ⅡB期肢体骨肉瘤189例综合治疗临床分析

Long-term results of combined therapy for primary osteosarcoma in extrimities of 189 cases

目的对肢体原发骨肉瘤综合治疗结果进行评估。方法术前无远处转移的肢体骨肉瘤患者189例,年龄4～39岁,平均年龄18岁,男性125例,女性64例;肿瘤部位:股骨下段86例,胫骨上段52例,股骨上段4例,肱骨上段19例,四肢其他部位28例,病理骨折22例。完成化疗方案的患者为规律化疗组116例,占61.4%;未完成化疗方案的患者为非规律化疗组73例,占38.6%。规律化疗组116例,依手术方法分为保肢组90例和截肢组26例;非规律化疗组73例中保肢组42例和截肢组31例。结果5年生存率:规律化疗组和非规律化疗组患者分别为78.5%和35.2%。局部复发率:规律化疗组保肢患者90例,复发15例(16.6%),而非规律化疗组保肢患者42例,复发16例(38.1%),差异有统计学意义(P<0.01),规律化疗组116例中,转移33例(28.4%);而非规律化疗组73例中,转移48例(65.7%),差异有统计学意义(P<0.01)。56例股骨下端和胫骨上端的保肢患者按照MSTS评分系统进行功能评定,灭活再植36例,异体骨置换10例,人工关节置换10例,功能恢复达85%～86%,三类术式随访期内功能恢复状况差异无统计学意义(P>0.05)。结论肺转移瘤是制约骨肉瘤患者生存率提高的重要因素;局部复发的发生与肿瘤的外科边界关系密切,恰当地选择外科边界可以提高保肢的安全性;规范的综合治疗应视为骨肉瘤治疗的首选,单纯外科治疗疗效有限,应辅以规律化疗。

Objective To evaluate the survival rates and complications of combined therapy for primary osteosarcoma of the extremities between 1992 and 2001. Methods From 1992 to 2002, 189 patients with non-metastatic osteosarcoma were treated. Their average age at diagnosis was 18 years old （ ranging from 4 to 39）. Tumors were located at distal femurs in 86 patients, proximal femurs in 4, proximal tibia in 52, proximal humors in 19 and other locations in 28. Combined therapy （ resection of tumor with chemotherapy） was given 116 patients and non-combined therapy （tumor resection only and unfinished chemotherapy） to 73. In combined therapy group, 90 patients underwent limb salvage surgery, and 26 patients received amputations. In non-combined therapy group, 42 patients underwent limb salvage surgery and 31 patients received amputations. Results The 5-year-survival rates were 78. 5% in the combined therapy group and 35.1% in the uncombined therapy group. Local recurrence rate was 16. 6% （15cases） in limb salvage surgery with combined therapy group（90 cases） and 38. 1% （16 cases） in limb salvage surgery with uncombined therapy group （42 cases） （P〈0. 007 ）. Metastasis rate was 28.4% （33 cases） in the combined therapy group（ 116 cases） and 65.7% （48 cases） in the uncombined therapy group（73 cases） （P 〈0.000）. Functional evaluation showed that the patients who underwent salvage surgery had higher funcitional scores than those who had an amputation. According to MSTS scoring system （ 1993 ）, 56 patients （excision alcohol replacement 36 cases, allograft 10 cases and prosthesis 10 cases） were evaluated functional scores. The average scores reached same level（P〉0. 5）. Conclusions （1） In this study, the 5-year-survival rate in the combined therapy is improved. The treatment for the patients with metastasis in lung is very difficult for improvement of the 5-year-survival rate. （2） The local recurrence is related the surgical margin. The adequate surgical margin is very important for the limb salvage. （3） The combined therapy is very essential for improving survival rate.