肢体恶性黑色素瘤的外科治疗

目的 探讨外科治疗在肢体恶性黑色素瘤中的临床作用.方法 回顾性分析1993年8月-2007年12月就诊于我院骨肿瘤科22例肢体恶性黑色素瘤病例.男性12例,女性10例;年龄20～73岁,平均50.1岁;发病部位足底14例,足背1例,第二足趾1例,拇指甲下2例,腹股沟、大腿、膝部软组织各1例,胫骨1例.按照AJCC外科分期,Ⅱ期8例,Ⅲ期12例,Ⅳ期2例.保肢14例,截肢（趾）8例;保肢病例中局部切除后采用游离植皮或转移皮瓣重建10例,胫骨病变1例采用瘤段截除、人工关节置换术.外科边界：边缘切除4例,广泛切除14例,根治性切除4例.二期行区域淋巴结清扫14例.术后辅助达卡巴嗪化疗6例（同时加用放疗1例）,干扰素和白介素生物治疗13例,中医药辅助治疗3例.有完整随访资料的17例,随访时间3-96个月,平均随访时间34.2个月.结果 Ⅱ期患者8例中1例术后91个月局部复发,1例随访19个月后出现骨转移,1例术后12个月腹股沟淋巴结转移,均再次行手术治疗;余5例随访未发现局部复发及远隔转移.Ⅲ期患者12例均行淋巴结清扫术,2例随访肺转移死亡,4例失访,余6例随访无局部复发及远隔转移.Ⅳ期患者2例,1例术后3个月因肺转移死亡.最终完整随访资料的17例患者中13例随诊无进展生存,原病灶局部无复发,植皮或转移皮瓣均成活或经过二期处理后愈合良好.结论 肢体黑色素瘤手术治疗后局部肿瘤可得到良好控制,并为肿瘤的综合治疗奠定基础.

Surgical treatment for malignant melanoma of extremity

Objective To investigate the efficacy of surgical treatment for malignant melanoma of extremity. Methods Retrospective analysis was performed in this study for 22 cases （12 males, 10 females） who were diagnosed with malignant melanoma of extremity in our hospital between August 1993 and December 2007. The mean age was 50.1 years （range, 20-73 years）. Of the lesions, 14 located in sole of the foot, 1 in dorsum of the foot, 1 in the second toe, 2 beneath the thumbnail, 3 in soft tissue of the inguinal groove, the thigh and the knee respectively, and 1 in the tibia. According to AJCC Staging system, 8 were in stage II, 12 in stage III, and 2 in stage IV. Extremities of 14 cases were saved, while 8 underwent amputation. Of the cases with limb salvage （n=14）, 10 underwent free skin grafting or local flap grafting reconstruction after local excision. 1 with lesion in the tibia was performed resection of tumor segment and prosthetic joint replacement. Of the surgical margin, marginal resection was performed on 4 cases, wide resection on 14 cases, and radical excision on 14 cases. In the second phase, 14 underwent regional lymphadenectomy. After the surgery, Dacarbazine adjuvant chemotherapy was performed on 6 patients （including 1 performed with radiotherapy simultaneously）, adjuvant biotherapy of interferon and interleukin on 13 patients, and adjuvant traditional Chinese medicine therapy on 3 patients. Of the follow-up patients, 17 had complete data, with the mean follow-up period being 34.2 months （range, 3-96 months）. Results Of the patients in stage II, 1 sustained post-operative local recurrence 91 months, 1 sustained bone metastasis 19 months, and 1 sustained post-operative inguinal metastasis of lymph node. All the 3 patients underwent re-operation. For the other 5 cases in stage II, they had neither local recurrence nor distant metastasis. Of the 12 patients in stage III, all underwent lymphadenectomy. Their follow-up data showed that 2 died from lung metastasis, 4 were withdrawn, and 6 had neither local recurrence nor distant metastasis. Of the 2 cases in stage IV, 1 died from lung metastasis 3 months after surgery. In all, 13 of the follow-up patients （n=17） survived with neither local recurrence nor distant metastasis, and their skin grafting or local flap grafting also survived, or they healed well after processing in the second phase. Conclusions Surgical treatment for malignant melanoma of extremity can well control the local tumor, and establish a good foundation for the comprehensive treatment against tumors.