盆环原发恶性肿瘤的切除与生物学重建

目的:探讨骨盆环恶性肿瘤的切除、重建方式与并发症的处理 .方法:手术治疗骨盆环原发恶性或低度恶性肿瘤5例,其中骶骨恶性畸胎瘤2例、脊索瘤1例,髂骨骨肉瘤1例、恶性骨软骨瘤1例.所有患者术前未行动脉栓塞、结扎髂内血管.髂骨翼肿瘤采用自体髂骨、髋臼肿瘤采用异体骨重建骨盆环、自体股骨头重建髋臼骨床 人工全髋关节置换术.结果:5例肿瘤均行根治性切除,3例骶骨肿瘤术中出血量150～800 mL,术后出血300～1 000 mL,1例切口感染,1例术后出现失血性休克.髂骨翼肿瘤和髋臼周围肿瘤术中出血量分别为1 000 mL和4 000 mL,术后分别为800 mL和1 100 mL.髂骨肿瘤切除与重建患者2月后恢复关节功能,髋臼肿瘤切除与重建患者6月后恢复功能,4例患者术后随访4～24个月,生存良好.结论:骨盆环恶性肿瘤的外科手术治疗关键是完整的手术切除,包膜外切除可以减少出血、预防复发,影响骨盆环稳定时应考虑重建,自体、异体骨移植能够恢复髋臼周围骨量、维持骨盆环生物学稳定.     

经腹直肌外侧切口入路治疗髋臼骨折的解剖学研究

目的　探讨经腹直肌外侧切口入路治疗髋臼骨折的安全性及临床应用价值。方法 新鲜成人尸体标本5具（3男2女）,同一尸体右侧腹壁行大体解剖,熟悉入路周围的解剖结构,左侧应用腹直肌外侧切口入路,模拟术中操作,显露骨盆环,进行解剖学观察,重点测量记录死亡冠血管相关解剖学参数。结果 （1）经腹直肌外侧入路的显露范围包括：耻骨联合至骶髂关节在内的真性骨盆环、髂骨翼、髋臼方形区和坐骨体内侧的髋臼后柱大部分。（2）根据对5具10侧骨盆的死亡冠统计分析发现,死亡冠的出现率为80%（8侧）,直径为（2.1±1.9）mm,长为（4.7±0.5）cm,距离耻骨联合的距离为（4.9±0.4）cm。男女之间差异无明显统计学意义。结论 经腹直肌外侧切口入路治疗髋臼骨折能够在不损伤重要神经血管的条件下,经腹膜外间隙对包括骶髂关节在内的大部分骨盆环结构进行显露。尤其方便显露结扎死亡冠,对髋臼后柱及髋臼内侧方形区的显露较传统入路有明显优势。     

经腹直肌外侧切口入路治疗髋臼骨折的解剖学研究

目的　探讨经腹直肌外侧切口入路治疗髋臼骨折的安全性及临床应用价值。方法 新鲜成人尸体标本5具（3男2女）,同一尸体右侧腹壁行大体解剖,熟悉入路周围的解剖结构,左侧应用腹直肌外侧切口入路,模拟术中操作,显露骨盆环,进行解剖学观察,重点测量记录死亡冠血管相关解剖学参数。结果 （1）经腹直肌外侧入路的显露范围包括：耻骨联合至骶髂关节在内的真性骨盆环、髂骨翼、髋臼方形区和坐骨体内侧的髋臼后柱大部分。（2）根据对5具10侧骨盆的死亡冠统计分析发现,死亡冠的出现率为80%（8侧）,直径为（2.1±1.9）mm,长为（4.7±0.5）cm,距离耻骨联合的距离为（4.9±0.4）cm。男女之间差异无明显统计学意义。结论 经腹直肌外侧切口入路治疗髋臼骨折能够在不损伤重要神经血管的条件下,经腹膜外间隙对包括骶髂关节在内的大部分骨盆环结构进行显露。尤其方便显露结扎死亡冠,对髋臼后柱及髋臼内侧方形区的显露较传统入路有明显优势。     

国产人工半骨盆假体置换治疗髋臼周围骨肿瘤

背景：髋臼周围骨肿瘤的治疗对骨科医生来说是一种挑战,但随着诊断技术的提高、新辅助化疗方案的应用以及肿瘤切除原则的确立,保肢手术成为一种趋势。 目的：分析应用国产人工半骨盆假体治疗髋臼周围骨肿瘤的效果。 方法：2001/2010共收治19例髋臼周围骨肿瘤病人,其中6例行国产半骨盆人工假体置换,术后随访6~72个月(平均50个月)。 结果与结论：按Enneking方法评估疗效,良4例,一般2例。提示只要严格掌握骨盆肿瘤切除重建的手术适应证,应用国产人工半骨盆假体治疗髋臼周围骨肿瘤具有较好的疗效。 关键词：髋臼;骨肿瘤;假体;人工半骨盆假体;疗效 doi:10.3969/j.issn.1673-8225.2012.13.042     

