明確病變性質(zhì)-脊柱腫瘤規(guī)范化治療的第一步課件

1、明確病變性質(zhì)： 脊柱腫瘤規(guī)范化治療的第一步2010.01Male, 54-year-old, lumbar pain 1 month in durationLocalization: L1 X-rayCTMRIImaging ExaminationPostoperative imaging examination(postoperative follow-up period of 3 months) Results of postoperative pathology : Plasma cell myelomaPostoperative imaging examination 2012.07

2、(postoperative follow-up period of 30 months) Revision surgery Postoperative X-RayPostoperative imaging examination 2014.06 (postoperative follow-up period of 23 months) Revision surgery with bone graft fusion and internal fixation via a combination of anterior and posterior approachPostoperative im

3、aging examination 2014.12 (postoperative follow-up period of 6 months) 回顧整個治療過程，我們是否會反思：治療策略是否得當(dāng)?Treatment goal for spine tumorsProlonging survival timeRelieving localized painPreserving spinal cord functionalityImproving quality of life Surgery Radiotherapy Chemotherapy Molecular-target therapyTher

4、apeutic strategy Complete tumor resection （especially for primary tumors） Decomposition Stabilization Surgery goal for spine tumorsNo obvious spinal cord compressionDecompression Stabilization1、Location 3 points: Junctional (C0-C2, C7-T2, T11-L1, L5-S1)2、Pain relief with recumbency and/or pain with

5、movement/loading of the spine 1 point: No (occasional pain but not mechanical)3、Bone lesion 2 points: Lytic4、Radiographic spinal alignment 0 points: Normal alignment5、Vertebral body collapse 0 points: None of the above6、Posterolateral involvement of the spinal elements (facet, pedicle or costoverteb

6、ral joint fracture or replacement with tumor) 0 points: None of the above Sum score 0-6: stable Sum score 7-12: indeterminate instability Sum score 13-18: instabilityFisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. A novel classification system for spinal instability in neo

7、plastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 2010; 35:E1221-9.warrant surgical consultationSpine Instability Neoplastic Score（SINS）Complete tumor resection - PathologyPlasma cell myeloma多發(fā)性骨髓瘤外科治療中國專家共識中國多發(fā)性骨髓瘤工作組外科治療委員會骨髓瘤骨病的外科手術(shù)適應(yīng)證合并脊柱

8、不穩(wěn)或病理性骨折或潛在病理性骨折脊髓及神經(jīng)根受壓迫致神經(jīng)功能進(jìn)行性損害四肢與脊柱軟組織漿細(xì)胞瘤 穿刺或切開活檢以提供病理診斷In this regard, the therapeutic strategy for spine tumor is mainly determined by its diagnosis, especially for the pathologicaldiagnosisBecause, the cover will deceive us!The diagnosis of spine tumors can not just rely on the typical clin

9、ical manifestations and imaging findingsFemale, 39-year-old, back pain and radiating pain of the both lower extremities 5 months in duration.X-rayCTMRIResults of preoperative needle biopsy: Spinal metastasesPiecemeal tumor resectionSong dianwenMale, 32-year-old, back pain 1 year and numbness of the

10、both lower extremities 5 weeks in duration.Imaging examination:Lumber 2 vertebral body lesion and pathologic fractureCT、MRI、PET-CT報(bào)告：1.骨巨細(xì)胞瘤可能；2.惡性腫瘤可能。Results of preoperative needle biopsy: granulomas 臥床休息、抗結(jié)核治療后，腰痛及雙下肢麻痛癥狀均明顯好轉(zhuǎn)，血沉等指標(biāo)明顯下降，病灶吸收。Song dianwenESR 2 mm/hWe should make a thorough inquiry

11、 about what is inside, instead of what is the cover！How to obtain the diagnosis?Percutaneous Diagnostic Biopsy TechniquesCurrent spinal biopsy techniques employ x-ray fluoroscopy, computed tomographic fluoroscopy (CTF) , conventional CT, and ultrasound (US) to assist in needle placement during biops

