骨盆骨肉瘤的外科治疗策略探讨

Objectives To investigate the clinical outcome of consecutive pelvic osteosarcoma treated with surgery and chemotherapy in a single institution, and to discuss the surgical strategy, resection and reconstruction. Methods Twenty-one consecutive cases with pelvic osteosarcoma underwent surgical procedures between June 2000 and June 2009. There were 12 male and 9 female with a mean age of 32 years. According to Enneking and Dunham pelvic classification system, type I was 3 cases, type I + IV 3 cases,type I + Ⅱ 4 cases,type Ⅱ + Ⅲ 4 cases,type I + Ⅱ + Ⅲ 1 case,type Ⅲ 1 case,and type I + Ⅱ + Ⅳ 5 cases. Among the 21 cases, 19 were diagnosed as classical osteosarcoma and 2 were diagnosed as low-grade pathologically. All the tumors were stage Ⅱ B. All the patients received en-bloc resection with 13 wide resection and 8 marginal resection. Thirteen patients underwent modular hemipelvic endoprosthesis reconstruction, and 5 patients underwent rod-screw system reconstruction combined with autograft. Two patients received hemipelvectomy and one type Ⅲ patients had resection without reconstruction. The mean follow-up period was 30. 3 months (range,6. 0-87. 0). Results Thirteen patients out of 21 survived after treatment The overall survival rate was 61. 9% , and 23. 8% patients were alive without disease. The estimated 5-year survival rate was 44. 2% based on Kaplan-Meier curve. The local recurrence rate was 28.6% , among which 4 cases were type Ⅱ resection, 1 was type I resection, 1 was type I + Ⅳ resection. No local relapse was found on the hemipelvectomy and type Ⅲ resection cases. The local recurrence rate after wide resection was 23. 1% ,and 37. 5% for marginal resection. Nine patients had lung metastases and one patient was found bone and lymph node metastases. The MSTS 93 function score was 20. 6±5. 4 for 13 patients,and 22. 5±2. 1 for rod-screw reconstruction cases. The function score was 17. 7±5. 5 for hemipelvic prosthetic reconstruction. Conclusion Limb salvage procedures could be performed on most pelvic osteosarcoma cases, and satisfying function outcome could be achieved with proper reconstruction,however,the overall survival is still lower compared with those in extremities.     

原位微波灭活术治疗骨盆恶性骨肿瘤的临床研究

目的 探讨原位微波灭活术治疗骨盆原发恶性肿瘤及转移瘤的疗效.方法 2000年2月至2009年4月对18例骨盆原发恶性肿瘤及转移瘤患者采用原位微波灭活及肿瘤全部或部分切除,男11例,女7例;年龄16～72岁,平均45岁.原发恶性骨肿瘤12例,转移瘤6例.肿瘤累及Ⅰ区6例、Ⅱ区10例、Ⅲ区2例.根据肿瘤所在区域采用传统髂腹股沟切口或髂腹股沟"T"形切口进行显露,以铜网保护周围软组织,用2450 MHz微波将肿瘤局部加热至50℃,持续20 min,全部或部分剥离坏死肿瘤组织,保留骨盆环的解剖连续性.结果 手术时间60～180min,平均110min;术中失血量400～800ml,平均480 ml.无严重的术中及术后并发症.随访0.5～7年,平均3.5年.1例软骨肉瘤患者术后8个月复发,随访6个月带瘤生存.1例恶性纤维组织细胞瘤患者术后24个月出现肺、脑和全身多发转移死亡.1例骨肉瘤患者术后18个月出现肺转移死亡.6例骨盆转移瘤患者中5例分别于术后6～19个月出现其他部位转移而死亡.术后3个月18例患者患侧髋关节屈曲80°～130°,后伸0°～10°,外展25°～35°,内收18°～23°.结论 原位微波灭活术具有操作简便、疗效可靠、创伤小的特点,可用于或辅助用于骨盆恶性骨肿瘤的治疗,能保持骨盆环的完整性.

Abstract：

Objective To investigate the clinical outcomes of microwave heliotherapy in situ on the primary or metastatic malignant tumors of the pelvis.Methods From February 2000 to April 2009,18 patients with primary or metastatic malignant tumors of the pelvis were treated with microwave heliotherapy in situ,and followed a total or partial tumor resection.There were 11 males and 7 females with an average age of 45 years(range,16-72).Twelve cases were diagnosed as primary malignant tumor and 6 as metastases.Locations of tumors involved:the Ⅰ region 6 cases.the Ⅱ region 10 cases.and the Ⅲ region 2 cases.The exposures of all tumors were via a"T"type or ilioinguinal approach.The lesions were heated at 50℃ for 20 min by 2450 MHz microwave,with surrounding soft tissue protected by copper.mesh.The necrotic tumor tissues were total or partial excised after treatment,with preservation of the anatomical continuity of the pelvic ring.Results The duration of surgery was 60-180 min (110 min on average).The blood loss was 400-800ml(480 ml on average).All patients were followed-up for 0.5-7 years(3.5 years on average).Tumor local recurred in 1 case with chondrosarcoma,and was survival in tumor-bearing after 6 months follow up.One case with malignant fibrous histiocytoma died due to brain,pulmonary,and all body metastases.One case with osteosarcoma died due to pulmonary metastases.Five cases with the metastases died due to non-pelvis metastases.Functions of hip joint in 18 patients were as follows:flexion 80°-130°,extension 0°-10°,abduction 25°-35°,and adduction 18°-23°.Conclusion The clinical result demonstrated that the advantages of microwave heliotherapy in situ were quick increase of temperature,sensitive responses,easy control of temperature,and effective inactivation of tumor cells in the malignant bone tumors of pelvis.     