经盆腔、会阴及臀部会师入路切除EnnekingⅡⅢ型骨盆肿瘤1例并文献复习

目的：报道盆腔、会阴及臀部会师入路在EnnekingⅡⅢ型骨盆肿瘤切除中的应用与临床体会。方法：复习相关文献,成功采用盆腔、会阴及臀部会师入路切除EnnekingⅡⅢ型骨盆肿瘤,钛板、骨水泥重建髋臼1例。结果：切口一期愈合,无感染、死腔、漏与疝,无任何神经血管及脏器副损伤,无大小便障碍及会阴部感觉障碍等并发症。术后随访2．5a,X线片内固定无松动,行走、下蹲、盘腿正常,髋关节存在不适,无疼痛。结论：会师入路避免了髂腹股沟入路辅助会阴入路在操作至臀区、会阴区及坐骨直肠窝后部的盲目性,对避免重要结构的副损伤及完整切除肿瘤更有意义。     

骶骨肿瘤手术入路和相关技术分析（附31例报告）

目的：探讨手术切除骶骨肿瘤的入路和相关技术问题。方法：手术治疗骶骨肿瘤31例,其中脊索瘤23例,骨巨细胞瘤3例,神经纤维瘤3例,动脉瘤样骨囊肿1例,平滑肌肉瘤1例。采用单纯后入路23例,前后入路8例,腰骶骨盆重建4例。结果：术后随访1—5a,平均32个月。围手术期感染2例,1例历经2年感染而死亡;5例手术后12个月内先后复发,其中3例再次手术、2例因肺部转移衰竭而死亡。4例行腰骶段重建,植骨愈合良好,无断钉断棒现象。结论：周密的术前计划、合适的入路选择、术中充分的瘤体外分离、骶1～3神经的保护、术后营养与引流是手术治疗的关键,侵犯骶1以上及骶髂关节时需腰骶骨盆重建。     

等离子喷涂陶瓷钛合金人工半骨盆置换术(附5例报告)

目的：介绍等离子喷涂陶瓷钛合金人工半骨盆在半骨盆切除术后行保肢手术中的应用方法，并评估其优缺点。方法：5例恶性骨肿瘤患者在行半骨盆根治性切除术后，用定制的钛合金人工半骨盆连同其全髋关节作假体置换术。结果：本组中，2例分别于术后3～6个月因肿瘤转移而死亡，1例术后8a因哮喘性肺炎而死亡，1例术后15a因肺心病而死亡，另1例术后17a至今仍存活，外出时需扶手持行走。结论：将半侧骨盆完全切除后采用人工半骨盆置换术而保全该侧肢体存活，使其具有神经支配状态良好的下肢，并保留该肢的满意功能，是一种值得推荐的手术方法之一。     

微创前路钢板内固定技术治疗不稳定性骨盆骨折

目的探讨应用微创前路钢板固定技术在治疗不稳定骨盆骨折中的应用,并评价其疗效。方法 2009年2月~2016年8月收治20例骨盆骨折的患者,其中男性9例,女性11例,平均年龄38.5岁,按照Tile分型,B型11例,C型9例;骨盆前环损伤类型,单侧耻骨支损伤11例,双侧耻骨支损伤9例;后环损伤类型,骶骨骨折6例,骶髂关节分离8例。骨盆前环骨折采用前路微创双切口髂腰肌下入路钢板固定,合并后环骨折的患者采用骶髂螺钉或钢板固定骶髂关节骨折脱位,并记录术中出血量和手术时间,术后应用Matta标准和Majeed评分系统对骨盆复位和功能恢复进行评价。结果20例患者均获得随访,平均26个月,手术切口一期愈合,前环骨折平均手术时间1h,出血215 m L,没有出现切口感染和神经血管损伤的手术并发症,骨折愈合时间在11周~14.5周,术后骨折复位Matta标准:优17例,良2例,一般1例。术后末次随访时Majeed功能评分:优15例,良3例,一般2例,优良率90%。1例Tile C型骨盆骨折的患者,术前合并骶丛神经损伤,术后骶丛神经没有完全恢复,遗留感觉部分障碍和跛行步态。结论对于不稳定骨盆骨折的患者采用微创髂腰肌下通道入路钢板治疗,重建骨盆前环,具有创伤小,不需显露股神经和血管等结构,手术时间短,出血少,临床疗效满意和手术安全的特点。     

