复发性肢体骨巨细胞瘤的临床诊治策略

Clinical diagnosis and surgical treatment on recurrent giant cell tumor of extremity

[目的]探讨复发性肢体骨巨细胞瘤的临床、影像学特点以及不同治疗方法及临床疗效。[方法]自1995年1月~2009年1月治疗29例复发性骨巨细胞瘤,男15例,女14例;复发时平均年龄32.4岁（13~56）岁;股骨远端和胫骨近端各12例,肱骨近端2例,股骨近端、尺骨远端、腓骨近端各1例。首次手术方式与例数：肿瘤刮除植骨26例,瘤段切除骨缺损修复术2例,单纯腓骨近端切除术1例。复发平均时间26.6个月（1~168）个月。再次手术方式与例数：瘤段切除骨缺损修复重建术17例（假体置换14例,自体骨移植2例,灭活再植1例）;肿瘤扩大刮除瘤腔灭活骨修复术7例（植骨4例,骨水泥填充内固定3例）,肿瘤扩大切除术3例;截肢术2例。[结果]随访时间24~180个月,平均70个月。2例再次复发;总再复发率为6.9%,肿瘤切除骨缺损修复组无复发,病灶内手术组中1例复发（1/7,14.29%）,局部扩大切除术组1例复发（1/3,33.33%）。随访期内2例死亡（1例死于非肿瘤原因）。病灶内手术组肢体功能优良率为100%,瘤段切除骨缺损修复组为73.33%。综合临床疗效评价病灶内手术优良率为85.71%。肿瘤切除骨缺损修复组为66.67%。[结论]骨巨细胞瘤术后定期随访对于早期诊断肿瘤复发至关重要;一旦复发诊断明确,尽管存在再次复发的风险,应首选瘤灶内手术;对放射学CompanacciⅢ级的复发性骨巨细胞瘤可选择瘤段切除骨缺损重建手术治疗,但存在一定的远期并发症。

[Objective]To investigate the clinical,radiological manifestations of recurrent giant cell tumor of the bone（RGCT）,and the clinical outcomes of different treatments.[Method]Twenty-nine patients with RGCT were treated during Jan.1995 to Jan.2009.There were 15 male and 14 female patients.The average age was 32.7 years old（range,13-56 years）.Twelve lesions were located at the distal femur and the proximal tibia.Two lesions at the proximal humerus,each at the proximal femur,the distal ulna and the proximal fibula.Twenty-six patients underwent curettage and bone grafting for primary lesion,two with en bloc resection of tumor and reconstruction,one with resection of proximal fibula.Seventeen patients underwent en bloc resection of tumor and reconstructions,seven with intralesional operation,three with wide resection and two with amputations.[Result]All were followed-up with the average time of 70 months（range,24-180 months）.Two patients developed re-recurrence（overall re-recurrent rate,6.9%）.No re-recurrence was found in en bloc resection of tumor and reconstruction group.In the intralesional group,one re-recurrent case was found（14.29%）.Another re-recurrent case was in wide resection group（33.33%）.Two patients died during the follow-up（one died of no-tumor factor）.The excellent and good results of the affected limb function were achieved in 100% of patients in the intralesional group according to the Eneecking system,and 73.33% in the tumor resection and reconstruction group.The excellent and good clinical outcomes were obtained in 85.71% of patients in the intralesional group according to the Markin system,and 66.67% in the tumor resection and reconstruction group.[Conclusion]It is important for the recurrence to be followed-up regularly after intralesional operation on GCT.The re-recurrence risk exists in the treatment of RGCT by intralesional curettage.However it is a choice of method,because better native joint function can be saved.In the management of Campanacci Stage-Ⅲ recurrent tumor,local recurrence rate can be reduced effectively and better outcome can be achieved by en bloc resection and reconstruction.Long term complications,such as prosthesis loosening,infection,will develop.