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Treatment department: Orthopedics Oncology Treatment cost: different hospitals have different charging standards, the city's top three hospitals are about (5000-10000 yuan) Cure rate: Treatment cycle: Treatment method: Surgical treatment General treatment of giant cell tumor of bone
Giant cell tumor of bone treatment
Based on the natural history of the disease. Hutter et al. pointed out that about 30% of curettors relapse within 2 years, and 50% relapse within 5 years. 90% of all relapsed patients occurred within 5 years. Therefore, local recurrence after 5 years should be considered for malignant transformation. They reported that only 1/3 of the cases were cured after one operation, 1/3 of the cases were cured after two operations, and the remaining 1/3 were cured after 3 to 5 operations.
Therefore, if you want to be cured by one operation, you must take radical surgery, that is, complete removal of the tumor, including mass resection of the appropriate amount of normal tissue. Complete curettage and bone grafting Thompon reported that the recurrence rate was 29.6% after the first year to 54.1% at the fifth year, and about 10% of giant cell tumors of bone became malignant. This also shows that curettage and bone grafting are not suitable for most giant cell tumors of bone. The prognosis of giant cell tumors of trunk bone after curettage and bone grafting is better than that of limb bones. In the case of repeated curettage and recurrence, segmentectomy should be considered for those with the possibility of malignant transformation. Segmental resection is also feasible with arthrodesis, hemi-articular transplantation or prosthesis.
For patients with primary malignant giant cell tumor or malignant sarcoma, amputation is required, and amputation should also be considered for those who have a wide range of tumor lesions or who have invaded the soft tissue after segmental resection.
There are more chances of sarcoma after radiation exposure, and it should be used cautiously only when certain parts of the human body are not suitable for surgery.
Surgery is the main method of treatment of giant cell tumor of bone. Expanded curettage is a commonly used method of resection within the lesion. Simple curettage has a higher local recurrence rate, so some auxiliary methods can be used to treat the tumor wall and expand the surgical boundary. Commonly used auxiliary methods include liquid nitrogen, phenol, high-speed drilling and so on. These methods can enlarge the scraping boundary by 1 to 4 mm, and can kill the remaining tumor cells and reduce the local recurrence rate. Fill the cavity created by curettage with bone cement or bone graft. For parts that will not cause severe dysfunction after resection, such as the proximal fibula and the distal ulna, a large-scale resection is feasible. In addition, if the tumor recurs repeatedly or the tumor is huge, extensive resection may also be considered. Because radiotherapy may lead to sarcoma or secondary malignant tumors, radiotherapy is only considered for rare cases that are difficult to remove.
1. Tumor curettage and bone grafting
(1) Recurrence rate and treatment methods
The treatment of giant cell tumor of bone was amputation in the 19th century. It was not until 1912 that Bloodgood used tumor curettage for the first time, treated the bone wall with phenol, and gave bone graft to the residual cavity. Because the cavity wall of the tumor is honeycomb-shaped in different sizes and depths, it is difficult to completely remove the tumor cells with simple curettage. A small amount of tumor cells hidden in the lacuna can cause tumor recurrence. The early recurrence rate can be as high as 50%.
