足踝部腱鞘巨细胞瘤的临床分型、分期与治疗

Classification and Treatment of Giant Cell Tumor of Tendon Sheath in the Foot and Ankle

目的总结足踝部腱鞘巨细胞瘤临床特点与治疗、预后之间的关系,建立一种能指导诊断、治疗、预测预后的临床分型、分期方法。方法回顾性分析1984～2009年期间21例足踝部腱鞘巨细胞瘤住院患者的临床资料及随访结果,据此对足踝部腱鞘巨细胞瘤进行临床分型、分期。结果 21例患者以男性居多,患者平均年龄为38.0岁,肿瘤好发于右足(71.4%)以及滑膜关节周围(81.0%),半数以上患者以无痛性肿物为主要症状(61.9%),X线检查对关节受肿瘤侵犯的检出率低(66.7%),但MRI非常敏感(100%),病理检查提示大部分肿瘤细胞增生活跃(52.4%)。根据肿瘤的生物学行为可将其分为两型:A型位于足踝部腱鞘周围;B型位于足踝部大关节周围。其中B型又划分为Ⅰ期:局限于包膜内;Ⅱ期:突破包膜局部浸润;Ⅲ期:弥漫侵袭并进入关节腔。21例病例中A型4例,B型17例(Ⅰ期6例,Ⅱ期9例,Ⅲ期2例)。对A型和B型Ⅰ期患者行边缘切除,B型Ⅱ期给予灶内切除和术后放疗,Ⅲ期在扩大切除的基础上辅以放疗。对所有病例经过平均119.6个月的随访,仅1例B型Ⅲ期患者于术后9月复发并恶性变,其余患者功能恢复满意。结论足踝部的腱鞘巨细胞瘤包含生物学行为特点不同的两种亚型,根据临床资料对肿瘤进行分型、分期,可以很好地指导治疗和改善预后。

Objective To describe the clinical classification and staging of the giant cell tumors of the tendon sheath（GCTTS） in the foot and ankle which can direct the diagnosis, treatment and forecast the prognosis. Methods We collected 21 cases whose feet and ankles were affected by GCTTS and treated in our hospital from 1984 to 2009. Their clinical features were retrospectively analyzed and the follow - up were conducted. By correlating the clinical features with the treatments and follow - up, the GCTTS of foot and ankle can be divided into different subtypes and stages. Results The mean age of the group was 38.0 years. The tumor tended to affect right foot （71.4%） and around synovial joints （81.0%）. The majority of the patient bear a asymptomatic neoplasm （61.9%） and the X - ray showed a low rate of bone erosion （66.7%）. MRI could sensitively detect bone destruction （ 100% ）. Pathology analysis showed active tumor cell proliferation （52,4%）. All 21 cases were devided into 2 subtypes according to their biological behavior ：type A （contains 4 cases） was the classical GCTTS which arising from the tendon sheath; type B （contains 17 cases） had a close relationship with the synovi- al joint, patients of type B can be further subdivided into 3stages. At stage I , the GCTTS was constrained by a pseudocapsule and out of the articulation （contains 6 cases） ; at stage II ,the tumor infiltrated the pseudocapsule and encroached soft tissues and bone nearby （con- tains 9 cases） ; at the late stage,GCTTS further break into the synovial articulation （contains 2 cases ）. The patients of type A and type B who at stage I were treated by marginally excise only,and those at stage II were treated by intralesional excision and adjuvant radio- therapy with the total radiation dose 18 -21 grays （Gy） ,and those at stage m got wide exploration and excision, and the adjuvant radio- therapy followed too. The median follow -up was 119.6 months. There was only one patient in type B who at stage III suffered recurrence 9 months after primary surgery. Conclusion Giant cell tumors of the tendon sheath in the foot and ankle have two distinguished subtypes which showes distinctive biological behavior. When the treatment was applied according to this classification and staging, the recurrence rate is low and the prognosis is better.