Nicolescu Tumori...Prof Curs Pt Specialist

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    TRATAMENTUL CHIRURGICAL

    ALTUMORILOR OSOASE

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    T. BENIGNE-- CHIURETAJ / PLOMBAJ

    -- REZECTIE MARGINALA

    T.MALIGNECHIR CONSERVATOARE RECONSTRUCTIVA-- AMPUTATIA

    EVOLUTIA MAJORA A TM

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    STRATEGIA TERAPEUTICA

    * BIOPSIA

    * PROTOCOL CHIMIO, RADIO

    * TRAT. CHIRURGICAL EMBOLIZARE

    Rx.TERAP PREOP

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    PLANUL PREZENTARII

    DEFINITIITERMINOLOGIE

    CHIURETAJPLOMBAJ

    REZECTIA

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    DEFINITII

    PRINCIPIILE LUI ENNEKING

    COMPARTIMENT

    CAPSULA

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    COMPARTIMENTAL

    =

    LIMITAT DE STRUCTURILE ANATOMICE(NU NEOFORMATE)

    CORTICALA

    APONEVROZE

    PERETII LOJELORCAPSULA ARTICULARA

    CARTILAJ DE CRESTERE

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    TUMORA

    Intra COMPARTIMENTALA

    Extra COMPARTIMENTALA = TRECE DE LIMITA C= SPATIU DESCHIS

    Ex. AXILARPOPLITEU

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    CAPSULA TUMORALA

    =

    STRUCTURA REACTIONALA PRODUSA DE TESINCONJURATE

    In TUM agresive = perforata

    = distrusa

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    TIPURI DE REZECTIE TUMORALA (Enneking) :1. radicala2. larga

    3. marginala4. intralezionala

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    ENNEKING

    CHIRINTRA LEZIONALA (Intra Caps) Ex. Chiuretaj

    CHIR MARGINALA= LA RAS DE LEZIUNE

    NU PENETREAZA IN LEZIUNE

    Ex. Excizia simpla

    (exereza limitata)

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    ENNEKING

    CHIR LARGA = LA DISTANTA IN TESUT SANATOS(DAR RAMANE IN COMPARTIMENT)

    CHIR RADICALA= EXTRACOMPARTIMENTALA= ABLATIA INTREG COMPARTIMENT

    (FARA A-L DESCHIDE)

    Ex. Tot femur, amput de gamba

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    REZECTIA

    = IN BLOC A TUMORII FARA A O PENETRA

    = REZECTIA LA RASUL CAPSULEI

    = REZECTIALARGA = LA DISTANTA CU O MARJA DE

    TES. SANATOS (INTRACOMP)

    !!! NU VEDEM TUMORA SAU CAPSULA

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    REZECTIA RADICALA

    = Extra COMPARTIMENTALA

    Ex: O.SARCOM FEMUR DISTAL cu invazie in qvadriceps

    = ABLATIA TOT FEMURUL + LOJA ANTER. DINCOLO

    DE APONEVROZE!!! EXCEPTIE

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    REZECTIA CONTAMINATA

    = PENETRARE ACCIDENTALA PRIN FRAGMENTARE

    - TUMORI VOLUMINOASE

    !!! REZECTII NECARCINOLOGICE RISC CRESCUT DE

    RECIDIVE

    REZECTII PALEATIVEDELIBERARI INCOMPLETE

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    AMPUTATIA- DEZARTICULATIA

    POATE FI :

    MARGINALA, LARGA, RADICALA,CONTAMINATA

    !!NU ADUCE PLUS DE SECURITATECARCINOLOGICA

    INDICATII: - INVAZIE MONSTRUOASA

    - INTERVENTII MULTIPLE

    - INFECTII

    - SECHELE RADIOTERAPIE

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    CHIURETAJ- PLOMBAJ

    CHIRURGIA INTRA LEZIONALA

    !! GEST EXTREM DE MINUTIOS TB

    2 TIMPI EXEREZA INTRA LEZIONALA

    PLOMBAJ

    EMBOLIZARE / RED. SANGERAREA

    VS HEMOSTAZA PRIN GAROU

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    METASTAZA TUMOARE GRAWITZLA UN PACIENT DE 54 ANI :CHIURETAJ + PLOMBAJ CIMENT + OSTEOSINTEZA LAMA - PLACA

