骨盆骨肉瘤的外科治疗策略探讨

目的 探讨手术治疗骨盆骨肉瘤的切除及重建方式.方法 回顾性分析2000年6月至2009年6月接受肿瘤切除重建手术的21例骨盆骨肉瘤患者的病例资料.其中男性12例,女性9例;平均年龄30岁.肿瘤累及范围:Ⅰ区3例,Ⅰ+Ⅳ区3例,Ⅰ+Ⅱ区4例,Ⅱ+Ⅲ区4例,Ⅰ+Ⅱ+Ⅲ区1例,Ⅲ区1例,Ⅰ+Ⅱ+Ⅳ区5例.其中经典骨肉瘤19例,高分化骨肉瘤2例.21例均为ⅡB期.所有病例均行整块切除,外科边界为13例广泛切除,8例边缘切除.重建方式包括:可调式人工半骨盆假体重建13例;自体骨移植+钉棒系统重建5例;半骨盆截肢2例;单纯切除1例.患者术后平均随访时间30.3个月(6.0～87.0个月).结果 21例患者中13例存活,总体生存率为61.9%,无瘤生存率23.8%;5年生存率为44.2%.局部复发率为28.6%(6/21),其中累及Ⅱ区肿瘤复发4例(4/13),Ⅰ区肿瘤复发1例(1/3),Ⅰ+Ⅳ区肿瘤复发1例(1/3),Ⅲ区肿瘤单纯切除的1例患者及2例半骨盆截肢患者未发生局部复发.肿瘤广泛切除术后复发率为23.1%(3/13),边缘切除术后复发率为37.5%(3/8).9例患者术后出现肺转移(42.9%),1例患者发生骨及淋巴结转移.13例存活患者MSTS 93功能评分为(20.6±5.4)分.4例自体骨移植+钉棒系统内固定患者功能评分为(22.5±2.1)分;7例町调式人工半骨盆重建患者,于术后8周开始扶拐行走,半年后可去拐行走,功能评分为(17.7±5.5)分.结论 选择合适的切除与重建方式,多数骨盆骨肉瘤患者可以行保肢治疗,可保留部分肢体功能.     

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.     

骶骨原发骨肉瘤的外科治疗效果评价

目的:评价骶骨原发骨肉瘤的外科治疗效果。方法:回顾性分析2000年6月~2013年12月在我院接受肿瘤切除重建手术的26例骶骨原发骨肉瘤患者资料。其中男15例,女11例;中位年龄28岁(12~68岁)。分析本组患者的手术方式、总体与无进展生存时间以及功能状态。采用卡方检验比较整块切除和分块切除术后复发率。Kaplan-Meier法计算总体生存率,比较整块切除和分块切除组的总体生存率及无进展生存率。结果:16例患者接受整块切除术,10例接受分块切除术。出血量3435.3±1529.0ml(400~6600ml),手术时间6.8±2.4h(3~12h)。无围手术期致死性并发症发生。8例(30.7%)出现伤口并发症,经再次手术治疗后愈合良好。3例保留至少单侧S3及以上神经根的患者,术后大小便功能基本正常;7例保留至少单侧S2及以上神经根的患者中,术后膀胱控尿功能及大便控制部分受损,但均可自行排尿排便;仅保留至少单侧S1以上神经根的6例患者,术后均留置尿管,行自主膀胱功能锻炼,半年后均可拔除尿管,经定时挤压腹部排尿,此类患者均有不同程度的大便困难,但未做结肠造瘘。9例行全骶骨切除的患者均切断双侧S1神经根,5例患者术后出现足的跖屈肌力减弱,但可借助双拐或支具下地行走。术后随访6~87个月(29.7±19.7个月)。13例(50%)患者术后出现远处转移,10例患者(38.5%)出现局部复发(其中5例为局部复发合并远处转移)。术后1年生存率为92.3%,5年生存率为38.7%。整块切除者复发率为3/16(18.8%),分块切除者复发率为7/10(70%),分块切除复发率较整块切除高(P=0.015)。中位生存时间整块切除者为24个月,分块切除者为18个月,总体生存率无统计学差异(P=0.22);中位无进展生存时间整块切除者为19个月,分块切除者为8个月,整块切除者的无进展生存率高于分块切除者(P=0.04)。结论:对于骶骨原发骨肉瘤,整块切除术的局部控制率及无进展生存率优于分块切除术;部分病例可获得长期生存,但5年整体生存率仍较低。     

