新辅助化疗结合新轴心式肿瘤特制型假体置换治疗膝关节周围骨肉瘤

The replacement of new axial tumor-type prosthesis combined with neoadjuvant chemotherapy in the treatment of osteosarcoma around the knee

目的探讨新辅助化疗结合新轴心式肿瘤型假体置换在膝关节周围骨肉瘤保肢治疗中的临床效果。方法采用新辅助化疗结合新轴心式肿瘤型假体置换保肢治疗膝关节周围骨肉瘤26例,其中男性15例,女性11例,年龄7～56岁,平均25.3岁。肿瘤部位股骨远端18例,胫骨近端8例。根据Enneking分期:I A期4例,I B期4例,II A期6例,II B期12例。采用化疗药物多柔比星、顺铂、甲氨蝶呤和异环磷酰胺进行新辅助化疗。术前化疗2～3个疗程,2-3周后进行保肢手术,术后继续化疗6个疗程。术前、术后每个化疗疗程间隔2-3周。所有病例切除标本均行病理检查并进行坏死率评估,以调整术后化疗方案。胫骨近端肿瘤切除后行腓肠肌内侧头肌瓣移位修复软组织缺损并与髌韧带缝合重建伸膝装置。术后根据Enneking评分标准评定疗效。结果 26例患者均获得随访,随访时间为8-56个月,平均28个月。经过术前化疗后患者疼痛迅速缓解,通过查体、X线片、CT或磁共振检查发现瘤体不同程度缩小、瘤体硬化、边缘清楚及有部分活动度。肿瘤坏死率测定:>90%共18例,<90%共6例。3例出现肺部转移,并因肺转移合并呼吸循环衰竭死亡,3例局部复发,行股骨下段截肢,20例无复发或远处转移。3年生存率为88.0%,复发率为11.5%,最终保肢率88.5%。26例患者术后根据Enneking评分标准评定疗效优19例,良4例,差3例,优良率88.5%。结论新辅助化疗结合新轴心式肿瘤型膝关节假体置换是膝关节周围骨肉瘤保肢治疗的一种有效方法 ,能减少复发、远处转移及提高临床治疗效果。

Objective To explore the clinical effect of limb salvage treatment of osteosarcoma around the knee by neoadjuvant chemotherapy combined with the replacement of new axial tumor-type prosthesis. Methods 26 patients of osteosarcoma around the knee were treated by neoadjuvant chemotherapy combined with new axial tumor-type prosthesis to achieve limb salvage, including 15 males and 11 females with the mean age of 25.3 years （range; 7-56 years）. Regions of the tumors were listed as following： 18/26 tumors located in the distal femur, 8/26 tumors located in the proximal tibia. According to enneking classification, 4/26 patients were classified at I A, 4/26 patients were classified at I B, 6/26 patients were classified at II A, and 12/26 patients were classified at II B. Doxorubicin, cisplatin, methot rexate and ifosfamide were applied for neoadjuvant chemotherapy. 2-3 courses of preoperative chemotherapy were given to. All patients underwent operations of limb salvage after 2-3 weeks. 6 courses of postoperative chemotherapy were given to. Preoperatively and postoperatively, there was a 2-3 weeks＇ interval between every chemotherapy course. All samples resected were conducted with pathological examination and the tumor necrosis rate was evaluated to adjust the postoperative chemotherapy plan. Medial gastrocnemius flap transposition was used to achieve the repair of soft tissue, and patellar tendon fixation was used for the extensor mechanism reconstruction after the resection of the tumor in the proximal tibia. The efficacy was evaluated by the enneking evaluating system. Results All the 26 patients were followed up for 8-56 months with an average of 28 months. After preoperative chemotherapy, obvious pain relief was observed. The tumor size was reduced, the tumor sclerosis appeared, the tumor margin became clear-cut and partial range of motion was maintained to different degrees through the confirmation of physical examination, X-ray, CT or MRI. Cell necrosis rates of tumors were listed as follows： 〉90% in 18 patients, 〈90% in 6 patients. Lung metastasis occurred in 3 patients, who died of breathing circulatory failure combined with lung metastasis. Local recurrence occurred in 3 patients, who underwent amputation at the lower part of the femur. No recurrence or distant metastasis was found in 20 patients. The survival rate was 88.0%, recurrence rate was 11.5%, and the limb salvage rate was 88.5% in 3 years. The results were evaluated by the enneking evaluating system as follows： excellent in 19 patients, good in 4, and fair in 3. The excellence rate was 88.5%. Conclusions Neoadjuvant chemotherapy combined with the replacement of new axial tumor-type prosthesis is effective in the treatment of osteosarcoma locating around the knee to achieve limb salvage, with low recurrence rate, distant metastasis rate and improved clinical effect.