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    METASTAZA HUMERUS :CHIURETAJ + PLOMBAJ CU CIMENT + OSETOSINTEZA CU PLACI

    INSURUBATE

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    CHIURETAJUL

    TREPANATIE LARGA (EFECT DE SURPLOMBA)

    IN AXUL OSULUI

    = SEPTURILE SE REZECA

    = AVIVAREA PERETILOR CU FREZA/ DALTA

    CAUTERIZARE (CEL.T RESTANTE)

    SER HIPOTON, APA DISTILATA, FORMOL, AZOT LICHID,

    ELECTROCAUTER

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    PLOMBAJUL

    = DESFIINTAREA SPATIULUI

    = REFACE REZISTENTA OSULUI Osteo-Sinteza

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    PLOMBAJ

    AUTOGREFE SPONGIOASE

    GREFA CORTICALA

    O.S.

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    AUTOGREFE

    CAVITATI MARI

    CONSOLIDARE LENTA

    FRAGM.MARE + LIPSURI

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    CIMENT CHIRURGICAL ANTIBIOTIC

    REZISTENTA MECANICA

    ACTIVITATEA ANTITUMORALA (CALDURA)

    NU PE TERMEN LUNG ( METASTAZE)

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    BIOMATERIALE AUTOGREFE

    O.S. < 2/3 DIN CORTICALA

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    RECIDIVE ?= DURERI, FEBRA

    = IMAG. GEODICE, LIZA GREFEI

    !! CT imediat POSTOPDE REFERINTA

    = Hiper Captare Scintigrafica

    !! O NOUA BIOPSIE

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    STRATEGIA OPERATORIE

    OBIECTIVE:

    * CALEA DE ABORD

    !! BIOPS INSUF.

    I timp CHIMIO -- PROTEZA PERSONALIZATA

    -- ALLOGREFA MASIVA

    !! BILANTUL EXTENSIEI LEZIUNII :

    CTos+ parti moi

    RMN- skip meta, vase

    ANGIOGRAFIA- invazie vase

    METASTAZELE

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    STRATEGIE

    OBIECTIVUL

    CHIRURGIA CONSERVATOARE

    VS

    AMPUTATIE + PROTEZA PERFORMANTA

    !!DECAT UN MEMBRU RIGID, PARALIZAT, INSENSIBIL,

    INFECTAT

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    CALEA DE ABORD

    ABLATIA CICATRICILOR BIOPSIEI

    CONTROLUL TUMORII

    VASE, NERVI RECONSTRUCTIA

    !! 2 CAI DE ABORD

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    EXEREZAMONOBLOC

    POSIBIL

    ITIMP * OSTEOTOMIE SUB SI DEASUPRA TUMORII

    ( TUM SE ROTEAZA PE EA INSASI)

    !!! CALITATEA TES. PERIFERIC

    NUGROSIMEA

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    NU ATINGE / PENETRA TUMORA!!! SA NU O VEZI

    DACA RAMAN NODULISE REIA EXCIZIA CARCINO

    A ZONEI

    PIESA ORIENTATA, NESEGMENTATA PT A IDENTIFICAZONA DE REZ.LIMITA/ INSUF

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    RECONSTRUCTIA

    ALLOGREFE POT FUZIONA (Merle DA,OHolenghi, Parish, Volkov)

    PSEUDARTROZE, FRACTURI,

    REZORBTII, SEPSIS

    !!! NUMAI ZONA SUPERFICIALA ESTE REABITATA

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    SARCOM PAROSTEAL LA UN PACIENT DE 44ANI :

    RECONSTRUCTIE CU ALOGREFA MASIVA

    FIXATA CU PLACA INSURUBATA

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    REZORBTIA

    * ? REACTIE IMUNITARA

    * ? TRANSFUZIEFACT. IMUNIZANT

    * RESPECTAREA HLA( HUMAN LEUKOCYTE ANTIGEN)= O MAI BUNA INTEGRARE A GREFEI

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    ALLOGREFE MASIVE

    * MASURAREA

    * FIXAREA RIGIDA /SOLIDA !! INTEGRARE LENTA

    * ZONA DE CONTACT -- AUTOGREFE

    -- CHEVRON

    -- INCASTRARE METAFIZARA

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    ANI :

