【作者】 周明；

【导师】 杨惠林；

【作者基本信息】 苏州大学 ， 骨外科（专业学位）， 2013， 硕士

【摘要】 第一部分靶血管栓塞后手术治疗脊柱骨巨细胞瘤的疗效分析目的：探讨靶血管栓塞后手术治疗脊柱骨巨细胞瘤的临床疗效。方法：对1995年6月至2011年8月在我院接受手术治疗的28名脊柱骨巨细胞瘤患者的临床资料进行回顾性分析。其中男性12例，女性16例，平均年龄29.6岁（11~58岁）。病变位于胸椎8例，腰椎5例，骶椎15例。患者术前均存在不同程度的疼痛症状，合并神经功能受累者17例，8例有大小便功能障碍。所有患者术前均行靶血管栓塞，栓塞后1～2天内手术。记录术中出血量、输血量，并观察术后神经功能及肿瘤复发情况。结果：所有患者未出现栓塞相关并发症，栓塞后均行病灶内肿瘤切除，手术过程顺利，无围手术期死亡病例。术中平均出血量1528.6mL（400～5800mL），平均输血量1514.3mL（400～6000mL）。28例手术患者中，前路手术8例，后路手术18例，前后联合入路2例，14例（50%）行内固定重建，6例（21.4%）行术后辅助放疗。平均随访时间86.5月（16～193月），复发8例（28.6%），死亡2例（7.1%）。8例（28.6%）发生并发症，其中6例伤口并发症，1例脑脊液漏，1例胸椎后凸畸形。14例行内固定重建的患者术后均未出现内固定松动、移位或断裂。24例（85.7%）患者术后神经功能正常，仅4例（14.3%）骶骨患者有不同程度的大小便功能障碍。结论：靶血管栓塞后手术治疗脊柱骨巨细胞瘤，能有效减少术中出血，使术野清晰，有助于肿瘤的彻底切除，是一项安全有效的技术。术前靶血管联合病灶内肿瘤切除，手术创伤小，并发症发生率低，患者术后神经功能满意。第二部分脊柱骨巨细胞瘤术后复发的相关因素分析目的：探讨影响脊柱骨巨细胞瘤术后局部无复发生存期（local recurrence-freesurvival time, LRFS）的因素。为今后预防或延缓脊柱骨巨细胞瘤术后复发，延长术后LRFS期提供参考依据。方法：对1995年6月～2011年8月间在我院完成手术的28例脊柱骨巨细胞瘤患者进行随访。收集这些患者的发病年龄、性别、肿瘤部位、肿瘤大小、侵袭范围、放疗、复发等资料，用免疫组化法检测肿瘤组织中胰岛素样生长因子Ⅱ mRNA结合蛋白3（insulin-like growth factor II mRNA-binding protein3, IMP3）及胰岛素样生长因子2（insulin-like growth factor2, IGF2）的表达情况。将患者术后LRFS期作为应变量，选取上述8个因素作为自变量，Kaplan-Meier法绘制LRFS曲线，Log-Rank检验进行统计学分析。以P <0.05为差异有显著性意义。结果：28例患者均行病灶内肿瘤切除。平均随访时间86.5月（16～193月），至随访结束时，复发8例（28.6%），平均复发时间35.6月（5～79月）。统计结果显示：间室内肿瘤组术后中位LRFS期73月，间室外肿瘤组43月；IMP3阳性组术后中位LRFS期43月，阴性组73月；IGF2阳性组术后中位LRFS期46.5月，阴性组75月。肿瘤侵袭范围、IMP3阳性与阴性组、IGF2阳性与阴性组之间术后LRFS期差异具有显著性意义，P值分别是0.025、0.002、0.007。不同年龄组、不同性别组、不同肿瘤部位组、不同肿瘤大小组及是否放疗之间术后LRFS期差异无统计学意义（P>0.05）。结论：间室外肿瘤、IMP3高表达及IGF2高表达的患者术后复发率较高，术后LRFS期较短。选择手术方式时需要权衡手术并发症与术后复发之间的关系，间室内肿瘤可以选择病灶内切除，对于间室外肿瘤，则需选择更加积极的手术方式。IMP3和IGF2可作为脊柱骨巨细胞瘤术后复发的预测指标。更多还原

