恶性骨肿瘤的手术问题——截肢或肢体挽救?

LIMB-SALVAGE OR AMPUTATION FOR MALIGNANANT BONE NEOPLASMS

长久以来,用截肢术来治疗肢体的恶性骨肿瘤,特别是骨肉瘤,是习惯采用的手术方法。在肿瘤早期,应当认为是一项有效的疗法。自七十年代以来,化学药物治疗成为较重要的一种辅助治疗,使截肢疗效从原来的8～14％提高到50％以上。可是,截肢在心理上和生命的质量上有时很难被病人和家属所接受。 自进入八十年代,由于手术技术的革新,抗肿瘤药物的发明和多种治疗方法的联合使用,对截肢是否是唯一的方法来治疗恶性骨肿瘤,提出疑问。例如在切除一个肿瘤时,是否要将肿瘤远侧的正常肢体一并牺牲;能否采用联合治疗。

Since the introduction of adjuvant chemotherapy, the surgical treatment tomalignant bone neoplasms has.been revised not only to increase the rate of survival,but also to save the diseased limb. In recent years. it has the tendency to neglectthe conveational amputation and prone to perform more limb-salvage reconstruction.When: limb-vage is considered instead of amqutation for a patient withprimary bone sarcoma in an extremity. at least three concerns should be considered. 1. The immediate and delayed morbidity for limb salvage reconstruction usuallyare higher than those for amputation. The failure of teconstruction will eventuallylead to final amputation.However. most complications could be prophylactic ifthe surgeons can manage high. surgical strategy and techniques in performing thelimb-salvage reconstruction. 2. The preservation of a limb is not only at the cosmetic point of view. butalso for the functional recovery.A partial salvage of a limb by doing limited ampu-tation with reconstruction, such as rotationplasty op help the patient to use artificialleg more efficiently than conventional prosthesis. The present recommendation of using total joint replacement. especially in the knee joint where the bone sarcomahad the highest incidence, gives good preservation of limb. The investigationof energyf expenditure confirmed,that rotationplasty is. preferable to above--the-knee amputation, despite some abnormalities in gait are still being observed. 3. The high survival rate is mainly related with the use of adjuvant chemo-therapy ed the high technology fo surgical. intarvention. The statistical reviewcannot prove the superiority of amputation nor limb salvage. reconstruction. Howeverthe 5-year survial rates of both surgical measures for osteosarcoma range trom40 to 70 per cent, although the rate of local recurrence seems higher in limb salvageoperation. After all. limb-salvage reconstruction is more indicated for primary bonesaucoma of low or moderate grade of malignancy. while amputation is indicated for thebigh grade cases. Both operations have no definite priority. They could be chosenaccording to the use of high quality abjuvant or neoadjuvant chemotherapeutic regimenpathology support, and surgical strategy and techniques.