计算机导航系统辅助下髋臼区肿瘤的保肢治疗

背景:下肢的不等长影响肢体保肢治疗的效果。即便通过透视监测,在手术中确保肢体等长,仍是一个难以把握的问题,尤其是对于髋臼区域恶性肿瘤的保肢治疗。在骨科的其他方面,如脊柱和关节,导航技术已经较多应用于内固定器械安置和假体放置。目的:回顾分析在计算机导航系统指导下髋臼区恶性肿瘤保肢治疗的效果。方法:选择2001-01/2009-06上海瑞金医院骨科收治的11例骨盆恶性骨肿瘤患者,术前经病理确诊,肿瘤切除后应用定制型假体重建。其中8例患者进行常规保肢手术,另外3例患者行计算机导航技术辅助保肢治疗。所有患者骨盆恶性肿瘤的切除范围位于髋臼周围区(骨盆Ⅱ区)。患者保肢治疗后予以临床、影像学检查,并行下肢保肢功能MSTS评分。结果与结论:随访12～60个月。经常规保肢治疗的8例患者,平均手术时间7.6h,平均失血量2400mL,1例患者因肺部转移而在术后3年死亡,1例患者因局部复发行截肢术。除去这2例患者,保肢治疗后有3例患者髋臼假体的移位超过2cm而形成下肢不等长。MSTS评分平均20.3分。在计算机导航技术辅助下保肢治疗的3例患者,平均手术时间8.3h,平均失血量2100mL,保肢治疗后未见下肢不等长现象。MSTS评分平均21.7分。提示在计算机导航系统指导下进行髋臼区恶性肿瘤保肢手术,可以精确截骨,准确安放假体,减少髋臼区恶性肿瘤保肢治疗后下肢不等长发生率,提高患肢功能。     

重建钢板治疗不稳定骨盆骨折并移位髋臼骨折

目的探讨不稳定骨盆骨折并移位髋臼骨折手术治疗效果.方法自1998年2月至2002年10月,对22例不稳定骨盆骨折并移位髋臼骨折采用骨盆重建钢板和螺钉进行复位和内固定,20例通过骼腹股沟入路手术治疗,其中9例加用Kocher-Langenbeck入路,另2例采用延长S-P入路.术后早期功能锻练.结果平均随诊时间为16个月(6-60个月),骨盆骨折均获复位.根据Matta影像学评分,髋臼解剖和复位满意20例,不满意2例.用改良的Merle d'Aubigne和Postel评分系统评估临床结果,优良16例,一般4例,差2例.一例发生异位骨化,无一例感染及不愈合.结论应用骨盆重建钢板手术治疗不稳定骨盆骨折并移位髋臼骨折,可有效复位固定骨折,矫正畸形,重建髋臼、骨盆环的稳定性,恢复髋臼关节面的平整和正常头臼关系,疗效满意.     

Histological and clinical characteristics of malignant giant cell tumor of bone

Malignant giant cell tumors of bone (MGCTB) are rare, and the diagnosis can be difficult due to the occurrence of a variety of malignant tumors containing giant cells. To better understand its clinicopathological features, we have reviewed our experience with 17 cases of MGCTB. Five cases were primary malignant giant cell tumor of bone (PMGCTB), and 12 cases were giant cell tumors of bone initially diagnosed as benign but malignant in a recurrent lesion (secondary MGCTB, SMGCTB). The patients included six women and 11 men (age ranged from 17 to 52 years; mean, 30.5 years). The tumor arose in the femur (six cases), the tibia (seven cases), the humerus (three cases), and the fibula (one case). Microscopically, PMGCTB showed both conventional giant cell tumor and malignant sarcoma features. SMGCTB were initially diagnosed as conventional giant cell tumor of bone, the recurrent lesion showing malignant features. Histologically, the malignant components included osteosarcoma (11 cases), undifferentiated high-grade pleomorphic sarcoma (two cases), and fibrosarcoma (four cases). SMGCTB cases showed strong expression of p53. Follow-up information revealed that four patients died of lung metastasis, two patients are alive with lung metastases, and 11 patients are alive without tumor. MGCTB should be considered as a high-grade sarcoma. It must be distinguished from GCTB and other malignant tumors containing giant cells. p53 might play a role in the malignant transformation of GCTB.     