骨盆骨肉瘤的外科治疗策略探讨

Objectives To investigate the clinical outcome of consecutive pelvic osteosarcoma treated with surgery and chemotherapy in a single institution, and to discuss the surgical strategy, resection and reconstruction. Methods Twenty-one consecutive cases with pelvic osteosarcoma underwent surgical procedures between June 2000 and June 2009. There were 12 male and 9 female with a mean age of 32 years. According to Enneking and Dunham pelvic classification system, type I was 3 cases, type I + IV 3 cases,type I + Ⅱ 4 cases,type Ⅱ + Ⅲ 4 cases,type I + Ⅱ + Ⅲ 1 case,type Ⅲ 1 case,and type I + Ⅱ + Ⅳ 5 cases. Among the 21 cases, 19 were diagnosed as classical osteosarcoma and 2 were diagnosed as low-grade pathologically. All the tumors were stage Ⅱ B. All the patients received en-bloc resection with 13 wide resection and 8 marginal resection. Thirteen patients underwent modular hemipelvic endoprosthesis reconstruction, and 5 patients underwent rod-screw system reconstruction combined with autograft. Two patients received hemipelvectomy and one type Ⅲ patients had resection without reconstruction. The mean follow-up period was 30. 3 months (range,6. 0-87. 0). Results Thirteen patients out of 21 survived after treatment The overall survival rate was 61. 9% , and 23. 8% patients were alive without disease. The estimated 5-year survival rate was 44. 2% based on Kaplan-Meier curve. The local recurrence rate was 28.6% , among which 4 cases were type Ⅱ resection, 1 was type I resection, 1 was type I + Ⅳ resection. No local relapse was found on the hemipelvectomy and type Ⅲ resection cases. The local recurrence rate after wide resection was 23. 1% ,and 37. 5% for marginal resection. Nine patients had lung metastases and one patient was found bone and lymph node metastases. The MSTS 93 function score was 20. 6±5. 4 for 13 patients,and 22. 5±2. 1 for rod-screw reconstruction cases. The function score was 17. 7±5. 5 for hemipelvic prosthetic reconstruction. Conclusion Limb salvage procedures could be performed on most pelvic osteosarcoma cases, and satisfying function outcome could be achieved with proper reconstruction,however,the overall survival is still lower compared with those in extremities.     

Clinical efficacy of superselective arterial embolization in the treatment of hemorrhage from malignant gestational trophoblastic tumor

<正>Objective:To evaluate the efficacy of superselective arterial embolization in controlling hemorrhage from malignant gestational trophoblastic tumor. Methods:From February 1990 to January 2008,44 patients with hemorrhage from malignant gestational trophoblastic tumor(including 29 cases of choriocarcinoma and 15 cases of invasive mole) were treated with superselective arterial embolization.The hemorrhage sites included uterus(40 cases),cervical metastasis(1 case) and vaginal metastasis (3 cases). Results:In 41 cases(93.2%),superselective arterial embolization successfully controlled the hemorrhage. Hysterectomy was performed in the 3 failed cases and uterine perforation was revealed by laparotomy.Five patients had normal term delivery after successful superselective arterial embolization and chemotherapy,and two patients are now in the healthy second trimester of pregnancy. Conclusion:Superselective arterial embolization can effectively control the hemorrhage from malignant gestational trophoblastic tumor.     

胰腺实性假乳头状瘤的诊治(附4例)

Objective To discuss the management of solid-pseudopapillary tumor of the pancreas. Methods Four patients of solid-pseudopapillary tumor of the pancreas (SPT) were diagnosed by pathology. One patient was underwent magnetic resonance and two enhanced computer tomography scan. The mass was located in tuberculum (1 case), neck (1 case), and body-tail (2 cases) of pancreases respectively. Four cases were underwent duodenopancreatectomy, local resection of mass, resection of body-tail of pancreases respectively. The maximal diameter of tumor ranged from 5 cm to 16cm, averaged 10.3cm. The blood regular test and biochemistry were normal, and the tumor markers including AFP,CA19-9,CA125,CEA also were normal. The specimens were examined by pathology and immunohistochemistry. Results Four cases all were diagnosed solid-pseudopapillary tumor of the pancreas by pathology. At histologic analysis, the tumor was composed of uniform polygonal cells with moderate to abundant amphophilic cytoplasm and arranged in solid nests with areas of degeneration characterized by separation of the cells into pseudopapillary aggregates with intervening accumulation of mucopolysaccharide rich ground substance. The expressions of Vimentin, α-ACT, α-AAT were positive, and CgA negative. Four cases were followed up for six months and norecurred. Conclusions SPT of pancreases was a kind of tumor of low potential malignancy, and the magnetic resonance and computer tomography were often to be used. The effective therapy was thoroughly resection, and the prognosis in most patients is excellent.     

