Modified kraske procedure with mid-sacrectomy and coccygectomy for en bloc excision of sacral giant cell tumors

Abstract

Sacral giant cell tumors are rare neoplasms, histologically benign but potentially very aggressive due to the difficulty in achieving a complete resection, their high recurrence rate, and metastization capability. Although many treatment options have been proposed, en bloc excision with tumor-free margins seems to be the most effective, being associated with long term tumor control, improved outcome, and potential cure. An exemplifying case of a 29-year-old female with progressive complaints of pain and paresthesias in the sacral and perianal regions, constipation, and weight loss for 6 months is presented. The surgical technique for en bloc excision of a large sacral giant cell tumor through a modified Kraske procedure with mid-sacrectomy and coccygectomy is described. Complete resection with wide tumor-free margins was achieved. At 5 years of follow-up the patient is neurologically intact, without evidence of local recurrence on imaging studies. A multidisciplinary surgical procedure is mandatory to completely remove sacral tumors. In the particular case of giant cell tumors, it allows minimizing local recurrence preserving neurovascular function, through a single dorsal and definitive approach.

Figure 1

Preoperative T2-weighted contrast enhanced MRI showing an expansive and osteolytic lower and mid-sacral lesion, extending up to the inferior half of S2 vertebra, with both intra- and extracanalar components and a ventral extension displacing the rectum anteriorly. (a) Coronal, (b) sagittal, and (c) axial views.

Figure 2

Previewed en bloc excision of the tumor on coronal MRI. Green and yellow lines represent the limits of the specimen to be resected, respectively, corresponding to the 3 sacral osteotomies and the inferior margin around the tumor.

Figure 3

Exposition of dorsal fascia from lumbosacral junction to the tip of the coccyx.

Figure 4

Inferior soft tissue dissection exposing the tip of the coccyx.

Figure 5

Initial finger dissection used to mobilize the rectum.

Figure 6

Kraske procedure providing access between mesorectum and presacral component of the tumor.

Figure 7

Superior subperiosteal dissection.

Figure 8

Soft tissues intentionally left behind and included in the specimen to be resected.

Figure 9

Thecal sac ligation distal to S2 nerve roots (red line).

Figure 10

Representation in a model of the 3 osteotomies performed (green lines) and the level of thecal sac ligation (thin red line). (a) Posterior view and (b) anterior view.

Figure 11

En bloc resected specimen. (a) Ventral surface and (b) dorsal surface.

Figure 12

S2 nerve roots were preserved and remained intact along their entire length.

Figure 13

Rotational flaps of the gluteus maximus provided for soft tissue reconstruction and wound closure.

Figure 14

(a) Hematoxylin-eosin stained tissue demonstrated a highly cellular, solid neoplasm consisting of mononuclear cells and osteoclast-like giant cells; (b) intense immunohistochemical staining for CD68 (KP1).

Figure 15

MRI scan evaluation 5 years after surgery, showing no recurrence of the tumor. (a) Coronal and (b) sagittal views.