In order to reduce the rate of rejuvenation, many auxiliary measures (adjuvant procedures) have been taken on the cavity wall after tumor scraping, such as liquid nitrogen freezing, chemical corrosion (including phenol, ethanol, zinc chloride, etc.), distilled water soaking, and high-speed grinding. Head grinding, etc., but the recurrence rate has not yet fallen to a satisfactory level. In addition, even dense bone grafting (densely parking) for cases where the lesions reach subchondral may cause the joint surface to collapse during weight bearing, resulting in degenerative joint disease. In recent years, the method of bone cement filling has been widely used at home and abroad, which has significantly reduced the recurrence rate. Its advantages are: the method is simple, and the patient can bear weight early. The heat of polymerization of the bone cement can kill the tumor cells on the cavity wall. The disadvantage is that when the residual bone shell is too weak, it can cause fractures. Therefore, it is often necessary to use steel plate screws for auxiliary fixation. For subchondral lesions, due to the rigid bone cement, the bone cancellous lacks the cushioning and protective effect of the cartilage. With the follow-up time
The lengthening of the cartilage will cause wear and tear, and degenerative joint disease may also occur. In addition, when the tumor is scraped, the aforementioned reliable auxiliary measures are not taken, and the polymerization heat of bone cement alone (surface temperature is about 60°C, lasting for several minutes) cannot completely kill the deep tumor cells, therefore, its recurrence rate Still can't take it lightly. The treatment of giant cell tumor of bone is mainly surgery. Radiation therapy is only suitable for some special situations, such as in areas where the operation is not easy to completely remove the lesion, trial radiation therapy may be able to control its development. According to reports in the literature, the effect of radiotherapy is unreliable, and the incidence of conversion to sarcoma is relatively high, which mostly occurs about 3 years after irradiation, with fibrosarcoma becoming the main one.
(2) The treatment experience of our hospital
Over the past 11 years, the Institute of Bone Tumors of this hospital has used the heat generated by microwave radiation to treat more than 600 cases of different types of bone tumors throughout the body. It has accumulated rich experience and made it a practical and effective treatment method. It has achieved very good results for the treatment of giant cell tumor of bone. The tumor is rich in blood supply and has a water content of more than 90%, which is very beneficial for absorbing microwave energy. The operation process is simple. Only the front and back walls of the tumor cavity are exposed. There is no need to peel off all the muscles. After the main vascular bundle is separated, there is no need to insert Cooling plastic bags, that is, 2 or 3 antennas can be directly inserted into the tumor cavity, and microwave energy can be input under strict thermal monitoring. After 2 to 3 minutes, the temperature in the cavity can reach about 70°C, and the distribution is uniform. When the temperature drops below 60°C, the radiation will be applied and maintained for 30 minutes or longer. In this way, the tumor cells deep in the tumor wall can be completely killed. And the cartilage tissue is continuously cooled down and remains active. The remaining bone wall tissue still retains the ability to regenerate bone (although its blood supply can also be blocked), and then it is easy to scrape off the fragile heat-inactivated tumor tissue. The bone reconstruction method is to use several longitudinal autologous bodies of appropriate length Or allogeneic cortical bone strips, which are placed between the bone marrow cavity and the bone shell and cartilage isthmus wall. The gap is filled with more than 50% allogeneic bone debris and about 40% bone cement mixture. After the bone cement is polymerized, its mechanical strength is very good. If the transverse diameter of the bone cavity exceeds 3/4 of the transverse diameter of the bone segment, a condyle plate is used for preventive internal fixation. After the operation, you can walk under the protection of a partial weigh-bearing brace. The stent can be removed after half a year.
102 cases of giant cell tumor of bone in various parts have been treated with the above method, of which more than 40% are cases transferred from another hospital after recurrence, only 1 case requires 2 operations, all cases have been followed up for 11 years, and no recurrence has been seen. By. Joint function is preserved to the utmost extent. Some patients can engage in heavy physical labor. In the early cases in this group, only bone transplantation was performed, and several cases of joint collapse occurred. After using the new bone graft material, the joint collapse phenomenon disappeared completely.
However, for the lesions close to the subchondral lesions, partial abrasion of the articular cartilage can be seen within a few years after reconstruction. Recently, in this case, we placed a filling with a minimum proportion of bone cement on the articular surface during reconstruction to make the elastic modulus as close as possible to the cancellous bone. There are two main surgical complications: one is postoperative fracture (3 cases of fractures need to be re-bonded and fixed), and 1 case has infection and needs to remove the tumor bone. After 3 months of infection control, the knee joint was fused with a large segment of allograft. Overall, the recurrence rate has dropped to a very satisfactory level, and the incidence of complications is also very low. Once the implanted bone is vascularized, the crawling replacement process can occur, and the implanted bone and the residual bone shell will be biologically anchored.
