Omuz kuşağı yerleşimli kemik ve yumuşak doku malign tümörlerinin cerrahi tedavisi, onkolojik ve fonksiyonel sonuçlar
Surgical treatment of bone and soft tissue malignant tumors of the shoulder girdle, oncological and functional results
Yazar: RECEP ÖZTÜRK
Danışman: PROF. DR. BEDİİ ŞAFAK GÜNGÖR
Sağlık Bakanlığı / Tıp Fakültesi / Ortopedi ve Travmatoloji Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2017
Konu: Ortopedi ve Travmatoloji = Orthopedics and Traumatology
Dizin: Omuz = Shoulder ; Tümörler =

Özet:
Kas iskelet sistemi tümörlerindeki ilerlemeler, biyomühendislik ve cerrahideki gelişmeler birçok ileri cerrahi teknik gerektiren ameliyatların yapımına olanak vermiştir.
Bu çalışmada, Ankara Onkoloji Hastanesi Ortopedi ve Travmatoloji Kliniğinde ocak 2001 ile ağustos 2016 tarihleri arasında omuz çevresi yerleşimli malign kas iskelet sistemi tümörü olan 187 hasta çalışmaya alınmıştır. Çalışmaya alınan 187 hastanın 79' u kadın (% 42.3), 108' i erkek (%57.7) hastalardan oluşmaktaydı. Hastaların cerrahi zamanındaki yaş ortalaması 47.9 ( 2 - 87 yaş arası) idi. Hastaların 108'inde tümör proksimal humerus yerleşimli, 32'inde omuz çevresi yumuşak dokular, 24'ünde skapula, 17'sinde klavikula, 3'ünde humerus proksimali ve skapula, 3'ünde skapula ve klavikula yerleşimli idi.
Hastaların 95'i primer tümör, 10'u nüks, 82'si metastaz idi.
Primer tümörlerin 21 tanesi ewing's sarkom, 18'i osteosarkoma, 17'si multiple myeloma, 16'sı kondrosarkom, 6'sı pleomorfik sarkom, 4'ü mmt, 3'ü rabdomyosarkom, 2'si ekstraskeletal osteosarkom, 2'si sinovial sarkom, 2'si liposarkom, 2'si leimyosarkom, 1'i epiteloid hemanjioendotelyoma 1'i malign periferik sinir kılıfı tümörü idi.
11 nüks tümörün, 3'ü osteosarkom, 3'ü pleomorfik sarkom, 1'i kondrosarkom, 1'i angiosarkom, 1'i fibrosarkom, 1 'i mmt idi.
81 metastatik hastada görülen en sık primer tümör lokalizasyonları, 19'u akciğer ca, 13'ü meme ca, 10'u lenfoma, 9'u primeri bilinmeyen metastatik tümör, 9'u renal cell ca, 5'i tiroit ca idi.
187 hastanın 42'sine insizyonel biopsi ile tanı konulması sonrası, ikincil bir cerrahi tedavi planlanmayarak, takip ve tedavi planı için ilgili medikal bölümlere konsulte edilerek devredildi. 42 hastanın dışında kalan 145 hastanın, hastanemizde cerrahi tedavisi yapıldı.
145 hastanın 131'ine geniş tümör rezeksiyonu yapıldı. 131 hastanın 70'ine humerus proksimal rezeksiyon protezi, 5'ine total humerus protezi, 3'üne custom made total skapula ve humerus proksimal rezeksiyon protezi ve 2'sine allogreft fibula, 2'sine revers total omuz rezeksiyon protezi, 1'ine total omuz tümör rezeksiyon protezi, 1'ine proksimal humerus sement imalat spacer, 1 ine sement ile imalat spacer + IMKK, 1'ine sement ile imalat spacer + İF yapıldı. 145 hastanın 8 ine skapulotorasik dezartikülasyon, 6'sına omuz dezartikülasyonu yapıldı.
İncelemeye alınan 187 hastanın, ortalama tümör boyutu 10.0 cm (3- 78 cm arası) idi.
Cerrahi tedavi uygulanan 145 hastanın, ortalama takip süresi 25.5 ay(2-166 ay arası) idi. Bu 145 hastanın, 39'u ortalama ortalama 54.2 ay (4-166 ay arası) takip edildi ve hala takibimiz altında. 41'i ortalama 10.5 ay (3-106 ay arası) takip sonrası takipten çıktı. 65'i ortalama 17.7 ayda (2-77 ay arası) ex oldu.
