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目的探讨有血缘关系的冷冻保存带血管同种异体骨移植用于儿童及青少年骨肉瘤保肢治疗的临床效果和技术要点。方法 2004年2月-2012年4月,对21例符合选择标准的儿童及青少年四肢长骨骨肉瘤患者,行有血缘关系的冷冻保存带血管同种异体骨移植保肢手术治疗。其中男13例,女8例;年龄7~16岁,平均12.6岁。Enneking分期:ⅡA期15例,ⅡB期6例。肿瘤部位:股骨下段10例,股骨上段1例,胫骨上段8例,肱骨上段1例,桡骨下段1例。影像学检查7例肿瘤侵袭骨骺。带旋髂深血管同种异体髂骨瓣取自患者直系亲属,采用两步冷冻保存后移植修复肿瘤切除后的骨缺损区;髂骨瓣切取范围为8.0 cm×3.0 cm×2.0 cm~14.0 cm×5.0 cm×2.5 cm。其中保留关节16例,关节融合5例;外固定支架固定。手术前后按照大剂量氨甲喋呤序贯阿霉素、顺铂方案施行化疗。结果 21例均获随访,随访时间5个月~11年,平均6.4年。术后2周E花结形成细胞为56.7%±3.9%,与正常对照58.3%±4.3%比较差异无统计学意义(t=1.56,P=0.13),提示无急性排斥反应。术后4周单光子发射计算机化断层显像骨扫描提示移植髂骨瓣血供丰富,代谢活跃。术后12周数字减影血管造影示髂骨瓣动脉通畅。X线片示术后5、6个月分别1例骨畸形愈合和1例骨不愈合;其余患者髂骨瓣均愈合,愈合时间3.2~6.0个月,平均4.4个月。末次随访时,美国肌肉骨骼肿瘤学会(MSTS)评分为(26.80±2.14)分,较术前(17.15±1.86)分显著提高(t=—4.15,P=0.00)。随访期内生存率为85.7%(18/21),复发率9.5%(2/21)。结论采用有血缘关系的冷冻保存带血管同种异体骨移植为儿童及青少年骨肉瘤保肢治疗提供了一种新方法,结合化疗可取得理想效果;正确的供骨切取、保存、移植技术和适应证选择是提高疗效的关键。
Objective To investigate the clinical effects and technical points of blood-borne cryopreserved vascular allograft transplantation for limb salvage in children and adolescent osteosarcoma. Methods From February 2004 to April 2012, 21 children with long bone osteosarcoma in children and adolescents with limbs and limbs were treated by limb salvage with blood-borne vascular allograft transplantation. Including 13 males and 8 females; aged 7 to 16 years, an average of 12.6 years old. Enneking staging: Ⅱ A 15 cases, Ⅱ B 6 cases. Tumor site: 10 cases of the lower femur, 1 case of upper femur, 8 cases of upper tibia, 1 case of upper humerus and 1 case of lower radius. Radiographic examination 7 cases of tumor invasion epiphysis. Allogeneic iliac crest with iliac vessels with iliac vessels were obtained from the immediate relatives of the patients and were cryopreserved in two steps for the repair of the bone defect after tumor resection. The range of the iliac bone flap was 8.0 cm × 3.0 cm × 2.0 cm to 14.0 cm × 5.0 cm × 2.5 cm. Among them, 16 cases had joint retention and 5 cases had joint fusion. The external fixation was fixed. Before and after surgery according to high-dose methotrexate sequential doxorubicin, cisplatin chemotherapy. Results 21 cases were followed up for 5 months to 11 years, an average of 6.4 years. There was no significant difference (P = 0.13) between E-form formation cells at 2 weeks and 58.3% ± 4.3% of normal controls (56.7% ± 3.9%), suggesting no acute rejection. Four weeks after surgery, single photon emission computerized tomography bone scan revealed that the iliac bone graft was rich in blood supply and was metabolically active. Digital subtraction angiography at 12 weeks showed iliac flap patency. The X-ray showed one case of osteonecrosis and one case of nonunion after 5 and 6 months respectively. The rest of the patients had healed iliac bone flap, the healing time was 3.2-6.0 months with an average of 4.4 months. At the final follow-up, the MSTS score was (26.80 ± 2.14) points higher than the preoperative (17.15 ± 1.86) points (t = -4.15, P = 0.00). The follow-up survival rate was 85.7% (18/21), the recurrence rate was 9.5% (2/21). Conclusion The use of blood-based cryoablation with allogenic bone graft provides a new method for limb salvage treatment of children and adolescent osteosarcoma, and combined with chemotherapy can achieve the desired effect; the correct technology for bone extraction, preservation, transplantation and adaptation Card selection is to improve the efficacy of the key.