分离手术结合三维适形调强放疗治疗骶骨复发、难治肿瘤的回顾性研究

Local disease control for relapse or refractory sacral tumor after separation surgery and adjuvant intensity modulated radiotherapy:outcomes analysis

背景:治疗骶尾部原发恶性肿瘤的方法包括外科手术和放疗两种策略。广泛边界的外科手术可获得最好的局部控制率,但严重的骶神经功能损失会造成患者术后二便和性功能障碍。三维适形调强放疗(intensity modulated radiotherapy,IMRT)可以使部分骶尾部肿瘤得到有效的局部控制,但大剂量的放疗可能会造成直肠、乙状结肠的继发损伤。目的:评估分离手术次全切除骶骨肿瘤后辅以IMRT的有效性和安全性。方法:本研究是一项非随机对照的回顾性研究。2015年1月至2016年12月,12例复发或难治的骶尾部肿瘤患者接受保留部分骶神经的次全骶骨切除术。男10例,女2例;年龄15~75岁,平均52.5岁,中位年龄60.5岁。病理诊断:脊索瘤7例、软骨肉瘤3例、尤文肉瘤1例、恶性外周神经鞘瘤1例。复发病例7例、初治病例5例。术中于瘤床残腔内置入皮肤扩张器水囊以隔离放疗易损的直肠和乙状结肠,术后对外科边界欠佳的高危区域实施IMRT。记录手术及放疗相关并发症,骶神经功能学评估采用北京大学人民医院骶神经功能评分体系,应用X线、CT和MRI等影像学方法随访局部复发率。结果:以放疗结束作为随访开始时间,末次随访时间为2017年12月,随访时间12~35个月(平均23.8个月)。边缘切除2例,囊内切除10例。IMRT剂量强度为46~74 Gy。2例患者手术或放疗后出现伤口并发症,未见放射性直肠损伤。随访期内1例患者死于肿瘤进展。局部复发率16.7%(2/12)。患者术后骶神经功能评分平均为22.7分。结论:分离手术次全切除骶骨肿瘤后IMRT,可有效降低骶骨复发难治性肿瘤的术后复发率以及放疗相关并发症,同时可以最大限度地保留骶神经的功能。

Background：Surgical treatment and radiotherapy are two strategies for primary malignant sacrococcygeal tumors.Wide margin surgery can achieve the best local control,but severe sacral nerve function loss may result in postoperative excretory and sexual dysfunctions.Intensity modulated radiotherapy（IMRT） can effectively control some sacrococcygeal tumors,but large doses of radiation may cause secondary damage to the rectum and sigmoid colon.Objective：To evaluate the safety and efficacy of separation surgery followed by IMRT in patients with relapse or refractory sacral tumor.Methods：Twelve patients who suffered from relapse or refractory sacral tumor and were treated with separation surgery and IMRT between January 2015 and December 2016 were enrolled in this retrospective study.There were 10 males and 2 females,aged 15-75 years（mean 52.5 years,median 60.5 years）,including 7 cases of chordoma,3 cases of chondrosarcoma,one case of Ewing sarcoma,and one malignant peripheral nerve sheath tumor.The skin expander was inserted into the residual cavity of the tumor bed to isolate the vulnerable rectum and sigmoid colon.Surgery and radiotherapy related complications were recorded.Sacral nerve function was evaluated by the scoring system designed by the Peking University People＇s Hospital.Local tumor control rate was evaluated with imaging findings including X-ray,CT and MR.Results：The end of the radiotherapy was taken as the start of the follow-up,and the cutoff date was December 2017.The follow-up ranged from15 to 35 months（mean 23.8 months）.Marginal resection was performed in 2 patients and intrapsac resection in the other 10 patients.The radiation doses were 46-74 Gy.Two patients had wound problem after surgery and radiation.One died of tumor progression during follow-up.The recurrence was observed in 2 cases（16.7%）.The average postoperative sacral nervefunction score was 22.7.Conclusions：IMRT following separation surgery is a safe and effective strategy for establishing durable local tumor control in patients suffering from relapse or refractory sacral tumor.Following this procedure,the complications of radiation,including injury of rectum,have been reduced,and the sacral nerve function is preserved.