骶骨骨巨细胞瘤的影像学诊断及治疗策略
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摘要
目的
回顾分析骶骨肿瘤患者的资料,观察骨巨细胞瘤和其他骶骨肿瘤在影像学表现上的差异,并对其进行统计分析,用以指导骶骨骨巨细胞瘤的早期影像学诊断;分析阐述骶骨骨巨细胞瘤采用肿瘤刮除术的可行性;观察术前实施放射治疗的骶骨骨巨细胞瘤患者放疗前后的病理检查结果的差异,分析术前放疗的作用。为骶骨骨巨细胞瘤患者的早期诊断及最佳治疗方案的选择,提供科学的依据。
方法
分析我院1991年1月至2008年8月间所收治的40例骶骨肿瘤患者,男性20例,女性20例,平均年龄45.75岁(4岁-72岁)。其中骶骨骨巨细胞瘤10例、骶骨脊索瘤7例、骶骨转移瘤9例,所有诊断均经影像学及病理组织学证实。首先选取部分影像学资料完整的病例行影像学分析:取7例骶骨骨巨细胞瘤作为实验组、取7例骶骨脊索瘤作为对照组A、取7例骶骨转移瘤作为对照组B。收集实验组及对照组的影像学资料,统计肿瘤发病部位、肿瘤生长情况、肿瘤边缘情况及肿瘤密度的情况,进行对比分析。第二步选取10例骶骨骨巨细胞瘤,收集其临床资料及影像学和病理学资料,患者均经穿刺活检确诊及放射影像学Campanicci’s分级,并根据活检及影像学分级结果确定治疗方案。10例中有7例行手术治疗,手术方式均为肿瘤刮除术,术中保留骶1-2神经根和至少一侧的骶3神经根,同时给予内固定(早期3例给予骶骨棒加大块植骨,近期4例给予钉棒系统固定);2例术前给予放疗,放射剂量分别为4000cGy和4500cGy,分别取2例术前经放射治疗患者的术前穿刺活检病理及术中病理分别作CD34和Ki67免疫组化染色,然后分别计数肿瘤内生血管密度(MVD)和肿瘤细胞增殖指数(PI)。分析骶骨骨巨细胞瘤术中给予肿瘤刮除术的可行性及骶骨骨巨细胞瘤术前给予放疗的可行性及效果差异。
结果
第一步:经过观察实验组及两个对照组病例的影像学资料发现,实验组:7例肿瘤全部位于上位骶骨;6例位于骶骨外侧,1例位于骶骨中央;5例边缘清楚,2例边缘呈虫蚀样改变;6例肿瘤内部密度均匀,1例肿瘤内部密度不均。对照组A:1例肿瘤位于上位骶骨, 6例位于下位骶骨;7例均位于骶骨中央;4例肿瘤边缘清楚,3例肿瘤边缘不清;2例肿瘤内部密度均匀,5例肿瘤内部密度不均。对照组B:5例肿瘤位于上位骶骨, 2例位于全骶骨;2例位于骶骨外侧,5例位于骶骨中央;7例肿瘤边缘不清;1例肿瘤内部密度均匀,6例肿瘤内部密度不均。经统计分析发现:骶骨骨巨细胞瘤与骶骨脊索瘤的好发部位、肿瘤生长情况及肿瘤内部密度方面不同,但二者肿瘤边缘情况相同;骶骨骨巨细胞瘤与骶骨转移瘤的好发部位相同,但二者的肿瘤边缘情况、肿瘤生长情况及肿瘤内部密度不同。第二步:10例骶骨骨巨细胞瘤经穿刺活检确诊后,根据放射影像学Campanicci’s分级结果,7例给予肿瘤刮除术,其中2例失访,5例经过门诊及电话获得随访。5例中1例于术后6个月复发,给予再次手术,5例均获无瘤生存,随访时间34.2(5-67)个月;4例术后大小便功能恢复良好,1例术后出现小便障碍,4个月后恢复;1例患者术后2年髂骨钉断裂,给予翻修,术后患者肢体功能均恢复良好;2例术前给予放射治疗,放射后肿瘤内生血管密度(MVD)及肿瘤细胞增殖指数(PI)均较放射前明显降低。
结论
1、骶骨骨巨细胞瘤患者可通过影像学诊断获得早期诊断;
2、骶骨骨巨细胞瘤的影像学表现:多发生于上位骶骨,呈偏心溶骨性改变,边缘清楚,肿瘤密度均匀;
3、骶骨骨巨细胞瘤与骶骨脊索瘤好发部位、肿瘤生长情况及肿瘤内部密度情况不同,两者肿瘤边缘情况相同;骶骨骨巨细胞瘤与骶骨转移瘤的好发部位相同,但肿瘤边缘情况、肿瘤生长情况及肿瘤内部密度情况不同;
4、肿瘤刮除术适用于骶骨骨巨细胞瘤,术后患者功能恢复较好,复发率较低;
5、术中保留双侧骶1-2神经根和至少一侧骶3神经根,术后患者神经功能恢复良好;
6、术中给予牢靠的内固定,可使患者早期下床活动,患者肢体功能恢复良好,提高了患者术后的生活质量;
7、术前行放射治疗,可降低患者肿瘤细胞活性,并可减少肿瘤的内部血管密度,是一种较好的辅助治疗手段。
Aim
Based on review and analysis of medical records of sacrum tumor patients, we studied the differences between images of giant cell tumor and other tumors related to the sacrum and analyzed them by the statistics method. Our results are informative to the early diagnosis of giant cell tumor by the imaging method and evaluation of the feasibility of curettage of the tumor. It is also critical to the observation of tumor morphology before radiotherapy, so that the psychiatrist is able to identify pathological changes before and after therapy in order to analyze the effectiveness of radiotherapy. Hence, our research is significant and provides scientific proof for the early diagnosis and options of therapeutic approach to patients of giant cell tumor of the sacrum.
