1.What does the surgical treatment of bone tumor include?
Benign bone tumor or tumor-like lesion is mainly scraped or excised by surgery. The surgery should be thorough to avoid recurrence, but the limb function should be preserved as much as possible. For malignant tumors, life saving should be the main concern, and limb preservation should be considered only if the survival rate is not reduced. At present, the commonly used surgical methods are scraping, resection, amputation and amputation.
Scraping is to cut open the bone wall containing the tumor and scrape away the tumor tissue in it. This procedure is indicated for benign bone tumors such as endogenous chondrosarcoma, bone cyst, eosinophilic granuloma of bone, and some giant cell tumors of bone. The cavity left after tumor scraping needs to be filled. Commonly used orthopedic filling materials include bone cement, autologous bone, allogeneic bone and artificial bone. After filling, internal fixation with plates and intramedullary pins is required to prevent fracture.
Excision is an operation to remove the tumor protruding outward to the bone from its base, which is mainly applied to osteochondroma.
Resection is to remove the whole section of the bone stem or even the joint where the tumor is located. It is suitable for giant cell tumors and malignant tumors such as osteosarcoma, fibrosarcoma, chondrosarcoma, etc., which are more destructive. Some of the defects left after stem amputation do not need to be repaired, such as the proximal fibula and distal ulna, but most of them need to be reconstructed with artificial prosthesis, allograft bone or autologous bone.
In case of malignant tumor, the recurrence rate of limb preservation surgery is higher, thus affecting the life, or the function of the preserved limb is poorer than that of prosthesis, amputation can be chosen.
2. Is it okay to cut open the tumor first before deciding the surgical plan?
Unless benign tumor is scraped out, the tumor should be removed together with its outer envelope or pseudo-envelope or even the normal tissues around it, so as to avoid tumor cell shedding causing implantation or recurrence. Therefore, under normal circumstances, the tumor will not be cut open during the operation. Usually, the histopathological examination of the tumor is completed by preoperative puncture biopsy, if it is difficult to make a clear diagnosis by puncture biopsy, incisional biopsy can be used.
3.How to determine the scope of surgical resection?
The relationship between surgical stage and surgery is as follows.
Benign tumor: Stage 1 is a quiescent tumor and can be scraped intracapsularly; Stage 2 is an active growth and can also be scraped intracapsularly; Stage 3 is invasive and is best excised at the margin.
Malignant tumor: stage I with extensive local excision; stage II with extensive local excision or amputation.
4.How to decide the level of amputation? Can amputation cure bone tumor?
When choosing the level of amputation, we must consider both the disease and function. The disease is to remove all the tumor tissues and amputate at the site with good soft tissue condition and satisfactory skin healing, i.e. the farthest site; the function level is to obtain the best function by amputation at this site. In recent years, with the improvement of prosthesis technology, the selection of amputation site has changed significantly from the past, so the amputation level is mainly determined by the scope of tumor invasion, and the installation of prosthesis is considered second. The general principle is that the soft tissue should be at least 5 cm away from the proximal end of the tumor and the tissue at the amputation site should be able to achieve satisfactory healing. The length of the residual limb should be preserved as much as possible so that its function can be maximized. The amputation site is directly related to the prosthesis fitting, compensatory function, energy consumption of lower limb amputation with prosthesis, patient’s ability to live, mobility and employability, etc. Therefore, surgeons should be extremely careful in choosing the amputation level.
In some cases, amputation is still an effective treatment for late diagnosis, tumor invasion or recurrence after limb preservation surgery, or limb non-function due to tumor. Therefore, amputation alone cannot cure the bone tumor, but must be combined with other treatments such as adjuvant chemotherapy to control the metastasis of bone tumor and cure it.
5.What are the conditions for limb preservation? How to correctly understand the recurrence rate of limb preservation?
Limb preservation therapy for malignant bone tumor is the common pursuit of both patients and bone tumor specialists, and certain conditions are required for limb preservation therapy.
(1) The tumor does not invade important blood vessels and nerves;
(2) The tumor can be completely removed outside the tumor and a good surgical border can be obtained;
(3) The local recurrence rate after limb-preserving surgery should not be higher than that of amputation;
(4) The local soft tissue condition is fair and the preserved limb function is expected to be better than that of prosthesis.
Although surgical treatment alone can control local lesions in the short term, it cannot solve the problem of distant metastases. Therefore, although traditional amputation removes the primary lesions more completely, its survival rate is not improved. For example, the 5-year survival rate of patients with osteosarcoma after amputation is still only 40%-70%, which is not significantly different from limb preservation treatment, but brings great physical and psychological trauma to patients and their families. With the development of chemotherapeutic drugs and chemotherapy regimens and the continuous improvement of medical technology, limb-sparing surgery has been widely performed in the last 20 years. The local recurrence rate of limb preservation surgery is 5%-10%, and the survival rate and local recurrence rate are the same as those of amputees, so limb preservation surgery is feasible.
