脊柱骨巨细胞瘤的外科治疗进展
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摘要
脊柱骨巨细胞瘤(Giant cell tumor,GCT是一种原发于脊柱的交界性肿瘤。发病原因尚不清楚,肿瘤血运丰富,侵袭性生长,手术后易复发,并可以发生肺转移。其发病率不高,全身骨巨细胞瘤中,约4.3%-12%发生于脊柱,在脊柱原发性骨肿瘤中,骨巨细胞瘤约占7.3%。肿瘤肉眼所见为特有的巧克力色,呈海绵状,易碎,由淡黄色向橘色褪变的囊腔普遍可见,腔内经常充满血液,可有不同程度的骨皮质膨胀、破坏,不过骨膜很少被破坏。镜下所见为多核巨细胞均匀散布于大量圆形、椭圆形或肥硕的短梭形单核问质细胞中,可表现出明显的有丝分裂活动,但细胞异型性少见。
大多数脊柱骨巨细胞瘤患者有背痛症状,如果肿瘤生长压迫神经组织,可表现出相应的神经功能障碍。颈椎骨巨细胞瘤同时可出现呼吸、吞咽困难及霍纳氏综合征,椎动脉受压可出现头晕等椎动脉缺血症状。骶骨巨细胞瘤一般发现较晚,早期主要以下腰部或臀部酸胀痛和持续性疼痛为主,可有放射痛和小便及性功能障碍。脊柱骨巨细胞瘤在普通平片及CT上表现为溶骨性的膨胀病灶,通常没有硬化缘及骨膜反应。大多数病灶侵犯椎体,向椎弓根或椎旁软组织生长,可造成椎体塌陷,脊柱畸形及压迫脊髓。MRI检查,在T1加权像上,骨巨细胞瘤表现出低到中等的不均匀信号,偶可见高信号区域,往往提示近期有新的出血。T2加权像上,肿瘤的实心区表现低到中等信号强度,因为含铁血黄素的原因,在梯度回波加权像上区域可以被放大,囊性区域在T2加权像上表现为高信号,偶而可见液平面。
临床上必须通过活组织检查来确定诊断,目前临床上常用的活检方法主要有经皮活组织检查、切开活组织检查、切除活组织检查。
因为局部解剖复杂,发生于脊柱的骨巨细胞瘤不易手术切除,所以其治疗对于外科医生来说极具挑战性。目前主要有手术、放疗、连续动脉内栓塞治疗及化疗应用于临床。
近年来针对脊柱骨肿瘤的间室概念及外科分期系统的应用,为术前更全面的评价脊柱肿瘤并指导手术提供了很好的依据。广泛应用于临床的有WBB及Tomita分期系统,根据这些分期系统,采用先进的手术技术,如:楔形椎体切除术及全椎体整块切除术,大多数脊柱肿瘤可以做到广泛或边界的整块切除,其术后复发率明显降低。肿瘤切除后脊柱重建的生物力学及重建技术取得了长足发展,为脊柱肿瘤的手术治疗提供了保障。
关于脊柱骨巨细胞瘤的手术治疗,目前主要存在两种方法。一些学者提倡采用广泛或边界的整块切除肿瘤来防止局部复发。但手术时间延长、感染机会增加,手术风险加大,多数情况下不得不切除受累神经根,造成患者术后出现相应神经功能丢失,代价较大。另一些学者认为为了保护患者的神经功能,减小手术并发症,应该采用较为保守的囊内刮除方法,但其术后复发率较高。经临床证实,广泛或边界的整块切除肿瘤是最有效的降低肿瘤局部复发率的方法。如果不能达到边界切除,则可以辅助放射治疗,消灭可能残留的肿瘤细胞,巨大的骶骨骨巨细胞瘤可采用连续动脉内栓塞治疗。对于发生肺转移的脊柱骨巨细胞瘤,可以通过肺叶切除和(或)采用化疗来控制。
Giant cell tumor(GCT) of the spine is a kind of primary borderline tumor occurs on spine.The pathogeny of the tumor is not clear yet,but it is rich in blood supply,invasive growth,and easy recurrence after surgery,and pulmonary metastasis.The incidence of this tumor is not high,about 4.3-12%in giant cell tumor of bone all over the body,about 7.3%in primarily spinal tumor. On gross inspection,these lesions are characteristically chocolate brown,soft, spongy,and friable.Yellowish-to-orange discoloration may be present.Cystic cavities within the tumor are common.Often,these cavities are blood filled, reveals a variable degree of cortical expansion and disruption.Despite the cortical disruption,the periosteum remains intact.Under microscopic lens, multinucleater giant cell well-distributed in bulk round,ellipse or big and fleshy fusiform shape mononuclear interstitial cells,showing evidently karyokinesis, but heteromorphosis is rare.
