骨盆原发恶性Ⅳ型肿瘤的骶骨侧外科分型  

Surgical classification and efficacy of sacral side for primary pelvic malignancies involving the sacrum and its therapeutic effect

作　　者：张熠丹[1] 郭卫[1] 杨荣利[1] 汤小东[1] 燕太强[1] 姬涛[1] 臧杰[1] 

机构地区：[1]北京大学人民医院骨肿瘤科,100044

出　　处：《中华骨科杂志》2014年第6期679-687,共9页Chinese Journal of Orthopaedics

基　　金：高等学校博士学科点专项科研基金（20100001120087）

摘　　要：目的 评估累及骶骨的骨盆原发恶性肿瘤骶骨侧外科分型及其在外科边界获得、围手术期风险控制、肿瘤学和功能学改善中的作用.方法 2003年2月至2013年2月,采用手术治疗累及骶骨的骨盆原发恶性肿瘤（修订的EnnekingⅣ型肿瘤）患者59例.男28例,女31例;年龄15～72岁,平均36岁.根据累及的骶骨范围不同将骨盆Ⅳ型肿瘤分为Ⅳa、Ⅳb、Ⅳc、Ⅳd四个亚型,Ⅳa型43例,Ⅳb型9例,Ⅳc型5例,Ⅳd型2例.不同的亚型采取相应的规范化肿瘤切除与重建方法.结果 外科边界满意43例（73％,43/59）,边界不满意16例（27％,16/59）.手术时间2.5～13 h,平均5.0 h;术中出血500,～6 000 ml,平均2 157 ml.没有因围手术期并发症而死亡的病例.53例患者获得随访,随访时间6～88个月,平均26个月.20例（38％,20/53）于术后1～52个月出现局部复发,平均复发时间12个月.10例（19％,10/53）出现转移,20例（38％）在末次随访时仍无瘤生存.美国骨与软组织肿瘤协会（Musculoskeletal Tumor Society,MSTS）93评分平均58.1％,其中Ⅳa型平均57％（10％～100％）,Ⅳb型平均66％（13％～100％）,Ⅳc型平均45％（13％～77％）,Ⅳd型平均30％（26％～33％）.结论 对EnnekingⅣ区肿瘤根据累及骶骨范围不同进行的亚分型,为手术入路和切除范围提供了依据.根据不同亚型进行手术切除与重建,能够获得良好的外科边界、肿瘤学预后及术后功能,降低手术风险.Objective To evaluate the surgical margin achievement,perioperative risk management and improvement in oncologic and functional result of a surgical classification on sacral side for primary pelvic malignancies involving the sacrum.Methods The study was conducted in 59 patients according to modified Enneking type Ⅳ surgical classification in our center from February 2003 to February 2013.There were 28 males and 31 females,with an average of 36 years old （range,15-72 years）.There were 43 cases conform to subtype Ⅳa,9 to Ⅳb,5 to Ⅳc and 2 to Ⅳd according to the extent of sacrum the tumor invades.Distinctive resection and reconstruction methods were designed for each subtype.Results Adequate margins were acquired in 43 cases （73％）,while inadequate margins were inevitable in 16 cases （27％）.Average operation time lasted 5 hours （range,2.5-13 h）.Average blood loss during operation was 2 157 ml （range,500-6 000 ml）.No case died of perioperative complications.53 of 59 patients were followed up with an average follow-up time of 26 months （range,6-88 months）.Local recurrence occurred in 20 cases （38％,20/53）,and average recurrence time was 12 months （range,1-52 months）.Metastasis occurred in 10 cases.20 patients （38％） were still surviving without recurrence.Average Musculoskeletal Tumor Society 93 score reached 58％.Average score after subtype Ⅳa resection reached 57％ （range,10％-100％）,Ⅳb 66％ （range,13％-100％）,Ⅳc 45％ （range,13％-77％）,and Ⅳ d 30％ （range,27％-33％）.Conclusion The modified Enneking＇s type Ⅳ surgical classification,which is classified as four distinct subtypes according to the extent the sacrum invaded,defines the standardized surgical approach and resection plane.It plays an important role in surgical margin achievement,improvement in oncologic and functional result,and perioperative risk management.

关 键 词：骨盆肿瘤 骶骨 外科治疗 保肢 

分 类 号：R738.1[医药卫生—肿瘤]