16例胫骨转移癌的外科治疗

Surgical managements for bone metastases in tibia of 16 cases

目的：探讨胫骨转移癌的外科治疗方案、术后生存情况、术后功能及并发症.方法：2000年1月至2013年2月,北京大学人民医院骨与软组织肿瘤中心共收治胫骨转移癌患者16例,其中来源于肺癌5例、乳腺癌3例、膀胱癌2例,肾癌、结肠癌、肝癌、淋巴瘤各1例,来源不明者2例.肿瘤位于胫骨上段11例,胫骨中段4例,胫骨下端2例（1例患者双侧胫骨转移）.合并病理性骨折1例,其他未发生骨折者以Mirels评分评价骨折风险.16例患者中,15例接受手术治疗,共16例手术,包括9例肿瘤刮除、骨水泥填充、髓内钉/钢板内固定术,6例肿瘤型膝关节置换术,1例截肢术.术前和术后均以VAS评分法评估患者疼痛程度,术后还依据MSTS评分分析患者功能情况,采用Kaplan-Meier生存曲线回顾分析患者的生存情况.结果：16例患者中14例获得随访,中位随访时间7个月（1~72个月）.术后中位生存期7个月（1~72个月）,半年总体生存率57.14%,两年总体生存率8.9%.术前病理性骨折高风险患者的Mirels评分为（9.8±1.0）分;术前VAS评分（7.62±1.03）分,术后VAS评分（1.36±0.86）分;采用肿瘤刮除内固定手术方式和关节置换手术的患者术后平均MSTS评分分别为（23.1±1.25）分和（21.0±0.63）分,所有患者均认为术后功能较术前有所改善.结论：胫骨转移癌十分罕见,其原发肿瘤以肺癌居多,外科手术治疗是其重要的治疗手段,结合术后放疗及全身治疗,可明显提高患者的生活质量.

Objective：To investigate the different surgical options for tibia metastatic disease and to evaluate the survival prognostic factors, postoperation function and complications. Methods： A retrospec- tive evaluation of 16 patients treated for tibia metastatic disease between Jan. 2000 and Feb. 2013 was conducted at our center. The underlying histology of the lesions showed metastatic lung carcinoma（ five）, breast carcinoma （ three）, bladder carcinoma （ two）, unknown （ two）, renal cell carcinoma, colon carci- noma, hepatic cellular cancer and lymphoma（ one each）. The locations of these lesions were proximal in 11 patients （with one patient having two synchronous lesions in the proximal metaphysis on both sides）, diaphyseal in 4 patients, and distal metaphyseal in two patients. One patient presented with a pathologic fracture, and the risk of impending pathologic fracture of the remainders was evaluated by Mirels scoring system. Of all the 16 patients, 15 were treated surgically （with 16 operations performed）. Six of them were reconstructed with proximal tibial replacement, 9 underwent curettage and cementation （with or without inner-fixations）, and 1 patient had lower third calf amputation. We employed VAS scoring sys- tem to evaluate the pain intensity of the lesions before and after operation. The post-operation function was assessed by MSTS scoring system. The survival rate was described by Kaplan-Meier survival curve. Re- sults： Fourteen of all the patients were followed-up and enrolled in the research. The median postopera- tive survival was 7 months （ 1 - 72 months）. The mean half year survival rate and 2-year survival rate were 57.14% and 8.9% respectively. The mean Mirels score was 9.8 ±1.0. The mean VAS score before the operation was 7.62 ± 1.03, which turned out to be 1.36 ± 0.86 after the operation. The mean MSTS score for the endoprosthesis and curettage was 21.0 ±0.63 and 23.1 ± 1.25 respectively. Conclusion： The mobidity of tibia metastatic diseases is very low. Surgical intervention, combined with the application of bisphosphonate and postoperative radiotherapy, is absolutely necessary for the treatment of tibial meta- static disease, contributing to animproved quality of life and limb function.