半骨盆置换术治疗骨盆恶性肿瘤的初步应用

目的探讨半骨盆置换术在骨盆恶性肿瘤广泛切除和功能性保肢手术中的应用。方法回顾中山大学附属第一医院骨肿瘤科2003年至2006年18例半骨盆切除和重建手术治疗案例，评估骨盆恶性肿瘤广泛切除和假体置换术的疗效和并发症。结果中山大学附属第一医院骨肿瘤科18例骨盆原发性恶性骨肿瘤患者，接受了骨盆Ⅰ区＋Ⅱ区＋（Ⅲ区）切除和人工半骨盆假体置换手术。患者平均年龄为19岁，病理类型包括12例骨肉瘤、3例尤文肉瘤和3例纤维肉瘤，外科分期均为ⅡB。患者经过术前肿瘤评估，MRI显示肿瘤尚未侵犯髂血管和坐骨神经，全身骨扫描未显示肿瘤跳跃或转移，肺部CT显示肿瘤无转移；同时患者接受两个循环规范化术前化疗后，初步化疗评估为良好。术前充分准备，常规切除骨盆Ⅰ区＋Ⅱ区＋（Ⅲ区），安装组合式半骨盆。组合式半骨盆假体设计突出骶骨座、无髂骨、可调髋臼及耻骨支。术中平均出血3000ml（1500～6000m1）。1例术后腓总神经损伤，5例有伤口并发症，其中1例感染和1例残腔愈合不良的患者接受了股外侧肌（皮）瓣转移，伤口均一期愈合。术后3周开始功能锻炼，2至3个月可扶拐行走。平均随访36．73个月（15-58个月），2例局部复发，3例死于远处转移，MSTS功能评分平均65％。结论在骨盆原发性恶性肿瘤的治疗中，广泛切除是治愈肿瘤的关键，应用半骨盆假体置换能有效重建骨骼缺损，联合肌皮瓣移植可以解决困难的伤口并发症，患肢功能可以接受。改进假体设计，改善患肢功能是今后努力的方向。     

骨盆包虫病的外科分区与手术治疗

[目的]探讨骨盆包虫病的外科分区与手术治疗方法。[方法]本组共7例,男性5例,女性2例;年龄28～42岁,平均31岁;髂骨包虫4例(Ⅰ区),骶髂关节3例(Ⅳ区),4例(Ⅰ区)采取边缘切除+骨水泥填充,3例(Ⅳ区)采用边缘切除+后路内固定。[结果]平均随访3年,2例复发,均为Ⅳ区病变复发。[结论]Enneking外科分区的方法对骨盆包虫的切除范围、是否重建有一定的现实意义;手术治疗是临床主要方法,边缘切除+骨水泥填塞方法疗效较好。     

骨盆Ⅱ区恶性肿瘤外科治疗建议

目的探讨骨盆Ⅱ区（髋臼周围）原发性和转移性恶性骨肿瘤的外科治疗方法,指导治疗计划设计和外科手术实施,提高骨盆肿瘤治疗水平。方法结合文献资料和我科的经验,分别针对骨盆Ⅱ区原发性和转移性恶性骨肿瘤临床治疗现状进行分析和评述,提出具体的外科治疗计划与建议。结果骨盆Ⅱ区恶性肿瘤的治疗效果依赖于良好的术前设计和综合治疗的实施;原发恶性骨肿瘤力求在有效的化疗基础上进行肿瘤的广泛性切除,同时根据成熟的经验选择适宜的骨盆重建方式,由此方能真正提高骨盆肿瘤的局部控制和功能效果;对于转移性骨肿瘤要以提高患者的生活质量为标准。结论骨盆Ⅱ区恶性肿瘤的外科治疗是骨盆肿瘤治疗的难点,充分认识其治疗特点和现有技术的不足将有利于提高其整体治疗水平。     

