四肢骨巨细胞瘤的外科治疗分析

Analysis of surgical treatment for giant cell tumor of long bones

目的探讨四肢骨巨细胞瘤（GCT）的外科治疗方法及其临床疗效，评估影响复发的因素及辅助治疗的必要性。方法回顾性分析2004年1月-2017年1月西安交通大学医学院附属红会医院骨病肿瘤科收治的154例四肢GCT患者的临床资料。其中男79例，女75例；年龄16～68岁。Campanacci影像学分级：Ⅰ级16例，Ⅱ级106例，Ⅲ级32例。Enneking外科分期：1期56例、2期61例、3期37例。根据患者年龄、GTC病灶部位、Campanacci影像学分级、Enneking外科分期采用不同手术方式，其中病灶刮除＋植骨／骨水泥填充（A组）64例、病灶刮除＋辅助治疗＋植骨／骨水泥填充（B组）48例、病灶段切除＋缺损部位重建（C组）42例。观察患者术后骨愈合情况，并发症发生情况。定期复查x线片，观察病灶转移、复发情况。术后6个月根据骨骼肌肉系统肿瘤协会（MSTS）制定术后重建功能评定标准评定临床疗效。采用x。检验分析GCT术后复发情况。结果所有患者手术顺利完成，术后伤口一期愈合，围手术期未出现异常及手术相关并发症。手术时间80～240min，平均130min；术中出血量150-800mL，平均350mL。154例患者随访10-84个月，平均40个月。术后随访X线片示植骨病例均融合，融合时间4-8个月，平均6个月。随访期间未发现内植物松动、断裂以及内植物周围感染等相关并发症，未发现肺转移者。局部复发16例（10．4％，16／154），复发时间为术后6～36个月，平均18个月。A组复发率10．9％（7／64），B组复发率10．4％（5／48），C组患者复发率9．5％（4／42）。不同性别、年龄段、肿瘤部位、Campanacci影像学分级、Enneking外科分期的患者术后局部复发率差异均无统计学意义（P值均〉0．05）；采用辅助治疗的B组与无辅助治疗A组比较，术后复发率差异无统计学意义（x^2=0．008，P〉0．05）。术后6个月按MSTS术后重建功能评定标准评定疗效：优84例，良43例，中19例，差8例，满意率94．8％（146／154）。结论根据Enneking外科分期以及Campanacci影像学分级选择合适手术方式治疗四肢GCT能够获得满意的疗效。患者性别、年龄、肿瘤部位、Campanacci影像学分级、Enneking外科分期及手术方式不能准确预测GCT患者术后病灶是否复发，术中辅助治疗的必要性有待进一步证实。

Objective To explore the surgical treatment and clinical efficacy of giant cell tumor （GCT） of bone, to evaluate the factors affecting recurrence and the necessity of adjuvant therapy. Methods Clinical data of 154 cases GCT of limbs treated from January 2004 to January 2017 in the Department of Orthopaedic Oncology, Honghui Hospital Affiliated Xi＇an Jiaotong University College of Medicine was retrospectively analysis. There were 79 males and 75 females, aged from 16 to 68 years. Imaging Campanacci grading： 16 cases in grade Ⅰ , 106 in grade Ⅱ , and 32 in grade Ⅲ. Enneking surgical stage： 56 cases in phase 1, 61 in phase 2, and 37 in phase 3. According to the patients＇ age, GCT location, Campanacei grading, Enneking surgical stage, respectively using focal curettage hone graft or cement filling in 64 cases（group A）, focal curettage combined with adjuvant treatment and bone graft or cement filling in 48 cases （group B） , focal resection and defect site reconstruction in 42 eases （group C）. The postoperative bone healing and complications were observed. The patients＇ X-rays were regularly reviewed to determine recurrence and metastasis. The clinical efficacy was evaluated according to the musculoskeletal system tumor （MSTS） postoperative reconstructive function assessment. The recurrence factors were analyzed by the X^2 test. Results All patients underwent surgery successfully. The wounds healed well. No abnormalities and surgical complications occarred during the perioperative period. The operation time was 80 -240 minutes, with an average of 130 minutes. Intraoperative blood volumes were 150 -800 mL, averaging 350 mL. All patients were followed up for an average of 40 months （from 10 to 84 months）. Postoperative X-rays showed that all the bone grafts were fused. The fusion time was 4 - 8 months, with an average of 6 months. During the follow-up period, no complications such as loosening and fracture of the internal plants, infections around the plants were found. No lung metastases were found. Local recurrence occurred in 16 patients （ 10.4% ） and the recurrence time was 6 -36 months with an average of 18 months. The recurrence rate was 10.9% （7/64） in the bone graft or bone cement-filled group after the curettage group, and 10.4 % （5/48） in using scrape curettage combined with adjuvant treatment and bone graft fixation group, and 9.5% （4/42） in tumor resection and reconstruction group. Patient＇s age, gender, tumor location, imaging Campanacei grade, Enneking surgical staging, operation method had no correlation with local recurrence rate （ all P values 〉 0.05 ）. There was no significant difference in postoperative recurrence rate between using adjuvant treatment A group and no adjuvant treatment B group （ X^2 = 0. 008, P 〉 0.05 ）. According to MSTS postoperative reconstructive function assessment： excellent in 84 cases, good in 43 cases, moderate in 19 cases, poor in 8 cases, and the overall satisfaction rate was 94.8% （146/154）. Condusions According to the Enneking Surgical Stage and imaging Campanacci grading, patients with GCT can achieve satisfactory results by the appropriate surgical treatment. The patient＇s gender, age, tumor location, imaging Campanacci grading, Enneking surgical staging, and surgical methods cannot predict the recurrence rate of postoperative lesions. The necessity for intraoperative adjuvant therapy remains to be further confirmed.