侵犯关节周围骨组织的软组织肉瘤外科治疗策略

目的探索侵犯关节周围骨组织的肢体软组织肉瘤的外科手术方法，并分析术后并发症、肢体功能和患者的生存状况。方法回顾性分析2004年5月至2011年10月期间，我中心所收治的30例局部侵犯关节周围骨组织的软组织肉瘤患者的临床资料。其中男14例，女16例，平均年龄51岁（17～75岁）。恶性纤维组织细胞瘤12例，脂肪肉瘤8例，原始神经外胚层肿瘤（PNET）4例，滑膜肉瘤、腺泡状软组织肉瘤和恶性神经鞘瘤2例。其中10例发病位于股骨近端，9例股骨远端，8例肱骨近端，2例胫骨近端，1例累及整个股骨。所有患者均采取了肿瘤连同受累骨组织一起广泛切除、以肿瘤型假体重建骨缺损的手术方式。术后定期复查患肢功能、x线片、肺CT等，并且密切随访，内容包括术后并发症的发生情况、肢体功能恢复情况及肿瘤学与生存状况等。结果平均随访25个月（3—84个月），1例暂时性腓总神经麻痹；3例术后伤口愈合不良行清创手术，其中1例因深部感染不愈而截肢；2例假体断裂行翻修手术；4例肿瘤复发，局部复发率13．3％，其中1例接受截肢手术。总的肺转移为15例，且11例死亡患者中均为肺转移，其中3例合并骨转移。至最后一次随访时14例无瘤生存，5例带瘤生存，平均MSTS评分股骨近端90％，股骨远端82％，胫骨近端73％，肱骨近端71％，全股骨为60％。2年和5年生存率分别为61．6％和30．8％。结论将受累骨组织和肿瘤一起广泛切除可获得无瘤边界，降低复发率，骨缺损采用肿瘤型假体重建可恢复良好的肢体功能。巨大肢体软组织肉瘤侵犯骨组织可能是患者预后不良的因素。

Surgical therapy strategy of soft tissue sarcomas with juxta-articular bone involvement

Objective To explore the surgical treating methods of extremity soft tissue sarcomas with juxta- articular bone involvement, and to analyze the postoperative complications, limb function and survival status of the patients. Methods 30 patients of soft tissue sarcomas with local juxta-articular bone involvement were adopted in our center from May 2004 to October 2011, whose clinical data were retrospectively analyzed. There were 14 males and 16 females, with a mean age of 51 years old （range; 17-75 years）. There were 12 cases of malignant fibrous histiocytoma （MFH）, 8 cases of liposarcoma, 4 cases of primitive neuroectodermal tumors （PNET）, and 2 cases of synovial sarcoma, alveolar soft part sarcoma and malignant peripheral nerve sheath tumors （MPNST） respectively. Among them, 10 patients had tumors in the proximal femur, 9 in the distal femur, 8 in the proximal humerus, 2 in the proximal tibia and 1 in the total femur. Bone defect reconstruction using tumor prostheses was performed on all the patients after the wide excision of tumors and bone tissues involved. The periodic reviews of limb function, X-ray images, pulmonary CT scans and so on were carried out postoperatively. All patients were followed up regularly, including the occurrence of postoperative complications, recovery condition of limb function, oncology and survival status and so on. Results The mean follow-up period was 25 months （range; 3-84 months）. 1 patient had temporary peroneal nerve palsy. 3 patients had poor wound healing, and then underwent debridement, 1 of whom underwent amputation due to deep infection. Implant fractures leading to additional revisions occurred in 2 cases. 4 patients had local tumor recurrence, and the recurrence rate was 13.3%, 1 of whom underwent amputation. 15 patients had lung metastases, and 11 patients died of disseminated metastases, including 3 patients with bone and lymph node metastases. In the latest follow-up, 14 patients survived tumor free, and 5 were alive with tumors. The mean Musculoskeletal Tumor Society （MSTS） score for proximal femur, distal femur, proximal tibia, proximal humerus and total femur were 90%, 82%, 73%, 71% and 60% respectively. The 2- and 5- year survival rates were 61.6% and 30.8% respectively. Conclusions The wide excision of tumors together with the bone and soft tissues involved can achieve satisfactory tumor-free borders, which may result in a lower recurrence rate. Bone defect reconstruction using tumor prostheses can be a good therapeutic strategy to preserve limb function. Adjacent bone invasion could be an adverse prognostic factor for huge extremity soft tissue sarcomas.