骨盆原发恶性Ⅳ型肿瘤的骶骨侧外科分型

 目的 评估累及骶骨的骨盆原发恶性肿瘤骶骨侧外科分型及其在外科边界获得、围手术期风险控制、肿瘤学和功能学改善中的作用。方法 2003年2月至2013年2月,采用手术治疗累及骶骨的骨盆原发恶性肿瘤（修订的Enneking Ⅳ型肿瘤）患者59例。男28例,女31例;年龄15~72岁,平均36岁。根据累及的骶骨范围不同将骨盆Ⅳ型肿瘤分为Ⅳa、Ⅳb、IVc、Ⅳd四个亚型,Ⅳa型43例,Ⅳb型9例,Ⅳc型5例,IVd型2例。不同的亚型采取相应的规范化肿瘤切除与重建方法。结果 外科边界满意43例（73%,43/59）,边界不满意16例（27%,16/59）。手术时间2.5~13 h,平均5.0 h;术中出血500~6 000 ml,平均2 157 ml。没有因围手术期并发症而死亡的病例。53例患者获得随访,随访时间6~88个月,平均26个月。20例（38%,20/53）于术后1~52个月出现局部复发,平均复发时间12个月。10例（19%,10/53）出现转移,20例（38%）在末次随访时仍无瘤生存。美国骨与软组织肿瘤协会（Musculoskeletal Tumor Society,MSTS）93评分平均58.1%,其中Ⅳa型平均57%（10%~100%）,Ⅳb型平均66%（13%~100%）,Ⅳc型平均45%（13%~77%）,Ⅳd型平均30%（26%~33%）。结论 对Enneking Ⅳ区肿瘤根据累及骶骨范围不同进行的亚分型,为手术入路和切除范围提供了依据。根据不同亚型进行手术切除与重建,能够获得良好的外科边界、肿瘤学预后及术后功能,降低手术风险。     

骨盆损伤的诊断及外科治疗

骨盆损伤的诊断范畴主要包括损伤机制、骨折类型、稳定程度、影像评估、合并损伤等一系列内容。一、损伤机制骨盆的稳定性主要由骶髂关节复合体、骶棘韧带及骶结节韧带维持。机械性损伤导致骨盆骨折的能量转换主要通过以下途径实现[1,2]:(一)前后压迫(ａｎｔｅｒｉｏｒｐｏｓｔｅｒｉｏｒｃｏｍｐｒｅｓｓｉｏｎ,ＡＰＣ):暴力经骨盆前后方向传递,先使前环结构耻、坐骨支骨折或耻骨联合分离。随着应力的继续,髂骨翼不断外翻,致骶结节韧带与骶棘韧带损伤,进而累及骶髂关节使其周围的骶髂前韧带甚或骶髂骨间韧带断裂。髂骨翼的旋转形变,使骨盆…     

骨盆原发恶性骨肿瘤的外科治疗

目的 评价不同切除重建方法治疗骨盆原发恶性骨肿瘤的疗效.方法 对1992年10月至2007年7月收治的、有完整随访资料的骨盆原发恶性骨肿瘤79例患者进行回顾性研究.其中低度恶性的Ⅰ B期肿瘤患者23例,高度恶性的ⅡB期肿瘤56例.根据术前诊断、治疗情况,采用不同的切除重建方法.术后按照Enneking外科边界的评定标准进行标本外科边界研究.随访时对患者进行MSTS功能评定.患者随访时间0～183个月,平均28.6个月,存活患者随访时间最短4个月.结果 本组患者保肢70例,其中无重建者42例,重建者28例;截肢9例.无重建患者术后MSTS功能评分2-30分,平均15分;重建患者术后MSTS功能评分5～29分,平均15分.术后局部复发25例,复发率31.6%.其中,低度恶性患者复发3例,复发率13.0%;高度恶性患者复发22例,复发率39.3%.低度与高度恶性患者复发率差异有统计学意义(P=0.023).保肢患者复发21例,复发率30.0%;截肢患者复发4例,复发率44.4%;二者差异无统计学意义(P=0.620).术后外科边界研究显示:包括囊内切除及边缘切除的边界不充分患者,局部复发率为38.1%;广泛切除边界充分患者局部复发率为6.3%,二者差异有统计学意义(P=0.014).术后发生远隔转移14例,其中复发后出现转移者12例,发生率48.0%,无复发出现转移者2例,发生率3.7%.二者差异有统计学意义(P=0.000).总生存率70.9%.结论 对于骨盆原发恶性肿瘤的外科治疗,确保广泛的外科边界是治疗成功的关键.如何选择、改进功能重建的方法是今后临床工作的重点`     

