Chondrosarcoma

ABSTRACT

Purpose: The purpose of this case report is to describe the acute and subacute physical therapy management for a patient with an external hemipelvectomy (EHP) due to chondrosarcoma of the pelvis. Summary: The subject is a 44-year-old male diagnosed with chondrosarcoma of the pelvis and underwent an EHP amputation. He was found to have functional limitations measured by using the Functional Independence Measure (FIM). The intervention consisted of 9 treatment sessions in the hospital and 20 treatments at home over the course of 9 weeks. Treatment included progressive strength training, endurance training, balance and postural awareness, and agility training. The patient improved his FIM scores from initial examination to discharge. Physical therapy can greatly affect a patient's functional outcome and subsequent quality of life. This has not been described in the literature thus far.

INTRODUCTION

There are approximately 2,400 cases of bone cancer reported each year. Chondrosarcoma makes up 26% of all bone cancers and most frequently occurs in the pelvis.1 When the tumor has invaded two of the three-the lumbosacral plexus, the femoral neurovascular bundle, and the hip joint-it is managed with an external hemipelvectomy (EHP).2,4 An external hemipelvectomy (EHP) is a rare and extensive amputation of the lower extremity at the level of the hip, with disarticulation through the pubic symphysis and sacroiliac joint. See radiograph 1 and picture 1. This extensive surgery affects a person's life both physically and emotionally creating challenges at all levels of the disablement model.8

Based on one author's (KP) experience working with patients with EHP, there may be a slightly prolonged postoperative period of decreased mobility and limited physical therapy participation due to pain management issues and physiologic consequences of many hours on the operating table when compared to other patients who have undergone amputations of smaller proportions. So while there are guidelines for patient's postamputation, to our knowledge there are none for individuals with EHP due to sarcoma resections. The impairments, functional limitations, and disabilities resulting from this surgery as well as specific physical therapy interventions will be described in this article.

Physical therapists working with patients' post-EHP may find information in the literature pertaining to surgical outcomes, functional prognosis, complications of EHP management, as well as outdated prosthetic options. The most recent articles on prosthetics for this population were published in the late 1970s.4-7,14-16 This information may be useful for goal setting and selected aspects of patient management, however, it does not guide the therapists with examination and designing a plan of care. To our knowledge there is nothing published in the literature about physical therapy management of a patient with an acute or subacute EHP. Therefore the purpose of this case report is to describe the acute and subacute physical therapy management and functional outcomes for a patient with an EHP. This was achieved using a combination of clinical experience and the Guide to Physical Therapist Practice.

CASE DESCRIPTION

History

The patient a 44-year-old male from Spain with no significant past medical history presented with left hip pain for 3 months. Findings on MRI (magnetic resonance imaging) revealed a lesion within his left hemipelvis. A CT scan (computed axial tomography) of the abdomen and chest was positive for a lytic lesion in the ilium and left acetabulum with soft tissue involvement indicating a malignant process. No evidence of distant metastasis was found on the bone scan. Due to the size of the tumor and soft tissue involvement as found by the preoperative imaging, a formal extended hemipelvectomy (excision of the pelvis and part of the sacrum) was necessary to ensure complete removal of the tumor and ensure negative margins. Tissue biopsy at the time of surgery confirmed the preoperative diagnosis of dedifferentiated chondrosarcoma stage II B involving the entire left hemipelvis with soft tissue mass extending medially. Possible postoperative chemotherapy and/or radiation were planned for when the surgical area was healed and when the patient returned to Spain. Prior to the hospital admission, the patient had no past medical history, was on no medications, and denied any alcohol or tobacco use. He was married, living with his wife and 8-year-old son in Barcelona, Spain, and employed full time as an attorney. He was extremely active and independent with all mobility and activities of daily living.

Examination and Evaluation

Initial physical therapy examination was on postoperative day number three. The patient had no range of motion, weight bearing, or other precautions except a 30-minute sitting limitation for the first week postoperatively due to the surgical wound. Range of motion of the patient's upper extremities and right lower extremity were grossly measured in supine using the standards described by Norkin and White.9 His upper extremity and right lower extremity strength was also measured in supine using the manual muscle testing technique as described by Hislop and Montgomery.10 His range of motion and strength in both upper extremities and his right lower extremity were all within normal limits. His sensation to light touch and proprioception tested as described by O'Sullivan and Schmitz11 was intact for his right lower extremity. He had intermittent complaints of phantom sensation that did not limit his participation in therapy. The phantom pain was managed by his medical team by administering the medication Neurontin. Functional mobility was measured using the FIM (Functional Independence Measure) at initial examination. The FIM was subsequently administered during the patient's re-evaluation, discharge from the hospital, initial examination of home care, and discharge from home care to monitor his functional improvement.12 See Figure 1.