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    ANI :RECONSTRUCTIE CU GREFA INTERCALARA

    + OSTEOSINTEZA CU TIJACENTROMEDUALARA

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    GREFE META-EPIFIZARE CU CARTILAJ

    * ALLOGREFA PERIPROTETICA

    BAZIN /GENUNCHIALLOGREFA + P. T.

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    ARTROPLASTIA MASIVA

    * PREFERATA LA M.inf, SOLD, GENUNCHI

    * ARTRODEZA Mb.Superior

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    OSTEOSARCOM CONDROBLASTIC :

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    OSTEOSARCOM CONDROBLASTIC :RECONSTRUCTIE CU ALOGREFA MASIVA + PERONEU AUTOLOG +

    FIXARE MIXTA

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    ARTROPLASTIA SOLD

    * PROTEZE MODULARE DE RECONSTRUCTIE

    PERSONALIZATE

    *COMPLICATII !!! SEPSIS

    LUXATIA CUPA RETENTIVA

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    SARCOM PAROSTEAL :RECONSTRUCTIE CU CILINDRU DE TITANIU UMPLUT CU

    ALOGREFA MORSELATA

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    OSTEOSARCOM EXTREM.PROX TIBIE CU INVAZIA AP.EXTENSOR LA UN PACIENT

    DE 21 ANI

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    TUMOARE CU CELULE GIGANTE LA UN PACIENT DE 37 ANI :

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    TUMOARE CU CELULE GIGANTE LA UN PACIENT DE 37 ANI :RECONSTRUCTIE CU ALOGREFA, FARA LEZAREA CARTILAJULUI

    ARTICULAR

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    PLASMOCITOM SOLITAR LA UN PACIENT DE 56 ANI :RECONSTRUCTIE CU O MEGAPROTEZA MANSONATA CU O ALOGREFA

    STRUCTURATA

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    ARTROPLASTIA GENUNCHI

    * PROTEZE CU BALAMA BALAMA ROTATORIE

    !!! POZITIONAREA ROTATORIE

    = INALTIMEA ROTULEI

    PROTEZE DE CRESTERE

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    OSTEOSARCOM LA UN PACIENT DE 19 ANI :

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    OSTEOSARCOM LA UN PACIENT DE 19 ANI :RECONSTRUCTIE CU MEGAPROTEZA SI ALOGREFA STRUCTURATA DE

    GENUNCHI ( REFACEREA AP. EXTENSOR)

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    OSTEOGENEZA PRIN DISTRACTIE

    ILIZAROV

    TRANSFER OSOS VASCULARIZAT -- FIBULA

    -- ARIPA ILIACA

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    REZECTII ARTICULARE

    *UMAR

    *GENUNCHI JUVARA 1921

    *BAZIN MERLE DA

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    AMPUTATIA

    A SCAZUT IN FRECVENTA

    * T. CU EXTENSIE LOCALA F IMPORTANTA

    * INVAZIA PEDICULILOR VASC-NERV.

    * CAND REZECTIA LARGA

    REZULTAT FUNCT DEZASTRUOS

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    AMPUTATATIA

    A SCAZUT IN FRECVENTA

    * T. CU EXTENSIE LOCALA F IMPORTANTA

    * INVAZIA PEDICULILOR VASC-NERV.