6.What are the special features of limb preservation for children?
The biggest problem of limb preservation in children is that the limbs are not equal in length. Since the lesions in children are mostly located in the epiphysis, the epiphysis and epiphyseal plate need to be removed together in order to completely remove the tumor, which inevitably causes the growth of the limb on that side to stop. If the limb preservation surgery is performed with conventional custom-made length prosthesis, the preserved limb will not grow taller after surgery, and the affected limb and the healthy limb will become unequal in length as the age increases. Therefore, limb-sparing surgery for malignant bone tumors in children is more complex than limb-sparing surgery in adults. Compared with adult limb preservation surgery, the main issue is how to remove the tumor while avoiding damage to the long bone epiphysis or using a lengthenable prosthesis as much as possible. Based on this, various surgical methods have emerged to avoid postoperative limb inequality. Such as extendable prosthesis, hemiarthroplasty, limb preservation surgery for malignant bone tumor with preservation of epiphysis, etc. However, each method has certain limitations. However, each method has certain limitations, so amputation is still preferred for malignant tumors in children.
7.What are the filling methods after scraping? What are the advantages and disadvantages of each?
There are many filling methods for bone defects after tumor removal, and the more common ones are: autologous bone graft, allogeneic bone graft, bone cement (polymethylmethacrylate) filling, artificial bone (hydroxyapatite) filling, etc. Autologous bone graft, with high healing rate, short healing time, safe and reliable, is the best graft. However, bone extraction adds new pain to the patient, and complications such as infection, hematoma, and pain can occur in the donor area. Autologous bone implantation is also limited by the amount of bone available. The relative abundance of allogeneic bone sources, especially the rapid development of bone banks in China in recent years, has made it more convenient to source allogeneic bone. The immunogenicity and osteoinductive ability of allogeneic bone preserved by different methods vary, and the main complications are rejection reaction and its secondary infection after allogeneic bone implantation, in addition to the risk of infectious diseases. Bone cement is highly resistant to stress and allows early movement without waiting for healing. However, its weak resistance to torque and its inappropriateness for use in growth-phase patients partially limit its use. Ultimately, it is only a mechanical filler support and cannot achieve biological healing. Hydroxyapatite particles are inorganic particles containing only calcium and phosphorus, which have good histocompatibility and compressive strength and are now widely used in clinical treatment of bone defects caused by fractures and bone tumors.
8.What are the reconstruction methods for large bone defects? What are the advantages and disadvantages of each?
After extensive resection of bone tumor, large bone defects are often caused. The common methods for reconstruction of these bone defects include: large allograft bone graft, autologous bone graft, inactivated replantation, artificial prosthesis, etc.
The advantage of autologous bone grafting is the high bone healing rate, but the disadvantage is that the choice of host bone is somewhat limited, most often choosing fibula graft.
Allogeneic bone grafting can preserve the morphology, size and strength of the bone, and can preserve the ligamentous appendages for soft tissue reconstruction. Allograft bone is osteoinductive and osteoconductive, and can achieve the bony healing desired by orthopedic surgeons. However, it has more nonunion, fatigue fractures, resorption of allograft bone, and infection than autologous bone. And its immune rejection has not been fully resolved.
It has been reported in the literature that compounding BMP-2, which has strong osteoinductive activity, with nano-hydroxyapatite, combining the osteoinductive and osteoconductive properties of biomaterials into one, can better repair bone defects, especially large segmental bone defects. However, it is still in the experimental stage, and its therapeutic effect on bone defects caused by tumors remains to be seen.
The most widely used reconstruction method is artificial prosthesis. The development of modern industry has led to the rapid development of artificial prosthesis, and its function and life span have developed significantly, but some complications often appear, such as loosening, infection, fracture, etc.
9.Why does it affect the function of urination and defecation after sacral osteoma resection?
An important problem that affects the quality of life after sacral tumor resection is urinary and fecal disorders, the reasons for which are as follows.
(1) Preservation of sacral nerve roots: the nerves innervating anorectum and bladder are divided into autonomic nerves and somatic nerves. The above nerves originate from the sacral marrow, while the early symptoms of sacral tumor are insidious, atypical and not easy to be diagnosed early, and when found, the tumor is often large and has invaded the sacral nerve, so the surgery of sacral tumor must involve the treatment of sacral nerve, which leads to the problem of postoperative urinary and fecal function.