【Abstract】 Part ⅠSurgical Treatment of Giant Cell Tumors of the SpineCombined with Preoperative Transarterial EmbolizationObjective: To investigate the efficacy of surgical excision with preoperativetransarterial embolization for the giant cell tumor of spine.Methods: Between June1995and August2011,28patients with giant cell tumor ofthe spine were interviewed retrospectively. There were12males and16females with theaverage age of29.6years (range:11~58years).15cases were located in the sacrum and13in the mobile spine (8thoracic and5lumbar). Most patients presented with pain at the siteof tumor involvement before surgery.17patients existed neurologic deficit, and8caseshad bowel and/or bladder dysfunction. All the patients were operated1to2days aftertranscatheter arterial embolization. The intraoperative blood loss and transfusion werereviewed. The local recurrence, complications, follow-up status and functional outcomewere observed.Results: There were no symptomatic complications associated with embolization, andall the patients were treated with intralesional excision after preoperative transarterialembolization. There were no perioperative deaths. The average intraoperative blood losswas1528.6mL (range:400~5800mL), and the average transfusion volume was1514.3mL(range:400~6000mL). The anterior approach was used for8cases, posterior approach wasused for18cases, and combined anterior and posterior approach was used for2cases.There were14(50%) patients underwent reconstruction, and6(21.4%) patients weretreated postoperatively with adjuvant radiation therapy. The average follow-up was86.5months (range:16-193months). Eight (28.6%) patients developed recurrence and two(7.1%) patients died. Eight (28.6%) patients experienced complications perioperatively orduring the follow-up, six (21.4%) patients had wound complications, one patientexperienced cerebrospinal fluid leakage and one thoracic patient developed kyphosis. The14patients who underwent reconstruction did not experience hardware failure requiring surgical revision. Twenty-four (85.7%) patients retained normal neurologic function, whilethe function of the sphincter muscles were impaired in only4sacral GCT patients.Conclusion: Preoperative embolization can significantly decrease intraoperativeblood loss, and facilitate the maximal removal of the tumor. It is a safe and effectivetechnique for excising giant cell tumors of the spine. Intralesional excision withpreoperative embolization may be a feasible choice for GCT of the spine. Part ⅡAnalysis of Risk Factors for Recurrence of Giant CellTumor of SpineObjective: To investigate the factors related to the local recurrence-free survival time(LRFS) after surgical treatment of giant cell tumor of the spine, in order to providetheoretic foundation for an improvement of LRFS.Methods: We retrospectively reviewed28consecutive patients with GCT of thesacrum and mobile spine who underwent initial surgical excision combined withpreoperative embolization between June,1995and August,2011. Data regarding age,gender, tumor location, tumor size, tumor extension, radiation therapy, and localrecurrences were reviewed. The expression of IMP3and IGF2was detected byimmunohistichemical staining. Local recurrence-free survival time was calculatedaccording to the Kaplan-Meier method and statistical analysis was performed usingLog-Rank test.Results: All the patients underwent intralesional resection. The average duration offollow-up was86.5months (range,16~193months).8(28.6%) patients developed localrecurrence. The average recurrence time was35.6months (range,5-79months). LRFSwas found statistically longer in intracompartmental (T1) tumors as compared toextracompartmental (T2) tumors (median:73versus43months, P=0.025). LRFS was alsofound significantly longer in IMP3negative group than IMP3positive group (median:73versus43months, P=0.002), and in IGF2negative group than IGF2positive group(median:75versus46.5months, P=0.007). LRFS was not found significant difference forage, gender, tumor location, tumor size, and radiation therapy.Conclusion: Extracompartmental tumor, positive expression of IMP3, and positiveexpression of IGF2will probably lead to shorter LRFS. The choice of surgical treatment should be balanced between the complications and tumor recurrence. Intralesional excisionmay be a feasible choice for T1tumors of the spine, but for T2tumors, more aggressivetreatment may be required. Overexpression of IMP3and IGF2may be used as prognosticindications of the recurrence of GCT of the spine.更多还原