四肢骨巨细胞瘤的外科治疗

Surgical strategy for giant cell tumor in extremity

目的回顾性分析四肢骨巨细胞瘤不同手术方法的疗效。方法自1997年7月至2005年7月收治四肢骨巨细胞瘤128例，男65例，女63例；年龄17-64岁，平均32岁。股骨远端49例，股骨近端8例，胫骨近端37例，肱骨近端14例，桡骨11例，腓骨4例，跟骨2例，胫骨远端1例，尺骨1例，指骨1例。Campanacci分级Ⅰ级29例、Ⅱ级67例、Ⅲ级32例。根据肿瘤的不同部位、放射线分级及患者年龄，采取不同的手术方法。其中刮除后植骨或骨水泥填充37例，刮除后植骨内固定42例，腓骨代桡骨11例，瘤段切除人工关节置换33例，单纯切除不重建5例。结果随访期间未见严重并发症，3例出现切口渗液，3例出现假体迟发性感染。局部复发：刮除后植骨或骨水泥填充组5例（13．5％），刮除后植骨内固定组5例（11．9％），人工关节置换组2例（6．1％）。肺转移2例，均为肱骨近端骨巨细胞瘤，良、恶性各l例。1例股骨远端骨巨细胞瘤患者刮除术后10个月复发。结论对骨巨细胞瘤的治疗应根据肿瘤的部位、放射线分级及患者年龄采取不同的手术方法。囊内切除适合于CampanacciⅠ、Ⅱ级骨巨细胞瘤，符合肿瘤治疗原则，具有较好的术后功能、较低的局部复发率及术后并发症发生率。瘤段切除适合于Campanacci Ⅲ级骨巨细胞瘤，与囊内切除相比局部复发率低，但术后并发症发生率高，可用于切除后无须重建的肿瘤、大的侵袭性病变或复发的骨巨细胞瘤。

Objective To study retrospectively the treatment results of different surgical procedures in giant cell tumor of extremities. Methods 128 cases with giant cell tumor in extremities from July 1997 to July 2005 were reviewed. 65 were males and 63 were females with an average of 32 years （range, 17-64 years）. The anatomic site for the lesions were the distal femur （49 cases）, proximal femur （8 cases）, proximal tibia （37 cases）, proximal humerus （14 cases）, radius （11 cases）, fibula （4 cases）, calcaneus （2 cases）, distal tibia, ulna and phalange （1 case for each site）. 29 cases had Campanacci stage Ⅰ tumors, 67 cases and 32 cases had Campanacci stage Ⅱ and Ⅲ respectively. 37 cases had been performed tumor curettage with bone graft, or cementation. 42 cases received internal fixation with bone graft after curettage. Fibula autograft had been applied in 11 cases. En block excision and reconstruction by endoprostheses were done for 33 cases. 5 cases had wide excision without reconstruction. Results 3 cases presented with wound problems were treated by conservative local care. 3 hmb salvage procedures with endoprostheses occurred late infection. The local recurrent rate was 5 cases （13.5%） in group of cases with bone graft or cementation, 5 cases （11.9%） with combining of bone graft and internal fixation, and 2 cases （6.1%） with joint replacement. Pulmonary metastases occurred in 2 proximal humerus giant cell tumor with one benign and one malignant. The pathology of one recurrent case treated with prosthesis replacement 10 months after primary curettage surgery was sarcoma transformation. Conclusion The optimum treatment should be determined by tumor site, radiographic signs and patient＇s age. Campanacci stage Ⅰ and Ⅱ tumors could be controlled by intralesional procedure according to tumor Surgery principle with good function, low local recurrence and complication rate. It has better local control to do en block excision for Campanacci stage Ⅲ giant cell tumor patients, but with more complications. Hence wide excision is suggested to be applied to the site in there no need reconstruction or in aggressive and recurrent cases.