原位微波消融术治疗骨转移癌

In situ microwave ablation for bone metastases

目的探讨原位微波消融术在骨转移癌治疗中的安全性和有效性。方法 2009年9月至2013年2月,我科收治的骨转移癌40例,共43处接受原位微波消融术治疗。其中男23例、女17例,平均年龄55.9(21~83)岁。单发骨转移16例,多发转移24例。肺癌14例,肝癌5例,肾癌6例,乳腺癌2例,子宫内膜癌3例,甲状腺癌2例,宫颈癌、食道癌各1例,原发不明6例。手术部位:骨盆16处,股骨13处,胫骨7处,肱骨6处,肩胛骨1处。病理骨折11例,均为肢体长骨病理骨折。43处中42处行原位微波消融后刮除手术,1处肩胛骨转移微波消融后行边缘切除;2处未进行重建,5处单纯使用骨水泥重建,其余36处行骨水泥填充加金属内固定物重建。术后每3个月一次随访,并对术后患者的生存率、局部复发率、围手术期并发症、VAS评分及功能评分进行评价。采用Kaplan-Meier方法和Log-Rank实验对比进行生存分析,分别在术前、术后1周、术后3个月用VAS法进行疼痛评分,采用MSTS保肢评分系统对术后随访超过3个月的患者进行功能评分。结果 40例均获随访,平均随访12.9(3~41)个月,中位随访时间10.4个月。随访期间死亡17例,存活23例。总体6个月生存率89.6%,1年生存率83.8%,2年生存率60.9%。17例死亡患者术后存活平均9.5(2~22)个月。是否发生病理骨折对生存率有显著影响(x^2=11.662,P=0.001),无病理骨折患者1年生存率80.8%,有病理骨折患者1年生存率29.2%0局部复发率11.6%(5,43),复发时间术后16.4(5~35)个月。围手术期并发症发生率4.7%,未出现内固定失效、病理骨折等其它并发症。术前vAs评分,平均7.8(5~9)分。术后1周评分,平均3.0(1~5)分。术后3个月评分,平均2.6(1~6)分。术后1周、3个月分别与术前相比,疼痛程度明显减轻,且差异有统计学意义(t=22.889,P=0.000和t=22.934,P=0.000)。参与功能评分41处,平均22(10~28)分。其中优68%(28/41),良17%(7/41),中10%(4/41),差5%(2/41),最终优良率85%。结论原位微波消融术治疗骨转移癌是一种安全有效的方法,对局部病灶可以缓解疼痛,控制肿瘤进展。

Objective To investigate the safety and effectiveness of in situ microwave ablation in the treatment of bone metastases. Methods From September 2009 to February 2013, 40 patients with bone metastases were adopted, who all underwent in situ microwave ablation with 43 lesions involved. There were 23 males and 17 females, whose average age was 55.9 years old （ range; 21-83 years ）. Solitary bone metastases were found in 16 cases and multiple metastases in 24 cases. There were 14 cases of lung cancer, 5 cases of liver cancer, 6 cases of renal carcinoma, 2 cases of breast cancer, 3 cases of endometrial carcinoma, 2 cases of thyroid carcinoma, 1 case of cervical carcinoma, 1 case of esophageal carcinoma and 6 cases of carcinoma of unknown primary. The operative sites included the pelvis （ n=16 ）, the femur （ n=13 ）, the tibia （ n=7 ）, the humerus （ n=6 ） and the scapula （ n=1 ）, and there were 11 case of long bone pathologic fractures of the extremities. Curettage after in situ microwave ablation was performed on 42 of the 43 lesions. Marginal resection after microwave ablation was performed on the patient with bone metastases in the scapula. No reconstruction was carried out in 2 lesions, and reconstruction of bone cement alone in 5 lesions. Bone cement iflling and reconstruction with metal implants were carried out in the other 36 lesions. All the patients were followed up once every 3 months. The evaluation indicators included the postoperative survival rate, local recurrence rate, perioperative complications, Visual Analogue Scale （ VAS ） score and functional score. The Kaplan-Meier method and log-rank test were used to analyze the survival rate. The VAS pain scores were recorded preoperatively and at 1 week and 3 months after the operation. The Musculoskeletal Tumor Society （ MSTS ） staging system was used to evaluate the function of the patients who were followed up for more than 3 months. Results All the 40 patients were followed up for a mean period of 12.9 months （ range;3-41 months ）, and the median follow-up period was 10.4 months. During the follow-up, 17 patients died and 23 patients were alive. The 6-month overall survival （ OS ） was 89.6%, and the 1-year and 2-year OS were 83.8%and 60.9%respectively. The postoperative survival time was 9.5 months on average （ range;2-22 months ） in the 17 patients who ifnally died. The occurrence of pathological fracture had a signiifcant effect on the OS （χ2=11.662, P=0.001 ）. The 1-year OS was 80.8%in the none-fracture group and 29.2%in the fracture group. The local recurrence rate was 11.6%（ 5/43 ）, which occurred at 16.4 months after the operation on average （ range;5-35 months ）. The perioperative complication incidence was 4.7%. No complications such as internal ifxation failure or pathological fracture were noticed. The mean VAS score was 7.8 points （ range;5-9 points ） before the operation and 3.0 points （ range;1-5 points ） and 2.6 points （ range;1-6 points ） at 1 week and 3 months after the operation respectively. The ache degree at 1 week and 3 months after the operation was obviously alleviated when compared with that before the operation, and the differences were statistically signiifcant （ t=22.889, P=0.000＆amp;t=22.934, P=0.000 ）. The mean MSTS score was 22 points （ range;10-28 points ） in 41 evaluable locations and the excellent and good rate was 85%. There were 28 excellent cases （ 68%）, 7 good cases （ 17%）, 4 fair cases （ 10%） and 2 poor cases （ 5%）. Conclusions Microwave ablation appears to be a safe and effective approach in the treatment of bone metastases, which can relieve local pain and control the development of bone metastases.