Aggressive angiomyxoma of pelvic soft parts: a clinicopathologic study of nine cases

Nine cases of aggressive angiomyxoma (AAM) of the pelvic soft parts were studied by light and electron microscopy and immunohistochemistry. The tumors were confined to the vulva, vagina, pelvic floor, and perineum in the seven women. The perineum and the para-anal region were involved in the two men. The patients ranged in age from 18 to 63 years. Aggressive angiomyxoma presented as a slowly growing, polypoid or cyst-like tumor. Six of the nine cases were followed up; all of the tumors recurred within nine to 84 months, and one recurred for the second time at 144 months. Recurrences were attributed to incomplete tumor excision. None of the six patients died or had metastases. The aggressive angiomyxomas had infiltrative borders and rubbery, white or soft, gelatinous cut surfaces. Histologically, the lesions were composed of stellate and spindle-shaped neoplastic cells embedded in a collagenous and hyaluronic acid-containing stroma. Nuclear atypia and mitoses were absent. Typically, the lesions had an important vascular component, often displaying medial hypertrophy and vascular grouping. Ultrastructurally, the neoplastic cells resembled fibroblasts rather than myofibroblasts. They showed strong immunoreactivity for actin but were negative for S-100 protein, Factor VIII, carcinoembryonic antigen, and keratin. The morphoimmunocytochemical characteristics of AAM cells favor a fibroblastic origin and differentiation. Aggressive angiomyxoma should be distinguished from the more common benign and malignant myxoid neoplasms or tumor-like conditions of the pelvic soft parts. Recurrence of AAM may be avoided by wide, local excision.     

A clinicopathological study on soft tissue tumors of the head and neck.

The present study consists of 651 cases of soft tissue tumors originating in the head and neck area. Among these tumors 628 were benign (96%), while there were only 23 malignant cases (4%). In the benign group hemangiomas showed the highest incidence (47%) followed by tumors of adipose tissue (19%) and those of peripheral nerves (12%). Rare tumors consisted of nodular fascitis, hibernoma, lipoblastomatosis, glomus tumor, granular cell tumor, and chondroma. The majority of cases in the malignant group were either those of muscle origin or blood vessel origin. Excepting for two cases of rhabdomyosarcoma of the embryonal type and two cases of angiosarcoma, all showed recurrence and/or metastasis and terminated in death. Three cases of liposarcoma of either well-differentiated or myxoid type had a good prognosis with all three living for 3 or more years without any recurrence. Other malignant tumors consisted of malignant schwannoma, fibrosarcoma, malignant fibrous histiocytoma, alveolar soft part sarcoma, and chordoma. The age, sex, anatomical location, and differential diagnosis have also been described.     

原发性骶骨肿瘤的手术治疗

目的：探讨原发性骶骨肿瘤手术治疗的方法及临床疗效。方法：手术治疗原发性骶骨肿瘤15例,其中脊索瘤7例、骨巨细胞瘤4例、神经纤维瘤2例、软骨肉瘤1例、恶性畸胎瘤1例。术后放疗5例。结果：随访6个月～4a,11例恢复良好,无永久性排尿排便障碍;1例因手术切口感染,于术后半年死于全身衰竭;2例脊索瘤患者分别于术后1年和2年复发;1例软骨肉瘤术后2年半复发。结论：骶骨肿瘤应采取以手术为主的综合治疗,正确的手术方法能够减少术后并发症和肿瘤的复发。     

246例子宫平滑肌肿瘤临床病理分析

目的:探讨子宫平滑肌肿瘤临床病理特征.方法:对246例子宫平滑肌肿瘤的临床病理资料进行回顾性分析.结果:子宫平滑肌肿瘤发病高峰年龄为40～50岁,可伴内膜增生或腺肌病,同时与卵巢、宫颈多种良恶性病变并存.246例子宫平滑肌肿瘤中,91.4%为普通型良性平滑肌瘤;6.9%为平滑肌瘤特殊组织学类型;0.8%为平滑肌肉瘤;0...     

A CLINICOPATHOLOGICAL STUDY ON SOFT TISSUE TUMORS OF THE HEAD AND NECK

The present study consists of 651 cases of soft tissue tumors originating in the head and neck area. Among these tumors 628 were benign (96%), while there were only 23 malignant cases (4%). In the benign group hemangiomas showed the highest incidence (47%) followed by tumors of adipose tissue (19%) and those of peripheral nerves (12%). Rare tumors consisted of nodular fasciitis, hibernoma, lipoblastomatosis, glomus tumor, granular cell tumor, and chondroma. The majority of cases in the malignant group were either those of muscle origin or blood vessel origin. Excepting for two cases of rhabdomyosarcoma of the embryonal type and two cases of angiosarcoma, all showed recurrence andlor metastasis and terminated in death. Three cases of liposarcoma of either well-differentiated or myxoid type had a good prognosis with all three living for 3 or more years without any recurrence. Other malignant tumors consisted of malignant schwannoma, fibrosarcoma, malignant fibrous histiocytoma, alveolar soft part sarcoma, and chordoma. The age, sex, anatomical location, and differential diagnosis have also been described. ACTA PATH. JAP. 29: 389 - 408, 1979.     

