头皮复发性隆突性皮肤纤维肉瘤的外科治疗

Plastic surgery treatment of recurrent scalp dermatofibrosarcoma protuberans

目的 探讨头皮复发性隆突性皮肤纤维肉瘤（dermatofibrosarcoma protuberans,DFSP）的外科治疗方法和效果.方法 对近3年收治的7例头皮复发性DFSP患者行回顾性分析.肿瘤术中先行活检做冰冻切片病理检查,确认为阳性病例后行距肿瘤边缘≥3 cm的扩大切除术,基底深部的颅骨组织如亦被侵及,一并做颅骨外板清除或全层颅骨切除.切除标本再次行术中冰冻切片病理检查,证实切缘和基底肿瘤阴性后,继发创面行皮瓣/筋膜组织瓣转移修复.肿瘤标本于术后行HE常规染色和免疫组织化学等病理检查.结果 7例肿瘤标本,术中冰冻切片病理检查和术后病理检查均证实为DFSP复发.7例均行≥3 cm的扩大切除,同时做颅骨切除,其中5例行颅骨外板清除,另2例做颅骨全层切除.术中冰冻切片病理和术后病理报告均证实切缘干净,免疫组织化学病理诊断显示肿瘤组织Ki-67均为阳性,CD34部分阳性.术后随访15～41个月,均未见肿瘤局部复发和远位转移.结论 扩大切除及彻底清除被肿瘤侵及的颅骨是头皮复发性DFSP有效的治疗方法,能减少术后复发;皮瓣转移技术的应用有助于肿瘤完全切除后的创面妥善修复.

Objective To explore the surgical procedures and effects for recurrent scalp dermatofibrosarcoma protuberans （DFSP）.Methods Retrospective review was conducted in 7 scalp recurrent DFSP cases in the past 3 years.Intraoperative frozen section analysis of surgical margins was performed.Wide local excision with margins of 3 cm or more was applied,and excision of the skull external lamina or the entire layer of the cranial bones was performed once the skulls under the tumors were invaded.Frozen section analysis was again performed on all the margins.Secondary wound was repaired with local skin flap or fascial pedicled flaps.Surgically removed tumor was paraffin-embedded for HE-staining and immunohistochemical analysis.Results All of 7 tumor specimens were proved recurrent DFSP with histologic findings of intraoperation or postoperation.7 patients were all performed with wide local excision with margins of 3 cm or more,also with skull excision （5 cases with excision of skull external lamina and 2 cases with excision of the entire layer of skull）.Negative margins were confirmed with intraoperative frozen sections or postoperative paraffin-embedded sections analysis were confirmed.Immunohistochemical analysis demonstrated that Ki-67 was all positive and CD34 was partially positive in 7 cases.No tumor recurrence or metastasis had been observed in any of our patients after a median follow-up duration of 17 months （range 15-41）.Conclusions Wide local excision together with the skull invaded by tumors completely is effective surgical treatments for recurrent scalp DFSP; Use of scalp transferring technique could improve wound repair after complete tumor excision.