Giant cell tumors that appear in large flat bones (such as the scapula and pelvis). There will be fierce bleeding during curettage. In the case of unclear vision, it is difficult to scrape thoroughly, and the aforementioned auxiliary measures are also difficult to implement. Therefore, the recurrence rate is very high. Microwave heat inactivation method is used to control the bleeding. The shoulder joint function was intact after 3 years of follow-up. During the second operation in this hospital. The peritoneum is severely adhered to the tumor mass, and a large piece of peritoneum needs to be removed. The internal structure of the pelvis (such as external iliac blood vessels, femoral nerve, ureter, etc.) is difficult to dissect. The pelvic ring was treated and reconstructed according to the heat inactivation method, the pelvic ring continuity was preserved, the patient was discharged from the hospital on foot, and the hip joint function was excellent.
Only used in the following situations:
① The tumor invades most of the bone ends, and the articular surface has collapsed; or the pathological manifestations have been changed by fibrosarcoma;
②There is no obvious dysfunction left after the excision, such as giant cell tumor of the fibula and ulna.
(2) Common methods:
For the bone ends that constitute large joints, reconstruction surgery is often required after amputation to restore limb function. Common methods are as follows:
①Knee joint fusion: The effect of massive allograft for knee joint fusion is reliable, durable, and the disadvantage is loss of knee joint mobility.
②Hemi-joint transplantation: replace the excised tumor with a cadaveric hemi-joint. Osteochondrial rejection is relatively small, and the recipient is basically acceptable. According to reports, the osteotomy was healed satisfactorily. But the knee joint is unstable and has poor mobility, and is prone to fracture collapse, infection, etc.
Complications, bone crawling replacement is difficult to complete, the final result is Charcoal joints. This method should be used very carefully.
③Artificial joint replacement: Due to the long lever of the prosthesis, the joint with the backbone may loosen. Mechanical obstacles, loosening, and infection are the main reasons for failure.
No matter which reconstruction method is selected, the joint function is completely or mostly lost. Therefore, the selection of the indications for segmental amputation should be very careful. Any type of destructive surgery should be performed. The decision to amputation should be especially cautious, and it is limited to cases where there is obvious malignant transformation or extensive local infiltration that cannot be completely removed.
3. Problems with lung metastasis
Not only cases of malignant transformation, but some cases whose pathological diagnosis is obviously "benign" (that is, grade 1 of Jaffe standard), lung metastases also occur frequently, mostly after multiple recurrences and repeated curettage. The pathological manifestations of lung metastases are exactly the same as the primary bone lesions, and there are also a large number of multinucleated giant cells, which cannot be understood as the accumulation of normal osteoclasts. In recent years, the treatment of such metastases has tended to adopt a positive attitude. Wedge resection or simple tumor removal often achieves better results, which has enabled many patients to survive. It has been reported that more than 90 metastases were removed from both lungs, and they were still alive 2 years after surgery.
Articular cartilage has a strong resistance to giant cell tumor of bone, and it is almost impossible to see that the tumor penetrates the cartilage directly into the joint cavity. In cases of joint involvement, most of the tumors grow outward, penetrate the cortical bone, erode the joint capsule and invade the joint, or erode the intercondylar tissue into the joint. Treatment includes removal of the lesion and fusion of the joint.
The vast majority of cases can be cured after timely and appropriate treatment, and satisfactory joint function can be retained. Incomplete or incomplete surgery is the main cause of recurrence. There may be lung metastases. The so-called recurrence is due to the incomplete removal of tumor cells from the primary tumor. Through a large number of case statistics, Spjut et al. found that all lung metastases occurred after certain treatment measures such as curettage or irradiation, and none of them occurred before the primary tumor was untreated. Based on this, he believes that the truncation method is more reliable. We believe that improving the thoroughness and reliability of the first treatment is the main measure to reduce lung metastasis. Lung metastasis is mostly caused by repeated local attacks and incomplete treatment. In cases of obvious malignant transformation, the survival rate after amputation is also much higher than that of other types of malignant tumors.
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