双环乳晕切口在多中心乳腺良性肿瘤中的应用优势探讨

目的　探讨采用双环乳晕切口在多中心乳腺良性肿瘤临床外科手术中的应用优势。 方法　回顾性分析我院肿瘤外科2016年1月-2017年7月收治的45例行“双环乳晕切口”治疗的“多中心乳腺良性肿瘤”的患者。对所有患者的临床病理因素、手术时间、术中出血量、术后拔管时间、并发症以及术后3个月美容效果、6个月后复发率进行评价。 结果　切除肿瘤数量单侧（5±1）个（2~8个）,双侧（8±2）个（3~13个）。肿瘤长径单侧（5.3±1.3）cm（1.5~8.5 cm）,双侧（3.0±1.5）cm（1.2~6.5 cm）。术中出血量单侧(8.0±2.8)ml（5~15 ml）,双侧(15.4±3.1)ml（10~25 ml）。术后3个月通过门诊和微信随访美容效果,患者满意度在93.3%。术后6个月有37例患者进行彩超复查,其中单侧病变患者22例,复发3例,复发率13.6%;双侧病变患者15例,复发2例,复发率13.3%。 结论　双环乳晕切口在处理分布在不同象限多发性肿瘤、以及有塑形需求的患者人群中具有一定优势。手术安全性高,操作方便,适合临床推广应用。     

Malignant mesothelioma with prominent adenomatoid features: a clinicopathologic and immunohistochemical study of 10 cases

The clinicopathologic and immunohistochemical features of 10 cases of pleural malignant mesothelioma with predominantly adenomatoid growth pattern are described to determine the clinical, histologic, and behavioral features of these tumors and to highlight the importance of separating this unusual pattern from the benign adenomatoid tumor. Seventy-seven cases of pleural biopsy and extrapleural pneumonectomy specimens for malignant mesothelioma were examined to identify the specific type of histologic growth pattern exhibited by the tumors. The 10 cases herein described were identified as an unusual histopathologic subset of these tumors. Nine patients were men and one was a woman with an age range of 56 to 82 years (mean, 68.5 years). The main presenting symptoms included cough, dyspnea, and chest pain. The typical features of pleural malignant mesothelioma were noted both radiologically and macroscopically. The tumors were characterized by diffuse pleural thickening with confluent nodular patches of tumor obliterating the pleural space. Histologically, a distinct morphology was observed composed of small tubular spaces lined by epithelioid cells, reminiscent of adenomatoid tumors of the genital tract. Immunohistochemical studies confirmed the mesothelial nature of the tumors. Clinical follow-up in 7 of 7 patients demonstrated a mean survival of 10 months from time of diagnosis. Adenomatoid mesothelioma is an unusual variant of epithelioid malignant mesothelioma that histologically may mimic a range of other tumors, including benign adenomatoid tumors and metastases of adenocarcinoma to the pleura. The clinical presentation, infiltrative growth, distinct histologic features, cytologic atypia and immunohistochemical profile all serve to differentiate adenomatoid malignant mesothelioma from other infiltrative processes involving the pleura.     

Sacrococcygeal Chordoma with a Malignant Spindle Cell Component

Two autopsy cases of sacrococcygeal chordoma which showed sarcomatous components in the primary and metastatic tumors are reported. Case 1 was a 48-year-old female who died 9 years after the development of the initial symptoms. Autopsy findings showed metastatic tumors consisted of malignant tumor cells similar to fibrosarcoma and osteosarcoma. Case 2 was a 63-year-old male who died 11 years after the development of the initial symptom. At autopsy only sarcomatous tumors resembling malignant fibrous histiocytoma (MFH) were observed in the metastatic lesions. Both cases were treated with irradiation. It is suggested that the appearance of sarcomatous tumor in current two cases of chordoma might be due to the phenomenon of tumor progression closely as sociated with irradiation therapy. These two cases can be categorized as "chordoma with a malignant spindle cell component" in a sense that highly malignant sarcomatous components existed in conjunction with chordoma in the primary tumors.