Intraoperative Extracorporeal Irradiation and RE-Implantation in Treatment of Osteogenic Sarcoma--Two Cases Experience

手術中體外放射線治療下肢骨肉瘤之二例病例報告

葉慧玲(Hui-Ling Yeh) ； 詹建勝(Jian-Sheng Jan) ； 譚台笙(Tai-Sheng Tan)

《放射治療與腫瘤學》 7卷2期 (2000/06) Pp. 113-119

https://doi.org/10.6316/TRO/200007(2)113

摘要

拜臨床化學治療之進步，肢體保留手術治療骨肉癌已成為目前的手術趨勢。腫瘤人工關節移植，異體骨移植，自體骨移植均被運用作為骨重建之要件。其中腫瘤人工關節移植的缺點為缺乏軟組織使腫瘤人工關節固定困難，另外會因長時間使用而發生鬆脫現像。異體骨移植的問題在於容易發生感染，骨骼癒合不良和骨質吸收。以自體骨移植不會發生上述問題，因此所得到的結果最好。但是經由肢體保留手術所切除之骨段甚長，幾乎不可能在同一人身上找到同等長度之骨段可作為自體骨移植。經由手術中體外放射線照射含腫瘤之骨段，可保留骨段之軟組織及去腫瘤之死骨架作為肢體重建的自體移植材料。由於採體外照射，因此沒有劑量提升之限制且不須考慮日後會造成鄰近軟組織的肉瘤變化。我們嘗試以這種新方法治療兩位患有下肢骨肉癌的病人。以術中體外放射線30000 cGy劑量照射帶腫瘤骨，並於照射後立即種回原來所取下來的位置(自體移植)。此二例病患於術後六個月均可不用拐杖自行行走。不幸這兩例病患均於手術後一年內發生局部復發。我們認為手術前化學治療劑量不足及手術時無法施行大範圍切除術是導致此二例病患早期發生局部復發的主因。手術中體外放射線治療雖然可提供良好的自 體移植材料，但是在對病患施行肢體保留手術前應嚴格篩選術前對化學治療反應良好及手術時較可能施行大範圍切除腫瘤的病患，才可降低手術後的局部復發率以達到肢體保留手術的目的。

關鍵字

手術中,體外放射線治療,再移植,骨肉瘤,自體移植

並列摘要

Limb salvage surgery is currently used in treatment of osteogenic sarcoma in extremities by the advances in chemotherapy. Tumor prosthesis, allograft and autograft had been used for bone defect reconstruction. The use of autograft avoids some disadvantages of tumor prosthesis such as difficulty of soft tissue attachment and implant loosening after a period of time and decreases the probabilities of wound infection and nonunion as what might happen with allograft. So autograft provides the best result in bone reconstruction. However, it is impossible to find exactly the same length of autograft as what we had resected in the operation from our body. By the use of intraoperative extracorporeal irradiation to the tumor bearing bone segment, the soft tissue is preserved and the dead bone can be used to re-implant and substitute the bone defect. There is no limitation in dose escalation for irradiation of bone extracorporeally. The sarcomatous change of the adjacent normal soft tissue induced by radiation need not to be considered. In this paper, we tried to use this new method to provide a tumor free autograft for limb salvage surgery in two cases of locally advanced osteogenic sarcoma in lower limbs. A tumor dose of 30000 cGy was applied to the tumor bearing bone segment resected from both cases. The heavily irradiated specimen was sent back to the operation room immediately for re﹒implantation. The initial functional result was encouraging after six months of immobilization. Intraoperative extracorporeal irradiation with no dose limitation plays an important role in providing a sterile tumor free autograft with good bone union of the diseased leg. Unfortunately both cases had local tumor recurrence within one year after operation, inadequate neoadjuvant chemotherapy and inadequate (marginal) resection for locally advanced disease may be the main reasons for these early recurrences. We think that limb salvage surgery is a potential method only for some highly selected patients with good neoadjuvant chemotherapeutic response. Moreover, the tumor bearing bone segment should be resected with wide surgical margin to achieve a better long-term local tumor control.

並列關鍵字

Intraoperative,Extracorporeal irradiation,Re-implantation,Osteogenic sarcoma,Autograft