In the acute phase, this patient's goals were for independent bed mobility, transfers, and ambulation with a rolling walker. The primary impairments limiting his mobility consisted of compromised skin integrity, edema, and pain at the wound site. We speculated that he might require a greater amount of time to meet these initial short-term goals compared to other patients with less extensive amputations and who did not have the diagnosis of cancer. His 7 hours of surgery, pain due to the location and size of the wound and how it would affect his mobility, cancer-related fatigue from the tumor, or postoperative fevers due to infection at the wound site were all comorbidities that would slowly recovery. However, once the patient's body adjusted to the initial trauma of the extensive surgery, it was realistic for him to meet his long-term goals at discharge from home care physical therapy of independent transfers, ambulation with crutches, and stair negotiation, as well as improvements in strength, balance, and endurance within the expected range of number of visits for patients with amputations (15-45) as described in the Guide to Physical Therapist Practice.8

Diagnosis and Prognosis

The patient's physical therapy diagnosis according to the APTA's Guide to Physical Therapist Practice was impaired motor function, muscle performance, and gait and balance associated with amputation. According to the Guide, the preferred practice pattern for this patient would be classified under 4J "Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgical Procedures." This practice pattern estimates optimal motor function, muscle performance, gait and balance, and a full functional recovery within 6 months. The expected number of visits per episode of care is 15 to 45 for 80% of the patients classified in this practice pattern.8 The amount of physical therapy treatment sessions this patient received does fall within this range. This patient's medical prognosis according to Pring et al 2001, states that the estimated 10-year survival rate for patients with dedifferentiated chondrosarcoma of the pelvis is 14%.2

Intervention

The patient received a total of 9 physical therapy sessions during his 12-day admission, each lasting 30 to 45 minutes while in the hospital. The physical therapy interventions initially included progressive strength training of the patient's right lower extremity using open chain bed exercises, bed mobility for rolling and scooting, transfers for supine to sitting at the edge of the bed, and stand pivot transfers from the bed to the wheelchair. See chart 1. The patient was provided with a custom made t-foam cushion with a cut out section on the surgical side to decrease the amount of pressure on the wound area on the second day of therapy. Initial gait training with a rolling walker began day three of physical therapy treatment. Endurance training was also added to increase the amount of time the patient was out of bed in the wheelchair. Balance activities progressed from static and dynamic sitting to static standing. Family training was performed during all treatment sessions in the hospital, and the patient's father was able to safely guard and assist him during transfers in and out of bed as well as for walking short distances with the rolling walker.

Upon discharge, the patient was seen at home by the same physical therapist. The patient participated in 20, sixty-minute sessions of physical therapy over a 9-week period. Physical therapy was progressed to include floor transfers, car transfers, gait training with forearm crutches, and stair negotiation. Closed chain strengthening exercises for the patient's right lower extremity and core consisted of squats, push-ups, and stabilization exercises. Endurance training was now part of gait and stair training; postural awareness activities were done in standing; and activities of daily living were used for task-specific agility training. See chart 1.

Training intensity was monitored and adjusted by patient's heart rate (HR), respiratory rate (RR), subjective response to activity, and observation of the patient's amount of perspiration and pallor. Due to the patient's young age, prior fitness level and lack of comorbid health issues, he was able to tolerate 45 minutes to an hour of continuous exercise with vital signs stable and responding appropriately. Treatment rationale was based on restoring functional independence. This was primarily done using task-specific training for strengthening, balance, and endurance. The patient's most limiting factor was decreased endurance and fatigue. This was monitored as subjective information reported by the patient daily and accounted for by attempting to schedule therapy in the early afternoon, which was the time of day the patient felt his best.

Initially, the patient tolerated 5 minutes of continuous exercise with seated rest breaks. As his endurance improved, he was able to tolerate increasing amounts of continuous activity with less rest breaks. Nine weeks after surgery and at the time of discharge from home care, the patient was able to perform 2 hours of continuous activity.

Gait training began up and down a level hallway with a rolling walker 50 to 100 feet and then with forearm crutches. Eventually, gait training was conducted outside on a level city street and within 2 weeks, progressed to uneven surfaces outside. Stair negotiation started with one crutch and a rail with a lot of assistance and slowly progressed over 4 weeks to 2 crutches with less assistance. At discharge, the patient was able to ascend and descend 2 flights of stairs with 2 forearm crutches independently (Figure 2).

Outcomes

The patient improved his FIM scores from initial examination as an inpatient to his discharge from home physical therapy services. He initially required minimal to moderate assistance with all mobility. Following 9 weeks of physical therapy, the patient was able to perform rolling independently and all other mobility with modified independence. (Based on the FIM instrument, modified independence is defined as "one or more of the following may be true: the activity requires an assistive device; the activity takes more than a reasonable time; or there are safety considerations."12) The patient's ambulation without rest was also tracked over time. Figure 3 shows how appreciably the patient's distance increased during the time he was receiving physical therapy. During his 12 days (weeks 1 and 2 in Figure 2) in the acute hospital, the patient ambulated 100 feet with a rolling walker. By week 4 postoperatively (2 weeks into home care physical therapy), he ambulated 400 feet independently using the rolling walker. The patient also began crutch training at this time, but not until week 7 was he able to tolerate increased distances of 1000 feet with supervision assist. By week 9, the patient tolerated 2 hours of transfers, standing and ambulation with forearm crutches independently through Times Square, New York City.