Current concepts in surgical treatment of osteosarcoma

Osteosarcoma is the most common malignant primary neoplasm of bone. For an optimal oncological outcome, surgical removal of tumor is an essential component of its multidisciplinary treatment. Limb salvage surgery has long been established as the standard of care for osteosarcoma. While limb-salvaging techniques have acceptable rates of disease control, amputation remains a valid procedure in selected cases. In current orthopedic oncology practice, the focus is on optimizing the balance between preservation of form and function of the limb and adequate oncological clearance at the same time. Improving the functional outcome and longevity of reconstructive procedures also remains a challenge.     

Outcome of surgical resection of pelvic osteosarcoma

Background:

The aim of the following study is to evaluate the morbidity, oncologic results and functional outcome in nonmetastatic patients with primary osteosarcoma of the pelvis treated with surgical resection.

Materials and Methods:

Twelve cases of nonmetastatic osteosarcoma of pelvis were operated as part of their multimodality treatment regime between November 2003 and May 2011. There were 5 males and 7 females with a median age of 22 years (range 8-39 years). Ten patients underwent limb sparing resections while 2 had a hindquarter amputation. All 10 cases of limb sparing surgery included resection of the acetabulum. A pseudarthrosis was carried out in 7 cases. Extracorporeal radiation therapy and reimplantation of the bone followed by fixation with plates was used in 1 case and an ischiofemoral arthrodesis was carried out in 2 cases.

Results:

Surgical margins were free in 11 patients. Seven patients had a poor histological response to chemotherapy while 4 patients had a good response to chemotherapy. In the patient reconstructed with radiated auto bone graft, the histological response to chemotherapy could not be assessed. Surgery related complications were seen in 8 out of 12 patients (67%). Three of these patients (25%) required additional surgical intervention for their complications. All patients were available for followup. The median followup of survivors was 56 months (range 24-102 months). Four patients (33%) developed a local recurrence. At 5 years, overall survival was 67%. Patients with a good response to chemotherapy had a better overall survival when compared with patients with a poor response to chemotherapy. The mean Musculoskeletal Tumor Society functional score was 22 (range12-27).

Conclusions:

Though complex and challenging, surgery provides good local control and oncologic outcomes with acceptable function in patients with osteosarcoma of the pelvis treated with appropriate surgical resection as part of their multimodality treatment.     

Limb-sparing surgical treatment in osteosarcoma]

From 1998 we performed limb-sparing surgery in 6 patients with osteosarcoma. No evidence of disease or local recurrence was noted in any of the patients after a mean follow-up period of 13 months. Age at the time of operation ranged from 8 to 14 years. Wide resection margins were achieved in all patients. The results of functional evaluation according to Enneking were excellent in 5 cases and poor in one. Bony defects created by limb-sparing procedures may be reconstructed by many methods. In growing children, limb-sparing surgery needs special consideration to avoid later limb-length discrepancy and expandable prostheses have been used to anticipate this problem.     

骨肉瘤治疗进展

骨肉瘤是临床最常见的骨恶性肿瘤。骨肉瘤病理确诊后需要即刻进行放化治疗,截肢手术则作为传统切除肿瘤组织的重要方法,该方式对病情起到了较好的控制效果,但对患者的身心伤害较大,严重影响术后生存质量。随着骨肉瘤发病机制的深入研究,针对该病的治疗也取得了较大的进展,保肢治疗成为当前主要治疗方式,具体方法包括手术联合化疗、分子靶向治疗、免疫治疗和基因治疗等,上述方案改善了部分骨肉瘤的治疗效果,减少术后痛苦,提高术后生存率,具有广泛的应用前景。本文对近10年有关该病的治疗进展进行了总结,现将其综述如下。     

Evaluation and surgical treatment of rectal prolapse: an international survey

Aim Validated guidelines for the surgical and non‐surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow‐up and treatment of patients with an internal or external RP. Method A 36‐question questionnaire in English about the evaluation, treatment and follow‐up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e‐mail. Results In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow‐up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients. Conclusion The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols.