骨肿瘤分期.ppt

骨肿瘤的外科分期骨肿瘤的外科分期Surgical Staging of Bone Surgical Staging of Bone TumorsTumors中山医院骨科中山医院骨科 姜南春姜南春1 1.Enneking-Musculoskeletal Enneking-Musculoskeletal Tumor Staging System Tumor Staging System 2 2.骨与软组织肿瘤骨与软组织肿瘤TNMGTNMG分期系统分期系统AJCC(American Joint Committee on AJCC(American Joint Committee on Cancer)Cancer)提出提出复杂，对手术治疗无指导价值复杂，对手术治疗无指导价值很少使用很少使用3 3.肌肉骨骼系统肿瘤的外科分期肌肉骨骼系统肿瘤的外科分期（MTSMTS分期系统）分期系统）佛罗里达大学，佛罗里达大学，EnnekingEnneking，19771977MTS(Musculoskeletal Tumor Society)MTS(Musculoskeletal Tumor Society)试试用用Clinical Orthopedics and Related Clinical Orthopedics and Related Research,1980Research,1980AJC(American Joint Committee)AJC(American Joint Committee)修订修订IUCC(International Union Against IUCC(International Union Against Cancer)Cancer)国际推广国际推广4 4.外科分期目的外科分期目的治疗的要求：手术时机、手术方法、切除范围的治疗的要求：手术时机、手术方法、切除范围的治疗的要求：手术时机、手术方法、切除范围的治疗的要求：手术时机、手术方法、切除范围的选择；辅助治疗方法的选择选择；辅助治疗方法的选择选择；辅助治疗方法的选择选择；辅助治疗方法的选择预后判断预后判断预后判断预后判断标准化的要求：统一标准、有利于治疗资料和疗标准化的要求：统一标准、有利于治疗资料和疗标准化的要求：统一标准、有利于治疗资料和疗标准化的要求：统一标准、有利于治疗资料和疗效的交流效的交流效的交流效的交流(interinstitutional and(interinstitutional and(interinstitutional and(interinstitutional and interdisciplinary communication)interdisciplinary communication)interdisciplinary communication)interdisciplinary communication)5 5.适用范围适用范围 肌肉、骨骼系统起源于间充质组织的肿瘤肌肉、骨骼系统起源于间充质组织的肿瘤6 6.排除范围排除范围来源于骨髓、网状内皮组织的肿瘤来源于骨髓、网状内皮组织的肿瘤 白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞白血病、淋巴瘤、骨髓瘤、尤文肉瘤、未分化小圆细胞肉瘤肉瘤肉瘤肉瘤转移性肿瘤转移性肿瘤7 7.EnnekingG-T-MEnnekingG-T-M外科分期系统外科分期系统G G G G（Histologic Grade)Histologic Grade)Histologic Grade)Histologic Grade)：分级：分级：分级：分级肿瘤的外科分级肿瘤的外科分级肿瘤的外科分级肿瘤的外科分级T(Anatomic Site)T(Anatomic Site)T(Anatomic Site)T(Anatomic Site)：肿瘤与解剖学间室的关系：肿瘤与解剖学间室的关系：肿瘤与解剖学间室的关系：肿瘤与解剖学间室的关系M(Metastasis)M(Metastasis)M(Metastasis)M(Metastasis)：肿瘤有无转移，包括区域和远处：肿瘤有无转移，包括区域和远处：肿瘤有无转移，包括区域和远处：肿瘤有无转移，包括区域和远处转移转移转移转移8 8.EnnekingEnneking分期分期良性骨肿瘤良性骨肿瘤良性骨肿瘤良性骨肿瘤 1 1 1 1期：潜隐性期：潜隐性期：潜隐性期：潜隐性 2 2 2 2期：活动性期：活动性期：活动性期：活动性 3 3 3 3期：侵袭性期：侵袭性期：侵袭性期：侵袭性恶性骨肿瘤恶性骨肿瘤恶性骨肿瘤恶性骨肿瘤 期（期（期（期（A A A A B B B B ）：低度恶性）：低度恶性）：低度恶性）：低度恶性 期（期（期（期（A A A A B B B B ）：高度恶性）：高度恶性）：高度恶性）：高度恶性 期（期（期（期（A A A A B B B B ）：有局部和远处转移）：有局部和远处转移）：有局部和远处转移）：有局部和远处转移 A A A A：间室内；：间室内；：间室内；：间室内；B B B B：间室外：间室外：间室外：间室外9 9.外科分级外科分级GG临床或外科分级临床或外科分级临床或外科分级临床或外科分级在恶性肿瘤反映生物学侵袭程度在恶性肿瘤反映生物学侵袭程度在恶性肿瘤反映生物学侵袭程度在恶性肿瘤反映生物学侵袭程度组织学、放射和临床三结合组织学、放射和临床三结合组织学、放射和临床三结合组织学、放射和临床三结合 组织学分级组织学分级组织学分级组织学分级BrodersBrodersBrodersBroders分级分级分级分级 放射学分级放射学分级放射学分级放射学分级LodwicksLodwicksLodwicksLodwicks分级分级分级分级G G G G0 0：良性病变；：良性病变；：良性病变；：良性病变；G G G G1 1：低度恶性；：低度恶性；：低度恶性；：低度恶性；G G G G2 2：高度恶性：高度恶性：高度恶性：高度恶性恶性肿瘤外科分级通常依从于组织学分级。但是，恶性肿瘤外科分级通常依从于组织学分级。但是，恶性肿瘤外科分级通常依从于组织学分级。但是，恶性肿瘤外科分级通常依从于组织学分级。但是，如组织学表现偏良性而放射和临床表现为高度侵如组织学表现偏良性而放射和临床表现为高度侵如组织学表现偏良性而放射和临床表现为高度侵如组织学表现偏良性而放射和临床表现为高度侵袭性者应定为高度恶性袭性者应定为高度恶性袭性者应定为高度恶性袭性者应定为高度恶性1010.组织学组织学细针穿刺活检细针穿刺活检 影像引导下穿刺活检如影像引导下穿刺活检如Fluoroscopy with Fluoroscopy with C-arm guidance C-arm guidance，CT-guided biopsy CT-guided biopsy 切取活检切取活检切除活检切除活检1111.影像学：影像学：X-ray Lodwick X-ray Lodwick 放射学分放射学分级级Grade 1A,1B,and 1C lesions represent Grade 1A,1B,and 1C lesions represent Grade 1A,1B,and 1C lesions represent Grade 1A,1B,and 1C lesions represent benign lesions with edge characteristics benign lesions with edge characteristics benign lesions with edge characteristics benign lesions with edge characteristics ranging from well defined to poorly ranging from well defined to poorly ranging from well defined to poorly ranging from well defined to poorly defined.defined.defined.defined.Grade 2 lesions are low-grade malignant Grade 2 lesions are low-grade malignant Grade 2 lesions are low-grade malignant Grade 2 lesions are low-grade malignant lesions with invasive features,lesions with invasive features,lesions with invasive features,lesions with invasive features,particularly those with total penetration particularly those with total penetration particularly those with total penetration particularly those with total penetration of the cortex.of the cortex.of the cortex.of the cortex.Grade 3 lesions are high-grade malignant Grade 3 lesions are high-grade malignant Grade 3 lesions are high-grade malignant Grade 3 lesions are high-grade malignant lesions with invasive,permeative,and lesions with invasive,permeative,and lesions with invasive,permeative,and lesions with invasive,permeative,and destructive features destructive features destructive features destructive features 1212.重要的放射学征象重要的放射学征象Pattern of destruction(geographic or not Pattern of destruction(geographic or not Pattern of destruction(geographic or not Pattern of destruction(geographic or not geographic,appearance of marginal geographic,appearance of marginal geographic,appearance of marginal geographic,appearance of marginal interface zone)interface zone)interface zone)interface zone)Penetration of cortex by lesion Penetration of cortex by lesion Penetration of cortex by lesion Penetration of cortex by lesion Absence or presence of a sclerotic rim Absence or presence of a sclerotic rim Absence or presence of a sclerotic rim Absence or presence of a sclerotic rim Absence or presence and extent(if present)Absence or presence and extent(if present)Absence or presence and extent(if present)Absence or presence and extent(if present)of the expanded cortical shellof the expanded cortical shellof the expanded cortical shellof the expanded cortical shell1313.SundaramSundaram分级系统分级系统Group 1 lesions are radiographically benign and do Group 1 lesions are radiographically benign and do Group 1 lesions are radiographically benign and do Group 1 lesions are radiographically benign and do not require further investigation or treatment.not require further investigation or treatment.not require further investigation or treatment.not require further investigation or treatment.Group 2 lesions have a high likelihood for being Group 2 lesions have a high likelihood for being Group 2 lesions have a high likelihood for being Group 2 lesions have a high likelihood for being benign,but this finding should be confirmed by benign,but this