Choice of bone reconstruction methods and materials after chondrosarcoma resection

doi:10.3969/j.issn.2095-4344.2013.43.020

Abstract

Abstract:

BACKGROUND: The prognosis of chondrosarcoma is closely associated with tumor location, size, removal methods and biological characteristics.
OBJECTIVE: To explore the choice of reconstruction materials for bone defects after chondrosarcoma resection based on the retrospective analysis of different resection methods.
METHODS: We retrospectively analyzed clinical data from 82 cases of chondrosarcoma who had received hondrosarcoma resection at the Department of Orthopedics, Changzhen Hospital of Second Military Medical University from January 1999 to January 2010. All the involved patients were confirmed pathologically as having chondrosarcoma, including 51 males and 31 females, with a mean age of 39.8 years (range, 15-68 years). Chondrosarcoma was found in the pelvis (n=26), spine (n=19), femur (n=19), tibia and fibula (n=8), and shoulder (including the humerus) (n=12). Preoperative X-ray, MRI or CT was taken as well as ECT. Clinical data, resection methods, and follow-up results were collected for multivariate analysis to screen the possible prognostic factors of chondrosarcoma.
RESULTS AND CONCLUSION: For chondrosarcoma, different types of resection result in a quite difference in recurrence rates, metastasis and mortality rates. The initial resection which is done outside the boundaries can significantly reduce the recurrence rate, metastasis rate and mortality. Autogenous bone, allograft bone, and prosthetic reconstruction materials are effective for functional reconstruction. Autologous bone graft is limited clinically because of its limited sources and complications at donor site. Allograft or prosthetic reconstruction of bone defects is an effective method. Limited number of clinical cases reported makes it difficult to determine the pros and cons of different reconstruction materials. The need for reconstruction depends on the defect site and size, and reconstruction method depends on the type of resection. The important criteria for the choice of reconstruction materials include both form and functional repair of bone defects, chondrosarcoma type and the patient’s request.

Key words: chondrosarcoma, mesenchymal, neoplasms, connective and soft tissue, bone transplantation, prognosis, joint prosthesis

CLC Number:

R318

Peng Jin-hui, Liu Ning, Xu Wei, Zhou Rong, Zhang Hao, Wang Zhi-wei, Qian Qi-rong. Choice of bone reconstruction methods and materials after chondrosarcoma resection[J]. Chinese Journal of Tissue Engineering Research, doi: 10.3969/j.issn.2095-4344.2013.43.020.

