术前不同穿刺活检方法诊断骨肉瘤的准确性及对预后的影响

Accuracy of different preoperative biopsy techniques in diagnosis of osteosarcomas and their value in prognostic evaluation

目的探讨不同组织学类型骨肉瘤应用不同穿刺活检方法行术前病理诊断的确切程度的差异，以及术前穿刺活检病理诊断准确性对骨肉瘤患者预后的影响。方法收集347例术前曾行穿刺活检、术后病理诊断证实为骨肉瘤，且临床、影像学资料完整的病例。参照病理诊断与技术规范，将术前穿刺活检病理诊断的确切程度分为6级，1级：明确病理诊断；2级：基本明确病理诊断；3级：具重要参考意义的病理诊断；4级：描述性病理诊断；5级：未穿刺到有效成分；6级：病理误诊。1～3级为诊断准确，4～6级为诊断不准确。结果347例骨肉瘤患者，术前252例由放射科医师在CT引导下行穿刺活检，95例由骨科医师在麻醉后目视下行粗针穿刺活检。目视下行粗针穿刺活检病理诊断的准确率(97．9％)高于CT引导下行穿刺活检(91．7％)。普通型骨肉瘤穿刺活检病理诊断准确率较高(95．4％)，血管扩张型骨肉瘤和髓内高分化骨肉瘤穿刺活检准确率较低(55．6％和63．7％)。穿刺活检病理诊断确切程度与患者年龄、血清碱性磷酸酶水平、影像学诊断、穿刺方式和骨肉瘤组织学类型相关。随访结果表明术前穿刺活检病理诊断准确和不准确病例组相比，术后复发率和病死率差异有统计学意义(P<0．01)。结论穿刺活检病理诊断的确切程度关系到骨肉瘤患者术后病死率和复发率，位于四肢长骨的骨肉瘤，医师目视下粗针穿刺活检+冷冻切片初诊+常规病理复诊是可靠而安全的方法。穿刺活检的病理诊断如能密切结合临床和影像学资料能将病理诊断确切程度提升1～3级。

Objective To study the difference in pathologic diagnostic accuracy among different histologic subtypes of osteosareoma and different methods of preoperative biopsy, and the influence of diagnostic accuracy on prognosis of osteosarcoma. Methods The preoperative biopsies, complete clinical, radiological and pathological data of 347 pathologically confirmed osteosarcomas were evaluated. According to the Pathological Diagnostic and Technical Specifications, the accuracy of preoperative biopsies was divided into 6 grades. 1 : definite diagnosis, 2 : basically definite diagnosis, 3 : significant diagnosis, 4 : descriptive diagnosis, 5 :inadequate sampling, 6 : misdiagnosis. 1 to 3 were defined as successful diagnosis, while 4 to 6 were defined as unsuccessful diagnosis. Results Of the 347 biopsies, 252 were CT-gnided needle biopsies by the radiologists, and 95 were core-needle biopsies by orthopedic surgeons without CT-gnidance. The latter showed a higher overall biopsy success rate (97. 9% ) in all osteosarcomas. Biopsies by surgeons showed a higher biopsy success rate (95.4%) in conventional osteosarcoma, but lower success rate in telangieetatic (55.6%) and low-grade central osteosareomas (63.7%). The accuracy of pathologic diagnosis of preoperative biopsy was related to patients' age, serum AKP level, imaging diagnosis, method of biopsy and the subtype of osteosareoma. Comparing the groups with successful and unsuccessful diagnosis, there weresignificant differences in recurrence rate and mortality after operation ( P < O. O1 ). Conclusions The accuracy of pathologic diagnosis of preoperative biopsy are related to recurrence rate and mortality after operation. Biopsy by orthopedic surgeons without CT-guidance is reliable and safe, followed by primary diagnosis at frozen section and final diagnosis by routine pathologic sections for osteosarcomas located in the long bones of the extremities. Close integration of the preoperative pathologic diagnosis with clinical and radiological data will improve the accuracy of diagnosis.