骨肉瘤磁共振成像反应区病理学基础的临床应用

Clinical application of pathological basis of the nuclear magnetic reaction zone of osteosarcoma

目的探讨骨肉瘤磁共振成像反应区病理学基础在临床的应用。方法选取48例骨肉瘤标本，股骨远端30个，胫骨近端18个。标本来源：男26例，女22例；年龄12～25岁，平均15.5岁，结果22例患者随访5～24个月，平均15.5个月。所有术中标本沿其矢状面纵剖为两半，肉眼观察肿瘤在髓腔内的侵袭及截骨面情况并拍照。在大体标本上指出肿瘤区、出血水肿区、骨膜充血区、正常组织区，分别从以上位置取样，一半沿矢状轴切片，一半沿水平轴切片，髓腔顺垂直轴取材，取下的每块标本从肉眼边界向截骨端作连续片，3位病理科医师显微镜下观察切片，直到发现骨肿瘤细胞消失作出病理诊断，记下切片数值，记录每张切片上各种细胞的数量，直到完全是正常的骨骼肌细胞，反应区的长度是肿瘤细胞消失的切片与正常切片之间的距离，用同样的方法，确定反应区的实际范围及其细胞构成，明确手术的准确范围。测量肿瘤的最大距离，肿瘤髓内实际侵袭范围为肉眼下测量范围与镜下测量范围之和，取平均值记录。分别记录X线片、MRI、病理测得的肿瘤范围。按Enneking肌肉骨骼肿瘤术后下肢功能评分标准，平均功能恢复率为85%。结果（1）肿瘤的长度与MRI反应区长度相关性方程是fan＝12.1388＋0.9698liu，说明随着肿瘤长度的增加，其反应区长度增加；（2）肿瘤长度与骨膜反应的长度之间的相关方程fan＝20.9262＋0.9033liu。说明随着肿瘤长度的增加，其骨膜反应长度增加；（3）在实体标本上，从MRI所示肿瘤边界切，发现肿瘤外4.41cm无肿瘤细胞。结论本实验确定手术的安全边界是MRI反应区以外4.41cm。反应区特征为多见于恶性骨肿瘤和具有侵袭性的良性骨肿瘤，位于肿瘤组织与正常组织之间，由肿瘤细胞、中性粒细胞、淋巴细胞、嗜酸性粒细胞、嗜碱性粒细胞、发生气球样变的坏死细胞组成。

Objective To investigate the clinical application of pathological basis of the nuclear magnetic reaction zone of osteosarcoma. Methods 48 cases of osteosarcoma were chosen, with 30 cases in the distal femur and 18 cases in the proximal tibia. There were 26 males and 22 females, with an average age of 15.5 years old （ range;12-25 years ）. 22 patients were followed up for an average of 15.5 months （ range;5-24 months ）. All the intraoperative specimens were cut into 2 halves along the sagittal longitudinal section, and the tumor invasion and osteotomy surface within the medullary cavity were observed by the naked eye and photographed. In the gross specimen, the tumor area, bleeding and edema area, periosteum congestive area and normal tissue area were pointed out respectively. Samples were taken from the locations above, with half sliced along the sagittal axis and half sliced along the horizontal axis. Samples were taken in the medullary cavity via the vertical axis, and each one was the serialgram from the naked eye border to the osteotomy serial section. The slices were observed under the microscope by 3 pathologists. When bone tumor cells were found to disappear, a pathological diagnosis was made, the slice values were written down and the number of cells was recorded in each slice, until they completely became normal skeletal muscle cells. The length of the reaction zone was the distance between the tumor cells disappearing slice and the normal slice. By using the same method, the actual range of the reaction zone, its cellular structure and the precise scope of the surgery were determined. The maximum distance of tumors was measured. The actual tumor intramedullary invasion range was the sum of the range measured by the naked eye and the range measured under the microscope, and the average value was recorded. The X-ray, MRI and pathological analysis were used to measure the range of tumors. According to the Enneking musculoskeletal tumors postoperative lower extremity function score, the average recovery rate was 85%.Results （ 1 ） The correlation equation between the tumor length and the length of the nuclear magnetic reaction zone was fan=12.1388＋0.9698 liu. With the increase of the tumor length, the length of the reaction zone also increased;（ 2 ） The correlation equation between the tumor length and the length of the periosteal reaction was fan=20.9262＋0.9033 liu. With the increase of the tumor length, the length of the periosteal reaction also increased;（ 3 ） In the physical specimens, along the tumor boundary shown in the MRI, there were no tumor cells 4.41 cm outside the tumor. Conclusions It is determined that the security border of the surgery is 4.41 cm outside the nuclear magnetic reaction zone. The characteristics of the reaction zone：occurring more commonly in malignant bone tumors and aggressive benign bone tumors, being located between the tumor tissues and normal tissues and comprising tumor cells, neutrophils, lymphocytes, eosinophils, basophils and ballooning degeneration necrotic cells.