Figures/Tables 1

2 相关研究结果分析 Result analysis 2.1 相关研究资料的获取检索CNKI数据库和SCI数据库的方法获取相关研究文献[18-19]。检索时间范围1990至2012年，检索词为“软骨肉瘤(chondrosarcoma)；切除(resection)；功能重建(functional reconstruction)；修复(repair)；自体骨移植(autogenous bone graft)；异体骨移植(allograft)；人工假体(artificial prosthesis)；人工关节(artificial joints)；生物力学(biomechanics)；生物相容性(biocompatibility)”，检索出相关研究文献32篇，其中CNKI数据库文献10篇，学术期刊7篇，学位论文2篇，会议论文1篇。SCI数据库文献22篇。按设定的主题要求，纳入研究的文献共13篇[20-32]。 2.2 入选标准 ①研究的主题包括软骨肉瘤切除方式的选择、软骨肉瘤切除后重建方式及重建材料的选择原则等。检索的文献中排除与研究主题无关的文献10篇。②研究所撰写的文章类型包括原著、实验分析及病例分析等。检索文献中排除综述类文章5篇。③文献内容筛选如下，检索的文献中比较软骨肉瘤切除方式的研究文献共2篇，2篇文献为同一实验项目，且为同一组实验人员进行的研究，定为重复研究文献，选取其中1篇进行深入分析。同样对软骨肉瘤切除后重建方式的选择研究3篇文献也为重复文献，选取其中1篇进行深入分析。在软骨肉瘤切除后重建材料的选择研究中，同样检索出重复的2篇研究文献，选取其中1篇进行深入分析。 2.3 质量评估符合纳入标准的13篇研究中，软骨肉瘤切除方式的选择[20-26]；选择重建方式应根据软骨肉瘤侵犯的部位[27-28]；选择重建材料应根据软骨肉瘤切除的类型[29-32]。 2.4 软骨肉瘤切除与重建的选择原则 2.4.1 软骨肉瘤切除方式的选择一般认为中高度恶性软骨肉瘤如Ⅱ、Ⅲ级，需考虑广泛性切除[20]。低度恶性软骨肉瘤的治疗尚存在争议。有学者认为软骨肉瘤瘤内切除或部分切除后的长期效果欠佳，因此要尽可能避免。但广泛的切除，易导致很多并发症和功能缺陷，Ryzewicz等[21]指出，越来越多临床研究证实，低度恶性四肢软骨肉瘤的治疗可采取病损内刮除加局部辅助治疗，这也是目前临床上常用的治疗方法。 Leerapun等[22]分析了70例非骨盆的低度恶性软骨肉瘤，发现病灶内刮除与广泛性切除患者在总生存率、转移率和复发率的差异无显著性意义，10年生存率达到80%。其他相关文献也证实病损内刮除加局部辅助治疗与广泛切除的复发率差别无显著性意义[23]。Streitbürger等[24]探讨了80例病理学Ⅰ级的软骨肉瘤切除方法，认为病灶内刮除只增加局部复发率，但是并不影响远处转移率和生存率，其中位于骨盆的Ⅰ级软骨肉瘤采用病灶内刮除，其复发率达到100%。同样的结果也被Donati等[25]和Schwab等[26]的研究结果证实。 2.4.2 选择重建方式应根据软骨肉瘤侵犯的部位软骨肉瘤切除后根据肿瘤原发部位、切除范围决定是否重建，腓骨近端、肩胛骨软骨肉瘤，广泛性切除后并不需要重建，也没有明显的功能丧失。而负重骨骼如股骨、胫骨，软骨肉瘤切除后需要进行自体骨、异体骨及人工假体等进行重建。而最困难的是位于骨盆和脊柱的高度恶性软骨肉瘤，这些部位的肿瘤较四肢骨部位更大，且临近重要结构，复发和死亡率更高。张伟滨等[27]认为，骨盆环的重建方式与肿瘤切除后骨盆环的稳定性相关，位于耻骨、坐骨部位、S2以下的骶尾骨的肿瘤切除后对骨盆环连续性和稳定性影响不大，因此不需要骨盆重建，相反，位于S1、髂骨翼、髋臼部位的肿瘤切除后，骨盆稳定性遭受破坏，因此需要重建骨盆环。重建的首要前提是完整的切除肿瘤，其次才能考虑功能重建。治疗过程中常把功能重建放在首要位置上考虑等因素致使软骨肉瘤有较高的复发率。不同的重建方式，有其各自的适应范围：①软骨肉瘤符合外科切除、保肢适应证。②患者全身状况能耐受重建。③患者心理上可接受重建，并且有一定的经济条件[28]。因此，合理而有效的重建相当重要，应尽量兼顾以下要求：①能够提供坚固可靠的固定，以利于患者早期活动，从而达到提高生活质量的目的。②应尽量减少周围软组织尤其是宿主骨的骨膜组织的损伤，这样更有利于宿主在骨缺损端成骨以提高愈合概率。③异体骨周围避免异物遮挡，以利于骨及软组织愈合。 2.4.3 选择重建材料应根据软骨肉瘤切除的类型患者的基本情况、经济条件，以及对功能的要求和当时所能获得的内植材料等因素，综合个体化考虑，灵活运用，尽量选择简单而不是复杂的重建。依据涉及不同部位的软骨肉瘤负重和几何特点，采用不同的重建材料。而不是越复杂的重建患者预后越好。刘祥厦等[29]探讨胸腹壁巨大骨外黏液样软骨肉瘤的治疗方法，认为切除是骨外黏液样软骨肉瘤治疗的首选方法，对于局部复发的患者行局部扩大切除仍可达到治愈的目的，肿瘤切除后腹壁全层缺损应尽量采用皮瓣等自体组织修复，在感染创面修复应用人工材料需慎重。郭东明等[30]探讨了胸腰椎软骨肉瘤的切除方式和脊柱稳定性重建方法的选择，认为重建材料根据软骨肉瘤切除的类型来选择：①椎间植骨，适用于全椎体切除，原发灶预期生存期较长病例。②“钢筋”水泥替代物，包括钢针、钛网加骨水泥，适用于经肿瘤病灶切除和病灶刮除后重建辅助侧前钉板系统稳定。③人工椎体替代物，适用于单纯椎板减压和辅助前路重建后的稳定[31]。理想的骨缺损重建材料应该具有以下特性：①良好的生物相容性。②足够的力学性能和良好的生物力学适应性。③骨传导性。④骨诱导性。⑤提供成骨细胞，直接成骨。⑥良好的材料-骨组织界面。⑦可塑性。目前主要应用自体骨、异体骨和人工假体3种骨缺损重建材料。自体骨因具有愈合快、无排斥反应等优点，是一种非常理想的骨缺损重建材料[32]。但自体骨因其来源有限及供体部位并发症使其应用受到一定限制。人工假体和异体骨都有各自的优缺点。因此，目前临床应用的骨修复材料中没有一种能符合上述理想的骨缺损重建材料应该具有的特性，只能具备上述条件中的一部分。"

