外科手术为主的综合方法治疗脊柱旁软组织肉瘤的临床疗效分析

Clinical outcomes of a comprehensive treatment approach centered on surgery for the treatment of paraspinal soft-tissue sarcoma

目的:探讨应用外科手术为主的综合方法治疗脊柱旁软组织肉瘤的临床疗效。方法:回顾性分析2017年4月~2022年10月在中山大学肿瘤防治中心收治的18例脊柱旁软组织肉瘤患者的资料。其中男性12例,女性6例。中位年龄为36岁(11~58岁)。病理诊断为滑膜肉瘤5例,纤维肉瘤2例,未分化肉瘤2例,恶性孤立性纤维性肿瘤2例,不能确定具体类型的高级别肉瘤有2例,骨肉瘤1例,尤文肉瘤1例,腺泡状软组织肉瘤1例,去分化脂肪肉瘤1例,低度恶性肌纤维母细胞肉瘤1例。按照改良的脊柱旁软组织肉瘤分型,1型10例,2型和3型分别为3例和4例,2+3型1例。均接受手术治疗,其中11例患者接受术前化疗,1例接受术前免疫治疗和靶向药物治疗。1~3型脊柱旁软组织肉瘤的手术计划分别为:1型肿瘤行广泛切除手术,2型肿瘤行经椎弓根截骨的整块切除手术,3型患者通过切除部分椎体行广泛切除手术。8例患者因肿瘤切除后脊柱不稳定而行人工椎体置入和钉棒系统固定手术。术后6例患者接受调强放疗(intensity-modulated radiation therapy,IMRT),剂量为55~63Gy/25~30F,11例接受化疗,1例接受免疫治疗和靶向药物治疗。术后观察伤口并发症及肿瘤复发、转移情况。结果:1型患者中,7例实施广泛切除,3例实施边缘切除;2型患者中,2例实现广泛切除,1例实施边缘切除;3型患者均采取边缘(2例)或广泛(2例)切除方式切除肿瘤;2+3型患者实现边缘切除。2例患者分别在术后9d和23d出现手术伤口感染,经清创和使用敏感抗生素后,感染得到控制;2例患者出现术后肌力下降,经康复治疗和营养神经治疗后改善。中位随访时间为16个月(1~50个月)。3例患者在术后3~10个月出现局部复发,均未接受放疗。1例患者在术后3个月因肿瘤脑转移而死亡;4例患者在术后3~38个月出现肺转移灶,均接受内科治疗和肺转移灶切除,目前带瘤生存;其余13例患者无瘤生存。结论:脊柱旁软组织肉瘤在准确的病理诊断基础上,采用以手术为主的综合方法治疗,可获得较为满意的临床疗效。

Objectives:To investigate the clinical outcomes of paraspinal soft-tissue sarcoma treated with a comprehensive treatment approach with surgical operation as the main.Methods:18 patients with paraspinal soft-tissue sarcoma treated at Sun Yat-sen University Cancer Center from April 2017 to October 2022 were retrospectively analyzed.There were 12 males and 6 females with a median age of 36 years(11-58 years).The pathological diagnoses were synovial sarcoma(5 cases),fibrosarcoma(2 cases),undifferentiated pleomorphic sarcoma(2 cases),malignant solitary fibrous tumor(2 cases),not otherwise specified-type high grade sarcoma(2 cases),osteosarcoma(1 case),Ewing sarcoma(1 case),alveolar soft part sarcoma(1 case),dedifferentiated liposarcoma(1 case),and low grade myofibrosarcoma(1 case).According to the modified classification of paraspinal soft-tissue sarcoma,10 patients were of class 1,3 were of class 2 and 4 were of class 3,and 1 patient was of class 2+3.All of the patients received surgery.Among them,11 patients had preoperative chemotherapy and 1 patient had immunotherapy and targeted therapy.The surgical plans for class 1-3 paraspinal soft-tissue sarcoma were:class 1,wide resection;class 2,en-bloc resection by pedicle osteotomy;class 3,wide resection by partial vertebral resection.8 patients with spinal instability after tumor resection underwent artificial vertebral body reconstruction and pedicle screw-rod system fixation.6 patients received intensity-modulated radiation therapy(IMRT)with 55-63Gy/25-30F after operation.After surgery,11 patients had chemotherapy and 1 patient had immunotherapy and targeted therapy.The patients were followed up for wound complication,recurrence and metastasis.Results:For class 1 patients,7 received wide resection and 3 received marginal resection;For class 2 patients,2 received wide resection and 1 received marginal resection;For class 3 patients,wide resection or marginal resection were obtained in 2 patients respectively.Marginal resection was obtained in the class 2+3 patients.The median follow-up time was 16 months(1-50 months).2 patients,who had wound infection 9d and 23d after surgery respectively,were successfully treated by debridement and antibiotics;2 patients,who developed muscle weakness after surgery,improved after rehabilitation and neurotrophic treatment.3 patients experienced local recurrence(3-10 months after surgery),all of which didn′t receive postoperative radiotherapy.1 patient died from brain metastasis within 3 months after surgery;4 patients who developed lung metastases at 3-38 months after surgery and received medical treatment and resection of pulmonary metastases lived with tumors;The remaining 13 patients was alive without tumors.Conclusions:On the basis of precise pathological diagnosis,treating paraspinal soft-tissue sarcoma with comprehensive treatment approach centered on surgical operation can yield satisfactory clinical outcomes.