股骨下段恶性骨肿瘤保肢术后中期肿瘤学预后及假体功能评估

Prosthetic knee replacement after resection of a malignant tumor of the distal femur:medium-term results

目的明确股骨下段恶性骨肿瘤保肢术后的中期肿瘤学预后,评估患肢功能状况及相关影响因素。方法回顾性分析2000年1月至2007年1月行股骨下段恶性骨肿瘤瘤段切除、膝关节肿瘤假体置换术的54例中获得随访的37例患者,男21例,女16例;年龄14～65岁,平均31.0岁。术后随访肿瘤学预后、患肢功能及两者的相关影响因素。功能评分采用1993年美国骨肿瘤学会评分系统(MSTS),并对功能评分采用t检验或秩和检验进行单因素比较。结果37例获得随访,随访时间2～9年,平均49.4个月。随访中存活26例(70.3%),其中无瘤生存24例(64.9%),带瘤生存2例(5.4%);局部复发4例(10.8%),截肢3例(8.1%)。其中18例骨肉瘤患者的总生存率为66.7%(12/18),其五年、七年生存率均为59.83%;24例ⅡB期肿瘤患者的总生存率为58.3%(14/24),其五年、七年生存率均为50.97%;24例ⅡB期肿瘤患者的中期肿瘤学预后较非ⅡB期肿瘤患者差(P=0.0215)。24例存活且未截肢患者的MSTS得分为(26.3±3.0)分,功能优秀率为87.5%;股骨下段恶性肿瘤患者中无病理性骨折患者保肢术后功能得分为(27.1±2.4)分,优于有病理性骨折患者的(23.8±3.5)分(P=0.027)。结论股骨下段恶性骨肿瘤假体保肢术具有较好的肿瘤学预后和术后功能;影响股骨肿瘤膝关节保肢术肿瘤学预后的重要因素是肿瘤的Enneking分期及肿瘤对化疗的敏感程度;导致股骨肿瘤膝关节MSTS功能评分的危险因素是术前病理性骨折,患者年龄、股骨截骨长度和肿瘤假体类型对术后功能无影响。

Objective To assess the oncology prognosis and risk factors of the malignant musculoskeletal tumor of the distal femur. Methods According to the inclusion criteria 54 patients had a limb-sparing procedure of lower extremities by means of the implantation of tumor endoprosthesis from January 2000 to January 2007 in the West China Hospital. A follow-up study focusing on the oncology prognosis, limb function and the risk factors was done on 37 patients with duration of follow-up ranging from 2 to 9 years （ mean 49.4 months）. The survival of the patients was analyzed regarding several risk factors with use of log-rank test. Function evaluated with the revised 30-point scoring system of the Musculoskeletal Tumor Society （MSTS） was analyzed by several risk factors using test or rank test. Results Of the 37 patients, 26 （70. 3% ） were alive at the latest follow-up, 24 （64. 9% ） lived without tumor, 2 （5.4%） lived with tumor. Local recurrence occurred in 4 （10. 8% ） cases. Three ended in amputation （8. 1% ）. Of the 18 eases with osteosarcoma, the overall survival was 66. 7% , the 5-year and 7-year survival were both 59.83%. The overall survival of the 24 patients with phase II B tumor was 58. 5% and the 5-year, 7-year survival were both 50. 97%, which were worse than patients without phase II B tumor （P = 0. 0215）. The mean MSTS was 26. 3 ±3.0, with excellent in 87. 5% patients. Those without pathological fracture had a mean score of 27. 1 ± 2. 4, which was higher than that with pathological fracture （23. 8±3.5, P = 0. 027 ）. Conclusion Limb salvage surgery with tumor-type knee prosthesis has a satisfactory oncology prognosis and postoperative limb function. Enneking stage and sensitivity to chemotherapy of the tumor were important factors affecting the oncology prognosis. The limb function was significantly impacted by pre-operative pathological fracture but not related to age, sex, resection length and prosthetic type etc.