Methods
Ecollected data from 40 cases of sacrum tumors from our institute between January 1991 and August 2008, including 20 males and 20 females of an average age of 45.75 years (total range from 4 to 72 years), that comprised of 10 cases of giant cell tumor, 7 cases of notochordoma and 9 cases of metastatic tumor, all of which were final diagnosed by imaging and tissue pathology diagnosis. First, we collected medical records containing full imaging results for image analysis: we took 7 cases of sacrum giant cell tumor as our experiment group, 7 cases of sacrum notochordoma as control group A, and 7 cases of sacrum metastatic tumor as control group B. We collected the imaging results from corresponding groups and analyzed the site of tumorigenesis, growing conditions of tumor, peripheral conditions of tumor, and the density of tumor growth. Second, we collected medical records and imaging results and pathological data from 10 cases of sacrum giant cell tumor patients, who underwent aspiration biopsy diagnosis, and were scored according to Campanicci’s system by radio-imaging. Among these cases, 7 patients underwent operation therapy, all of which were curettage of the tumor, where S1-2 of the sacrum and S3 of at least one side of the sacrum were retained by internal fixation during operation (the previous 3 cases were performed by iliac bar enlarged bone graft while the recent 7 cases were done by screw-rod system). 2 patients underwent radiotherapy before operation, the radiation dose of which were 4000cGy and 4500cGy respectively. We took aspiration biopsy and operative pathology data from 2 patients for CD34 and Ki67 imm unohisto chemistry staining respectively, and counted the microvessel density (MVD) and proliferation index (PI) respectively. We studied the feasibility of curettage of the tumor during operation as well as the feasibility and different outcomes of performing radiotherapy before operation for patients of giant cell tumor of the sacrum.
