21例瘢痕癌患者诊疗分析

Analysis of diagnosis and management of 21 patients with Marjolin＆#39;s ulcers

目的 了解瘢痕癌患者的临床特征及诊疗方法. 方法 回顾性分析2007年1月—2013年1月笔者单位收治的21例瘢痕癌患者的临床资料,统计其年龄、性别、致伤原因、原发病发展至瘢痕癌的时间、溃疡持续时间、病变部位、溃疡区面积、溃疡区症状、术前细菌学培养结果、组织病理学类型、癌细胞分化程度、侵袭深度、治疗方法以及预后情况. 结果 （1）21例瘢痕癌患者年龄为19 ～74（47±13）岁,男女比例约为0.9∶1.0.（2）原发病以火焰烧伤、热液烫伤为主,分别为12例占57.1％、7例占33.3％;原发病发展至瘢痕癌的时间为10 ～56（40±14）年.（3）12例患者的瘢痕溃疡持续时间超过1年,占57.1％.（4）病变部位常见于四肢、头面部,分别为13例占61.9％、6例占28.6％.（5）溃疡区面积为0.25 ～ 74.25（39±25）cm2.多数患者溃疡区出现恶臭分泌物、出血、疼痛加剧、溃疡面积逐渐扩大现象.（6）术前细菌学培养显示,16例患者创面分泌物培养呈阳性,占76.2％;血培养结果均为阴性.（7）组织病理学观察显示,20例患者为鳞状细胞癌、1例患者为基底细胞癌,分化程度以高、中分化为主,近40％患者的癌细胞侵袭至皮下组织或更深.（8）患者均采用手术治疗,其中11例患者切除病灶后行自体皮移植术、5例患者切除病灶后行皮瓣修复术、5例患者行截肢术.12例患者术后接受康复治疗,占57.1％.本组2例癌细胞肺部转移患者接受化学治疗.（9）术后大多数皮瓣或皮片存活良好,少数未成活者经再次植皮修复.随访6个月～5年,4例患者复发瘢痕癌,其中2例死亡;其余患者存活良好. 结论 笔者单位收治瘢痕癌多为鳞状细胞癌.对瘢痕溃疡病程长、反复发作的患者,应考虑病理学确诊.目前手术切除仍是治疗瘢痕癌的首选方法;瘢痕癌切除术后应定期随访,监测癌变是否复发转移.

Objective To investigate the clinical manifestation,diagnosis,and treatment of patients with Marjolin＆#39;s ulcers.Methods The clinical materials of 21 patients with Marjolin＆#39;s ulcers hospitalized from January 2007 to January 2013 were retrospectively analyzed,including age,gender,injury causes,duration time of primary disease in developing Marjolin＆#39;s ulcer,duration of ulcer,lesion site,ulcer area,symptoms and signs of ulcer region,bacterial culture results before operation,histopathological type,grade of carcinoma cell differentiation,depth of invasion,treatment,and outcome.Results （1） The age of 21 patients at the time of diagnosis of Marjolin＆#39;s ulcers was 19-74 （47 ± 13） years,and the ratio of male to female was nearly 0.9∶ 1.0.（2） The main primary lesions were flame burns and high temperature liquid scald,respectively occurred in 12 cases （57.1%） and 7 cases （33.3%）.The time for development of Marjolin＆#39;s ulcers from primary injury was 10-56 （40 ± 14） years.（3） Ulceration on top of scar lasted for longer than one year in 12 patients （57.1%）.（4） Lesion site was mainly located in the limbs in 13 patients （61.9%）,and on head and face in 6 patients （28.6%）,respectively.（5） Ulcer area ranged 0.25-74.25 （39 ± 25） cm2.Foul excretion,bleeding,intensified pain,and gradual enlargement of ulceration were observed in the lesion of most patients.（6） Bacterial cuhure of wound excretion before operation showed positive results in 16 patients （76.2%）.Results of bacterial culture of blood were negative in all patients.（7） Pathological examination revealed squamous cell carcinoma in 20 cases and basal cell carcinoma in 1 case,and mostly of high or medium differentiation.Cancer cells in nearly 40% patients had invaded the subcutaneous tissue or deeper area.（8） All patients were treated by surgery,among them autologous skin grafting was done after excision of lesion in 1 1 patients,and in 5 patients the defects were closed with skin flaps after excision of lesion,and in 5 patients limbs harboring the lesion were amputated.Twelve patients （57.1%） received postoperative rehabilitation treatment.Two patients with pulmonary metastasis received chemotherapy.（9） Most of the flaps and skin grafts survived well after surgery,and a few cases with failure of skin grafting or transplantation of flaps underwent skin grafts again.Patients were followed up for 6 months to 5 years,in 4 patients recurrence occurred after surgery,and 2 of them died.The other patients survived without recurrence.Conclusions Squamous cell carcinoma was the most common pathological type of Marjolin＆#39;s ulcer admitted to our unit.A recurrent ulcer with long course should be considered as Marjolin＆#39;s ulcer,and it should be scrutinized pathologically.Currently,surgery remains the optimal treatment for Marjolin＆#39;s ulcer.Regular follow-up should be carried out after resection of the lesion to detect carcinoma recurrence and metastasis.