Typical case – I

Surgical treatment of a patient with multiple bone metastases from liver cancer

Patient Information: Male, 51 yrs old,

Medical history: The patient had a history of previous liver transplantation, had pain and discomfort in the left hip and right thigh for 3 months, and had no limitation in the movement of the right thigh.MRI examination was performed in another hospital, which showed that the left iliac bone occupied obviously.PET-CT showed bone destruction of the left ilium with soft tissue density mass formation, and osteolytic bone destruction of the middle and lower part of the right femur with soft tissue density formation.For further diagnosis and treatment in our hospital, since the onset of the disease, the patient has clear mind, good spirit, good diet, general sleep, normal stool and urine, and no significant change in weight. The patient is usually in general health, history of hepatitis, history of hepatitis B, liver transplantation status, and history of "psoriasis".One year ago, he underwent "liver transplantation" for primary liver cancer.No history of trauma, no history of blood transfusion, no history of food and drug allergy.

Preoperative discussion and surgical plan:

The patient is currently diagnosed with multiple bone metastases of liver cancer and liver transplantation status.At present, the main metastatic lesions were located in the left iliac region I and the middle and lower part of the right femur.The basic physical condition of patients is general, and patients with liver cancer are often accompanied by abnormal coagulation function, so the risk of bleeding is relatively high, and it is impossible to complete the resection and reconstruction of two metastases at the same time.The cortex of the middle and lower segment of the right femur was obviously destroyed, and the risk of pathological fracture was high.After evaluation, it was decided to perform primary resection of the middle and lower segment of the right femur + 3D printing segmental tumor prosthesis reconstruction + plate internal fixation, and after the patient recovered for a period of time, the secondary operation was performed to resect the iliac metastasis.Because the patient's iliac metastases were located in zone I and did not significantly invade the sacroiliac joint and acetabulum, simple tumor resection was performed without pelvic prosthesis reconstruction.

Preoperative three-dimensional CT imaging of the right femur showed bone destruction and soft tissue mass in the middle and lower segment of the right femur, and metastatic tumor was considered in combination with the medical history.

Preoperative enhanced MRI scan of pelvis showed bone destruction and soft tissue mass formation in the left ilium.

Inspection conclusion:

1. Bone destruction of the left ilium, accompanied by the formation of soft tissue density mass, increased metabolism, SUVmax about 3.9 osteolytic bone destruction of the middle and lower part of the right femur, accompanied by the formation of soft tissue density foci, increased metabolism, SUVmax about 4.3 or more to consider bone metastases, please combine with clinical.
2. Splenic portal hypertension after liver transplantation.
3. There were several small nodules in both lungs, and no abnormal metabolism was found. Follow-up of coronary calcification was recommended.
4. Low density nodules in the right lobe of the thyroid gland, slightly increased metabolism, SUVmax of about 1.5, recommended to be combined with ultrasound examination.
5. Nodular metabolic hypertrophy in the anal canal area, SUVmax about 4.4, please exclude hemorrhoids in combination with clinical practice.
6. Bilateral maxillary sinus chronic inflammation and lacunar foci in the right basal ganglia.

Prosthesis Design:

Postoperative reexamination

DR anteroposterior and lateral position of right thigh was reexamined three weeks after operation: the position of prosthesis and plate was ideal.

Three weeks after the operation, CT three-dimensional imaging of the pelvis showed that the tumor did not invade the sacroiliac joint and acetabulum.

Second Surgery

During the operation, the iliac bone was cut along the distance of about 2 cm from the tumor boundary by ultrasonic osteotome, and the intestinal wall in the abdominal cavity was fully explored without damage, and the tumor tissue and part of the iliac wing were completely removed.

Follow up

One month after the second operation, CT three-dimensional imaging of the right thigh and left ilium showed that the position of the prosthesis and plate was ideal.

Three months after the second operation, CT three-dimensional imaging of the right thigh and left ilium showed that the position of the prosthesis and plate was ideal.Quality of life: At present, the patient has not complained of obvious pain and discomfort for 4 months after operation, and can walk and move.It can move about 300-400 meters away from the Walker.At present, the patient is receiving comprehensive medical treatment.

Case summary

Bone is one of the most common metastatic sites of malignant tumors.Because the skeleton is an important weight-bearing organ of the body, the metastasis of skeletal tumors often leads to severe pain and dysfunction, which affects the quality of life of patients.In recent years, with the emergence of new methods of cancer treatment, the survival time of cancer patients has been prolonged, so reasonable treatment is of positive significance to prolong the survival time of patients, alleviate their symptoms and improve their quality of life.
The choice of surgical strategy for patients with long bone metastasis, pathological fracture or significant risk of pathological fracture is mainly determined by the expected survival time of patients.After liver transplantation, the survival of patients with liver cancer has been significantly improved, and the risk of pathological fracture in the middle and lower right femur is very high, so we choose to deal with femoral lesions first.The patient had a large range of tumors in the middle and lower part of the right femur, so he chose to use 3D printing segmental prosthesis replacement after tumor resection, supplemented by bridging plate fixation, to promote the recovery of lower limb mobility in the short term after operation, and to improve the long-term quality of life and lower limb function of patients.
For bone metastases involving only the iliac wing (zone I), the bone above the acetabulum can be preserved after resection of the metastases.Whether the posteromedial part of the ilium (responsible for the stress conduction between the acetabulum and the sacrum) can be preserved after lesion resection is the key factor to determine whether bone reconstruction is needed.After resection of the left iliac tumor, the posteromedial part of the ilium was preserved, so only the lesion was resected and no bone reconstruction was performed in this patient.
At present, the patient has good lower limb function, no obvious pain and discomfort, and continues to follow up in the outpatient department of liver medicine and bone oncology.At present, the Department of Bone Oncology of the Affiliated Hospital of Qingda University has routinely carried out surgical treatment of various bone metastases, including spine (cervical spine, thoracolumbar spine), long bones of limbs (femur, humerus, ulna and radius, tibia and fibula, etc.), pelvis, sacrum and other parts of metastatic cancer.Using personalized 3D printing prosthesis and precise osteotomy during operation, the function of the affected limb can be preserved as much as possible on the premise of ensuring the resection boundary of the tumor, which greatly improves the quality of life of patients and prolongs their survival time.

Attending physician