    * CAND REZECTIA LARGA

    REZULTAT FUNCT DEZASTRUOS

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    PRINCIPII

    * M. InferiorREZ. FUNCT MAI BUNE DISTAL

    * INVERS AMPUT. COAPSEI

    * DEZARTIC SOLD

    INTERILIO-ABD

    DEFICIT MAXIM

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    AMPUTATATIA MEMB. SUP

    !!! CAT MAI DISTAL POSIBIL

    REZULTATE MEDIOCRE

    PIERDEREA COTULUI

    DEFICIT IMPORTANT

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    CONCLUZIA

    * MAJORITATEA INDICATIILOR

    = CONSERVAREA MEMBRELOR

    !!! CONSERVAREA FUNCTIILOR

    (MAI IMPORTANT DECAT CANSERVAREA CU ORICE PRET AMEMBRULUI)

    * AICI INCEPE DISCUTIA AMPUTATIA

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    TUMORI

    OSOASE

    MALIGNE57

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    Tumori osoase maligne

    Osteosarcomul

    Condrosarcomul

    Fibrosarcomul

    Sarcomul Ewing

    Limfosarcomul Parker-Jackson

    Mielom multipluMetastaze

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    Osteosarcomul

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    OsteosarcomulTumora maligna ce produce tesut osos

    Cea mai frecventa (30%) din TOM

    Localizare: oase lungi, metaepifizar

    in jurul genunchiului, humerus

    Varsta: primele doua decade de viata

    Sex: M/F = 4/1

    Clinic: - durere cu caracter osteocop, nocturna;

    tumefactie; atitudini vicioase; fractura- fara adenopatie

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    Osteosarcomul

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    Osteosarcomul

    Rx: zona osteolitica metafizara fara contururi nete;

    corticala intrerupta; reactie periostala; spiculi

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    Osteosarcomul

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    Osteosarcomul

    Rx: - OS osteolitic

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    Osteosarcomul

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    Osteosarcomul

    Rx: - OS osteocondensant

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    Osteosarcomul

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    Osteosarcomul

    Rx: - Os mixt

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    Osteosarcomul

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    Osteosarcomul

    Dupa localizare: - forma centrala

    - forma periferica

    Biologie: saraca; VSH crescut; fosfataze alcaline (Fal)

    crescute 64

    Osteosarcomul

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    Osteosarcomul

    A.P.: macroscopic - aspect carnos, cenusiu, encefaloid +/-

    calcificari

    microscopic - celule sarcomatoase cu tesut osteoid,

    travee osoase anarhice

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    Osteosarcomul

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    Osteosarcomul

    A.P.: Trei forme majore: - OS osteoblastic

    - OS condroblastic

    - OS fibroblastic

    Diag. diferential: OS parosteal, OS cu cel. gigante,

    fibrosarcom, osteomielita 66

    Osteosarcomul

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    Osteosarcomul

    BILANT :

    - C.T.

    - R.M.N.

    - scintigrafie

    - arteriografie

    - meta?? (plaman, creier, ficat, os) 67

    Osteosarcomul

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    OsteosarcomulTratament:

    Chimioterapie - preop.

    - polichimioterapie

    - adriamicina, cisplatinium, MTX

    - postop. (in functie de indicele decitonecroza)

    Chirurgical - conservator

    - rezectie largita +/- reconstructie- radical - amputatie/dezarticulatie

    Radioterapie - putin eficace68

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    * JUVARA

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    parosteal

    Osteosarcom juxta-cortical

    Grad scazut de malignitate; pana in 5% din TOM

    Localizare: diafizo-metafizara

    genunchi 65%, rar extremitatiVarsta: intre 20 si 30 de ani

    Sex: M/F = 1/1

    Clinic: durere, tumefactie, stare generala buna

    85

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    parosteal

    Rx: imagine densa, omogena cu contur regulat,

    localizat extracortical metafizar cu baza

    sesila de implantare, sant radiotransparent intre

    tumora si corticala osoasa (patognomonic)

    Biologie: fara modificari specifice

    86

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    parosteal

    A.P.: macroscopic - masa osoasa ce alterneaza cu zone

    fibroase sau condroide

    microscopic - os tumoral de neoformatie in lamele cu

    aspect pagetoid

    Diag. diferential:

    - miozita osifianta

    - osificari postraumatice- exostoze osteogenice

    - condrosarcom juxta-cortical

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    parostealTratament:

    Chirurgical

    - rezectie oncologica extracompartimentala

    - reconstructie cu - proteze, grefe sau ciment acrilic

    - amputatie sau dezarticulatie in recidivele locale

    Chimioterapie - in curs de evaluare

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    Tumori osoase maligne

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    Tumori osoase maligne

    <