References

[1] Murphey MD,Walker EA,Wilson AJ,et al.From the archives of the AFIP: imaging of primary chondrosarcoma: radiologic-pathologic correlation.Radiographics. 2003;23(5): 1245-1278.
[2] 王定华,王富仓.软骨肉瘤的临床X线诊断(附98例报告)[J].中国社区医师(医学专业),2010,12(10):93.
[3] Boriani S,De Iure F,Bandiera S,et al.Chondrosarcoma of the mobile spine: report on 22 cases.Spine (Phila Pa 1976). 2000; 25(7):804-812.
[4] 刘禄明,王雪燕,段书宏.肋骨软骨肉瘤1例报告[J].医学影像学杂志,2001,11(4):207.
[5] Rozeman LB,Hogendoorn PC,Bovée JV.Diagnosis and prognosis of chondrosarcoma of bone.Expert Rev Mol Diagn. 2002;2(5):461-472.
[6] Gelderblom H,Hogendoorn PC,Dijkstra SD,et al.The clinical approach towards chondrosarcoma.Oncologist.2008; 13(3): 320-329.
[7] Espejo-Sánchez G,Rico-Martínez G,Linares-González LM,et al.Periacetabular pelvic reconstruction for chondrosarcoma with autograft of the proximal femur.Acta Ortop Mex.2012; 26(4):250-254.
[8] Healey JH,Lane JM.Chondrosarcoma.Clin Orthop Relat Res.1986;(204):119-129.
[9] Lichtenstein L,Jaffe HL.Chondrosarcoma of Bone.Am J Pathol.1943;19(4):553-589.
[10] Kito M,Moriya H,Mikata A,et al.Establishment of a cell line from a human giant cell tumor of bone.Clin Orthop Relat Res.1993;(294):353-360.
[11] Zhang Q,Zhao H,Maheshwari AV,et al.Isolated cardiac metastasis from a histologically "benign" giant-cell tumor of the distal end of the femur: a case report.J Bone Joint Surg Am.2010;92(16):2725-2731.
[12] Lee FY,Mankin HJ,Fondren G,et al.Chondrosarcoma of bone: an assessment of outcome.J Bone Joint Surg Am.1999; 81(3):326-338.
[13] Zeifang F,Buchner M,Zahlten-Hinguranage A,et al. Complications following operative treatment of primary malignant bone tumours in the pelvis.Eur J Surg Oncol. 2004;30(8):893-899.
[14] Fiorenza F,Abudu A,Grimer RJ,et al.Risk factors for survival and local control in chondrosarcoma of bone.J Bone Joint Surg Br.2002;84(1):93-99.
[15] Lexer E.The use of free osteoplasty together with trials on arthrodesis and joint transplantation. Archiv für klin Chirurgie. 1908;86(4):939-954.Clin Orthop Relat Res.2008; 466(8): 1771-1776.
[16] Moore AT,Metal hip joint: a case report. 1942.Clin Orthop Relat Res.2006;453:22-24.
[17] Ortiz-Cruz E,Gebhardt MC,Jennings LC,et al.The results of transplantation of intercalary allografts after resection of tumors. A long-term follow-up study.J Bone Joint Surg Am. 1997;79(1):97-106.
[18] 中国知网.中国学术期刊总库[DB/OL].2013-5-15. https://www.cnki.net
[19] SCI数据库.Web of Sciencevia ISI Web of Knowledge [DB/OL].2013-5-15.http://ip-science.thomsonreuters.com/mjl
