合并病理骨折骨肉瘤的治疗

The surgical treatment and outcome of nonmetastatic osteosarcoma of the extremity with pathologic fractures

目的探讨不同手术方式对合并病理骨折骨肉瘤患者生存率及预后的影响。方法1992年至2001年原发肢体骨肉瘤患者中发生病理骨折且未经外院治疗的22例患者进行回顾性研究。其中男性15例，女性7例；年龄8～36岁，平均18岁。病变主要位于肱骨及股骨，其中肱骨近端10例，股骨远端6例，股骨干4例，股骨近端及腓骨近端各1例。施行保肢治疗12例（保肢组），其中人工假体置换4例，异体半关节置换2例，骨水泥临时假体4例，单纯局部切除1例，旋转成形术1例；施行截肢治疗10例（截肢组）。本组所有患者均接受新辅助化疗。术后随访8～146个月，平均54．7个月。对于存活病例，最短随访时间36个月。结果本组病例保肢率为54．5％，截肢率为45．5％。较非病理骨折患者保肢率（71．9％）低，但差异无统计学意义（P=0．096）。9例患者发生肺转移，死亡时间术后8～26个月。5年生存率为53．4％。对于保肢组和截肢组病例，局部复发率分别为16．7％和10．0％；肺转移率分别为25％和60％。结论正确选择保肢手术可以使患者在不增加局部复发风险的基础上得以保留肢体，并获得与无病理骨折骨肉瘤患者一致的生存率。

Objective To demonstrate the influence of pathologic fracture and the form of surgical therapy on the survival rate and the prognosis of the patients with osteosarcoma. Methods From 1992 to 2001 retrospective analysis was done for 22 patients with pathological fracture out of 189 patients with primary extremity osteosarcoma. The 22 patients presented as primary extremity osteosarcoma with pathologic fracture without prior treatment. They were 7 females and 15 males and their age ranged from 8 to 36 years old. Most of diseases located in humerus and femurs. Limb salvage underwent in 12 patients （ allograft 2, bone cement spacer 4, local resection 1, prosthesis 4 and rotationplasty 1 ） and amputation in 10. All these patients had pre and post operative chemotherapy. The 22 patients followed 8 to 146 months after surgery, and the average was 54.7 months. The minimum follow-up for survive patient was 36 months. Results The 54. 5% patients had limb-salvage surgery and 45.5% had amputation, and the limb salvage was lower than non-fracture patients （ 71.9% ）, but without significance （ P = 0. 096 ）. Nine patients developed lung metastases and died in 8 to 26 months postoperatively. The five-year estimated survival rate was 53.4%. The recurrent rates were 16.7% and 10. 0% in limb salvages and amputation respectively. The lung metastases rates were 25% and 60% in limb salvages and amputation respectively. Conclusion The performance of a limb-salvage procedure in carefully selected patients with pathologic fracture does not significantly increase the risk of local recurrence or death.