累及髋臼的原发良性与交界性骨肿瘤的术式选择与预后评估

doi:10.3969/j.issn.1674-8115.2021.11.010

摘要/Abstract

摘要：

目的·探讨并总结累及髋臼的良性与交界性骨肿瘤（benign and aggressive bone tumors， BABT）的一般特点、处理原则及预后因素。方法·收集88例髋臼病灶患者病例资料，其中41例为髋臼BABT，就患者人口学资料、外科治疗的选择以及患者的预后情况等进行分析。结果·41例髋臼BABT术后中位随访时间42.6个月。其中30例行病灶刮除植骨术，2例行病灶刮除骨水泥填充术，8例行瘤段切除联合骨盆假体重建术，1例行半骨盆截肢术。术后病理提示良性者23例，其中8例伴有骨皮质破损（34.8%），仅有2例复发。术后病理提示交界性者18例，其中14例伴有骨皮质破损（77.8%），共有5例复发。7例骨巨细胞瘤中1例复发（14.3%），4例非典型软骨肿瘤中3例局部复发（75.0%）。结论·髋臼良性肿瘤不伴骨皮质破损者，单纯刮除术后复发罕见。交界性肿瘤和/或伴骨皮质破损者，单纯刮除术复发率较高，需术前严格确定手术边界。其中，骨巨细胞瘤可酌情采用病灶刮除骨水泥填充术或是瘤段切除术，而非典型软骨肿瘤建议行瘤段切除联合骨盆假体重建术。

关键词: 髋臼, 良性与交界性骨肿瘤, 手术方式, 预后因素

Abstract:

Objective·To summarize the general characteristics, management principles and prognosis of benign and aggressive bone tumors (BABT) involving the acetabulum.

Methods·A total of 88 cases of primary acetabular lesions were collected, including 41 cases of BABTs. The demographic data of the patients, the surgical procedures and the prognosis of the patients were analyzed.

Results·The median follow-up time of the 41 cases of BABTs was 42.6 months. Lesion curettage with bone grafting was performed in 30 cases, followed by curettage with cement reconstruction (n=2), enbloc resection with endoprosthesis reconstruction (n=8), and hemi-pelvic amputation (n=1). Postoperative pathology confirmed a benign tumor in 23 cases, 8 of which were accompanied by bone cortical damage (34.8%), and only 2 patients had local recurrence. Postoperative pathology demonstrated an aggressive histology in 18 cases, 14 cases of which were accompanied by bone cortical damage (77.8%), and a total of 5 cases had local recurrence. Of the 7 giant cell tumors of bone, one recurred (14.3%), in comparison to 3 local recurrence (75.0%) of the 4 cases of atypical cartilage hyperplasia.

Conclusion·Benign acetabular tumors without cortical bone damage have a low recurrence rate following lesion curettage. Aggressive tumors and/or tumors with cortical bone damage have a higher recurrence rate following simple curettage, and the surgical margin needs to be strictly determined prior to surgery. Specifically, lesion curettage with bone cement or enbloc resection with endoprosthesis reconstruction could be an appropriate option for giant cell tumor of bone, while enbloc resection with endoprosthesis reconstruction should be always recommended for atypical cartilage tumor.

Key words: acetabular, benign and aggressive bone tumors (BABT), surgery methods, prognostic factors

中图分类号:

R323.5

张珠晟, 刘琦, 鲍其远, 沈宇辉, 张伟滨, 万荣. 累及髋臼的原发良性与交界性骨肿瘤的术式选择与预后评估[J]. 上海交通大学学报(医学版), 2021, 41(11): 1470-1477.

Zhu-sheng ZHANG, Qi LIU, Qi-yuan BAO, Yu-hui SHEN, Wei-bin ZHANG, Rong WAN. Surgical approach and prognosis evaluation of primary benign and aggressive bone tumors involving the acetabulum[J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2021, 41(11): 1470-1477.