[20] Bruns J,Elbracht M,Niggemeyer O.Chondrosarcoma of bone: an oncological and functional follow-up study.Ann Oncol.2001; 12(6):859-864.
[21] Ryzewicz M,Manaster BJ,Naar E,et al.Low-grade cartilage tumors: diagnosis and treatment.Orthopedics.2007; 30(1): 35-46.
[22] Leerapun T,Hugate RR,Inwards CY,et al.Surgical management of conventional grade I chondrosarcoma of long bones.Clin Orthop Relat Res.2007;463:166-172.
[23] Ahlmann ER,Menendez LR,Fedenko AN,et al.Influence of cryosurgery on treatment outcome of low-grade chondrosarcoma.Clin Orthop Relat Res.2006;451:201-207.
[24] Streitbürger A,Ahrens H,Balke M,et al.Grade I chondrosarcoma of bone: the Münster experience.J Cancer Res Clin Oncol.2009;135(4):543-550.
[25] Donati D,Colangeli S,Colangeli M,et al.Surgical treatment of grade I central chondrosarcoma.Clin Orthop Relat Res.2010; 468(2):581-589.
[26] Schwab JH,Wenger D,Unni K,et al.Does local recurrence impact survival in low-grade chondrosarcoma of the long bones?Clin Orthop Relat Res.2007;462:175-180.
[27] 张伟滨,沈宇辉.骨盆肿瘤切除重建术[J].国外医学(骨科学分册), 2005,26(3):133-135.
[28] 郭卫,杨荣利,汤小东,等.髋臼周围肿瘤的切除与重建[J].中华外科杂志,2004,42(23):1419-1422.
[29] 刘祥厦,唐庆,苏爱云,等.胸腹壁巨大骨外黏液样软骨肉瘤的治疗[J].中山大学学报(医学科学版),2006,27(2):82-83.
[30] 郭东明,徐中和,蔡维山,等.胸腰椎转移肿瘤手术切除和稳定性重建[J].广东医学,2004,25(6):683-684.
[31] 马忠泰,方志伟,栗怀广.自制“钢筋水泥”人工椎体修复椎体肿瘤切除后骨缺损[J].中华骨科杂志,1995,15(1):10.
[32] Finkemeier CG.Bone-grafting and bone-graft substitutes.J Bone Joint Surg Am.2002;84(3):454-464.
[33] Evans HL,Ayala AG,Romsdahl MM.Prognostic factors in chondrosarcoma of bone: a clinicopathologic analysis with emphasis on histologic grading.Cancer.1977;40(2):818-831.
[34] Asavamongkolkul A,Pimolsanti R,Waikakul S,et al.Periacetabular limb salvage for malignant bone tumours.J Orthop Surg (Hong Kong).2005;13(3):273-279.
[35] Pant R,Moreau P,Ilyas I,et al.Pelvic limb-salvage surgery for malignant tumors.Int Orthop.2001;24(6):311-315.
[36] Onishi AC,Hincker AM,Lee FY.Surmounting chemotherapy and radioresistance in chondrosarcoma: molecular mechanisms and therapeutic targets.Sarcoma.2011; 2011: 381564.
[37] Pritchard DJ,Lunke RJ,Taylor WF,et al.Chondrosarcoma: a clinicopathologic and statistical analysis.Cancer.1980; 45(1):149-157.
[38] Etchebehere M,de Camargo OP,Croci AT,et al.Relationship between surgical procedure and outcome for patients with grade I chondrosarcomas.Clinics (Sao Paulo).2005;60(2): 121-126.
[39] Jelinek JS,Murphey MD,Welker JA,et al.Diagnosis of primary bone tumors with image-guided percutaneous biopsy: experience with 110 tumors.Radiology.2002;223(3):731-737.