胰腺实性假乳头状瘤的诊治(附4例)

Objective To discuss the management of solid-pseudopapillary tumor of the pancreas. Methods Four patients of solid-pseudopapillary tumor of the pancreas (SPT) were diagnosed by pathology. One patient was underwent magnetic resonance and two enhanced computer tomography scan. The mass was located in tuberculum (1 case), neck (1 case), and body-tail (2 cases) of pancreases respectively. Four cases were underwent duodenopancreatectomy, local resection of mass, resection of body-tail of pancreases respectively. The maximal diameter of tumor ranged from 5 cm to 16cm, averaged 10.3cm. The blood regular test and biochemistry were normal, and the tumor markers including AFP,CA19-9,CA125,CEA also were normal. The specimens were examined by pathology and immunohistochemistry. Results Four cases all were diagnosed solid-pseudopapillary tumor of the pancreas by pathology. At histologic analysis, the tumor was composed of uniform polygonal cells with moderate to abundant amphophilic cytoplasm and arranged in solid nests with areas of degeneration characterized by separation of the cells into pseudopapillary aggregates with intervening accumulation of mucopolysaccharide rich ground substance. The expressions of Vimentin, α-ACT, α-AAT were positive, and CgA negative. Four cases were followed up for six months and norecurred. Conclusions SPT of pancreases was a kind of tumor of low potential malignancy, and the magnetic resonance and computer tomography were often to be used. The effective therapy was thoroughly resection, and the prognosis in most patients is excellent.     

小儿原发性心脏肿瘤27例分析

目的 探讨原发性心脏肿瘤的治疗经验.方法 回顾性分析1999年5月至2009年5月27例经心脏超声检查确诊为心脏肿瘤患者的临床资料.男性20例,女性7例;年龄24 d～12.6岁,＜1岁者16例,占59.2%.22例为单发心脏肿瘤,5例为多发.其中22例因心律失常、心包积液、呼吸困难、晕厥等症状进行手术切除,5例未施行手术.根据肿瘤的具体位置选择不同的切口径路,14例完整切除肿瘤,8例部分切除;5例行二尖瓣整形,2例行三尖瓣整形.结果 术后肿瘤组织学结果:纤维瘤5例,横纹肌瘤8例,黏液瘤4例,毛细血管瘤3例,纤维肉瘤和卵黄囊瘤各1例.16例术后循环稳定;2例出现低心排血量,经治疗后心功能恢复;4例因严重低心排血量并发多器官功能衰竭死亡.18例术后随访1～10年,2例横纹肌瘤残余肿块缩小,1例消失;1例纤维肉瘤、1例血管瘤残余肿块未增大;黏液瘤术后无复发或远处种植转移.5例未手术者随访1～3年,其中2例无明显症状;1例左心室游离壁肿瘤因心律失常死亡,另1例仍存活;1例多发性心脏肿瘤伴低心排血量患者因心力衰竭死亡.结论 小儿原发性心脏肿瘤应采用个体化治疗原则,对有明显症状者应行手术治疗,对无明显症状者要密切随访.手术的目的 不是完整切除肿瘤,而是要恢复正常的血流动力学状态.

Abstract：

Objective To analyze the experience of treatment strategies for pediatric patients with primary cardiac tumors. Methods The clinical data of 27 patients with primary cardiac tumors which detected by echocardiography from May 1999 to May 2009 was analyzed retrospectively. There were 20 male and 7 female patients, aged from 24 d to 12. 6 years. There were 59. 2% less than 1 year old at the time of diagnosis. A single tumor were present in 22 cases and multiple in 5 cases. Surgery was performed for 22 patients due to the varied significant symptoms such as arrhythmia, pericardial effusion, swoon and congestive heart failure with dyspnoea. Five patients were discharged hospital without surgical treatment. The surgical approachs were adopted according to tumor location. Complete surgical resection was performed in 14 patients and partial resection in 8 patients. Seven patients were underwent valve reconstruction,5 involving the mitral valve and 2 involving the tricuspid valve. Results Histologic examination of the surgically resected tumors showed rhabdomyomas in 8 cases, fibromas in 5 cases, hemangiomas 3 cases,myxomas in 4 cases, fibrosarcoma in 1 case and yolk sac sarcoma in 1 case. Sixteen cases revealed stable haemodynamic status postoperative. Two cases occurred apparent symptoms of low cardiac output and significant arrhythmias, finally recovery after comprehensive treatment of restoration the heart function. There was a total of 4 patients in-hospital death following surgery due to multiorgan system failure. Of the 18 patients who survived after the surgery were followed up from 1 to 10 years, echocardiography showed the residual mass of the tumor with partial resection, rhabdomyoma diminishing in 2 patients and almost vanishing in 1 patient. The residual mass of one fibrosarcoma patient and one hemangioma patient were not increased. Patients with myxomas had no recur or systemic embolisation after the initial surgery. Five nonsurgical patients were followed up from 1 to 3 years, 2 patients without haemodynamic alterations,1 patients with giant tumor of left ventricular free wall was died of arrhythmia, the other one was alive; the patient of multiple cardiac tumor with low cardiac output was died of heart failure. Conclusions Despite the benign histology of most paediatric primary cardiac tumours, there may be significant associated with morbidity and occasional mortality. Therapy strategies should be individualised: surgery is indicated in cases with significant clinical symptoms and close follow-up is necessary for asymptomatic patients. Total resection is not the only therapeutic aim. Most important is the restoration of the normal haemodynamic heart function.     