Result
First, we compared the imaging data of the experiment group and the control groups. We found out that: in the experiment group, all 7 cases occurred in the epistasis of the sacrum, given 6 cases occurred on the peripherals of the sacrum and 1 case in the center of the sacrum, with 5 cases showing a neat line and 2 cases showing eclipse on the border of tumor, and all but 1 case showed even density in the center of the tumor;in control group A,1 case occurred in the epistasis of the sacrum and 6 cases occurred in the hypostasy of the sacrum, given all 7 cases occurred in the center of the sacrum, with 4 cases showing a neat border and 3 cases showing a vague border, and all but 2 cases showed uneven density in the center of the tumor; in control group B, 5 cases occurred in the epistasis of the sacrum and 2 cases throughout the sacrum, given 2 cases on the peripherals of the sacrum and 5 cases in the center of the sacrum, with all 7 cases showing a vague border, and all but 1 case showed uneven density in the center of the tumor. We analyzed the results and concluded that sacrum giant cell tumor and sacrum notochordoma has similar tumor peripheral conditions but different predilection sites, tumor growth conditions and tumor density; while sacrum metastatic tumor has different tumor peripheral conditions, tumor growth conditions and tumor density, but similar predilection sites as sacrum giant cell tumor. Second, 10 cases were final diagnosed by aspiration biopsy diagnosis and scored according to Campanicci’s system, wherein 7 patients underwent curettage of the tumor. Among these patients, 5 cases were lost of visit and 2 cases were followed-up by return visit or telephone. 1 case out of the 5 cases experienced recurrence 6 months after operation and subsequently underwent another operation. Follow-up time was 34.2 months in average (in a range of 5 to 67 months). 4 cases recovered their excretion function after operation, 1 case had difficulty in urination and recovered in 4 months. 1 case had fractured sacral rod 2 years after operation, so the patient underwent overhauling and recovered extremity function thereafter. 2 cases were provided radiotherapy before operation, and reduced microvessel density (MVD) and proliferation index (PI) after radiotherapy were perceived.
Conclusion
1. Sacrum giant cell tumor patients could be diagnosed by imaging diagnosis in early diagnosis.
2. The imaging data of giant cell tumor of the sacrum revealed that its predilection site is in the epistasis of the sacrum, resulting in decenter osteolysis, together with tumor with a neat border and even density.
3. Sacrum giant cell tumor and sacrum notochordoma has similar tumor peripheral conditions but different predilection sites, tumor growth conditions and tumor density; while sacrum metastatic tumor has different tumor peripheral conditions, tumor growth conditions and tumor density, but similar predilection sites as sacrum giant cell tumor.