图/表 7

表1 41例髋臼肿瘤骨皮质表现与肿瘤类型、手术方式、肿瘤转归及术后并发症的相关性

Tab 1 Correlation of bone cortical manifestations of 41 acetabular tumors with tumor types， surgical methods， tumor outcomes， and postoperative complications

Characteristic	Incomplete cortical bone （n=22）	Complete cortical bone （n=19）	χ²	P value
Tumor type/n（%）			‒	0.011
Benign	8 （36.4）	15 （78.9）
Aggressive	14 （63.6）	4 （21.1）
Operation selection/n（%）			12.980	0.005
Prosthesis reconstruction	8 （36.4）	0 （0）
Curettage with bone grafting	11 （50.0）	19 （100.0）
Curettage with cement reconstruction	2 （9.1）	0 （0）
Hemi-pelvic amputation	1 （4.5）	0 （0）
Relapse/n（%）			‒	0.419
No	17 （77.3）	17 （89.5）
Yes	5 （22.7）	2 （10.5）
Complication/n（%）			4.806	0.187
None	18 （81.8）	18 （94.7）
Prosthesis loosening	2 （9.1）	0 （0）
Wound healing delay	0 （0）	1 （5.3）
Debridement	2 （9.1）	0 （0）

图1 1例髋臼骨囊肿刮除植骨术后X线表现Note： A. X-ray manifestations of bone cyst on top of acetabulum after curettage with bone grafting. B. X-ray appearance of the 7-year follow-up after the operation showed no signs of recurrence. C. CT appearance of the 3-year follow-up after the operation showed no signs of recurrence.

Fig 1 X-ray appearance of an acetabular bone cyst after curettage with bone grafting

图2 1例髋臼骨巨细胞瘤行刮除骨水泥填充影像学表现Note： A. MRI appearance of the giant cell tumor before the operation. B. MRI appearance of the 4-year follow-up after the operation showed no signs of recurrence. C. CT appearance of the giant cell tumor before the operation. D. CT appearance of the 2-year follow-up after the operation showed no signs of recurrence.

Fig 2 Imaging appearance of a giant cell tumor of acetabulum after curettage with cement reconstruction

图3 7例髋臼骨巨细胞瘤骨盆累及区域分布

Fig 3 Distribution of pelvic involvement in giant cell tumor of acetabulum

图4 1例非典型软骨肿瘤术后影像学表现Note： A. CT findings of recurrence after curettage with bone grafting. B. X-ray appearance of the 3-year follow-up after the endoprosthesis reconstruction showed no signs of recurrence. C. MRI appearance of the 6-year follow-up after the endoprosthesis reconstruction showed no signs of recurrence.

Fig 4 Imaging appearance of atypical cartilage hyperplasia

表2 41例患者肿瘤复发风险的相关因素

Tab 2 Relevant factors of tumor recurrence risk in 41 patients

Characteristic	Relapse （n=7）	No relapse （n=34）	P value （Fisher）
Sex/n（%）			1.000
Male	3 （42.9）	15 （44.1）
Female	4 （57.1）	19 （55.9）
Age/n（%）			1.000
< 65 years	6 （85.7）	29 （85.3）
≥ 65 years	1 （14.3）	5 （14.7）
Tumor size/n（%）			0.010
< 8 cm	2 （28.6）	28 （82.4）
≥ 8 cm	5 （71.4）	6 （17.6）
Tumor type/n（%）			0.209
Benign	2 （28.6）	21 （61.8）
Aggressive	5 （71.4）	13 （38.2）
Operation selection/n（%）			0.165
Lesion curettage	4 （57.1）	28 （82.4）
Enbloc resection	3 （42.9）	6 （17.6）
Cortical bone morphology/n（%）			0.419
Complete	2 （28.6）	17 （50.0）
Damage	5 （71.4）	17 （50.0）

表3 18例交界性肿瘤手术方式与术后复发/转移的关系

Tab 3 Relationship between the operation method of aggressive tumors and the progression in 18 cases

Disease	Curettage		Resection		P value （Fisher）
Disease	Relapse （n=2）	No relapse （n=9）	Relapse （n=3）	No relapse （n=4）	P value （Fisher）
Erdheim-Chester disease/n	0	1	0	0	0.326
Osteoblastoma/n	0	1	0	0
Langerhans cell histiocytosis/n	0	4	0	0
Giant cell tumor of bone/n	0	3	1	3
Atypical cartilaginous tumor/n	1	0	2	1
Fibromatosis/n	1	0	0	0

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