Limb-Salvage Treatment of Malignant Pelvic Bone Tumors in China: 20 Years of Progress

Malignant pelvic bone tumors are among the most complex cancers to treat. Their deep location means they often go undetected until they’re large, and the pelvis’s proximity to critical nerves, blood vessels, and organs (like the intestines and bladder) makes surgery high-risk. For decades, hindquarter amputation—removing the entire leg and part of the pelvis—was the only way to stop the cancer. But over the past 20 years, Chinese orthopedic oncologists have transformed care: limb-salvage surgery (keeping the leg) is now standard for most patients, with better survival, fewer complications, and improved quality of life. Here’s how we got here.

The Past: Hindquarter Amputation—A Last Resort

Before the 1980s, hindquarter amputation was the gold standard for malignant pelvic tumors. It was classified into four types (classical, modified, extended, compound) based on how much tissue was removed, but all versions left patients with permanent disability and emotional distress. By the 1990s, however, new surgical techniques (like partial hemipelvectomy) offered a way to remove tumors while sparing the leg. Today, only patients with extremely large or aggressive tumors still need amputation—but it’s no longer the first choice.

The Shift to Limb-Salvage: Partial Hemipelvectomy

The breakthrough came from the Enneking classification, which divides pelvic tumors into four types based on their location:

Type I: Affects the iliac bone (upper pelvis)
Type II: Involves the hip socket (periacetabular)
Type III: Targets the pubis/ischium (lower pelvis)
Type IV: Invades the sacroiliac joint (where the pelvis meets the spine)

Most tumors spread to two or more areas, but Enneking’s system showed that partial hemipelvectomy—removing only the affected parts—could achieve the same cancer control as amputation. Chinese surgeons began using this approach in the 1980s, and results quickly improved. At the Musculoskeletal Tumor Center of Peking University People’s Hospital (PKUPH), a leading center for pelvic cancer care, researchers reported:

90.5% limb-salvage rate
61.9% rate of en-bloc resection (removing the tumor in one piece, critical for preventing recurrence)
44% 5-year survival rate

These numbers were better than global averages—and they proved limb-salvage was not just possible, but effective.

Reconstruction: Fixing the Pelvis After Tumor Removal

Removing a pelvic tumor leaves a gap—rebuilding that gap to restore function is where Chinese surgeons truly innovated. Here’s how they tackled different tumor types:

Type I (Iliac Bone) or Type I+IV (Sacroiliac Joint)

Early on, surgeons didn’t reconstruct Type I defects, but this led to pelvic tilt, scoliosis, and hip problems. By 2002, PKUPH started using pedicle screws and titanium rods to stabilize the pelvis, with bone grafts from the fibula or remaining iliac bone. In 2015, they took it further with the 3D-printed modular iliac prosthesis (GPS Type I). Its porous metal trabecular structure let the prosthesis fuse with the remaining bone, and its modular design made surgery faster and more precise.

Type II (Hip Socket) or Type II+III (Lower Pelvis)

The hip socket is the trickiest area to rebuild—old prostheses like the saddle prosthesis (1979) had a 60% complication rate (dislocation, fracture, infection). Even newer devices like the Ice-Cream Cone Prosthesis (2001) had infection rates up to 47%.

PKUPH changed the game with its modular hemipelvic endoprosthesis (2002). In a 100-patient study, the team reported:

15% deep infection rate (vs. 20–40% for older prostheses)
5% mechanical failure (vs. higher rates for custom devices)
9% dislocation rate (vs. 20% for Ice-Cream Cone)

Patients also regained function: the average Musculoskeletal Tumor Society (MSTS) score—a measure of mobility—was 57.2%, meaning most could walk with a cane or without assistance.

In 2016, PKUPH introduced 3D-printed pelvic prostheses (GPS Type II), which are custom-made to fit each patient’s anatomy. The porous surface promotes bone growth, reducing long-term complications. Over 200 patients have now received these prostheses, with promising early results.

Type I+II+IV: Complex Defects

For tumors that spread to multiple pelvic areas, PKUPH developed a translumbar fixed hemipelvic prosthesis (2007). It uses a bi-axle gear to adjust the hip angle during surgery and connects to the lumbar spine via screws, adding stability. In 2015, they upgraded it with a 3D-printed sacral surface (GPS Type III), which fuses with the spine and cuts mechanical failure rates.

Tackling Sacral Involvement: A New Classification

Tumors that spread to the sacrum (lower spine) are especially dangerous—they’re close to the spinal cord, nerves, and blood vessels. The Enneking system classified these as Type IV, but it didn’t offer clear surgical guidelines. In 2016, PKUPH created the P-s classification to fill this gap:

P-s I: Tumor affects the ipsilateral sacroiliac joint
P-s II: Invades the ipsilateral sacral foramina (nerve openings)
P-s III: Reaches the contralateral sacral foramina
a: No hip socket involvement
b: Hip socket involvement

This divides sacral tumors into six types (e.g., P-s Ia, P-s IIb) and matches each to a specific surgical approach and reconstruction method. The result? Better cancer control, fewer complications, and improved function for patients with sacral spread.

Beyond Surgery: Adjuvant Therapies Save Lives

Surgery alone isn’t enough—Chinese teams have integrated adjuvant therapies (treatments that support surgery) to improve outcomes:

Aortic Balloon Occlusion: Pelvic/sacral tumors bleed heavily during surgery (up to 5,000 mL historically). By inflating a balloon in the aorta (main artery) to temporarily stop blood flow, PKUPH cut average blood loss to 2,000 mL. This makes surgery safer and reduces transfusion needs.
Targeted Therapy: For giant cell tumors of bone (a rare, aggressive cancer), the drug denosumab (a RANKL inhibitor) shrinks tumors before surgery. This lets more patients have limb-salvage and lowers recurrence rates.
Radiation/Chemotherapy: Modern radiation targets tumors more precisely, even for radiation-resistant cancers like Ewing sarcoma. For pelvic osteosarcoma (common in young adults), debates remain about chemotherapy’s role—but combined therapy improves survival for some patients.

Where We Stand Now: Progress and Challenges

Over 20 years, Chinese orthopedic oncologists have:

Raised limb-salvage rates from <50% to 90.5%
Cut infection rates for prostheses from 40% to 15%
Developed 3D-printed prostheses that fuse with bone
Created a global standard for sacral tumor surgery

But challenges remain:

Local Control: Some tumors still recur, especially if they’re large or aggressive.
Survival: 5-year survival rates (44%) are better than before but still lower than limb tumors.
Long-Term Prosthesis Durability: Even 3D-printed devices need monitoring for wear and tear.

The Future: Hope for Patients

Today, a patient with a malignant pelvic tumor in China has more options than ever. Limb-salvage is the norm, not the exception, and new technologies like 3D printing and targeted therapy are making surgery safer and more effective. For the team at PKUPH and other Chinese centers, the goal is clear: to keep improving survival, reduce complications, and help patients regain their quality of life.

The past 20 years have been transformative—but the journey isn’t over. With continued innovation, we’re one step closer to turning pelvic cancer from a death sentence to a manageable disease.

This article is based on research by Wei Guo, Professor at the Musculoskeletal Tumor Center, Peking University People’s Hospital, Beijing, China. The original study was published in the Chinese Medical Journal (2019).

doi.org/10.1097/CM9.0000000000000509

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