4. Curettage of the tumor is appropriate for giant cell tumor of the sacrum. Patients undergone operation therapy recovered well and had low recurrence.
5. Retaining S1-2 of the sacrum and S3 of at least one side of the sacrum during operation facilitated proficient recovery of the nervous system.
6. Good internal fixation during operation enabled patients to exercise soon after operation and facilitated the recovery of extremity functions, resulting in a higher quality of post-operative life.
7. Performing radiotherapy before operation reduced tumor cell proliferation and microvessel density. It is thus considered a good adjunctive therapy.
回顾分析骶骨肿瘤患者的资料,观察骨巨细胞瘤和其他骶骨肿瘤在影像学表现上的差异,并对其进行统计分析,用以指导骶骨骨巨细胞瘤的早期影像学诊断;分析阐述骶骨骨巨细胞瘤采用肿瘤刮除术的可行性;观察术前实施放射治疗的骶骨骨巨细胞瘤患者放疗前后的病理检查结果的差异,分析术前放疗的作用。为骶骨骨巨细胞瘤患者的早期诊断及最佳治疗方案的选择,提供科学的依据。
方法
分析我院1991年1月至2008年8月间所收治的40例骶骨肿瘤患者,男性20例,女性20例,平均年龄45.75岁(4岁-72岁)。其中骶骨骨巨细胞瘤10例、骶骨脊索瘤7例、骶骨转移瘤9例,所有诊断均经影像学及病理组织学证实。首先选取部分影像学资料完整的病例行影像学分析:取7例骶骨骨巨细胞瘤作为实验组、取7例骶骨脊索瘤作为对照组A、取7例骶骨转移瘤作为对照组B。收集实验组及对照组的影像学资料,统计肿瘤发病部位、肿瘤生长情况、肿瘤边缘情况及肿瘤密度的情况,进行对比分析。第二步选取10例骶骨骨巨细胞瘤,收集其临床资料及影像学和病理学资料,患者均经穿刺活检确诊及放射影像学Campanicci’s分级,并根据活检及影像学分级结果确定治疗方案。10例中有7例行手术治疗,手术方式均为肿瘤刮除术,术中保留骶1-2神经根和至少一侧的骶3神经根,同时给予内固定(早期3例给予骶骨棒加大块植骨,近期4例给予钉棒系统固定);2例术前给予放疗,放射剂量分别为4000cGy和4500cGy,分别取2例术前经放射治疗患者的术前穿刺活检病理及术中病理分别作CD34和Ki67免疫组化染色,然后分别计数肿瘤内生血管密度(MVD)和肿瘤细胞增殖指数(PI)。分析骶骨骨巨细胞瘤术中给予肿瘤刮除术的可行性及骶骨骨巨细胞瘤术前给予放疗的可行性及效果差异。
结果
第一步:经过观察实验组及两个对照组病例的影像学资料发现,实验组:7例肿瘤全部位于上位骶骨;6例位于骶骨外侧,1例位于骶骨中央;5例边缘清楚,2例边缘呈虫蚀样改变;6例肿瘤内部密度均匀,1例肿瘤内部密度不均。对照组A:1例肿瘤位于上位骶骨, 6例位于下位骶骨;7例均位于骶骨中央;4例肿瘤边缘清楚,3例肿瘤边缘不清;2例肿瘤内部密度均匀,5例肿瘤内部密度不均。对照组B:5例肿瘤位于上位骶骨, 2例位于全骶骨;2例位于骶骨外侧,5例位于骶骨中央;7例肿瘤边缘不清;1例肿瘤内部密度均匀,6例肿瘤内部密度不均。经统计分析发现:骶骨骨巨细胞瘤与骶骨脊索瘤的好发部位、肿瘤生长情况及肿瘤内部密度方面不同,但二者肿瘤边缘情况相同;骶骨骨巨细胞瘤与骶骨转移瘤的好发部位相同,但二者的肿瘤边缘情况、肿瘤生长情况及肿瘤内部密度不同。第二步:10例骶骨骨巨细胞瘤经穿刺活检确诊后,根据放射影像学Campanicci’s分级结果,7例给予肿瘤刮除术,其中2例失访,5例经过门诊及电话获得随访。5例中1例于术后6个月复发,给予再次手术,5例均获无瘤生存,随访时间34.2(5-67)个月;4例术后大小便功能恢复良好,1例术后出现小便障碍,4个月后恢复;1例患者术后2年髂骨钉断裂,给予翻修,术后患者肢体功能均恢复良好;2例术前给予放射治疗,放射后肿瘤内生血管密度(MVD)及肿瘤细胞增殖指数(PI)均较放射前明显降低。
结论
1、骶骨骨巨细胞瘤患者可通过影像学诊断获得早期诊断;
2、骶骨骨巨细胞瘤的影像学表现:多发生于上位骶骨,呈偏心溶骨性改变,边缘清楚,肿瘤密度均匀;
3、骶骨骨巨细胞瘤与骶骨脊索瘤好发部位、肿瘤生长情况及肿瘤内部密度情况不同,两者肿瘤边缘情况相同;骶骨骨巨细胞瘤与骶骨转移瘤的好发部位相同,但肿瘤边缘情况、肿瘤生长情况及肿瘤内部密度情况不同;
4、肿瘤刮除术适用于骶骨骨巨细胞瘤,术后患者功能恢复较好,复发率较低;
5、术中保留双侧骶1-2神经根和至少一侧骶3神经根,术后患者神经功能恢复良好;
6、术中给予牢靠的内固定,可使患者早期下床活动,患者肢体功能恢复良好,提高了患者术后的生活质量;
7、术前行放射治疗,可降低患者肿瘤细胞活性,并可减少肿瘤的内部血管密度,是一种较好的辅助治疗手段。
Aim
Based on review and analysis of medical records of sacrum tumor patients, we studied the differences between images of giant cell tumor and other tumors related to the sacrum and analyzed them by the statistics method. Our results are informative to the early diagnosis of giant cell tumor by the imaging method and evaluation of the feasibility of curettage of the tumor. It is also critical to the observation of tumor morphology before radiotherapy, so that the psychiatrist is able to identify pathological changes before and after therapy in order to analyze the effectiveness of radiotherapy. Hence, our research is significant and provides scientific proof for the early diagnosis and options of therapeutic approach to patients of giant cell tumor of the sacrum.