肩胛带S2区恶性肿瘤保肢术的疗效评价

目的 评估肩胛带S2区恶性肿瘤保肢术后的疗效.方法 2005年1月至2009年1月,17例肩胛带S2区恶性骨肿瘤患者行保肢术,男13例,女4例;年龄14～55岁,平均32.6岁;软骨肉瘤6例,骨肉瘤4例,纤维肉瘤、骨髓瘤、Ewing肉瘤、横纹肌肉瘤、非霍奇金淋巴瘤、恶性骨巨细胞瘤、复发的软骨肉瘤各1例.Enneking分期:Ⅰ B期4例,ⅡB期13例.按国际骨与软组织肿瘤协会(MSTS)肩胛带分区标准,11例累及S2区和外1/3 S1区,6例累及S2区和S1区.肩袖均不同程度受累,肩关节囊受累8例.14例行新辅助化疗.8例瘤体范围较广或肩关节囊受累者行人工全肩胛骨置换术,9例瘤体范围较小或肩关节囊可保留者行肩胛骨次全切除、异体肩胛骨重建、肩关节囊及肩袖修复术.结果 随访16～62个月,平均35.1个月.9例患者出现并发症,其中发生异体骨排斥反应和异体骨吸收1例,异体骨排斥反应1例,假体肩峰外露3例,异体骨吸收4例.局部复发1例,死亡3例,死亡原因均为术后肿瘤广泛转移.MSTS功能评分53.3%～93.3%,平均74.1%.结论 在肩胛带S2区保肢手术中,将肿瘤完整切除与功能重建行个体化平衡,可获得较满意的肿瘤学疗效及稳定、美观、功能良好的肩关节.

Abstract：

Objective To investigate and discuss the limb salvage strategies of malignant bone tumors in region S2 of shoulder girdle.Methods The data of 17 patients(13 males and 4 females)were retrospectivelv analyzed.All of them had malignant scapular tumor at least in region S2,and underwent limb salvage between January 2005 and January 2009.They aged from 14 to 55 years old(mean,32.6 years).The histologic types of them were chondrosarcoma in 6 patients,osteosarcoma in 4,fibrosareoma in 1,myeloma in 1,Ewing's sarcoma in 1,rhabdomyosarcoma in 1,non-Hodgkin lymphoma in 1,malignant giant cell tumor of bone in 1 and recurrent chondrosarcoma in 1.The tumors were staged according to Enneking surgical staging system:IB in 4 and IIB in 13.According to the MSTS classification system,the region S2 and lateral 1/3 of region S1 were effected in 11 cases,the region S2 and large part of region S1 were effected in 6 cases.The rotator cuff was involved to some extent in all patients,and the articular capsule were involved in 8 cases.Neo-adjuvant chemotherapy was given to 14 patients.The surgical strategies were depended on the range of tumor and preservation of articular capsule.The scapular prosthetic replacement was done in 8 cases with a relatively large range of tumor or resection of articular capsule,otherwise the scapular allograft replacement was done.Among the 11 cases with region S2 and lateral 1/3 of region S1 effected,the scapular allograft replacement was done in 9 cases with articular capsule preserved and the prosthetic replacement was done in 2 cases with articular capsule resected.And the prosthetic replacement was done in the other 6 cases.The articular capsule and partial rotator cuff were preserved and reconstructed preferentially.Results All patients were followed up 16-62 months (mean,35.1 months).Postoperative complications were noted in 9 patients, including mild allograft rejection and mild allograft resorption in 1 patient,allograft rejection in 1,prosthetic acromion exposure in 3,allograft resorption in 4.Local recurrence were noted in 1 patients.Three patients were dead because of extensive metastasis.The average function scores were 74.1%(range,53.3%-93.3%).Conclusion During the limb salvage surgery.it's very important to guarantee the en bloc resection of the tumor.In the meanwhile,the en bloc resection and functional reconstruction should be well balanced.     

Resection and reconstruction of the inferior vena cava for neoplasms

AIM: To evaluate the results of an aggressive surgical approach of resection and reconstruction of the inferior vena cava (IVC). METHODS: The approach to caval resection depends on the extent and location of tumor involvement. The supraand infra-hepatic portion of the IVC was dissected and taped. Left and right renal veins were also taped to control the bleeding. In 12 of the cases with partial tangential resection of the IVC, the flow was reduced to less than 40% so that the vein was primarily closed with a running suture. In 3 of the cases, the lumen of the vein was significantly reduced, requiring the use of a polytetrafluoroethylene (PTFE) patch. In 2 of the cases with segmental resection of the IVC, a PTFE prosthesis was used and in 1 case, the IVC was resected without reconstruction due to shunting the blood through the azygos and hemiazygos veins. RESULTS: The mean operation time was 266 min (230-310 min) with an average intraoperative blood loss of 300 mL (200-2000 mL). The patients stayed in intensive care unit for 1.8 d (1-3 d). Mean hospital stay was 9 d (7-15 d). Twelve patients (66.7%) had no complications and 6 patients (33.3%) had the following complications: acute bleeding in 2 patients; bile leak in 2 patients; intra abdominal abscess in 1 patient; pulmonary embolism in 2 patients; and partial thrombosis of the patch in 1 patient. General complications such as pneumonia, pleural effusion and cardiac arrest were observed in the same group of patients. In all but 1 case, the complications were transient and successfully controlled. The mortality rate was 11.1% (n = 2). One patient died due to cardiac arrest and pulmonary embolism in the operation room and the second one died 2 d after surgery due to coagulopathy. With a median follow-up of 24 mo, 5 (27.8%) patients died of tumor recurrence and 11 (61.1%) are still alive, but three of them have a recurrence on computed tomography. CONCLUSION: There are a variety of options for reconstruction after resection of the IVC that offers a higher resectable rate and better prognosis in selected cases.     