finding should be confirmed by benign,but this finding should be confirmed by benign,but this finding should be confirmed by means of clinical or radiographic follow-up means of clinical or radiographic follow-up means of clinical or radiographic follow-up means of clinical or radiographic follow-up examination.examination.examination.examination.Group 3 lesions are benign lesions that require Group 3 lesions are benign lesions that require Group 3 lesions are benign lesions that require Group 3 lesions are benign lesions that require surgical resection because of aggressive behavior surgical resection because of aggressive behavior surgical resection because of aggressive behavior surgical resection because of aggressive behavior or risk of pathologic fracture.or risk of pathologic fracture.or risk of pathologic fracture.or risk of pathologic fracture.Group 4 lesions are aggressive-appearing lesions Group 4 lesions are aggressive-appearing lesions Group 4 lesions are aggressive-appearing lesions Group 4 lesions are aggressive-appearing lesions that should be considered malignant.Biopsy should that should be considered malignant.Biopsy should that should be considered malignant.Biopsy should that should be considered malignant.Biopsy should be performed to confirm the histologic grade and be performed to confirm the histologic grade and be performed to confirm the histologic grade and be performed to confirm the histologic grade and the diagnosis.the diagnosis.the diagnosis.the diagnosis.1414.影像学：影像学：CTCTEvaluation of local disease in detail Evaluation of local disease in detail Assessing the lungs for pulmonary Assessing the lungs for pulmonary metastases metastases 1515.CT in evaluation of local CT in evaluation of local diseasediseaseComplements radiography Complements radiography Complements radiography Complements radiography Assess disease in areas not easily Assess disease in areas not easily Assess disease in areas not easily Assess disease in areas not easily visualized with radiography,eg,the spine visualized with radiography,eg,the spine visualized with radiography,eg,the spine visualized with radiography,eg,the spine and pelvis and pelvis and pelvis and pelvis CT is better in assessing the type of CT is better in assessing the type of CT is better in assessing the type of CT is better in assessing the type of cortical destruction and the presence of cortical destruction and the presence of cortical destruction and the presence of cortical destruction and the presence of matrix mineralization.matrix mineralization.matrix mineralization.matrix mineralization.CT is also helpful in determining the CT is also helpful in determining the CT is also helpful in determining the CT is also helpful in determining the internal contents of some lesions.internal contents of some lesions.internal contents of some lesions.internal contents of some lesions.1616.CT in evaluating the lungs for CT in evaluating the lungs for metastases metastases More accurate than chest radiographsMore accurate than chest radiographsMay produce false-positive results May produce false-positive results when small lung nodules are detected.when small lung nodules are detected.Follow-up CT scans are useful in Follow-up CT scans are useful in monitoring the nodules.monitoring the nodules.1717.