Methods
Ecollected data from 40 cases of sacrum tumors from our institute between January 1991 and August 2008, including 20 males and 20 females of an average age of 45.75 years (total range from 4 to 72 years), that comprised of 10 cases of giant cell tumor, 7 cases of notochordoma and 9 cases of metastatic tumor, all of which were final diagnosed by imaging and tissue pathology diagnosis. First, we collected medical records containing full imaging results for image analysis: we took 7 cases of sacrum giant cell tumor as our experiment group, 7 cases of sacrum notochordoma as control group A, and 7 cases of sacrum metastatic tumor as control group B. We collected the imaging results from corresponding groups and analyzed the site of tumorigenesis, growing conditions of tumor, peripheral conditions of tumor, and the density of tumor growth. Second, we collected medical records and imaging results and pathological data from 10 cases of sacrum giant cell tumor patients, who underwent aspiration biopsy diagnosis, and were scored according to Campanicci’s system by radio-imaging. Among these cases, 7 patients underwent operation therapy, all of which were curettage of the tumor, where S1-2 of the sacrum and S3 of at least one side of the sacrum were retained by internal fixation during operation (the previous 3 cases were performed by iliac bar enlarged bone graft while the recent 7 cases were done by screw-rod system). 2 patients underwent radiotherapy before operation, the radiation dose of which were 4000cGy and 4500cGy respectively. We took aspiration biopsy and operative pathology data from 2 patients for CD34 and Ki67 imm unohisto chemistry staining respectively, and counted the microvessel density (MVD) and proliferation index (PI) respectively. We studied the feasibility of curettage of the tumor during operation as well as the feasibility and different outcomes of performing radiotherapy before operation for patients of giant cell tumor of the sacrum.
Result
First, we compared the imaging data of the experiment group and the control groups. We found out that: in the experiment group, all 7 cases occurred in the epistasis of the sacrum, given 6 cases occurred on the peripherals of the sacrum and 1 case in the center of the sacrum, with 5 cases showing a neat line and 2 cases showing eclipse on the border of tumor, and all but 1 case showed even density in the center of the tumor;in control group A,1 case occurred in the epistasis of the sacrum and 6 cases occurred in the hypostasy of the sacrum, given all 7 cases occurred in the center of the sacrum, with 4 cases showing a neat border and 3 cases showing a vague border, and all but 2 cases showed uneven density in the center of the tumor; in control group B, 5 cases occurred in the epistasis of the sacrum and 2 cases throughout the sacrum, given 2 cases on the peripherals of the sacrum and 5 cases in the center of the sacrum, with all 7 cases showing a vague border, and all but 1 case showed uneven density in the center of the tumor. We analyzed the results and concluded that sacrum giant cell tumor and sacrum notochordoma has similar tumor peripheral conditions but different predilection sites, tumor growth conditions and tumor density; while sacrum metastatic tumor has different tumor peripheral conditions, tumor growth conditions and tumor density, but similar predilection sites as sacrum giant cell tumor. Second, 10 cases were final diagnosed by aspiration biopsy diagnosis and scored according to Campanicci’s system, wherein 7 patients underwent curettage of the tumor. Among these patients, 5 cases were lost of visit and 2 cases were followed-up by return visit or telephone. 1 case out of the 5 cases experienced recurrence 6 months after operation and subsequently underwent another operation. Follow-up time was 34.2 months in average (in a range of 5 to 67 months). 4 cases recovered their excretion function after operation, 1 case had difficulty in urination and recovered in 4 months. 1 case had fractured sacral rod 2 years after operation, so the patient underwent overhauling and recovered extremity function thereafter. 2 cases were provided radiotherapy before operation, and reduced microvessel density (MVD) and proliferation index (PI) after radiotherapy were perceived.
Conclusion
1. Sacrum giant cell tumor patients could be diagnosed by imaging diagnosis in early diagnosis.
2. The imaging data of giant cell tumor of the sacrum revealed that its predilection site is in the epistasis of the sacrum, resulting in decenter osteolysis, together with tumor with a neat border and even density.
3. Sacrum giant cell tumor and sacrum notochordoma has similar tumor peripheral conditions but different predilection sites, tumor growth conditions and tumor density; while sacrum metastatic tumor has different tumor peripheral conditions, tumor growth conditions and tumor density, but similar predilection sites as sacrum giant cell tumor.
4. Curettage of the tumor is appropriate for giant cell tumor of the sacrum. Patients undergone operation therapy recovered well and had low recurrence.
5. Retaining S1-2 of the sacrum and S3 of at least one side of the sacrum during operation facilitated proficient recovery of the nervous system.
6. Good internal fixation during operation enabled patients to exercise soon after operation and facilitated the recovery of extremity functions, resulting in a higher quality of post-operative life.
7. Performing radiotherapy before operation reduced tumor cell proliferation and microvessel density. It is thus considered a good adjunctive therapy.
引文
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