Aboulafia A J, Malawer M M
Department of Orthopedics, Washington Hospital Center, Washington, DC 20010.
Cancer. 1993 May 15;71(10 Suppl):3358-66. doi: 10.1002/1097-0142(19930515)71:10+<3358::aid-cncr2820711738>3.0.co;2-o.
Between 60-80% of all patients with osteosarcomas of the pelvis and the extremities can now be safely treated with limb-sparing surgery. Results (as defined by rates of local recurrence, overall survival, and function) are equal to or better than those associated with amputation. Successful use of limb-sparing procedures, however, depends on a well-developed surgical plan. An understanding of the biologic behavior and growth patterns of these lesions is fundamental. Staging of the primary tumor must involve a full complement of imaging modalities, including plain radiography, bone scintigraphy, computerized axial tomography (CAT), magnetic resonance imaging (MRI), and angiography. The biopsy must be well placed to reduce the possibility of tissue contamination, which is a common reason for amputation. Restaging is necessary before surgery for patients who have undergone neoadjuvant therapy; there is recent evidence that preoperative therapy may make limb-sparing surgery possible in more than 50% of patients who otherwise would have required amputation. Relative contraindications to limb-sparing surgery include major involvement of the neurovascular bundle, pathologic fracture, inappropriate biopsy site, infection, immature skeletal age, and extensive muscle involvement. Each of these factors is relative, and patient selection decisions must be made on an individual basis. Limb-sparing surgery consists of the following three phases: tumor resection, skeletal reconstruction, and soft tissue and muscle transfers. The range of reconstruction techniques has been broadened by developments in bioengineering. Among the more commonly used techniques are custom endoprostheses and allograft replacements. Future progress in induction regimens and reconstructive techniques will undoubtedly enable limb-sparing surgery to be a satisfactory alternative to amputation in even more patients.
骨盆和四肢骨肉瘤患者中,60%至80%现在可以通过保肢手术得到安全治疗。(以局部复发率、总生存率和功能来定义的)结果与截肢相关结果相当或更好。然而,保肢手术的成功应用取决于完善的手术计划。了解这些病变的生物学行为和生长模式至关重要。原发肿瘤的分期必须采用全面的影像学检查方法,包括X线平片、骨闪烁显像、计算机断层扫描(CAT)、磁共振成像(MRI)和血管造影。活检部位必须恰当,以降低组织污染的可能性,组织污染是截肢的常见原因。对于接受新辅助治疗的患者,术前必须重新分期;最近有证据表明,术前治疗可能使超过50%原本需要截肢的患者能够进行保肢手术。保肢手术的相对禁忌证包括神经血管束严重受累、病理性骨折、活检部位不当、感染、骨骼未成熟以及肌肉广泛受累。这些因素都是相对的,必须根据个体情况做出患者选择决定。保肢手术包括以下三个阶段:肿瘤切除、骨骼重建以及软组织和肌肉转移。生物工程学的发展拓宽了重建技术的范围。更常用的技术包括定制内置假体和同种异体移植替代物。诱导方案和重建技术的未来进展无疑将使保肢手术成为更多患者截肢的令人满意的替代方案。