医学精品课件：07.Bone Tumor（2017）.ppt-teaching.ppt

1、Bone TumorGao shichangThe First affiliated hospital of ChongQing Medical University1Epidemiology Incidence of bone sarcomas 0.2%of all cancers 0.8 new cases per 100,000 population per year in North America and Europe Most common bone sarcomas#1:Osteosarcoma#2:Chondrosarcoma#3:Ewing sarcoma2 Age dist

2、ribution is bimodalFirst peak:Second decade of life Osteosarcoma predominates at this age Ewing sarcoma Second peak:60 years old Chondrosarcoma predominates Secondary osteosarcomasPagets osteosarcomaPostradiation osteosarcoma3Gerneral principles Diagnostic Evaluation An adequate history and physical

3、 examination are the first and most important steps in evaluating a patient with a musculoskeletal tumor.Patients present to the orthopaedic oncologist with pain,a mass,or with an abnormal radiographic finding detected during the evaluation of an unrelated problem.4Gerneral principles The pain initi

4、ally may be activity related,but the patient with a malignancy of bone often complains of progressive pain at rest and at night.Patients with benign bone tumors also may have activity-related pain if the lesion is large enough to weaken the bone5Gerneral principles Most notably osteoid osteoma,may i

5、nitially cause night pain.6Gerneral principles Age may be the most important information obtained in the history because most musculoskeletal neoplasms,both benign and malignant,occur within specific age ranges.The physical examination should include evaluation of the patients general health,as well

6、 as a careful examination of the part in question.7Gerneral principles A mass should be measured,and its location,shape,consistency,mobility,tenderness,local temperature,and change with position should be noted.Atrophy of the surrounding musculature should be recorded,as well as neurological deficit

7、s and adequacy of circulation.8Gerneral principles Potential sites of lymph node metastases should be palpated.All suspected musculoskeletal neoplasms should be evaluated initially with plain roentgenograms.9Gerneral principles Often,the patients age and plain roentgenographic findings are sufficien

8、t to arrive at a specific diagnosis.10Gerneral principles Inactive lesions usually are well marginated,often with a surrounding rim of reactive bone formation.Aggressive lesions usually have a less well-defined zone of transition between the lesion and the host bone.Cortical expansion can be seen wi

9、th aggressive benign lesions,but frank cortical destruction usually is a sign of malignancy.1112Gerneral principles Periosteal reactive new bone formation results when the tumor destroys cortex and may take the form of a Codmans triangle,onion-skinning,or a sunburst pattern.It usually is a sign of m

10、alignancy but may be present with infection or histiocytosis.1314Gerneral principles Computed tomography(CT)is most helpful in assessing ossification and calcification and in evaluating the integrity of the cortex.CT of the lungs also is the most effective study to detect pulmonary metastases.15Gern

11、eral principles CT also is the best imaging study to localize the nidus of an osteoid osteoma,to detect a thin rim of reactive bone around an aneurysmal bone cyst.16Gerneral principles Technetium bone scans are indicated to detect skeletal metastases and to determine the presence of multiple lesions

12、.Virtually all malignant neoplasms of bone demonstrate increased uptake on technetium bone scans.1718Gerneral principles A normal bone scan is therefore very reassuring;however,the converse statement is not true because most benign lesions of bone also demonstrate increased uptake.19Gerneral princip

13、les Magnetic resonance imaging(MRI)has replaced CT as the study of choice to determine the size,extent,and anatomical relationships of both bone and soft tissue tumors.It is the most accurate technique for determining the limits of disease both within and outside bone.2021Gerneral principles MRI is

14、not very useful in differentiating benign from malignant lesions.In general,any soft tissue neoplasm deep to the fascia or larger than 5 cm in its greatest dimension should be considered highly likely to be a sarcoma.22Gerneral principles Ultrasonography is useful for distinguishing cystic from soli

15、d soft tissue.23Gerneral principles Blood and urine tests rarely lead to a diagnosis but can be useful in selected situations.Risk of wound-healing problems and infection have been shown to be significantly greater in patients whose serum albumin is less than 3.5 g/dl or whose total lymphocyte count

16、 is less than 1500/ml.24Gerneral principles A complete blood count may be helpful to rule out infection and leukemia.The erythrocyte sedimentation rate（ESR）usually is elevated in infection,metastatic carcinoma,and Ewing sarcoma.A prostate-specific antigen(PSA)should be ordered if prostate carcinoma

