title: Multimodality management of a giant cell tumor arising in the proximal sacrum: case report.
abstract: METHODS
  Descriptive.
  
  
  OBJECTIVE
  To outline a novel multimodality approach for a difficult surgical resection of a giant cell tumor in the cephalad portion of the sacrum.
  
  
  BACKGROUND
  Giant cell tumors of the sacrum are rare primary bone tumors. Recent reports have demonstrated diminished giant cell tumor recurrence with cryosurgery by using a "direct pour" technique with liquid nitrogen. Although successful in decreasing tumor recurrence, this technique is accompanied by a 4%-8% rate of skin necrosis and high rates of pathologic fracture. The authors describe resection and a novel, controlled method of argon-based cryotherapy (followed by a unique pelvic reconstruction) for a large, difficult giant cell tumor of the sacrum.
  
  
  METHODS
  A 29-year-old woman presented with complaints of right foot drop and decreased sensation of the right buttock, posterior thigh, posterior calf, and lateral aspect of the right foot. Radiographic evaluation revealed a mass in the right sacrum; histologic examination of CT-guided biopsy revealed a giant cell tumor. A combined anterior abdominal and posterior sacral approach was performed, the tumor was resected, and the margin of the cavity was treated with controlled argon-based cryotherapy. The combination of thermocouples, electromyographic monitoring, and rapid freeze-thaw cycles allowed a controlled ablation of the tumor margin while ensuring that surrounding structures, such as the rectal wall, sacral nerves, and gluteal muscles, were not damaged. Posterior spinal fusion L4 to sacrum, posterior spinal instrumentation L4 to pelvis, and allograft reconstruction of the right sacrum were performed.
  
  
  RESULTS
  The patient recovered well without skin necrosis or pathologic fracture. Urinary and fecal continence were preserved. At the 20-month follow-up the patient has no evidence of local tumor recurrence and is fully ambulatory without a brace or narcotic medication.
  
  
  CONCLUSIONS
  A novel multimodality approach, consisting of resection, controlled cryosurgery, and a unique lumbopelvic reconstruction, was safe and successful in managing a challenging proximal sacral giant cell tumor. Twenty months after surgery the patient has excellent bowel and bladder control, no tumor recurrence, and functional ambulation without a brace or pain.
authors.affiliation: Department of Orthopedics, University of California, Davis, Medical Center, Sacramento, California 95817, USA.
authors.forename: Peter L
authors.initials: PL
authors.lastname: Althausen
authors.forename: Philip D
authors.initials: PD
authors.lastname: Schneider
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Bold
authors.forename: Munish C
authors.initials: MC
authors.lastname: Gupta
authors.forename: James E
authors.initials: JE
authors.lastname: Goodnight
authors.forename: Vijay P
authors.initials: VP
authors.lastname: Khatri
mesh_terms: D000328:Adult; D003131:Combined Modality Therapy / Q000379:methods; D003452:Cryosurgery; D005260:Female; D020233:Gait Disorders, Neurologic / Q000209:etiology; D005870:Giant Cell Tumors / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy*; D006801:Humans; D006987:Hypesthesia / Q000209:etiology; D019651:Plastic Surgery Procedures; D012447:Sacrum / Q000473:pathology*; D013123:Spinal Fusion; D013125:Spinal Neoplasms / Q000175:diagnosis* / Q000473:pathology / Q000628:therapy*; D016896:Treatment Outcome