neoadjuvant (preoperative) or adjuvant (postoperative) chemotherapy along with complete resection of all clinically detectable disease.5 More than 80% of patients with extremity osteosarcoma can be treated with limb-sparing surgery. However, patients who undergo amputation have lower local-recurrence rates, although no difference in overall survival is observed among patients based on initial treatment with these two approaches.5
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HEMIPELVECTOMY
Pelvic resection is a commonly used surgical approach in the management of sarcomas. A limb-sparing surgical procedure is always preferable, but in cases in which partial pelvic resection does not allow for safe surgical margins or limb functionality, hemipelvectomy may be indicated.1 Specifically, patients presenting with metastatic primary bone tumors or patients for whom resection of at least two of the following¾the sciatic nerve, the femoral neurovascular bundle, and the hip joint¾require resection for adequate margins are potential candidates for hemipelvectomy.4 The incidence of hemipelvectomy in the United States is unknown but is estimated at approximately one case per 1 million annually.4 Hemipelvectomy is classified as either internal (a local resection of the hemipelvis that preserves the ipsilateral lower extremity) or external (involving resection of the innominate bone [ilium, pubis, and ischium] and the entire lower extremity).6 Hemipelvectomy procedures are traditionally defined by Enneking’s classification of pelvic lesion resection, which includes three types:
- Resection confined to the ilium
- Resection confined to the periacetabulum
- Resection confined to the pubis
Postoperative complications occur in 20% to 50% of cases and most commonly include wound infection and flap necrosis.4 Additional considerations include the challenges of postoperative prosthetics, including difficulty in anchoring the prosthetic, some of which require a waist and shoulder strap, as well as the energy expenditure related to the swing gait required to ambulate with the prosthetic. Both of these often preclude older patients from prosthetic use.4 Quality of life and functional status are also significant considerations for patients undergoing hemipelvectomy. Pain and fatigue are reported sequelae of patients who have had a hemipelvectomy2; however, several studies have shown impressive improvement or maintenance of functional status following this procedure.2,7 Although not directly measured in studies to date, clinical observations reveal the potential for an altered body image following this procedure.1