Araştırmaya dahil edilen 187 hastanın opere edilen 145 inin 18'inde (% 12,4) takip süreleri boyunca her hangi bir zamanda komplikasyon gelişmiştir. Komplikasyonlar olarak, yara iyileşmesinde gecikme, yüzeyel enfeksiyon, vida veya k teli migrasyonu, stem gevşemesi, herhangi bir zamanda gelişen dislokasyon, nörolojik defisit, ağrı, cilt defekti, protez enfeksiyonu ve osteomyelit görülmüştür. Hiç bir hastamızda stem kırığı görülmedi.
Sonuç olarak, Kas-iskelet sistemi tümörlerinin, multidisipliner bir konsey tarafından değerlendirilip, tartışılarak tedavi planlaması yapılmalıdır. Tedavi, tümörün histopatolojik tipine göre; cerrahi, kemoterapi, radyoterapi veya bunların birlikte kullanıldığı protokollere göre düzenlenmelidir.

Abstract:
Improved survival muscle system in tumor development and advanced in bioengineering surgery has allowed the construction of many surgical procedures that require surgery.
This study the shoulder area of localized malignant muscule sketoral tumors of 182 patients who were enrolted in the study between in August 2001 and January 2016 at orthopedic clinic in Ankara Oncology Hospital. 108 many of 187 patients were in the study.The meanage of the patients were 47.9 (2-87 between age) at the time of surgery was.
Proximal humerus tumor was localized in 108 patients and 32 patients were located in the soft tisues of the shoulder area. 24 patients were scapula, 17 patients were clavicula.3 patients were humerus proximal and scapula. 3 patients were scapula and clavicula were sealed.Ninety-five percent of patients were with primary tumors. Five percent of patients were relapse.
Eighty-two parent of patients were metastazis. Ewing's surcoma twenty –one of the primary tumor. Eighteen of them osteosarcoma, seventeen of them multiple myeloma, sixteen of them were chondrosarcoma, six points are pleomorphic sarcoma, 4 of them were mmt, 3 of them were rhabdomyosarcoma, two of them were ekstraskletal. Osteosarcoma, two of them were synovial sarcoma, two of them were liposarcoma, two of them were leiomyosarcoma. One of them was epitheloid hemangioendothelioma. One of them was malignant peripheral nevre sheat tumor.
11 was recuirent tumor, 3 were osteosarcoma, 3 were pleomorphic sarcoma, 1 was chondrosarcoma, 1 was angiosarcoma, 1 was fibrosarcoma, 1 was mmt.
The most common primary tumor localization was seen in patients with metastatic eighty-one. Nineteen of them were lung cancer. 13 of them were breast cancer, 10 of them were lymphoma. Nine of them were metastatic tumors of unknown primary, nine of them were renal cell cancer, five of them were thyroid cancer.
After 42 of the 187 patients diagnosed with incisional biopsy. The patients was consulted about the medical department for follow up and treatment because of the second surgery wasn't planned. Except of 42 patients 143 patients was operated in our hospital.
131 of the 145 patients was performed large tumor resection 70 of the 131 patients was performed proximal resection arthroplasty, five of them was performed total humeral prosthes, three of them was performed custom made prosthesis total scapula and humerus, proximal resection, two at them were performed, allograft fibula, two of them were performed revere total shoulder arthroplasty resection, one of them was performed. Manufacturing segment proximal humerus spacer, one of them was performed manufacturing space with cement + IMKK.
One of them was performed manufacturing space with cement + İF.8 of the 145 patients were performed disarticulation of scapula thoracic. 6 of them were performed shoulder disarticulation.
18 patients who were examined the average tumor was10.0 cm.(between 3-78 cm)
145 patients who between underrent surgical treatment the average follow-up was 25.5months(2-166 betweeen months)
39 of the 145 patients was followed nearly34.2months (between months 4-166) and they have been following by us.
41 patients left the treatment nearly after10.5months(between months 3-106). 65 patients died nearly 1. Months(2-77 between months).
Of the 187 patients who participated in the study 18of 145 who were operated(%12,4) complications developed at any time during follow up. Delay in round healing as complications was seen, superficial in tection, screw or k pinned migration, stem loosening, dislocation at any time, neurological deficit, ache, skin defect, prosthetic infection and osteomyelitis. No stem fracture was seen in any of our patients.
As a result of which musculo skeletal tumors which treatment planning should be done after that evoluated by a multi disciplinary council. The treatment tumor must be treated by surgery, chemotherapy, radiotherapy or they should be organized according to the protocols used together.