17、is a possibility.25 Benign tumors are staged as follows:Stage 1 lesions are intracapsular,usually asymptomatic,and frequently incidental findings.Roentgenographic features include a well-defined margin with a thick rim of reactive bone.There is no cortical destruction or expansion.STAGING 26Gerneral

18、 principles These lesions do not require treatment because they do not compromise the strength of the bone and usually resolve spontaneously.27Gerneral principles Stage 2,active 1 The lesions also are intracapsular but are actively growing and therefore can cause symptoms or lead to pathological fra

19、cture.2 They have well-defined margins on roentgenograms but may expand and thin the cortex.Usually they have only a very thin rim of reactive bone.3 Treatment usually consists of extended curettage.28Gerneral principles Stage 3,aggressive The lesions are extracapsular.Their aggressive nature is app

20、arent both clinically and roentgenographically.29Gerneral principles They usually have broken through the reactive bone and possibly the cortex.MRI may demonstrate a soft tissue mass,and metastases may be present in up to 5%of patients with these lesions.Treatment consists of extended curettage and

21、marginal or even wide resection,and local recurrences are common.30Gerneral principles Musculoskeletal sarcomas also can be staged according to the surgical staging system as described by Enneking et al.The system is based on the histological grade of the tumor,its local extent,and the presence or a

22、bsence of metastases.31Gerneral principles Low-grade lesions are designated as stage I.These lesions are well-differentiated,have few mitoses,and exhibit only moderate cytological atypia.The risk for metastases is low(3 cm)and that do not involve major neurovascular structures.45Results Diagnostic a

23、ccuracy rate 83%to 93%for musculoskeletal tumors Diagnostic accuracy is lower if the lesion is thought to be benign.46Open incisional BiopsyAdvantages Principal advantage relates to the larger size of the tissue sample obtained,reducing the risk of sampling error and allowing for more extensive hist

24、ologic assessment as well as molecular diagnostic assessment when needed.Gold standard in achieving high diagnostic accuracy.47Disadvantages Principal disadvantage of open biopsy is potential for improper execution by surgeon.Potential adverse consequences of tissue contamination/exposure during ope

25、n biopsy.48Indications Many bone and less accessible deep soft tissue tumors are best approached with open biopsy(see details below for incisional versus excisional biopsy).Results Accuracy rates of 96%for extremity bone and soft tissue lesions following final analysis have been reported at major ca

26、ncer centers.49Three Most Important Principles of Biopsy Incision Orientation Longitudinal,not transverse,incisions Longitudinal,not transverse,incisions Longitudinal,not transverse,incisions505152Treatment Surgical techniques Curettage:1 Many benign bone tumors are adequately treated by curettage.2

27、 Compared with resection,curettage is associated with a higher rate of local recurrence;however,curettage often allows for a better functional result.53Gerneral principles Curettage is done by first making a large cortical window over the lesion.This window must be at least as large as the lesion it

28、self.If the window is smaller than the lesion,the surgeon will inevitably leave residual tumor on the undersurface of the near cortex.54Gerneral principles Extended curettage includes the use of adjuvants,such as liquid nitrogen,phenol,PMMA,or thermal cautery.55Gerneral principles The final issue th

29、at must be considered involves filling the cavity left after curettage.Options include autogenous bone graft,allograft,bone graft substitutes,and bone cement.5657 Calcaneus Chondrosarcoma Two years laterGerneral principles Resection and Reconstruction Tumor types Treatment Stage IA Local wide resect

30、ion Stage IB Wide amputation Stage IIA Local radical resection Stage IIB Radical amputation58Gerneral principles Margins are determined by analysis of the surgical specimen to properly prepare for the resection.Intralesional margins:Dissection passes within the lesion.Marginal margins:Dissection pas

31、ses within reactive tissue contiguous with the lesion.59Gerneral principles Wide margins:Dissection is carried out through the normal tissue at a distance from the lesion.Radical margins:All normal tissues of one or more compartments involved are removed from origin to insertion.60616263Adjunctive T

32、reament Radiation therapy Most primary bone malignancies are relatively radioresistant.Exceptions are the marrow cell tumors including multiple myeloma,lymphoma,and Ewing sarcoma,which are each exquisitely sensitive.64Gerneral principles For most other bone tumors,radiation has a very limited role b

33、ecause local control is better achieved with surgery.65Gerneral principles Radiotherapy can be used to reduce the incidence of local recurrence of malignant soft tissue tumors treated with marginal resection.Radiation also can be used for preoperative treatment of soft tissue sarcomas in the hopes o

