Conservative surgery for giant cell tumors of the sacrum. The role of cryosurgery as a supplement to curettage and partial excision.

BACKGROUND: Giant cell tumors (GCTs) of the sacrum are a difficult clinical problem. Wide excision (total sacrectomy) is associated with high morbidity and pelvic/spinal instability. Curettage with or without supplemental radiotherapy is associated with a high recurrence rate. In view of the proven effectiveness of cryosurgery as an adjunct to curettage for extremity GCT, cryosurgery was used for treatment of GCTs of the sacrum.
METHODS: Seven patients with GCTs of the sacrum were treated at our institution by conservative surgery from 1973 to 1992. Four patients presented with recurrent tumors after failing previous radiation treatment (dose, 5040 cGy). Four patients were treated with curettage with cryosurgery and three with limited excision with cryosurgery. In the latter procedure after limited excision of the caudal (below S2) part of the tumor, the upper sacral segments were treated with curettage and cryosurgery. This spared the important upper sacral roots and maintained the skeletal integrity.
RESULTS: At a median follow-up of 12.25 years (range, 2-14.2 years), all patients were disease free. Local recurrence developed in two patients. Both of these underwent repeat curettage and cryosurgery and have since remained disease free. Two patients had positive second look biopsy with microscopic tumor. Both of these were treated with repeat cryosurgery and have remained disease free. Two patient who developed solitary pulmonary metastases, underwent wedge resection and are alive without disease. No patient suffered neurologic deterioration.
CONCLUSION: Conservative surgery (curettage or partial excision) with adjunct of cryosurgery is our preferred technique for the treatment of GCT of the sacrum. Satisfactory local control could be obtained by close observation, second look biopsy and repeat cryosurgery. The chief advantages of this method include preservation of pelvic and spinal continuity, speed and ease of surgical procedure and less potential blood loss. We recommend it over more radical sacrectomy due to low morbidity and less resultant neurologic deficits.