肾源性腺瘤临床病理学分析

目的 探讨肾源性腺瘤临床病理学特点.方法经病理确诊的肾源性腺瘤患者11例.男5例,女6例.平均年龄56(37～78)岁.对肿瘤进行临床病理学观察并复习文献.结果 11例肿瘤发生于输尿管2例,膀胱9例.9例膀胱肾源性腺瘤中行膀胱部分切除术1例,行经尿道膀胱肿瘤电切术8例.发生于输尿管2例分别行右输尿管镜检术及左输尿管切开取石术.患者术后病理确诊为肾源性腺瘤8例,非典型性肾源性腺瘤2例,肾源性腺瘤恶变1例.镜下肾源性腺瘤表现为典型的肾小管样形态;非典型性肾源性腺瘤细胞核大、深染、核仁明显及核分裂象;肾源性腺瘤恶变者局部瘤细胞保持典型肾源性腺瘤的基本组织结构,周围同种形态的细胞失去细胞间黏附力,呈弥漫实性生长并侵犯浅肌层.非典型性及恶变者3例分别定期行羟喜树碱、吡柔比星及表柔比星膀胱内灌注治疗.11例患者平均随访46(24～104)个月.复发1例,死于其他疾病1例,未复发9例.结论肾源性腺瘤临床少见,临床症状及膀胱镜检查均无特异性;病理形态学与肌浸润行为证据上提示肾源性腺瘤可以恶变;治疗以局部切除为主,非典型性和恶变者进一步行膀胱内定期灌注治疗;肾源性腺瘤术后需长期密切随访.

Abstract：

Objective To investigate the clinical and pathological characteristics of nephrogenic adenoma. Methods Eleven patients were diagnosed as nephrogenic adenoma including 5 men and 6 women, aged 37-78 years (56 on average). The pathological findings in all cases of nephrogenic adenoma were presented with a review of the literature. Results Eleven cases of nephrogenic adenomas were evaluated, 2 cases were in ureter and 9 cases were in the bladder. Eight of the 9 bladder cases underwent TUR-BT surgery in continuous epidural anesthesia, 1 case underwent partial cystectomy with general anesthesia. A right ureteroscopy and left ureterolithotomy were performed respectively in continuous epidural anesthesia for the 2 cases in ureter. The final diagnosis was based on histopathological findings. For all of cases, 8 cases were diagnosed as nephrogenic adenomas, 2 cases as atypical nephrogenic adenoma and 1 case as nephrogenic adenoma with malignant transformation. The microscopic appearance of nephrogenic adenoma demonstrated that morphology closely resembled aberrant tubules of the kidney. In addition, atypical nephrogenic adenomas appeared as the presence of cytologic atypia, including nuclear enlargement, nuclear hyperchromasia and prominent nucleoli. The morphologic changes of nephrogenic adenomas with malignant transformation were that tumor cells retained the basic structural characteristics of typical nephrogenic adenomas, and the similar morphological cells lost adhesion ability among cells and presented diffuse solid growth in the surrounding area.Intravesical perfusion was further performed for treating the patients with atypical nephrogenic adenomas or nephrogenic adenomas with malignant transformation. The mean patient follow up was 46 months (range, 24- 104 months), and there was only 1 case of recurrence. Conclusions Nephrogenic adenoma is an uncommon benign lesion of the urinary tract. The symptoms and cystoscopic manifestations are not unique. We reported one patient of nephrogenic adenomas with malignant transformation and provided some evidence for malignant alteration in morphology and invasive behavior. All patients underwent local excision of the lesions. Intravesical perfusion was further performed for treating the patients of atypical nephrogenic adenomas or nephrogenic adenomas with malignant transformation. Whether it is nephrogenic adenoma or atypical nephrogenic adenoma, long-term follow-up after treatment is necessary.     

股骨近端上移重建骨盆肿瘤切除后的骨缺损

 目的 总结以股骨近端上移重建骨盆肿瘤切除后骨缺损的手术技术要点,探讨其手术适应证。方法 自2006年10月至2011年5月,对5例骨盆恶性肿瘤患者采用同侧股骨近端截骨上移重建骨盆环连续性、肿瘤型人工关节假体重建髋关节,男3例,女2例;年龄19~55岁,平均30.6岁。软骨肉瘤3例、原始神经外胚层瘤2例。3例肿瘤累及骨盆Ⅰ+Ⅱ区,2例累及Ⅱ+Ⅲ区。所有患者均获得随访,统计并发症发生情况,采用国际骨肿瘤协会(Musculoskeletal Tumor Society, MSTS)功能评分评价患肢功能,评价肿瘤学预后。结果 至末次随访时5例患者中1例死亡,1例带瘤生存,其余3例无瘤生存。主要并发症包括肿瘤局部复发、假体松动、植骨不愈合、浅表感染、坐骨神经麻痹。1例患者术后15个月发生植骨不愈合,内固定松动,可扶拐行走。1例患者因假体松动,术后26个月行翻修手术。1例患者术后6个月肿瘤局部复发改行截肢手术;1例术后18个月局部复发,未进一步处理带瘤生存。MSTS评分为11~25分,平均19.2分。结论 同侧股骨近端上移重建骨盆肿瘤切除后的骨缺损是一种有效重建骨盆连续性的方法,既适用于骨盆Ⅱ+Ⅲ区缺损,也适用于骨盆Ⅰ+Ⅱ区缺损。但此术式仍具有较高的并发症发生率,其近期效果与骨盆假体类似,远期疗效有待于进一步观察。     

