肩胛骨恶性肿瘤保肢治疗19例报告

Limb salvage surgery for scapular sarcoma:a review of 19 cases

目的评价不同治疗方式对肩胛骨恶性肿瘤患者的生存率、功能和外观的影响。方法 2001年5月至2012年5月,25例累及肩胛骨的原发恶性骨肿瘤及转移瘤患者在我科接受治疗。其中男17例,女8例,年龄0.25-73岁,平均43岁。25例包括转移瘤9例,4例行保肢手术;骨原发性恶性肿瘤16例,15例行保肢手术。按照Enneking外科分期：II B期16例,III期9例。4例转移瘤保肢患者中2例行肩胛骨部分切除,保留了肩肱关节;1例行全肩胛骨切除后肱骨头悬吊;1例行全肩胛骨切除后限制性全肩胛骨肩关节假体置换。15例原发恶性肩胛骨肿瘤保肢患者中有7例行肩胛骨部分切除而保留了肩胛盂和肩肱关节;1例行异体肩胛骨移植;1例行病灶刮除、骨水泥填充;1例行自体肩胛骨灭活回植;3例行肩胛骨全切除和肱骨头悬吊;2例进行了全肩胛骨的整体切除,人工限制性全肩胛骨肩关节置换术。19例随访6-60个月,平均36个月。结果 6例死亡,其中2例肝癌肩胛骨转移瘤患者和1例血管肉瘤肩胛骨转移瘤患者死于原发肿瘤多处转移、脏器衰竭。1例肩胛骨骨肉瘤患者死于肺转移。1例肩胛骨滑膜肉瘤患者死于局部复发加肺转移。1例肩胛骨骨髓瘤患者死于非原发疾病。依据美国骨肿瘤学会（musculoskeletal tomor society,MSTS）（93）对各类重建手术进行评分。1例异体肩胛骨18分,1例自体肩胛骨灭活回植26分,肩胛骨部分切除保留肩胛盂平均24分,肩胛骨全部切除肱骨头悬吊平均21分,人工限制性全肩胛骨全肩关节置换平均24.7分。肩关节前屈和后伸90°-20°。外展范围在40°-95°。结论肩胛骨部分切除保留肩胛盂和人工全肩胛骨全肩关节置换可以最大限度地保留肩关节功能,对于学龄前儿童肩胛骨恶性肿瘤采用自体肩胛骨灭活后回植不失为一种可供选择的方法;无论是人工假体还是自体或异体肩胛骨可以恢复肩关节稳定性和部分功能,改善其外观。

Objective To investigate functional and oncological results of different limb salvage strategies for scapular sarcoma.Methods A retrospective analysis of 25 patients diagnosed with malignant tumor of the scapula from May 2001 to May 2012 was performed.There were 17 males and 8 females and the mean age was 43 years（ range：0.25-73 years）.Tumors include 9 metastatic tumors and 16 primary malignant tumors.Nineteen patients received limb salvage surgery（ 4 metastatic tumors,15 primary malignant tumors）.According to Enneking surgical staging：II B 16 cases,stage III 9 cases.In 4 metastases cases of limb salvage,2 cases received partial resection of the scapula and the scapulohumeral joint was preserved,1 case received humeral head suspension after complete scapula resection,1 case received constrained shoulder prosthesis after complete scapula resection.In 15 primary malignant tumors cases of scapula limb salvage,7 cases received partial resection of the scapula and the glenoid and scapulohumeral joint were preserved,1 case received scapula allogeneic transplantation,1 case received lesion curettage and bone cement filling,1 case received inactivated autologous scapula replantation,3 cases received humeral head suspension after complete scapula resection,2 cases received constrained shoulder prosthesis after complete scapula resection.19 cases were followed up with the mean period of 36 months（ range：6-60 months）.Results In 6 dead cases,2 cases of scapula metastases in liver tumors and 1 case of scapula metastases in angiosarcoma died of primary tumors metastases and organ failure,1 case with osteosarcoma died of lung metastases,1 case with scapula synovial sarcoma died of local recurrence plus lung metastases,1 case with scapula myeloma died of non primary disease.According to MSTS（ 93） scored for the various types of reconstructive surgery.One case of allogeneic scapula got 18 points,1 case of inactivated autologous replantation got 26 points,cases of scapula partial resection and glenoid preservation got 24 points on average,cases of scapula total removal and the humeral head suspension got 21 points on average,cases of constrained shoulder prosthesis after complete scapula resection got 24.7 points on average.Shoulder flexion and extension were in the range of the 90°to 20°.Outreach range was of 40° to 95°.Conclusions Partial scapulectomy with the preservation of glenoid,and total scapulectomy with constrained scapular prosthesis both can preserve the shoulder functions to the greatest degree.Inactivated autologous replantation can be regarded as an alternative for preschool children with scapula malignant tumors.Prosthesis,autologous or allogeneic scapula can restore stability,functions,and improve appearance.