骨巨细胞瘤的治疗及复发病例分析

CASE ANALYSIS ON TREATMENT AND RECURRENCE OF GIANT CELL TUMOR OF BONE

目的分析骨巨细胞瘤（giant cell tumor of bone，GCT）患者的临床特点、治疗方法及复发相关因素，探讨GCT治疗方法的选择。方法分析1993年1月～2005年1月收治的获随访的GCT患者38例，男13例，女25例。年龄14～59岁，平均31．1岁。经术前穿刺活检及术后证实为GCT，总结其临床特点并进行同顾性分析。所有患者均经病理诊断证实，Campanicci’s放射学分级：I级5例，Ⅱ级22例，Ⅲ级11例。按Enneking分期：I期9例，Ⅱ期21例，Ⅲ期8例。Jaffe’s病理分级：I级7例，Ⅱ级24例，Ⅲ级7例。29例GCT位于膝关节周围（股骨远端13例，胫骨近端16例），股骨近端、尺骨近端、桡骨远端、骶尾部各2例，腰椎1例。3种基本手术方法分别为：单纯刮除植骨4例；刮除植骨＋磨钻、石碳酸、50％ZnCl2、3％碘酒、骨水泥等辅助治疗26例；瘤段截除8例。结果38例术后获随访12～144个月，平均67个月。4例行单纯刮除植骨均复发；8例行瘤段切除，术后无复发；26例刮除植骨＋辅助灭活方法，8例复发。按Campanicci’s放射学分级：I级5例无复发，Ⅱ级22例复发6例，Ⅲ级11例复发6例。按Enneking分期：I期9例复发2例，Ⅱ期21例复发6例，Ⅲ期8例复发4例。术后共复发12例，复发率31．6％，均位于膝关节周围，复发时间为2～36个月，平均14．3个月。复发12例患者均行二次手术治疗，其中8例选择瘤段切除，4例行刮除植骨＋辅助灭活方法，术后均无复发。结论GCT术后复发多发生于膝关节周围，以胫骨侧为主，Campanicci’s放射学分级的Ⅱ级和Ⅲ级，且临床表现侵蚀性较高者。单纯刮除植骨复发率较高，正确使用辅助方法结合现代广泛刮除技术及现代的诊疗技术是降低复发率的重要手段。

Objective To analyze the clinical features, treatment methods, and recurrence factors of giant cell tumor of the bone and to investigate the surgical therapy choice for the tumor around the knees. Methods Thirty eight patients （13 males and 25 females; average age 31. 1 years, range 14 59 years） with giant cell tumor of the bone were treated and followed up from January 1993 to January 2005. The patients＇ diagnoses were established by biopsies of the specimens from the preoperative punctures or operations. The clinical features and the radiological and laboratory data from the 38 patients were reviewed. By the Campanicci＇s radiological grading system, 5 patients were in Grade Ⅰ , 22 in Grade Ⅱ , and 11 in Grade Ⅲ. By the Enneking classification, 9 patients were in Grade Ⅰ , 21 in Grade Ⅱ , and 8 in Grade Ⅲ. By the Jaffe＇s classification, 7 patients were in Grade Ⅰ , 24 in Grade Ⅱ , and 7 in Grade Ⅲ. The intralesional excision （curettage） with the bone grafting was performed on 4 patients; the curettage with some adjuvant treatments （high speed burring, phenol, alcohol, cement, hydrogen peroxide, 50% ZnC12, 3% iodine tincture, or bone cement） was used in 26 patients; and resection of the whole tumor was performed on 8 patients. Results The follow up of the 38 patients for 12-144 months （average, 67 months） revealed that giant cell tumor of the bone was found around the knees in 29 of the 38 patients （13 at the distal femur, 16 at the proximal tibia）, at the proximal femur in 2, at the proximal ulna in 2, at the distal radius in 2, at the sacroiliac area in 2, and at lumbar spine in 1. Of the 38 patients, 4 had a recurrence after simple curettage, 8 had no recurrence after resection of the whole tumor, and 8 of the remaining 26 patients had a recurrence after curettage with some adjutant treatments. Five patients in Grade Ⅰ （Campanicci＇s radiological grading） had no recurrence, 6of the 11 patients in Grade Ⅱ had a recurrence, and 6of the 11 patients in Grade Ⅲ had a recurrence. Two of the 9 patients in Grade I （Enneking grading） had a recurrence, 6of the 21 patients in Grade Ⅱ had a recurrence, and 4 of the patients in Grade Ⅲ had a recurrence; all the recurrent lesions were around the knee, with a duration of the recurrence ranging from 2 months to 36 months （average,14.3 months）.Of the patients with the recurrence, 12 underwent reoperations （8 by the total resection of the recurrent tumor, 4 by the curettage with adjuvant treatments）, and there was no recurrence after the reoperation. Conclusion Giant cell tumor of the bone usually recurs around the knee joint, especially at the proximal tibia, usually graded as GradeⅡ or Ⅲ by the Campanicci＇s radiological grading system. Simple curettage has a higher recurrence rate; therefore, extensive curettage and resection of the lesions combined with some adjuvant treatments after the correct diagnosis can be used to reduce the high recurrence rate of giant cell tumor of the bone.