34、f reducing the tumor volume and thus making the resection easier.66Gerneral principles Chemotherapy it refers to chemotherapy administered postoperatively to treat presumed micrometastases.Neoadjuvant chemotherapy refers to chemotherapy administered before surgical resection of the primary tumor.67A

35、MPUTATION VERSUS LIMB SALVAGE Advances in diagnostic imaging,chemotherapy,radiation therapy,and surgical technique for resection and reconstruction now allow limb salvage to be a reasonable option for most patients with bone or soft tissue sarcomas.68 Preoperative radiation therapy for soft tissue s

36、arcomas and neoadjuvant chemotherapy for bone sarcomas have helped surgeons to successfully resect some tumors that in the past would have been deemed unresectable.69 the choice between limb salvage and amputation must be made on the basis of the expectations and desires of the individual patient an

37、d the family.70 Four issues that must be considered whenever contemplating limb salvage instead of an amputation:71Will survival be affected by the treatment choice?How do the short-term and long-term morbidity compare?How will the function of a salvaged limb compare to that of a prosthesis?Are ther

38、e any psychosocial consequences?72 With the use of multimodal treatment including surgery and chemotherapy,long-term survival for osteosarcoma patients has improved from approximately 20%to as high as 70%in some series.73 For osteosarcoma of the distal femur,the rate of local recurrence after wide r

39、esection and limb salvage is approximately 5%to 10%.This is equivalent to the rate of local recurrence after a transfemoral amputation in this setting.74 With regard to overall patient survival,the most important technical aspect of the surgical procedure is the attainment of a wide margin regardles

40、s of whether this is achieved by amputation or local resection.75 A patient with a salvaged limb is much more likely to need multiple future operations for treatment of complications.These complications include periprosthetic fractures,prosthetic loosening or dislocation,nonunion of the graft-host j

41、unction,allograft fracture,leg length discrepancy,and late infection.76 After initially successful limb salvage surgery,up to one third of the long-term survivors may ultimately require an amputation depending on the location of the tumor and the type of reconstruction.77 Future limb length inequali

42、ty also must be considered.Although expandable prostheses and limb-lengthening procedures are available,the complications may outweigh the benefits especially in a child under 10 years of age.78 With regard to function,location of the tumor is the most important issue.Resection of a proximal femoral

43、 or pelvic lesion with local reconstruction generally provides better function than would be possible after a hip disarticulation or hemipelvectomy.7980 Around the ankle and foot,however,large sarcomas frequently are treated with amputation followed by prosthetic fitting.Treatment for sarcomas aroun

44、d the knee must be individualized.81 Resection of an upper extremity lesion with limb salvage,even with the sacrifice of one or two major nerves,generally provides better function than amputation and subsequent prosthetic fitting.8283Osteochondroma Osteochondromas are the most common of the benign b

45、one tumors.They are probably developmental malformations rather than true neoplasms and are thought to originate within the periosteum as small cartilaginous nodules.84Osteochondroma The lesions consist of a bony mass,often in the form of a stalk,produced by progressive endochondral ossification of

46、a growing cartilaginous cap.Their growth usually parallels that of the patient and usually ceases when skeletal maturity is reached.85Osteochondroma Osteochondromas may occur on any bone preformed in cartilage but usually are found on the metaphysis of a long bone near the physis.They are seen most

47、often on the distal femur,the proximal tibia,and the proximal humerus.86Osteochondroma Many of these lesions cause no symptoms and are discovered incidentally.Some cause pain by irritating the surrounding structures.The physical finding usually is a palpable mass.87OsteochondromaRoentgenographically

48、 and grossly osteochondromas are of two types:those that are stalked those that are broad based8889BroadstalkedOsteochondroma Stalked tumors are more common,and any definite stalk is directed away from the physis adjacent to which it takes its origin.The lesion is covered by a cartilaginous cap that

49、 is often irregular and usually cannot be seen on roentgenograms.9091Osteochondroma Surgery is indicated when the lesion is large enough to be unsightly or produce symptoms from pressure on surrounding structures,or when roentgenographic features suggest malignancy.9293Chondroma Benign tumors of mat

50、ure hyaline cartilage(chondromas)usually are located centrally in bone and are known as enchondromas Less frequently they are located subperiosteally and are known as subperiosteal chondromas.94Chondroma Chondromas are considerably less common than osteochondromas,most occur during the second,third,