影像学：影像学：MRIMRI accurate depiction of the soft accurate depiction of the soft tissues allows sensitive detection of tissues allows sensitive detection of soft tissue extension and medullary soft tissue extension and medullary involvement by tumor involvement by tumor 1818.MRIMRI良恶性影像学特征良恶性影像学特征Benign lesions are well defined and sharply Benign lesions are well defined and sharply Benign lesions are well defined and sharply Benign lesions are well defined and sharply demarcated from the surrounding healthy demarcated from the surrounding healthy demarcated from the surrounding healthy demarcated from the surrounding healthy tissue.tissue.tissue.tissue.Malignant lesions are typically more Malignant lesions are typically more Malignant lesions are typically more Malignant lesions are typically more extensive and involve surrounding tissue to extensive and involve surrounding tissue to extensive and involve surrounding tissue to extensive and involve surrounding tissue to a greater extent than do benign lesions.a greater extent than do benign lesions.a greater extent than do benign lesions.a greater extent than do benign lesions.MRI signal intensity alone is not reliable MRI signal intensity alone is not reliable MRI signal intensity alone is not reliable MRI signal intensity alone is not reliable in distinguishing benign tumors and in distinguishing benign tumors and in distinguishing benign tumors and in distinguishing benign tumors and malignant tumors.malignant tumors.malignant tumors.malignant tumors.1919.MRIMRI对分期的价值对分期的价值Assessing local spread of tumor(Enneking Assessing local spread of tumor(Enneking Assessing local spread of tumor(Enneking Assessing local spread of tumor(Enneking sites T1 and T2).sites T1 and T2).sites T1 and T2).sites T1 and T2).Accurately detecting tumor involvement of Accurately detecting tumor involvement of Accurately detecting tumor involvement of Accurately detecting tumor involvement of neurovascular structures,muscle neurovascular structures,muscle neurovascular structures,muscle neurovascular structures,muscle compartments,growth plates,and partments,growth plates,and partments,growth plates,and partments,growth plates,and joints.Usually accurately depicts intramedullary Usually accurately depicts intramedullary Usually accurately depicts intramedullary Usually accurately depicts intramedullary spread and soft tissue extension of tumor spread and soft tissue extension of tumor spread and soft tissue extension of tumor spread and soft tissue extension of tumor 2020.MRAMRAProvide additional information Provide additional information regarding neurovascular bundle regarding neurovascular bundle involvement.involvement.Assessing peripheral vascular Assessing peripheral vascular branches and tumor neovascularity.branches and tumor neovascularity.2121.