Most patients with giant cell tumor of the spine have the symptom of notalgia.If tumor growth and compress the nervous tissue,corresponding nerve functional disability can be seen.GCTs of the cervical vertebra simultaneously appear respiration,dysphagia and Homer's syndrome.After arteria vertebralis compressed,dizziness and other ischemia symptoms of arteria vertebralis could be seen.GCTs of the sacrum are usually detected late.Patients with sacral GCTs mostly present with localized gas pains and rest pains in the low back or rump, which may radiate to other place.Bladder and sexual function symptoms may also be present.GCTs of the spine show osteolytic expansile focus on X-rays film and CT,and usually have no sclerotic margin and periosteal reaction.Most focus invade into the body of vertebra,growing toward pedicle of vertebral arch and soft tissue,causing collapse of vertebra,rachiterata and spinal cord compression.On Tl weighting magnetic resonance imaging,GCTs show unequable signals from low to middle,high signal area may be presented by chance,which usually indicate new hemorrhage.On T2 weighting magnetic resonance imaging,solid area of tumor presents signal intensity from low to middle.On gtadient echo weighting image,the area could be amplified due to hemosiderin.Cystic areas presents high singnal on T2 weighting magnetic resonance imaging,fluid plane may be presented by chance.
GCT of the spine is usually diagnosed by biopsy.The commonly used biopsy methods include percutaneous biopsy,incisional biopsy,excisional biopsy.
On account of the complicated topography,GCT of the spine can't be excised easily.So its treatment is a big challenge for a surgeon.In present, clinically used therapy are operation,radiotherapy,continuous artery embolotherapy and chemotherapy.
In recent years the concept of compartment and the application of the surgical staging system for spinal tumors have offered very sound basis for evaluating the spinal tumors and guiding the surgeries.The widely used are the WBB and the Tomita classification system,according to these system,surgeons take the advanced surgical techniques,such as wedge-shaped vertebra resection and Total En bloc spondylectomy(TES),most of the spinal tumors can be removed widely or marginally by the edge,the recurrence rate decreased obviously after the surgery.The big development of the biomechanical and the techniques of reconstruction after tumor resection provide guarantees for spinal tumor surgeries.
Respect to the therapy of the spinal giant cell tumor of bone,there are two main ways,some experts advocate the wide or marginal removal of the tumor tissues in order to get rid of the recurrence,but this method cost more time of operation and also increase the chance for infection,so more risk in the process, and most of the time the surgeons have to sacrifice affected nerve roots,then the corresponding function lost too.The price paid is bigger.Other experts think in order to preserve the function of the nerves,surgeons should take the conservative intracapsular curettage way,but the recurrence rate is a little high. It is established that En bloc resection with wide margins is the most effective method to lower the recurrence rate of spinal tumors.And if the surgeons are not able to do the marginal removal,it is wise to take the radiology therapy as a assistance to clean the remaining tumor cells.The huge Sacrum giant cell tumor can be treated by consecutive arterial embolization.For those with lung metatasis,they can be controlled by lobectomy and/or chemotherapy.
大多数脊柱骨巨细胞瘤患者有背痛症状,如果肿瘤生长压迫神经组织,可表现出相应的神经功能障碍。颈椎骨巨细胞瘤同时可出现呼吸、吞咽困难及霍纳氏综合征,椎动脉受压可出现头晕等椎动脉缺血症状。骶骨巨细胞瘤一般发现较晚,早期主要以下腰部或臀部酸胀痛和持续性疼痛为主,可有放射痛和小便及性功能障碍。脊柱骨巨细胞瘤在普通平片及CT上表现为溶骨性的膨胀病灶,通常没有硬化缘及骨膜反应。大多数病灶侵犯椎体,向椎弓根或椎旁软组织生长,可造成椎体塌陷,脊柱畸形及压迫脊髓。MRI检查,在T1加权像上,骨巨细胞瘤表现出低到中等的不均匀信号,偶可见高信号区域,往往提示近期有新的出血。T2加权像上,肿瘤的实心区表现低到中等信号强度,因为含铁血黄素的原因,在梯度回波加权像上区域可以被放大,囊性区域在T2加权像上表现为高信号,偶而可见液平面。
临床上必须通过活组织检查来确定诊断,目前临床上常用的活检方法主要有经皮活组织检查、切开活组织检查、切除活组织检查。
因为局部解剖复杂,发生于脊柱的骨巨细胞瘤不易手术切除,所以其治疗对于外科医生来说极具挑战性。目前主要有手术、放疗、连续动脉内栓塞治疗及化疗应用于临床。
近年来针对脊柱骨肿瘤的间室概念及外科分期系统的应用,为术前更全面的评价脊柱肿瘤并指导手术提供了很好的依据。广泛应用于临床的有WBB及Tomita分期系统,根据这些分期系统,采用先进的手术技术,如:楔形椎体切除术及全椎体整块切除术,大多数脊柱肿瘤可以做到广泛或边界的整块切除,其术后复发率明显降低。肿瘤切除后脊柱重建的生物力学及重建技术取得了长足发展,为脊柱肿瘤的手术治疗提供了保障。
关于脊柱骨巨细胞瘤的手术治疗,目前主要存在两种方法。一些学者提倡采用广泛或边界的整块切除肿瘤来防止局部复发。但手术时间延长、感染机会增加,手术风险加大,多数情况下不得不切除受累神经根,造成患者术后出现相应神经功能丢失,代价较大。另一些学者认为为了保护患者的神经功能,减小手术并发症,应该采用较为保守的囊内刮除方法,但其术后复发率较高。经临床证实,广泛或边界的整块切除肿瘤是最有效的降低肿瘤局部复发率的方法。如果不能达到边界切除,则可以辅助放射治疗,消灭可能残留的肿瘤细胞,巨大的骶骨骨巨细胞瘤可采用连续动脉内栓塞治疗。对于发生肺转移的脊柱骨巨细胞瘤,可以通过肺叶切除和(或)采用化疗来控制。
