骨旁骨肉瘤的治疗

Parosteal osteosarcoma:a clinical study of 48 cases

目的 探讨骨旁骨肉瘤外科切除边界、髓腔受累情况等与预后之间的关系 ,以提高治疗水平。 方法 对 196 4年 6月～ 2 0 0 1年 12月收治的骨旁骨肉瘤 6 6例中资料完整的 4 8例进行回顾性研究。患者年龄 13～ 4 7岁 ,平均 2 9 2岁。男性 16例 ,女性 32例。最好发部位为股骨远端 (36例 ) ,其次为股骨干 (6例 ) ,胫骨近端 (2例 )等。以原发肿瘤就诊的 39例 ,外院术后复发就诊的 9例。结果 随访时间从 3个月～ 2 4年 ,平均 5 2年。保肢治疗 39例 ,其中行瘤段截除灭活再植术 2 3例 ,瘤段截除人工关节置换术 9例 ,瘤段截除异体半关节置换术 4例 ,受累皮质局部切除术 3例。截肢组9例。广泛切除组 35例 ,边缘切除组 13例。本院治疗后 ,局部复发 8例 ,其中广泛切除组 3例 ,边缘切除组 5例。在复发的病例中 ,髓腔未受累组 4例 ,髓腔受累组 4例。发生肺转移 6例 ,其中死亡 4例 ,带瘤生存 2例。应用Kaplan Meier法计算五年生存率为 85 8%。 结论 安全的外科边界是骨旁骨肉瘤获得良好预后的保证。在广泛切除绝大部分肿瘤的基础上 ,于血管神经束部位行谨慎的边缘切除是合理的。反复的复发可能会使预后变差。当复发肿瘤包绕血管神经束或表现为软组织内多个散在结节 ,局部切除不能达到安全广泛的外科边界时 。

Objective To investigate the way of diagnosis and therapy of parosteal osteosarcoma. Methods A retrospective review was conducted of 48 patients treated at our department between June 1964 and December 2001. The average age of patients in this study was 29.2 years (13-47 years). Thirty-two of the patients were female; sixteen were male. The single most common site is the posterior aspect of the distal femur (in 36 patients), followed by the femur shaft (in 6 patients), the proximal tibia (in 2 patients), etc. Nine patients had been operated on before referral to our department. Results The average follow-up period from the first operation was 5.2 (0.25-24) years. In 36 of the 39 patients in whom a limb-salvage procedure was performed, a segment of the tumor-bearing bone was excised along with the tumor, whereas in 3 patients only the subadjacent cortex was excised with the tumor. In the limb-sparing group, the reconstruction was achieved by means of attenuated tumor bone or allograft in 23 cases, by endoprosthetic replacement in 9 cases, and by allograft replacement in 4 cases. The local resections were wide in 35 cases, and marginal in 13 cases. After marginal surgery, local recurrence occurred in 5/13 patients, whereas it occurred in 3/35 patients treated with wide resection. Pulmonary metastases developed in 6 patients, four patients died, and 2 patients are alive with disease. There were 4 cases of fractures of bone grafts. Four patients developed an infection. Long-term survival rate is 85.8%. For tumors that invaded the medullary canal there was no statistical association with local recurrence or metastasis. There is statistical significance between surgical margin and local recurrence. Conclusions Wide surgical excision alone is adequate treatment for patients with conventional parosteal osteosarcoma. A tumor-free margin remains the critical factor determining overall prognosis. When a marginal excision was knowingly done to preserve a major neurovascular bundle, the risk of recurrence was less than when it was done to shell-out a presumptively benign lesion. Repeated recurrence probably increases the risk of dedifferentiation and thereby worsens the prognosis. Recurrent lesions with multiple soft-tissue satellite nodules or involvement of the neurovascular structures may however require amputation to provide sufficient local control when a wide margin cannot be achieved. An individualized resection will be performed in the future probably under the help of the advanced technique of image to distinguish the reactive zone from the normal tissue precisely.