其他影像学检查其他影像学检查Radionuclide bone scans Radionuclide bone scans UltrasonographyUltrasonographyAngiography Angiography Positron Emission Tomography Positron Emission Tomography 2222.外科分级外科分级GGG G0 0 良性病变良性病变临床：肿瘤边界清，有完整包膜，极少远处转移临床：肿瘤边界清，有完整包膜，极少远处转移临床：肿瘤边界清，有完整包膜，极少远处转移临床：肿瘤边界清，有完整包膜，极少远处转移X X X X线表现：肿瘤界清，囊内生长呈膨胀性，罕见穿破线表现：肿瘤界清，囊内生长呈膨胀性，罕见穿破线表现：肿瘤界清，囊内生长呈膨胀性，罕见穿破线表现：肿瘤界清，囊内生长呈膨胀性，罕见穿破囊壁者囊壁者囊壁者囊壁者组织学表现：细胞分化良好，基质细胞比例正常，组织学表现：细胞分化良好，基质细胞比例正常，组织学表现：细胞分化良好，基质细胞比例正常，组织学表现：细胞分化良好，基质细胞比例正常，核分裂相极少见核分裂相极少见核分裂相极少见核分裂相极少见2323.外科分级外科分级GGG G1 1 低度恶性病变低度恶性病变临床：肿瘤可向囊外生长，但生长速度较慢，可有临床：肿瘤可向囊外生长，但生长速度较慢，可有临床：肿瘤可向囊外生长，但生长速度较慢，可有临床：肿瘤可向囊外生长，但生长速度较慢，可有软组织肿块，偶有远处转移软组织肿块，偶有远处转移软组织肿块，偶有远处转移软组织肿块，偶有远处转移X X X X线表现：肿瘤界欠清，呈侵袭性生长线表现：肿瘤界欠清，呈侵袭性生长线表现：肿瘤界欠清，呈侵袭性生长线表现：肿瘤界欠清，呈侵袭性生长组织学表现：细胞分化中等，基质细胞较多，可见组织学表现：细胞分化中等，基质细胞较多，可见组织学表现：细胞分化中等，基质细胞较多，可见组织学表现：细胞分化中等，基质细胞较多，可见核分裂相但较少核分裂相但较少核分裂相但较少核分裂相但较少2424.外科分级外科分级GGG G G G2 2 高度恶性病变高度恶性病变高度恶性病变高度恶性病变临床：症状明显，肿瘤生长快，有跳跃性生长和软组织临床：症状明显，肿瘤生长快，有跳跃性生长和软组织临床：症状明显，肿瘤生长快，有跳跃性生长和软组织临床：症状明显，肿瘤生长快，有跳跃性生长和软组织肿块，常早期就发生局部和远处转移肿块，常早期就发生局部和远处转移肿块，常早期就发生局部和远处转移肿块，常早期就发生局部和远处转移X X X X线表现：病变侵袭破坏明显，骨膜反应，软组织肿块线表现：病变侵袭破坏明显，骨膜反应，软组织肿块线表现：病变侵袭破坏明显，骨膜反应，软组织肿块线表现：病变侵袭破坏明显，骨膜反应，软组织肿块组织学表现：细胞分化极差，基质细胞多，核分裂相多组织学表现：细胞分化极差，基质细胞多，核分裂相多组织学表现：细胞分化极差，基质细胞多，核分裂相多组织学表现：细胞分化极差，基质细胞多，核分裂相多见见见见2525.肿瘤与解剖学间隙的关系肿瘤与解剖学间隙的关系TTT T0 0：良性囊内和间室内病变：良性囊内和间室内病变T T1 1：间室内病变：间室内病变T T2 2：间室外病变：间室外病变2626.间室内间室内 T T1 1无真性包膜，但有假包膜无真性包膜，但有假包膜反应带内有指状突起或卫星灶反应带内有指状突起或卫星灶原发病灶和反应带均局限在病灶的原发间原发病灶和反应带均局限在病灶的原发间室内室内2727.间室内间室内 T T1 1皮质骨内，未穿破骨膜和骨髓腔皮质骨内，未穿破骨膜和骨髓腔关节内，未穿破关节囊关节内，未穿破关节囊骨旁间隙内，未进入骨皮质，未穿破骨膜骨旁间隙内，未进入骨皮质，未穿破骨膜侵犯肌、筋膜侵犯肌、筋膜2828.间室外间室外 T T2 2间室内病变穿破解剖学间室：间室内病变穿破解剖学间室：间室内病变穿破解剖学间室：间室内病变穿破解剖学间室：肿块本身穿出肿块本身穿出肿块本身穿出肿块本身穿出 反应带超出原发间室反应带超出原发间室反应带超出原发间室反应带超出原发间室意外创伤和不恰当的手术切除污染多个间室意外创伤和不恰当的手术切除污染多个间室意外创伤和不恰当的手术切除污染多个间室意外创伤和不恰当的手术切除污染多个间室病变或其反应带临近或侵犯主要血管、神经束者病变或其反应带临近或侵犯主要血管、神经束者病变或其反应带临近或侵犯主要血管、神经束者病变或其反应带临近或侵犯主要血管、神经束者一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，一些缺乏阻止肿瘤扩散的内在屏障的解剖学部位，如腹股沟等如腹股沟等如腹股沟等如腹股沟等2929.间室外间室外 T2 T2骨内病变向软组织侵犯骨内病变向软组织侵犯骨旁病变侵犯骨皮质骨旁病变侵犯骨皮质侵犯髓腔侵犯髓腔肘窝、腋窝、肘窝、腋窝、guoguo窝、腹股沟、骨盆内窝、腹股沟、骨盆内3030.病变范围的确定病变范围的确定临床资料临床资料常规常规X X线检查线检查CTCTMRIMRI血管造影血管造影同位素扫描同位素扫描3131.转移转移 M M跳跃转移、区域淋巴结或远处转移跳跃转移、区域淋巴结或远处转移M M0 0：无局部和远处转移：无局部和远处转移M M1 1：有局部和远处转移：有局部和远处转移3232.良性骨肿瘤良性骨肿瘤1 1 1 1期：潜隐性（期：潜隐性（期：潜隐性（期：潜隐性（latent)-Glatent)-Glatent)-Glatent)-G0 0 0 0 T T T T0 0 0 0 M M M M0 0 0 02 2 2 2期：活动性期：活动性期：活动性期：活动性(active)-G(active)-G(active)-G(active)-G0 0 0 0 T T T T0 0 0 0 M M M M0 0 0 03 3 3 3期：侵袭性期：侵袭性期：侵袭性期：侵袭性(aggressive)-G(aggressive)-G(aggressive)-G(aggressive)-G0 0 0 0 T T T T1 1 1 1 或或或或T T T T2 2 2 2 M M M M0 0 0 0 或或或或 M M M M1 1 1 1 3333.1 1期期 G G0 0T T0 0M M0 0 ，良性潜隐性，良性潜隐性 临床：无症状，无功能障碍，无意中发现，缓临床：无症状，无功能障碍，无意中发现，缓临床：无症状，无功能障碍，无意中发现，缓临床：无症状，无功能障碍，无意中发现，缓慢增大，有接触抑制，无骨皮质变形慢增大，有接触抑制，无骨皮质变形慢增大，有接触抑制，无骨皮质变形慢增大，有接触抑制，无骨皮质变形放射学：平片示病灶界限清楚、形状和边界规放射学：平片示病灶界限清楚、形