Giant cell tumor(GCT) of the spine is a kind of primary borderline tumor occurs on spine.The pathogeny of the tumor is not clear yet,but it is rich in blood supply,invasive growth,and easy recurrence after surgery,and pulmonary metastasis.The incidence of this tumor is not high,about 4.3-12%in giant cell tumor of bone all over the body,about 7.3%in primarily spinal tumor. On gross inspection,these lesions are characteristically chocolate brown,soft, spongy,and friable.Yellowish-to-orange discoloration may be present.Cystic cavities within the tumor are common.Often,these cavities are blood filled, reveals a variable degree of cortical expansion and disruption.Despite the cortical disruption,the periosteum remains intact.Under microscopic lens, multinucleater giant cell well-distributed in bulk round,ellipse or big and fleshy fusiform shape mononuclear interstitial cells,showing evidently karyokinesis, but heteromorphosis is rare.
Most patients with giant cell tumor of the spine have the symptom of notalgia.If tumor growth and compress the nervous tissue,corresponding nerve functional disability can be seen.GCTs of the cervical vertebra simultaneously appear respiration,dysphagia and Homer's syndrome.After arteria vertebralis compressed,dizziness and other ischemia symptoms of arteria vertebralis could be seen.GCTs of the sacrum are usually detected late.Patients with sacral GCTs mostly present with localized gas pains and rest pains in the low back or rump, which may radiate to other place.Bladder and sexual function symptoms may also be present.GCTs of the spine show osteolytic expansile focus on X-rays film and CT,and usually have no sclerotic margin and periosteal reaction.Most focus invade into the body of vertebra,growing toward pedicle of vertebral arch and soft tissue,causing collapse of vertebra,rachiterata and spinal cord compression.On Tl weighting magnetic resonance imaging,GCTs show unequable signals from low to middle,high signal area may be presented by chance,which usually indicate new hemorrhage.On T2 weighting magnetic resonance imaging,solid area of tumor presents signal intensity from low to middle.On gtadient echo weighting image,the area could be amplified due to hemosiderin.Cystic areas presents high singnal on T2 weighting magnetic resonance imaging,fluid plane may be presented by chance.
GCT of the spine is usually diagnosed by biopsy.The commonly used biopsy methods include percutaneous biopsy,incisional biopsy,excisional biopsy.
On account of the complicated topography,GCT of the spine can't be excised easily.So its treatment is a big challenge for a surgeon.In present, clinically used therapy are operation,radiotherapy,continuous artery embolotherapy and chemotherapy.
In recent years the concept of compartment and the application of the surgical staging system for spinal tumors have offered very sound basis for evaluating the spinal tumors and guiding the surgeries.The widely used are the WBB and the Tomita classification system,according to these system,surgeons take the advanced surgical techniques,such as wedge-shaped vertebra resection and Total En bloc spondylectomy(TES),most of the spinal tumors can be removed widely or marginally by the edge,the recurrence rate decreased obviously after the surgery.The big development of the biomechanical and the techniques of reconstruction after tumor resection provide guarantees for spinal tumor surgeries.
Respect to the therapy of the spinal giant cell tumor of bone,there are two main ways,some experts advocate the wide or marginal removal of the tumor tissues in order to get rid of the recurrence,but this method cost more time of operation and also increase the chance for infection,so more risk in the process, and most of the time the surgeons have to sacrifice affected nerve roots,then the corresponding function lost too.The price paid is bigger.Other experts think in order to preserve the function of the nerves,surgeons should take the conservative intracapsular curettage way,but the recurrence rate is a little high. It is established that En bloc resection with wide margins is the most effective method to lower the recurrence rate of spinal tumors.And if the surgeons are not able to do the marginal removal,it is wise to take the radiology therapy as a assistance to clean the remaining tumor cells.The huge Sacrum giant cell tumor can be treated by consecutive arterial embolization.For those with lung metatasis,they can be controlled by lobectomy and/or chemotherapy.
引文
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