12、y.Biopsy via X-ray fluoroscopyLimitation:small lesions;lesions in the thoracic region in which a transpedicular approach cannot be used; lesions involving the cervical spine; lesions involving the posterior vertebral arch;lesions involving the epidural space; lesions involving the neural foramen; le

13、sions involving the peripheral nerves.Male, 14-year-old, lumbosacral pain and aching pain of the right lower extremity 1 month in duration.Results of preoperative needle biopsy: Ewings sarcomasWith a combination of VAC/IE for 12 weeks,the volume of tumor downsized distinctlySacrectomy and internal f

14、ixation via a posterior approach only after chemotherapySpecimen Postoperative X-Ray with a disease-free follow-up of 18 monthsFemale, 62-year-old, radiating pain and numbness of the right arm 6 months in duration.Results of preoperative needle biopsy: chordomaIntraoperative imagesPosterior approach

15、Intraoperative images :Anterior approachSpecimen Postoperative X-Ray女性，62歲，腰背部疼痛伴發(fā)熱1月余既往史：3年前有“肺結(jié)核”病史，在當(dāng)?shù)蒯t(yī)院行抗癆治療3月實(shí)驗(yàn)室檢查RBC: 3.471012/L;WBC: 4.411012/LHb: 108g/LCRP: 21.11mg/LESR: 117mm/H腫瘤標(biāo)志物(包括M蛋白電泳)檢測：均未見異常；血培養(yǎng)：陰性PPD：（-）T-Spot ：（-）2014-2-1 胸椎MRI2014-2-1 胸椎MRI2014-2-1 胸椎CT在當(dāng)?shù)蒯t(yī)院按“脊柱感染”予頭孢噻肟鈉、來立信抗感染治

16、療1周無好轉(zhuǎn)轉(zhuǎn)上海市肺科醫(yī)院治療血紅蛋白：95g/L血沉：120mm/H結(jié)核感染T細(xì)胞（A抗原）：4個結(jié)核感染T細(xì)胞（B抗原）：0個堿性磷酸酶：444IU/L總蛋白：54g/L, 白蛋白 24g/L胸部CT：雙肺多發(fā)條索影，雙側(cè)胸腔積液，胸膜增厚粘連B超：雙側(cè)頸部、雙側(cè)腋下、雙側(cè)腹股溝淋巴結(jié)腫大考慮脊柱結(jié)核，抗癆方案：HREZL3月8日復(fù)查MRI情況結(jié)核科、血液科和影像科討論影像科意見：考慮炎癥性病變，腫瘤可能小血液科意見：炎癥性病變可能大，淋巴瘤及多發(fā)性骨髓瘤（骨髓穿刺未見漿細(xì)胞）基本排除，但建議行淋巴結(jié)活檢；結(jié)核科：多發(fā)椎體病變，結(jié)核？惡性待排發(fā)熱不退原因：考慮結(jié)核為復(fù)治，存在多耐藥菌可能建議繼續(xù)抗癆治療按上述方案繼續(xù)治療1周后，癥狀仍無明顯緩解穿刺活檢病理報(bào)告：轉(zhuǎn)移性低分化癌PET-CT直腸乙狀結(jié)腸交界處腸壁增厚伴葡萄糖代謝增高疼痛偶然發(fā)現(xiàn)腫塊神經(jīng)損害既往史脊柱病灶病史體格檢查實(shí)驗(yàn)室檢查影像學(xué)檢查穿刺活檢血沉、M蛋白、T-spot、腫瘤標(biāo)記物等脊柱局部：X線、CT、MRI全身檢查：胸腹部、骨骼或PET-CTCT或超聲引導(dǎo)下穿刺活檢（選擇最安全處活檢）臨床影像學(xué)再次活檢或切開活檢活檢困難、失敗或陰