四肢长骨转移瘤诊断和外科治疗分析

目的 探讨四肢长骨转移瘤的诊断技巧、外科治疗方法及临床意义。方法 回顾性分析西安交通大学医学院附属红会医院骨病肿瘤科2012年1月—2017年1月治疗的54例四肢长骨转移瘤患者的临床资料,其中男29例、女25例,年龄48~72(60.6±12.5)岁;股骨38例(70.4%),肱骨16例(29.6%)。54例长骨转移瘤患者均行X线、CT、MRI及全身骨扫描检查,19例进行组织活检。术前Tokuhashi评分≥12分者31例、9~11分者8例、≤8分者15例,术前Mirls评分为9~11分,平均10.3分;依据Tokuhashi评分及骨转移瘤部位拟定治疗方案,按照Mirls评分对濒临骨折患者的治疗决策进行评估。采用VAS于术前及术后3个月对患者疼痛进行评估、Karofsky体能状况评分(KPS) 评估患者术前及术后3个月身体状况、骨与软组织肿瘤协会(MSTS)评分评价患者术后肢体功能情况,应用Kaplan-Meier法进行生存分析。结果 35例(64.8%)患者通过病史资料和影像学评估获得长骨转移瘤的诊断,其与术后病理诊断结果一致;19(35.2%)例通过病史资料、影像学评估和组织活检(15例芯针经皮穿刺活检+4例切开组织活检)获得长骨转移瘤诊断。54例患者术后随访4~36个月,平均18个月。随访期间病死31例,术后平均存活10.5(4.5~30)个月;存活23例。Kaplan-Meier法生存分析显示,6个月生存率70.4%(38/54),1年生存率57.4%(31/54),2年生存率46.2%(25/54)。围手术期内患者未出现并发症,随访期间手术部位未发生内植物失效、病理性骨折等并发症。术后3个月疼痛VAS与术前比较,差异有统计学意义(t=4.085, P＜0.01);术后3个月患者KPS明显改善,与术前比较差异有统计学意义(χ²=21.476, P＜0.01)。MSTS功能评分:术后3个月平均21.95(16~28)分,上肢平均20.54分、下肢平均23.36分;其中优24.07%(13/54)、良53.70%(29/54)、中20.37%(11/54)、差1.85%(1/54),优良率77.78%(42/54)。结论 病史资料评估结合详细的影像学分析可以对大部分四肢长骨转移瘤做出正确诊断;对于难以确诊的病例,需进行组织活检。恰当的外科治疗能够有效地缓解长骨转移瘤患者的疼痛,提高患者的生活质量。

Diagnosis and surgical treatment analysis of long bone metastases in extremities

Objective To discuss the diagnosis skills, surgical treatment and clinical significance of long bone metastases. Methods Clinical data of 54 patients with long bone metastases of limbs treated from January 2012 to January 2017 in the Department of Orthopaedic Oncology, Honghui Hospital Affiliated Xi'an Jiaotong University College of Medicine were retrospectively analyzed. There were 29 males and 25 females with age of from 48 to 72 years old. The operative sites included the femur 38 patients (70. 4%) and the Innnerus 16 patients (29. 6%). Totally 54 patients underwent X-ray, CT, MRI and the whole body bone scan. Preoperative tissue biopsy was performed in 19 patients. The treatment plan was made by using the Tokuhashi score and sites of bone metastases. The Mirls scoring system was used to evaluate treatment decisions for the endangered fractures. Preoj疋rative Tokuhashi scores were M12 in 31 patients, 9 to 11 in 8 patients, and W8 in 15 patients. The preoperative Mirls score was 9 ~ 11 points with an average of 10. 3 points. In preoperative and postoperative 3 months, pain levels were assessed by visual analogue scale (VAS), The Karofsky performance score ( KPS) was used to assess the physical status of the patients. The Musculoskeletal Tumor Society( MSTS) score was used to evaluate the postoperative functional status of the patients and Kaplan-Meier method was used for survival analysis. Results Thirty-five ( 64. 8%) patients were diagnosed metastases by medical history data and imaging evaluations, the diagnostic consistency made sense between this method and postoperative pathology. Nineteen ( 35. 2%) cases were diagnosed metastases by medical history , imaging assessment, and biopsy. Fifty-four patients were followed up for 4 to 36 months with an average of 18 months. During the follow-up period, 31 patients died of disease, and the average survival time was 10. 5 (4. 5 to 30) months. Twenty-three patients survived. Kaplan-meier survival analysis showed that the 6-month survival rate was 70. 4%(35/54), the 1 -year survival rate was 57. 4%(31/54), and the 2-year survival rate was 46. 2%( 25/54 ). No complications occurred during the perioperative period. No complications such as internal fixation failure or pathological fractures occurred during the followup period. In preoperative and postoperative 3 months, the VAS showed statistical significance(t = 4. 085 , P <0. 01);The postoperative KPS score showed statistical significance (x^2= 21.476, P V 0. 01 ). MSTS score: average score 21.95 after 3 months, upper limb 20. 54, lower limbs 23. 36. The final good rate was 77. 78%. Conclusions Medical history data assessment combined with detailed radiographic analysis can confirm the right diagnosis of most long bone metastases of the extremities. Surgical biopsy is required for difficult cases to diagnose. Appropriate surgical treatment can effectively relieve pain and improve patients' quality of life.