脊柱原发性骨肉瘤外科治疗临床观察

Surgical treatment for primary osteosarcoma in the mobile spine

目的脊柱原发性骨肉瘤的发病率低,约占脊柱原发肿瘤的3%~15%,占原发性骨肉瘤的3%~5%。本研究通过分析脊柱原发性骨肉瘤患者临床资料,探讨手术治疗脊柱原发性骨肉瘤的临床疗效。方法回顾性分析北京大学第三医院2012-01-01-2017-03-01手术治疗的11例脊柱原发性骨肉瘤患者临床资料。采用Kaplan-Meier法分析患者生存情况。结果 11例患者中男6例,女5例,接受手术治疗时年龄16~75岁,中位年龄48岁。入院时Frankel分级B级1例,C级3例,D级1例,E级6例;10例局部疼痛患者的VAS(Visual Analogue Scale)评分为(6.3±2.5)分。全脊椎切除术2例,刮除术9例。手术入路单纯后路6例,单纯前路1例,前后联合入路4例。手术时间90~668 min,平均(279±180)min;出血量100~4 000mL,平均(1 227±1 218)mL。接受辅助治疗11例,其中单纯行术后放疗6例,单纯化疗3例(术前采取新辅助化疗1例,单纯行术后化疗2例),同时行放疗和化疗2例。11例患者均获得随访,随访时间6~59个月,平均16.8个月,随访率100%,中位生存期为36个月,3年累积生存率为40.4%。3例死亡(死于肿瘤转移相关疾病),2例带瘤生存(局部进展及远处转移各1例),6例无瘤生存。术前存在脊髓损害5例,术后改善为D级1例,E级4例。末次随访仍生存的8例患者平均生存29.3个月,VAS评分均有改善,从术前的(6.4±3.0)分降低为(1.4±2.8)分,t=4.48,P<0.01。3例接受刮除术老年患者,术后单纯行局部调强放疗,目前均无瘤生存,平均生存39.7个月。结论脊柱原发性骨肉瘤预后差,肿瘤切除结合化疗、放疗可获得较好疗效。对于老年单发骨肉瘤患者,姑息手术结合局部调强放疗可获得满意疗效。

OBJECTIVE To investigate the effectiveness of treatment for primary osteosarcoma in the mobile spine. METHODS We retrospectively analyzed clinical data of 11 cases with primary osteosareoma in the mobile spine surgically treated in Peking University Third Hospital from January 1 st,2012 to March 1st, 2017. We utilized Kaplan-Meier method to analyze survival of these patients. RESULTS A total of 11 patients with 6 males and 5 females was recruited. The median age at surgery was 48 years old,ranging from 26 to 75 years old. The Frankel grade of the eleven patients was level B in one,level C in three,level D in one and level E in six. Visual Analogue seale（VAS） was 6.3±2.5 in ten patients presented with local pain. Two patients underwent en bloc spondylectomy, and nine patients underwent intralesional resections. A single posterior approach was performed in six, a single anterior approach in one, combined posterior and anterior approach in four. Operation time was 90 - 668 min, average （279 ±180） min. Estimated blood loss was 100 - 4 000 mL, average （1 227 ± 1 218） mL. Eleven patients underwent adjuvant therapy, postoperative radiotherapy in six, chemotherapy in three （neoadjuvant chemotherapy in one and postoperative chemotherapy in two）, combined radiotherapy and chemotherapy in two. All patients were regularly followed up from 6 to 59 months（average 16.8 months）. Overall median survival time of the eleven patients was 36 months, and 3-year survival rate was 40. 4%. At the final follow-up, three patients died of tumor-related diseases,two patients survived with tumor, six patients had no evidence of disease. For five patients with myelopathy, the Frankel grade improved to level D in one,and level E in four. For eight patients were alive at the final follow-up,mean survival was 29.3 months,VAS improved from （6.4±3.0） to （1.4±2. 8）,t=4.48,P〈0.01. All three elder patients who underwent intralesional resection and postoperative Intensive Modulated Radiotherapy（IMR） had no evidence of disease,and the mean survival was 39.7 months. CONCLUSIONS Prognosis of osteosarcoma of the mobile spine is poor. Tumor resection combined with chemotherapy and radiotherapy may improve the life expectancy. It will be a good choice to perform palliative surgery combined with IMR for eider patients with one single lesion.