髋臼及其周围肿瘤的分区与重建方法

目的 回顾性分析髋臼及其周围恶性肿瘤行整块切除、不同方法髋臼重建的疗效.方法 72例髋臼及其周围恶性肿瘤患者接受了肿瘤整块切除、髋臼重建手术,男42例,女30例;年龄16～78岁,平均41岁.软骨肉瘤39例、骨肉瘤10例、骨巨细胞瘤9例、Ewing肉瘤5例、恶性纤维组织细胞瘤3例、恶性神经鞘瘤2例、血管外皮瘤l例、单发转移癌3例.肿瘤累及Ⅱ区、Ⅰ+Ⅱ区、Ⅱ+Ⅲ区、Ⅰ～Ⅲ区、Ⅰ～Ⅳ区和Ⅱ+Ⅲ+Ⅴ区者分别为4、16、29、7、10和6例.髋臼重建包括组配式人工半骨盆50例、马鞍式关节置换7例、骨盆灭活再植8例、股骨近端与盆骨融合7例.结果 61例获得随访,平均随访3.5年(1～8年).11例局部复发,8例深部感染,6例脱位.45例行组配式人工半骨盆置换术患者ISOLS评分平均22分.优7例、良24例、可9例、差5例.其中优良病例均为累及Ⅱ区和Ⅱ+Ⅲ区者,评分差的病例均为累及Ⅳ区者.5例行马鞍式关节置换、5例骨盆灭活再植和6例股骨近端与盆骨融合术患者,ISOLS评分平均为10、17和14分.结论 髋臼周围肿瘤切除后重建方法以组配式人工半骨盆置换术后功能最好,骨盆灭活再植次之,马鞍式关节置换术后功能最差.组配式人工半骨盆置换对单纯Ⅱ区肿瘤切除重建功能最好,其次为Ⅱ+Ⅲ区、Ⅰ+Ⅱ区、Ⅰ～Ⅲ区、Ⅱ+Ⅲ+Ⅴ区,术后功能最差为Ⅰ～Ⅳ区.     

髋臼周围恶性肿瘤的外科治疗

目的 探讨髋臼周围恶性肿瘤保肢手术的方法和疗效.方法 回顾性分析1999年1月至2006年12月行保肢手术的31例髋臼周围恶性肿瘤患者的临床资料.其中男性17例,女性14例;年龄42～75岁,平均53岁.软骨肉瘤24例、尤文肉瘤4例、骨肉瘤1例、转移性肿瘤2例.Ⅱ区切除16例,Ⅰ+Ⅱ区切除5例,Ⅱ+Ⅲ区切除5例,Ⅰ+Ⅱ+Ⅲ区切除5例.肿瘤切除后重建17例,未重建14例.结果 31例患者随访时间12～84个月,平均52个月.14例患者无瘤生存,4例带瘤生存,13例死亡.软骨肉瘤的复发率为20.8%,死亡率33.3%.2例转移性肿瘤患者广泛转移,死于术后11和34个月.1例骨肉瘤和2例尤文肉瘤患者死于肺转移.采用Enneking骨肿瘤术后患者的功能评估方法,18例存活的患者参加功能评价.13例切除后重建的患者中优6例、良好6例、差1例.6例未重建患者优3例、良好2例、差1例.6例患者术后出现可控性并发症.结论 广泛切除肿瘤降低局部复发率是围髋臼肿瘤保肢手术的基本要求,重建髋关节的功能应综合考虑肿瘤破坏的范围和手术切除的范围,遵循个体化原则.     

骨盆定制假体的设计及有限元分析

目的:介绍骨盆定制假体的设计,利用有限元分析方法评价骨盆肿瘤定制假体在3种不同工况下的生物力学性能。方法:利用CAD软件设计1例骨盆肿瘤患者重建所需的钛合金材质假体,用有限元法分析检查和评估该定制假体在静态和缓慢步态工况下的强度和刚度值。结果:有限元分析结果表明,3种工况下骨盆的最大Von Mises应力分别为39.0、202.8、42.4 MPa;最大位移分别为0.199、0.766、0.847 mm。假体中的最大Von Mises应力分别为62.3、318、468 MPa。骨盆和假体中的最大Von Mises应力都远低于相应材料的屈服强度。结论:该研究可以根据患者情况对定制假体的形状和尺寸做精确设计,通过有限元法强度计算可以降低骨骼应力水平和骨折风险,延长假体的使用寿命,保证了患者术后正常步态下的安全性和稳定性。     

