累及骶骨的骨盆恶性肿瘤的外科治疗

Surgical management of malignant pelvic tumors involving the sacrum

目的总结累及骶骨的骨盆恶性肿瘤手术治疗的病例,探讨合理的外科切除及重建方式,评估不同外科治疗结果。方法回顾1999年7月至2011年10月,68例在我中心接受肿瘤切除重建手术的累及骶骨的恶性骨盆肿瘤病例。Ⅰ+Ⅳ区39例,采用钉棒系统内固定,其中10例进行了自体腓骨或髂骨植骨。Ⅰ+Ⅱ+Ⅳ区22例,其中半盆离断7例,钉棒联合半骨盆假体重建7例,自体股骨头植骨联合半骨盆假体重建8例。Ⅰ+Ⅱ+Ⅲ+Ⅳ区7例,其中半盆离断1例,钉棒联合半骨盆假体重建4例,自体股骨头联合半骨盆假体重建2例。结果无围手术期死亡病例。保肢重建的60例中,13例出现伤口并发症,6例出现内固定物松动折断或髋关节脱位。8例半骨盆截肢患者中有3例获得边缘或广泛切除边界。其中仅1例软骨肉瘤患者无瘤生存。60例保肢患者中,27例达到边缘或广泛切除边界,其中有6例局部复发。39例Ⅰ+Ⅳ区肿瘤切除重建的患者术后ISOLS功能评分平均93%。21例行人工半骨盆置换患者的ISOLS评分平均63%。钉棒联合异型半骨盆假体重建与自体股骨头植骨联合半骨盆假体重建后的ISOLS评分差异无统计学意义。结论累及骶骨的骨盆肿瘤手术比较困难。部分患者可以获得安全的切除边界。Ⅰ+Ⅳ区切除的患者应用钉棒系统重建骨缺损可获得很好的功能结果。肿瘤累及Ⅱ区的保肢患者可选择钉棒联合异型半骨盆假体或自体股骨头植骨联合半骨盆假体重建骨关节功能,术后也可以获得较好的功能结果。

Objective To summarize the cases of malignant pelvic tumors involving the sacrum with surgical management, to find out the reasonable surgical resection and reconstruction strategies, and to evaluate the outcomes of different surgical methods. Methods The data of 68 patients with malignant pelvic tumors involving the sacrum who were treated with tumor resection and reconstruction from July 1999 to October 2011 were reviewed. A vertebral pedicle screw-rod fixation system was used in 39 patients who had region Ⅰ＋Ⅳ resection, and autogenous bone graft of the fibula and ilium was used in 10 cases. Region Ⅰ＋Ⅱ＋Ⅳ resection occurred in 22 cases, including 7 cases of hemipelvic amputation, 7 cases of screw-rod fixation combined with hemipelvic endoprosthesis reconstruction and 8 cases of femoral head autograft. Region Ⅰ＋Ⅱ＋Ⅲ＋Ⅳ resection occurred in 7 cases, including 1 case of hemipelvic amputation, 4 cases of screw-rod fixation combined with hemipelvic endoprosthesis reconstruction and 2 cases of femoral head autograft combined with hemipelvic endoprosthesis reconstruction. Results No patient died perioperatively. 13 of the 60 patients who underwent limb salvage reconstruction had wound complications, and loosening or breaking in the internal fixation or hip dislocation occurred in 6 patients. Marginal or wide resection of the border was obtained in 3 of the 8 patients who underwent hemipelvic amputation, and only 1 patient with chondrosarcoma was alive without evidence of disease recurrence. Marginal or wide resection of the border was obtained in 27 of the 60 patients who underwent limb salvage procedures, and local recurrence occurred in 6 cases. The mean postoperative International Society of Limb Salvage （ ISOLS ） functional score was 93% in 39 patients of the region Ⅰ＋Ⅳ resection group, which was 63% in 21 patients of the artificial hemipelvic endoprosthesis group. There was no statistically significant difference in the ISOLS scores after screw-rod fixation combined with heterotype hemipelvic endoprosthesis reconstruction and femoral head autograft combined with hemipelvic endoprosthesis reconstruction. Conclusions Although the surgical resection of malignant pelvic tumors involving the sacrum is challenging, a safe border can be obtained in a number of patients. A vertebral pedicle screw-rod fixation system couldbe used to reconstruct the bone defect after region Ⅰ＋Ⅱ resection, and excellent postoperative functional outcomes can be expected. For the patients undergoing limb salvage procedures, with tumors in the region Ⅰ＋Ⅳ, screw-rod fixation combined with heterotype hemipebcic endoprosthesis or femoral head autograft combined with hemipelvic endoprosthesis reconstruction can also achieve better functional outcomes postoperatively.