四肢骨巨细胞瘤术后复发再次手术的疗效观察

CLINICAL OBSERVATION OF SURGICAL MANAGEMENT FOR RECURRENT GIANT CELL TUMOR OF BONE

目的探讨四肢骨巨细胞瘤术后复发患者再次手术术式选择及疗效。方法回顾1988年2月-2007年6月收治且获完整随访的79例骨巨细胞瘤术后复发再次手术患者临床资料。男42例,女37例;年龄15～72岁,平均33.1岁。初次行囊内刮除76例,整块切除3例;初次手术后2～176个月肿瘤局部复发。肿瘤病灶位于上肢14例,下肢65例。初次手术前影像学Companacci分级,Ⅰ级1例、Ⅱ级33例、Ⅲ级45例。再次手术37例采用囊内刮除植骨联合辅助灭活,42例采用肿瘤整块切除治疗。结果术后2例出现同种异体骨免疫排斥反应,导致切口不愈合;余患者切口均Ⅰ期愈合。患者均获随访,随访时间18～221个月,平均68个月。其中12例于术后6～32个月局部再次复发,采用囊内刮除植骨联合辅助灭活措施者中再复发9例(24.3%,9/37),均再次行肿瘤整块切除;肿瘤整块切除再复发3例(7.1%,3/42),均截肢;两种术式复发率比较差异有统计学意义(χ2=4.508,P=0.034);再复发患者术后随访3年均未见复发。结论复发性四肢骨巨细胞瘤可以通过囊内刮除植骨联合辅助灭活治疗,但肿瘤局部复发率高于肿瘤整块切除。对于肿瘤范围超过横断面50%预测不能彻底刮除及恶性复发性骨巨细胞瘤患者,建议采用肿瘤整块切除方法。

Objective To discuss the surgical selection and effectiveness for patients with recurrent giant cell tumor of bone. Methods Between February 1988 and June 2007, 79 patients with recurrent giant cell tumor of bone were treated. There were 42 males and 37 females, with a mean age of 33.1 years （range, 15-72 years）. In primary surgery, 76 patients underwent intralesional curettage, and the other 3 patients underwent resection; the recurrence time was 2-176 months after primary surgery. The locations of tumor were upper extremities in 14 cases and lower extremities in 65 cases. According to Companacci grade, 1 case was at grade I, 33 cases at grade II, and 45 cases at grade III before primary surgery. In secondary operation, 37 patients underwent intralesional curettage and bone grafting combined with adjuvant inactivated, and 42 patients underwent wide resection. Results Bone allograft immune rejection occurred in 2 cases, which led to poor healing; primary healing of incision was obtained in the other patients. The patients were followed up 68 months on average （range, 18-221 months）. Recurrence occurred in 12 patients at 6-32 months after operation. The re-recurrence rate was 24.3% （9/37） in cases of intralesional curettage and bone grafting combined with adjuvant inactivated, and they were given the wide resection. The re-recurrence rate was 7.1% （3/42） in cases of wide resection and they were amputated. There was significant difference in the re-recurrence rate between the intralesional curettage and the wide resection （χ2=4.508, P=0.034）. No recurrence was observed during 3-year follow-up among re-recurrence patients. Conclusion For benign recurrent giant cell tumor of bone, intralesional curettage and bone grafting combined with adjunctive therapy could get an acceptable effectiveness, however, it has higher local recurrence than wide resection. For large tumor and recurrent malignant giant cell tumor of bone, wide resection is recommended.