毗邻或“累及”骨的软组织肉瘤外科手术策略及其局部复发的影响因素

Surgical strategies for soft tissue sarcomas adjacent to or“involving”bone and their impact on local recurrence

目的评价毗邻或"累及"骨的软组织肉瘤外科手术策略局部复发的影响因素。方法对新疆医科大学第三临床医学院收治的64例毗邻或"累及"骨的软组织肉瘤患者的临床资料进行回顾性分析,所有患者术前均行MRI和CT检查,并对部分解剖结构复杂部位软组织肉瘤的CT数据进行三维重建。根据肿瘤与骨的关系拟定了三种手术方案:肿瘤与骨之间小边界或无明确的骨膜侵犯,选择的手术方案是一并切除相应部位的外骨膜;肿瘤侵及骨膜但骨皮质未受累和(或)肿瘤侵及骨皮质但骨髓腔未受累,手术方案的选择是一并切除受累的骨皮质,根据具体情况是否要进行重建;肿瘤侵及骨髓腔,选择的手术方案是进行相应范围的节段切除加肢体重建。结果64例患者均获得R0切除,5例患者失访,59位患者中位随访时间为50.2月。切除外骨膜10例,中位随访时间41.4月,局部复发率30%,3年无局部复发生存期约为78%;切除骨皮质29例,中位随访时间48.2月,局部复发率27.5%,3年无局部复发生存期约为80%;节段切除20例,中位随访时间49.3月,局部复发率30%,3年无局部复发生存期约为70%。结论STS病灶选择外科手术方法时需要考虑多种因素,需要建立在在多学科基础上的系统思维上考虑肉瘤的诊断、分级与分期,肿瘤大小、肉瘤病灶与邻近重要结构之间的关系,评估综合治疗(放疗及化疗的敏感性等)。对毗邻或"累及"骨的软组织肉瘤,为控制局部复发,提高患者的总存率,初始治疗应必须做到扩大切除,根据肿瘤与骨的关系分层处理,既要保证肿瘤的R0切除,又尽可能保留正常的组织,减少重建的复杂性及并发症的风险。

Objective To evaluate the risk factors for local recurrence in surgical strategies for soft tissue sarcomas with adjacent or"involved"bone.Methods Retrospective analysis was performed on the clinical data of 64 patients with soft tissue sarcomas adjacent to or involving bone in our hospital.Preoperative MRI and CT examination were performed on all patients,and 3D reconstruction was performed on the CT data of soft tissue sarcomas in parts with complex anatomical structures.According to the relationship between the tumor and bone,three kinds of surgical programs were prepared.(1)Small boundary between the tumor and bone or no clear periosteum invasion,the selected surgical program was to remove the periosteum of the corresponding site together;If the tumor invaded the periosteum but the bone cortex was not involved and/or the tumor invaded the bone cortex but the bone marrow cavity was not involved,the surgical option was to remove the involved bone cortex together with the reconstruction according to the specific situation.(3)The tumor invaded the bone marrow cavity,and the selected surgical plan was to carry out segment excision and limb reconstruction in the corresponding range.Results All 64 patients received R0 resection,5 patients were lost to follow-up,and the median follow-up time of 59 patients was 50.2 months.The median follow-up time was 41.4 months,the local recurrence rate was 30%,and the 3-year survival without local recurrence was about 78%.The median follow-up time was 48.2 months,the local recurrence rate was 27.5%,and the 3-year survival without local recurrence was about 80%.Segmentectomy was performed in 20 patients.The median follow-up time was 49.3 months,the local recurrence rate was 30%,and the 3-year survival without local recurrence was about 70%.Conclusions Multiple factors need to be considered in the selection of surgical approaches for STS lesions,and the diagnosis,grading,and staging of sarcoma,tumor size,and relationship between sarcoma lesions and adjacent important structures need to be considered in a multidisciplinary and systematic way of thinking to evaluate the comprehensive treatment(radiotherapy and chemotherapy sensitivity,etc.).For soft tissue sarcomas with"adjacent"or"involved"bone,in order to control local recurrence and improve the total survival rate of patients,the initial treatment should be expanded resection and stratified treatment according to the relationship between tumor and bone,so as to not only ensure the R0 resection of tumor,but also retain normal tissue as much as possible to reduce the complexity of reconstruction and the risk of complications.