病灶残腔灭活治疗长骨ⅠA期软骨肉瘤的安全性观察

Intralesional curettage and electrocauterization for the treatment of grade IA chondrosarcoma of long bones

目的：探讨采用病灶刮除、残腔打磨、电刀烧灼处理肿瘤残腔方法治疗肢体长骨EnnekingⅠA期软骨肉瘤的有效性及可行性。方法回顾性分析2003年5月至2011年12月采用病灶刮除、残腔处理的方法治疗25例四肢长骨EnnekingⅠA期软骨肉瘤患者资料，男11例，女14例；年龄28~72岁，平均49岁；根据Enneking骨与软组织肿瘤外科分期系统，病变分期均为ⅠA期，且既往均未行外科手术治疗；病变位置：股骨13例，胫骨4例，肱骨8例。手术方式为显露长骨皮质后，使用湿纱布保护好周围软组织，于肿瘤位置开一个足够大的骨窗，在直视条件下彻底刮除病灶，而后使用高速磨钻打磨残腔，冲洗后，使用电刀烧灼处理病灶残腔，最后进行病灶植骨。根据患者病变缺损的情况，股骨及胫骨均进行钢板内固定，肱骨开窗长度＞5 cm，宽度超过周径1/3时行钢板内固定；对肱骨开窗长度＜5 cm的患者，无需进行内固定。结果25例患者术后均获得随访，随访时间38~142个月，平均80个月。所有病例X线片均显示病变部位有明显钙化，病变长度4~11 cm，平均7 cm。19例患者为预防术后出现骨折，行钢板内固定，另6例未进行内固定。术后2个月，1例患者（4%，1/25）出现深部感染，经清创及抗生素骨水泥填充后治愈；术后13个月，1例（4%，1/25）出现肿瘤复发，行肿瘤瘤段切除及关节置换术，现患者无瘤生存67个月。25例患者均无瘤生存，Kaplan？Meier曲线预测患者的五年生存率为100%。骨与软组织肿瘤重建术后功能评分为83%~100%，平均93%。结论病灶刮除、高速磨钻打磨、电刀烧灼残腔灭活是治疗EnnekingⅠ级软骨肉瘤的有效治疗手段，该术式复发率低，并发症少，可以最大限度保留患者的功能。

Objective To explore the recurrence rate, the complications and functional status of 25 patients with grade I chondrosarcoma of long bones treated by intralesional curettage and electrocauterization, and to determine the feasibility and effi？cacy of this method for grade IA chondrosarcoma of long bones. Methods Twenty？five eligible patients treated in our hospital from May 2003 to December 2011, were collected in this study with a mean age of 49 years （range, 28-72 years）. According to En？neking staging system, all the lesions were staged as IA. Patients received surgery of the lesion before were excluded. The involved bones were femur （13 patients）, tibia （4 patients）, and humerus （8 patients）. During the operation, a large elliptical cortical window about the size of the longest dimension of the lesion was made to ensure the thorough exposure of the lesion and avoid inadequate curettage. The lesion was curettaged thoroughly after the cortical window was made, then the high speed bur drill was applied to clear away a thin layer of the reactive bone shell. After a thorough lavage of the cavity, electrocauterization was done alongside the cavity wall slowly twice. Allograft or artificial bone was used to fill in the cavity to enhance bone healing. If mechanical property of the long bone was endangered by the cortical window and the surgical procedure, plate and screws were applied to strengthen the bone to avoid post？operative fracture. Results All the 25 patients were followed up regularly. The period of follow？up was from 38 months to 142 months, with a mean time of 80 months. Calcification was observed clearly in all the lesions. The length of the le？sions varied from 4 cm to 11 cm, with an average length of 7 cm. Nineteen patients received a plate and screws fixation because the mechanical property of the affected bone, while the rest received no internal fixation. Deep infection occurred in 1 patient （4%, 1/25） two months after operation. Thorough debridement and packing of bone cement with antibiotics was done to control the infec？tion. The infection has been controlled till the latest follow？up at 62 months after operation. Local recurrence occurred in one pa？tient thirteen months after the primary operation. Tumor resection, mega？prosthesis replacement was applied to the patient. The pa？tient has been disease free till now for 67 months. Mean Musculoskeletal Tumor Society （MSTS） 93 functional score of all patients was 93%（range, 83%-100%）. The five？year survival rate of these twenty？five patients was 100%. Conclusion Intralesional cu？ rettage together with the application of high？speed bur drill and electrocauterization is an applicable method for grade I chondrosar？coma of long bones. The excellent functional result and low recurrence rate make it a favorable option for the selected cohort of pa？tients.