骨盆原发恶性肿瘤外科治疗疗效及预后影响因素分析  

Analysis of factors influencing the efficacy and prognosis of surgical treatment for primary malignant pelvic bone tumors

作　　者：刘巍峰 郝林 李卓宇 金韬 孙扬 杨勇昆 李远 杨发军 鱼锋 张清 牛晓辉 Liu Weifeng;Hao Lin;Li Zhuoyu;Jin Tao;Sun Yang;Yang Yongkun;Li Yuan;Yang Fajun;Yu Feng;Zhang Qing;Niu Xiaohui(Department of Orthopaedic Oncology Surgery,Beijing Ji Shui Tan Hospital,Capital Medical University,Beijing 100035,China)

机构地区：[1]首都医科大学附属北京积水潭医院骨肿瘤科,北京100035

出　　处：《中华肿瘤杂志》2024年第4期344-353,共10页Chinese Journal of Oncology

基　　金：北京市自然科学基金(L212042);国家重点研发计划(2021YFC2400500,2023YFB4706300);北京市属医院科研培育计划(PX2021015);北京积水潭医院“学科骨干”计划专项经费资助(XKGG202105);北京积水潭医院院级科研基金(2023OSR-GCZX202206)。

摘　　要：目的探讨不同分期骨盆肿瘤预后因素及外科边界对预后的影响。方法回顾性收集2000年1月至2017年12月于北京积水潭医院接受整块切除手术治疗骨盆原发恶性肿瘤患者(208例)的临床病理资料。生存分析采用Kaplan-Meier法和Log rank检验,影响因素分析采用Cox比例风险回归模型。结果208例患者中,初次治疗183例,外院治疗后复发25例。根据Enneking分期,IB期110例,ⅡB期98例。Ⅰ区(髂骨)切除19例,Ⅱ区(髋臼周围)切除1例,Ⅲ区(耻、坐骨)切除15例,Ⅰ+Ⅱ区切除29例,Ⅱ+Ⅲ区切除71例,Ⅰ+Ⅳ区(骶髂关节)切除29例,Ⅰ+Ⅱ+Ⅲ区切除35例,Ⅰ+Ⅱ+Ⅳ区切除3例,Ⅰ+Ⅱ+Ⅲ+Ⅳ区切除6例。外科切缘为囊内7例,污染边缘21例,边缘67例,广泛113例。全组208例患者术后局部复发37例(17.8%),包括最终截肢12例,再次切除25例,5年无复发生存率为79.4%。边缘切除患者5年复发率(22.3%)高于广泛切除患者(4.3%),5年无复发生存率(77.7%)低于广泛切除患者(95.7%,均P<0.05);R0切除与R1切除患者的5年复发率(分别为11.1%和60.7%)及5年无复发生存率(分别为88.8%和39.3%)差异均有统计学意义(均P<0.05)。切除后未重建92例,重建116例。至随访结束,208例患者中死亡63例(30.3%),5、10和15年生存率分别为70.4%、66.8%和61.3%,其中ⅠB期患者5年生存率为90.4%,ⅡB期患者5年生存率为46.8%(P<0.05)。术后切口并发症29例,盆腔脏器损伤1例。最终功能可评价患者132例,肌肉骨骼肿瘤学会评分为(25.1±3.6)分。多因素分析显示,诊断分期(HR=3.135,95%CI:1.447~6.791,P=0.004)、外科R0/R1边界(HR=0.481,95%CI:0.252~0.920,P=0.027)、肿瘤转移(HR=6.172,95%CI:3.271~11.645,P<0.001)是骨盆肿瘤的独立预后因素。结论骨盆肿瘤整块切除安全外科边界是控制复发的关键因素;ⅡB期骨盆肿瘤生存率显著低于ⅠB期肿瘤;切口感染是最主要的术后并发症;外科分期、R0/R1边界、肿瘤转移是骨盆肿瘤的独立预后因素�Objective To analyze the prognostic factors and the influence of surgical margin to prognosis.Methods A retrospective analysis was performed for 208 pelvic tumors who received surgical treatment from January 2000 to December 2017 in our instituition.Survival analysis was performed using the Kaplan-Meier method and Log rank test,and impact factor analysis was performed using Cox regression models.Results There were 183 initial patients and 25 recurrent cases.According to Enneking staging,110 cases were stageⅠB and 98 cases were stageⅡB.19 lesions were in zoneⅠ,1 in zoneⅡ,15 in zoneⅢ,29 in zoneⅠ+Ⅱ,71 in zoneⅡ+Ⅲ,29 in zoneⅠ+Ⅳ,35 in zoneⅠ+Ⅱ+Ⅲ,3 in zoneⅠ+Ⅱ+Ⅳ,and 6 in zoneⅠ+Ⅱ+Ⅲ+Ⅳ.Surgical margins including Intralesional excision in 7 cases,contaminated margin in 21 cases,marginal resection in 67 cases,and wide resection in 113 cases.Local recurrence occurred in 37 cases(17.8%),25 cases were performed by reoperation and 12 cases received amputation finally.The 5-year recurrence rate of marginal resection was higher than wide resection(P<0.05),and the recurrence-free survival rate of marginal resection was lower than wide resection(P<0.05).There was significant differences in recurrence rate and recurrence-free survival rate between R0 and R1 resection(P<0.05).92 cases were not reconstructed and 116 cases were reconstructed after pelvic surgery.At the last follow-up,63 patients(30.3%)died,and the 5-year,10-year and 15-year survival rates were 70.4%,66.8%and 61.3%,respectively.The 5-year survival rate of stageⅠB andⅡB tumor was 90.4%and 46.8%,respectively.There were 29 cases had postoperative wound complications(13.8%),1 case with pelvic organ injury.The final function was evaluated in 132 patients,with an average MSTS score of 25.1±3.6.Cox multivariate analysis showed that surgical staging,R0/R1 margin and metastasis were independent prognostic factors for pelvic tumors.Conclusions The safe surgical margin is the key factor for recurrence-free of pelvic tumor.The survival ra

关 键 词：骨盆恶性肿瘤 切除 外科边界 重建 复发 并发症 

分 类 号：R738.1[医药卫生—肿瘤]