累及骶骨的骨盆恶性肿瘤切除及重建

目的 探讨累及骶骨的骨盆恶性肿瘤合理的手术切除及重建方式.方法 1999年7月至2007年7月,共有19例累及骶骨的骨盆恶性肿瘤患者在北京大学人民医院骨肿瘤科接受肿瘤切除重建手术.平均年龄37岁(12～78岁);男性12例,女性7例. 其中,软骨肉瘤5例、尤文肉瘤4例、骨肉瘤4例、恶性纤维组织细胞瘤(MFH)1例、骨巨细胞瘤1例、转移癌4例.切除髂骨翼及部分骶骨、保留髋臼手术10例,采用了钉棒系统内固定,其中5例患者同时进行了自体腓骨或髂骨植骨;切除部分骶骨、髂骨翼及髋臼手术9例,应用组配式人工半骨盆重建骨盆环完整性.结果 肿瘤学结果:7例出现局部复发(7/19,36.9%),其中骨肉瘤2例、软骨肉瘤2例、尤文肉瘤2例及转移癌1例.19例患者随访时间为1至7年,平均4.5年.功能结果:9例保留髋臼、钉棒重建的患者术后正常行走,无步态异常.9例行Ⅱ区肿瘤切除、人工半骨盆重建的患者中,8例术后2个月能够扶拐行走.ISOLS评分平均20分以上,其中,良好3例,一般5例,较差1例.人工半骨盆重建的患者中,术后脱位1例,行切开复位;因深部感染取出假体1例.结论 对于保留髋臼的髂骨肿瘤切除,采用钉棒内固定结合自体骨植骨是一种理想的重建骨盆环稳定性的方法,可使患者早期恢复行走功能.将股骨头颈植于骶骨侧方,将组配式人工半骨盆卡于质骨块的下方,重建累及骶骨及髋臼的骨盆切除,是一种可取的重建方式.     

新型复合重建技术重建髋臼周围肿瘤切除后骨缺损

目的 评价新型复合重建技术对髋臼周围肿瘤切除后骨缺损的重建效果.方法 2001年3月至2007年3月,对23例髋臼周围肿瘤患者行切除复合重建,其中男性16例,女性7例,平均年龄43岁(16～78岁).肿瘤类型:原发性恶性骨与软组织肿瘤17例,其中软骨肉瘤7例、成骨肉瘤4例、尤文肉瘤2例、恶性纤维组织细胞瘤2例、恶性神经鞘瘤1例、滑膜肉瘤1例;骨巨细胞瘤2例;侵袭性骨母细胞瘤1例;转移瘤3例,其中甲状腺癌1例、乳腺癌l例、卵巢癌1例.术后对肿瘤控制和功能结果进行评定.结果 原发性恶性骨盆肿瘤中Ⅰ A期1例,Ⅰ B期5例,ⅡA期3例,ⅡB期8例,3例良性骨肿瘤均为Ⅲ期,原发瘤患者平均随访时间36.8个月(9～73个月);3例转移瘤患者生存期9.6～36.6个月.肿瘤局部复发4例,肺转移5例,死亡5例,术后无深部感染和皮肤坏死.深静脉血栓2例;坐骨神经不全损伤1例,股骨头假体脱位2例,螺钉松动3例,肢体短缩3例,其中植入物相关并发症发生率为21.7%,术后6个月MSTS功能评分平均为68%;随访5年以上的6例患者MSTs功能评分平均为62%.结论 新型复合重建技术可有效重建髋臼周围肿瘤切除后骨缺损同时可以较好恢复髋关节功能,术后并发症少.     

Tumors of the pelvis: complications after reconstruction

Introduction Complications after pelvic sarcoma surgery are frequent; however, the reports on complications are limited. Results of the authors' experience with 110 primary pelvic tumor resections and methods to achieve low complication rates for pelvic reconstruction are reported.Materials and methods From 1982 to 1996, 110 patients with pelvic sarcoma (42 Ewing sarcomas, 40 chondrosarcomas, 21 osteosarcomas, and 7 other malignant tumors) underwent surgery. Sixteen patients underwent implantation of a hemipelvic megaprosthesis, 13 patients had implantation of an allograft for sacroiliac arthrodesis, 12 patients had implantation of an autograft for sacroiliac arthrodesis, and 17 patients underwent hip transposition. There were 9 hindquarter amputations, 6 implantations of allograft and total hip endoprosthesis, 1 implantation of prosthesis with autograft, and 1 implantation of allograft and autograft. No skeletal reconstruction was done in 35 patients.Results Postoperative function was as follows: 37% in patients with prosthesis, 60% in allograft, 66% in autograft, 66% in hip transposition, 37% in amputation, and 79% without reconstruction. In total, 10/16 patients with prosthetic replacement, 9/13 with allograft implantation, 4/12 with autograft implantation, 7/17 with hip transposition, 5/9 with amputation, 6/6 with prosthesis and allograft, and 12/35 without skeletal reconstruction had complications. Frequent complications depending on the reconstruction were infection in 6/10 prostheses and in 5/13 allografts, leg length discrepancy in 2/12 autografts and 4/17 hip transpositions, hematoma in 3/9 amputations, and infection (6) and skin problems (5) in 6 prostheses with allograft.Conclusion Because of the small number of complications and good function, autograft implantation after iliac resection and hip transposition after acetabular resection are advisable.     

