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1、骨肿瘤的外科分期Surgical Staging of Bone Tumors,1,Enneking-Musculoskeletal Tumor Staging System,2,骨与软组织肿瘤TNMG分期系统,AJCC(American Joint Committee on Cancer) 提出 复杂，对手术治疗无指导价值 很少使用,3,肌肉骨骼系统肿瘤的外科分期（MTS分期系统）,佛罗里达大学，Enneking，1977 MTS(Musculoskeletal Tumor Society)试用 Clinical Orthopedics and Related Research,1980 A
2、JC(American Joint Committee)修订 IUCC(International Union Against Cancer) 国际推广,4,外科分期目的,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 预后判断 标准化的要求：统一标准、有利于治疗资料和疗效的交流(interinstitutional and interdisciplinary communication),5,适用范围,肌肉、骨骼系统起源于间充质组织的肿瘤,6,排除范围,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、未分化小圆细胞肉瘤 转移性肿瘤,7,EnnekingG
3、-T-M外科分期系统,G（Histologic Grade)：分级肿瘤的外科分级 T(Anatomic Site)：肿瘤与解剖学间室的关系 M(Metastasis)：肿瘤有无转移，包括区域和远处转移,8,Enneking分期,良性骨肿瘤 1期：潜隐性 2期：活动性 3期：侵袭性 恶性骨肿瘤 期（ A B ）：低度恶性 期（ A B ）：高度恶性 期（ A B ）：有局部和远处转移 A：间室内； B：间室外,9,外科分级G,临床或外科分级 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 组织学分级Broders分级 放射学分级Lodwicks分级 G0：良性病变；G1：低度恶性；G2：
4、高度恶性 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袭性者应定为高度恶性,10,组织学,细针穿刺活检 影像引导下穿刺活检如Fluoroscopy with C-arm guidance ，CT-guided biopsy 切取活检 切除活检,11,影像学：X-ray Lodwick 放射学分级,Grade 1A, 1B, and 1C lesions represent benign lesions with edge characteristics ranging from well defined to poorly defined. Grade
5、 2 lesions are low-grade malignant lesions with invasive features, particularly those with total penetration of the cortex. Grade 3 lesions are high-grade malignant lesions with invasive, permeative, and destructive features,12,重要的放射学征象,Pattern of destruction (geographic or not geographic, appearanc
6、e of marginal interface zone) Penetration of cortex by lesion Absence or presence of a sclerotic rim Absence or presence and extent (if present) of the expanded cortical shell,13,Sundaram分级系统,Group 1 lesions are radiographically benign and do not require further investigation or treatment. Group 2 l
7、esions have a high likelihood for being benign, but this finding should be confirmed by means of clinical or radiographic follow-up examination. Group 3 lesions are benign lesions that require surgical resection because of aggressive behavior or risk of pathologic fracture. Group 4 lesions are aggre
8、ssive-appearing lesions that should be considered malignant. Biopsy should be performed to confirm the histologic grade and the diagnosis.,14,影像学：CT,Evaluation of local disease in detail Assessing the lungs for pulmonary metastases,15,CT in evaluation of local disease,Complements radiography Assess
9、disease in areas not easily visualized with radiography, eg, the spine and pelvis CT is better in assessing the type of cortical destruction and the presence of matrix mineralization. CT is also helpful in determining the internal contents of some lesions.,16,CT in evaluating the lungs for metastase
10、s,More accurate than chest radiographs May produce false-positive results when small lung nodules are detected. Follow-up CT scans are useful in monitoring the nodules.,17,影像学：MRI,accurate depiction of the soft tissues allows sensitive detection of soft tissue extension and medullary involvement by
11、tumor,18,MRI良恶性影像学特征,Benign lesions are well defined and sharply demarcated from the surrounding healthy tissue. Malignant lesions are typically more extensive and involve surrounding tissue to a greater extent than do benign lesions. MRI signal intensity alone is not reliable in distinguishing beni
12、gn tumors and malignant tumors.,19,MRI对分期的价值,Assessing local spread of tumor (Enneking sites T1 and T2). Accurately detecting tumor involvement of neurovascular structures, muscle compartments, growth plates, and joints. Usually accurately depicts intramedullary spread and soft tissue extension of t
13、umor,20,MRA,Provide additional information regarding neurovascular bundle involvement. Assessing peripheral vascular branches and tumor neovascularity.,21,其他影像学检查,Radionuclide bone scans Ultrasonography Angiography Positron Emission Tomography,22,外科分级G,G0 良性病变 临床：肿瘤边界清，有完整包膜，极少远处转移 X线表现：肿瘤界清，囊内生长呈膨胀
14、性，罕见穿破囊壁者 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,23,外科分级G,G1 低度恶性病变 临床：肿瘤可向囊外生长，但生长速度较慢，可有软组织肿块，偶有远处转移 X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，可见核分裂相但较少,24,外科分级G,G2 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肿块，常早期就发生局部和远处转移 X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，核分裂相多见,25,肿瘤与解剖学间隙的关系T,T0：良性囊内和间室内病变 T1：间室内病变 T2：间室外病变
15、,26,间室内 T1,无真性包膜，但有假包膜 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室内,27,间室内 T1,皮质骨内，未穿破骨膜和骨髓腔 关节内，未穿破关节囊 骨旁间隙内，未进入骨皮质，未穿破骨膜侵犯肌、筋膜,28,间室外 T2,间室内病变穿破解剖学间室： 肿块本身穿出 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 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，如腹股沟等,29,间室外 T2,骨内病变向软组织侵犯 骨旁病变侵犯骨皮质 侵犯髓腔 肘窝、腋窝、guo窝、腹股沟、骨盆内,30,病变范围的确定,临床资料
16、 常规X线检查 CT MRI 血管造影 同位素扫描,31,转移 M,跳跃转移、区域淋巴结或远处转移 M0：无局部和远处转移 M1：有局部和远处转移,32,良性骨肿瘤,1期：潜隐性（latent)-G0 T0 M0 2期：活动性(active)- G0 T0 M0 3期：侵袭性(aggressive)- G0 T1 或T2 M0 或 M1,33,1期 G0T0M0 ，良性潜隐性,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 放射学：平片示病灶界限清楚、形状和边界规则，有皮质骨样反应骨包围（LodwickA)；CT示病灶呈均质性，无骨皮质穿破 组织学：基质成熟，分化好，细胞基质比例低，无恶性细胞学表现，如：细胞核深染、核分裂相、间变、多行性；病灶被成熟的纤维组织或皮质骨包围，极少反应性间质浸润、炎症反应和新生血管形成,34,1期（G0T0M0）,35,1期（G0T0M0）,36,2期 G0T0M0 ，良性活动性,临床：肿瘤持续、稳定生长，引起症状，有接触抑
