Marcove R C, Sheth D S, Brien E W, Huvos A G, Healey J H
Orthopaedic Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021.
Cancer. 1994 Aug 15;74(4):1253-60. doi: 10.1002/1097-0142(19940815)74:4<1253::aid-cncr2820740412>3.0.co;2-9.
Giant cell tumors (GCTs) of the sacrum are a difficult clinical problem. Wide excision (total sacrectomy) is associated with high morbidity and pelvic/spinal instability. Curettage with or without supplemental radiotherapy is associated with a high recurrence rate. In view of the proven effectiveness of cryosurgery as an adjunct to curettage for extremity GCT, cryosurgery was used for treatment of GCTs of the sacrum.
Seven patients with GCTs of the sacrum were treated at our institution by conservative surgery from 1973 to 1992. Four patients presented with recurrent tumors after failing previous radiation treatment (dose, 5040 cGy). Four patients were treated with curettage with cryosurgery and three with limited excision with cryosurgery. In the latter procedure after limited excision of the caudal (below S2) part of the tumor, the upper sacral segments were treated with curettage and cryosurgery. This spared the important upper sacral roots and maintained the skeletal integrity.
At a median follow-up of 12.25 years (range, 2-14.2 years), all patients were disease free. Local recurrence developed in two patients. Both of these underwent repeat curettage and cryosurgery and have since remained disease free. Two patients had positive second look biopsy with microscopic tumor. Both of these were treated with repeat cryosurgery and have remained disease free. Two patient who developed solitary pulmonary metastases, underwent wedge resection and are alive without disease. No patient suffered neurologic deterioration.
Conservative surgery (curettage or partial excision) with adjunct of cryosurgery is our preferred technique for the treatment of GCT of the sacrum. Satisfactory local control could be obtained by close observation, second look biopsy and repeat cryosurgery. The chief advantages of this method include preservation of pelvic and spinal continuity, speed and ease of surgical procedure and less potential blood loss. We recommend it over more radical sacrectomy due to low morbidity and less resultant neurologic deficits.
骶骨巨细胞瘤是一个棘手的临床问题。广泛切除（全骶骨切除术）会带来较高的发病率以及骨盆/脊柱不稳定。刮除术无论是否辅以放疗，复发率都很高。鉴于冷冻手术作为肢体巨细胞瘤刮除术辅助手段已被证实有效，故将其用于骶骨巨细胞瘤的治疗。
1973年至1992年期间，我院对7例骶骨巨细胞瘤患者采用了保守手术治疗。4例患者在先前放疗（剂量5040厘戈瑞）失败后出现复发性肿瘤。4例患者接受了刮除术加冷冻手术治疗，3例患者接受了有限切除术加冷冻手术治疗。在后一种手术中，在有限切除肿瘤尾侧（S2以下）部分后，对骶骨上段进行刮除术和冷冻手术。这样可保留重要的骶骨上段神经根并维持骨骼完整性。
中位随访12.25年（范围2至14.2年）时，所有患者均无疾病。2例患者出现局部复发。这2例患者均接受了再次刮除术和冷冻手术，此后一直无疾病。2例患者二次活检显微镜下有肿瘤阳性。这2例患者均接受了再次冷冻手术治疗，且一直无疾病。2例出现孤立性肺转移的患者接受了楔形切除术，目前无病存活。没有患者出现神经功能恶化。
保守手术（刮除术或部分切除术）辅以冷冻手术是我们治疗骶骨巨细胞瘤的首选技术。通过密切观察、二次活检和再次冷冻手术可获得满意的局部控制。该方法的主要优点包括保留骨盆和脊柱的连续性、手术速度快且操作简便以及潜在失血量少。由于发病率低且神经功能缺损较少，我们建议采用该方法而非更激进的骶骨切除术。