(2) Special surgical site: the sacrum is removed after sacral tumor surgery, and the sacrum is an integral part of the pelvis, and the muscles of the pelvis and abdomen are involved in the activities of defecation and urination, so the damage of the sacrococcygeal incision will also cause the patient’s urinary and fecal dysfunction.
(3) Psychological factors: the change of one’s defecation pattern is related to emotion. Due to the disease and surgical blow, sacral tumor patients are in a state of long-term psychological tension, anxiety and irritability, plus worrying about the effect of defecation on the wound, they do not take the initiative to defecate, resulting in the patient’s urinary and fecal dysfunction, so it is also very important to maintain a good psychological state.
(4) Environmental factors: defecation has strong privacy. Postoperative patients with sacral tumor are often required to defecate in the ward due to large surgical trauma and weakness, resulting in defecation dysfunction due to change of patient’s defecation environment.
10.What is the effect of preoperative embolization? What are the side effects of embolization?
Since pelvic and spinal tumors are rich in blood flow, in order to reduce bleeding, preoperative selective embolization of tumor blood vessels through arteriography is used, which can significantly reduce bleeding, clear surgical field and complete resection of tumor.
Possible complications after embolization include pulmonary embolism, renal failure, lower limb venous thrombosis, distal limb ischemic necrosis, spinal cord or peripheral nerve injury, skin necrosis and so on. These complications can be minimized through superselection and other methods.
11.How to treat bone tumor combined with fracture?
The treatment of pathological fracture is different from the treatment of general fracture, which focuses more on the treatment of the primary disease based on the treatment of fracture. Combined pathological fracture is often one of the highly malignant manifestations of osteosarcoma, so it is usually not possible to wait until the fracture heals before surgery.
Since malignant bone tumors combined with pathological fractures often lead to hematoma production, which can spread or contaminate adjacent soft tissues, neurovascular bundles or joints, amputation was usually used in the past to avoid the spread of tumor cells. With the gradual development of neoadjuvant chemotherapy, some researchers have reported that chemotherapy can heal pathological fractures and facilitate the implementation of limb preservation surgery. Therefore, amputation is recommended unless the tumor or hematoma invades important neurovascular structures or joints, or a large amount of muscle must be removed to ensure the normal function of the limb. For patients with pathological fracture without displacement, if there is a good response to chemotherapy, it can be used as an indication for limb preservation surgery. With the further development of bone tumor diagnosis and treatment technology, more patients with bone tumor combined with pathological fracture will receive limb preservation treatment.
12.Can bone tumor be massaged or hot compressed?
Malignant bone tumor mainly affects teenagers, and because of the insidious symptoms, it is easily confused with trauma in treatment. Some doctors treat it as trauma or arthritis due to insufficient understanding of bone tumor, and adopt local massage or hot compress treatment. Since cancer cells are loosely connected with each other, when they are squeezed by external force or other stimulation, they will easily fall off from the tumor and enter into the lymphatic tract or blood vessels, causing metastasis. Therefore, instead of curing the disease, this method accelerates the growth of the tumor so that the early treatment opportunity is missed and the condition deteriorates. Therefore, if teenagers feel the pain in their legs is not the same as before, it is better to ask the doctor to make a scientific diagnosis to find out if the cause of the pain is caused by trauma. For bone tumor that has been diagnosed, it is necessary to strive for treatment in oncology hospital or oncology specialist, and strive to treat thoroughly for the first time in order to reduce the metastasis and recurrence of cancer.
13.What are the factors of recurrence after bone tumor resection? Why does recurrence occur even after “complete” resection?
There are many reasons for recurrence of bone tumor after surgery. Generally speaking, factors such as high malignancy, late surgical stage, inadequate chemotherapy before surgery or poor responsiveness to chemotherapy, incomplete surgical resection may cause recurrence of tumor after resection, and other factors such as age, size and location of tumor, onset and consultation time may affect the prognosis of bone tumor. The so-called “complete” resection refers to the surgical boundary of tumor resection, which is only a necessary condition to prevent tumor recurrence after surgery, other factors such as tumor malignancy, surgical stage and responsiveness to chemotherapy can not be solved by surgery. Therefore, we cannot think that the tumor will not recur after “complete” resection.
14.Is amputation the only option after bone tumor recurrence?
Whether amputation is needed after bone tumor recurrence again depends mainly on the size and location of the recurring tumor. If the tumor is large and not easy to be removed completely, or if the tumor invades the main nerve and blood vessel bundle, amputation is often the only option. If the surgeon thinks that the tumor can be completely removed and some functions can be preserved according to the preoperative examination, then limb preservation surgery can be performed. In addition, for some diseases, although the tumor is large, the tumor can be shrunk through radiotherapy and so on, thus achieving the purpose of limb preservation.