New surgical procedure for the protection of the small intestine before postoperative pelvic irradiation

A prosthesis was designed to protect the intestinal loop from external beam radiation therapy when post-operative radiation is indicated. It is a silicone inflatable balloon, which, when implanted displaces the intestinal loops out of the pelvic irradiation field. The prosthesis can be deflated between each course of irradiation, without surgery. The device has been used in 8 patients: 6 patients with recurrent pelvic tumor (2 rectal cancers, 1 anal cancer, 1 cancer of the endometrium, 1 cervical carcinoma, 1 ovarian carcinoma), 2 patients with primary tumor (1 malignant paraganglioma, 1 cervical carcinoma). Radiotherapy was administered by means of high power appliances. After radiotherapy, the prosthesis was deflated, then removed through a 3 cm incision under local or peridural anesthesia. The tolerance of the small intestine to the radiation therapy has been satisfactory in each case with no bowel injury due to radiation. Therefore, this simple device might be useful to prevent bowel injury during postoperative radiation in the treatment of abdominal and retroperitoneal tumor masses.     

Immediate reconstruction of oncologic hemipelvectomy defects

BACKGROUND: Soft tissue and bony tumors of the pelvis are rare, but when they occur, treatment presents both an oncologic surgical and a reconstructive challenge. After reconstruction, soft tissue defects can be large and there is usually exposed bone and/or joint. A retroperitoneal abdominal wall defect may also be present. Flap mobilization is generally necessary to eliminate dead space and cover the exposed bone, viscera, and/or prosthetic orthopedic material. We performed immediate reconstruction on 11 patients after radical pelvic resections for tumor. PATIENTS AND METHODS: Eleven cases of radical pelvic resection and immediate reconstruction were identified during the period from 1992 to 2002 at University Hospital, Newark, New Jersey. All patients were treated by both the orthopedic oncology and plastic surgery teams. A retrospective review of office charts and hospital records was performed. Data were gathered regarding the following: tumor type and oncologic history, extent of resection, reconstructive modality, complications, and outcome. RESULTS: All patients underwent radical resection of pelvic masses depending on the tumor type and location. Tumor types included chondrosarcoma (6), Paget osteosarcoma (1), giant cell tumor (1), metastatic uterine carcinoma (2), and invasive squamous cell carcinoma arising in a chronic decubitus ulcer (1). The reconstructive procedures performed were the following: rectus abdominus flaps (6), gluteus maximus musculocutaneous flaps (3), and thigh fillet flaps (2). The retroperitoneal defects were repaired with primary tissue approximation of the surrounding available musculature. Additionally, Gore-Tex mesh was used in 2 cases, tensor fascia lata was used in 2 cases, and acellular dermal matrix in 1 case. Blood loss for the combined procedures ranged from 400 mL to 1400 mL. The follow-up period in this series ranged from 24 to 114 months. Complications included skin flap loss with subsequent infection (1), local cellulitis controlled with antibiotics (1), regional recurrence (2). The postoperative course was uneventful for the remainder of the cases. CONCLUSION: Soft tissue reconstructions after extensive pelvic resections always present as complex reconstructive problems. Reconstruction is dictated by the size of the defects and by tissue availability. The extent and type of resections vary according to tumor size and location. In our experience, local pedicled muscle-based flaps, if available, usually provide adequate tissue mass to eliminate dead space, cover the extent of the wound, and close the retroperitoneal defect. Microvascular tissue transfer is always an option but was reserved in our series for cases with no suitable local alternative.     

Pelvic reconstruction with a structural pelvic allograft after resection of a malignant bone tumor

BACKGROUND: Reconstruction of the pelvic arch after resection of a malignant pelvic tumor remains a major surgical challenge because of the high rate of associated complications. The purpose of this investigation was to assess the functional outcome and complication rate following treatment with a bone allograft to reconstruct the pelvis. METHODS: Twenty-four consecutive patients underwent excision of a malignant pelvic bone tumor and reconstruction with a pelvic bone allograft. The living patients were followed for a minimum of twenty-four months. There were nineteen primary malignant bone tumors, sixteen of which were high-grade sarcomas, and there were five isolated metastases. Patients were examined clinically and radiographically and were assessed functionally with the Musculoskeletal Tumor Society score. RESULTS: The mean age of the patients at the time of the index surgery was thirty-four years, and the mean duration of follow-up was forty-one months. Eighteen of the twenty-four resections involved the periacetabular area and were followed by reconstruction either with a hip prosthesis (thirteen) or with an osteochondral allograft alone (five). The six other resections involved the iliac bone. All patients received a massive bone allograft that had been sterilely procured without secondary irradiation. At the time of our last evaluation, eight patients were alive and free of disease. Seven patients had a local recurrence. Neurological deficits were present in six patients, and three had a deep infection. Nonunion of three of the sixteen allografts that could be evaluated was observed. Neither graft fracture nor lysis was observed. Eleven patients underwent surgical revision, with nine of these revisions related to the reconstruction. The average Musculoskeletal Tumor Society score at the time of the latest follow-up was 73% of the maximal possible score. The average score was 82% for the eleven patients with an age of less than twenty years at the time of the index procedure and 65% for the thirteen older patients. Ten patients walked without any assistive device, and five of them had normal function with no or only a slight limp. CONCLUSIONS: Pelvic reconstruction after a limb-sparing resection is associated with a high risk of surgical complications and usually should be reserved for patients with a primary bone sarcoma. A pelvic allograft can restore the anatomy and provide good functional results, especially in young patients. Nonunion was the most common allograft-related complication.