Discussion

This was a case report of a patient with an external hemipelvectomy amputation who had impairments, functional limitations, and disabilities in the acute phase postoperatively. Physical therapy interventions and functional outcomes for patients with EHPs are seldom reported in the literature and although the diagnosis is more complex than a standard lower extremity amputation, PT examination, evaluation, diagnosis, prognosis, and treatment can follow the practice pattern 4J in the Guide to Physical Therapist Practice as described in this paper. The patient was able to meet all determined goals within an appropriate amount of time as specified in the Guide.8 He was only limited in the acute phase of rehabilitation by mild fatigue that was measured subjectively by the patient's ability to participate in therapy, postoperative pain, measured using a visual analog scale and fevers. He was successful in achieving the endurance capacity necessary to be independent in all mobility and activities of daily living before discharge from home care physical therapy and the possible start of adjuvant chemotherapy and radiation treatment back in Spain.

Physical therapists working with the oncology population may use this case to illustrate how regaining function and independence with activities of daily living may be a realistic goal despite the stage or medical prognosis of the disease. As long as the goals are patient and time specific, rehabilitation and functional independence can make a positive impact on a patient's mobility and resumption of premorbid life. Physical rehabilitation in the acute cancer setting can be challenging due to various factors of the disease processes and from the side effects of specific cancer treatments. Many of the effects can have a direct influence on the patient's functional status. Cancer related fatigue, cancer pain, anemia, thrombocytopenia, and the emotional and psychological burden of a cancer diagnosis can all significantly impact rehabilitation.1,4,6,7,13

This case is an example of how a patient with an extensive tumor and a radical surgery can regain full function and resume most aspects of his premorbid life. Information about the patient's quality of life would have completed the examination process and aided in evaluating the outcome of the intervention.

REFERENCES

1. Types of Bone Cancer. Available at: http://www.mskcc.org/ mskcc/html/11604.cfm. Accessed February 12, 2002.

2. Pring, Weber, Unni, Sim. Chondrosarcoma of the pelvis. J Bone Joint Surg. 2001;83;1630-1642.

3. Wirbel, Schulte, Wutschler. Surgical treatment of pelvic sarcomas: Oncologic and functional outcomes. Clin Orthop Rel Res. 2001;1(390):190-205.

4. Apffelstaedt, Spellman, Velez, Gibbs, Karakousis. Complications and outcome of external hemipelvectomy in the management of pelvic tumors. Ann Surg Oncol. 1996;3(3): 304-309.

5. Enneking. An abbreviated history of orthopedic oncology in North America. Clinical Orthop Rel Res. 2000;1(314):115-124.

6. Enneking, Dunham, Gebhardt, Malawar, Pritcard. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Rel Res. 1993;286:241-246.

7. Mankin, Hornicek, Temple, Gebhardt. Malignant tumors of the pelvis: an outcome study. Clin Orthop Rel Res. 2004; 1(425):212-217.

8. Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.

9. Norkin, White. Measurement of Joint Motion: A Guide to Goniometry. 2nd ed. Philadelphia, Pa: RA. Davis Company; 1985.

10. Hislop, Montgomery. Muscle Testing: Techniques of Manual Examination. 6th ed. Philadelphia, Pa: W.B. Saunders Company; 1995.

11. O'Sullivan, Schmitz. Physical Rehabilitation Assessment and Treatment. 3rd ed. Philadelphia, Pa: F.A. Davis Company; 1988.

12. Dodds TA, Matrin DP, Stolov WC, Deyo RA. A validation of the Functional Independence Measurement and its performance among rehabilitation inpatients. Arch Phys Med Rehabil: 1993;74(5):531-536.

13. Echenique-Elizondo, Concuera, Usabiaga Zarranz. (2003). Extended hemipelvecomy- quality of life 20 years later. The Lancet Oncology. 2003;4(3):186-186.

14. Van der Geest, Servaes, Schreuder, (2002). Chondrosarcoma of bone: Functional outcome and quality of life. Journal of Surgical Oncology, 81 (2), 70-74.

15. Sneppen, Johansen, Heerfordt, Dissing, Peterson. Hemipelvectomy. Post-operative rehabilitation assessed on the basis of 41 cases. Acta Orthop Scand: 1978;49(2):175-179.

16. Walden, Davis. Prosthetic fitting and points of rehabilitation for hindquarter and hip disarticulation patients. Physiotherapy. 1979; 66(1):4-6.

Karen Palgi, PT, DPT;1 Judith Deutsch, PT, PhD2

1 Memorial Sloan Kettering Cancer Center, New York, NY. Senior Physical Therapist

2 UMDNJ, SHRP- Doctoral Program in Physical Therapy

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