89例下肢瘢痕癌的诊治体会
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摘要
目的:总结下肢瘢痕癌的临床特点及其诊治方法。方法:回顾性分析中南大学湘雅医院烧伤重建外科1998年1月至2017年12月收治的89例下肢瘢痕癌患者的临床资料,包括人口统计学、致伤因素、癌变潜伏期、病变部位、溃疡面积、病理类型、骨质侵犯、淋巴结转移情况、手术方式、修复方法与预后等。结果:89例下肢瘢痕癌患者中,男70例,女19例;最常见致伤因素依次为火焰烧伤(42例)、创伤(19例)、烫伤(12例)。病变最常见于小腿(31例),其次为大腿(11例)、足跟(11例);溃疡面积为1.5～600.0 cm2。其中鳞状细胞癌80例、疣状癌8例、肉瘤1例。术前发现腹股沟淋巴结肿大78例,行腹股沟淋巴结清扫49例,单纯淋巴结活检、切除29例;9例发现淋巴结转移,8例有骨质侵犯;24例行截肢术,53例行病灶扩大切除皮片移植术,12例行病灶扩大切除皮瓣修复术。65例得到随访,8例出现复发,其中截肢者2例,扩大切除者6例,且肿瘤复发与手术方式无关(P>0.05)。结论:下肢瘢痕癌复发转移率较高,需早期发现、早期诊断,应尽早手术治疗并定期随访;腹股沟淋巴结肿大较常见,需行淋巴结活检、切除或清扫;局部扩大切除、植皮或皮瓣修复是其主要治疗方法,但癌肿较大、侵犯较深且下肢瘢痕广泛、畸形严重者可考虑截肢。
Objective: To summarize the clinical features of Marjolin's ulcers in lower limbs and the diagnosis and treatment meth ods for it.Methods: The clinical data of 89 patients with lower limbs Marjolin's ulcers, who were treated in Xiangya Hospital, Central South University from Jan 1998 to Dec 2017, were retrospectively analyzed, including demographics, injury factors, length of cancer incubation period, lesion location, ulcer area, path ological type, bone invasion, lymph node metastasis, surgical meth ods, repair methods and prognosis.Results: There were 70 males and 19 females among 89 patients with lower limbs Marjolin's ulcers. The most common injuries were flame burn(42 cases), trauma(19 cases), and burns(12 cases). The lesions were most common in the lower leg(31 cases), followed by the th igh(11 cases) and the heel(11 cases). The ulcer area was 1.5–600.0 cm2. There were 80 cases of squamous cell carcinoma, 8 cases of verrucous carcinoma, and 1 case of sarcoma. Before operation, 78 cases of inguinal lymphadenectasis were found, 49 cases of inguinal lymph node dissection, 29 cases of simple lymph node biopsy and resection, and 9 cases of lymph node metastasis and 8 cases of bone invasion were observed; 24 cases of amputation, 53 cases of extended resection and skin grafts, and 12 patients of extensive resection and flap transplantation were performed. Sixty-five cases were followed up, and 8 cases recurred, including 2 cases of amputation patients and 6 cases of extended resection patients. There was no relationship between recurrence of tumors and surgical meth ods(P>0.05).Conclusion: The recurrence and metastasis rate of Marjolin's ulcers in lower limbs is high, requiring early detection, early diagnosis, early surgical treatment and regular follow-up. Lnguinal lymphadenectasis is more common and requires lymph node biopsy and lymphadenectomy, or lymph node dissection. Extended local resection, skin graft or flap repair is the main treatment meth ods. However, amputation can be considered if the cancer is big, the invasion is deep, and the lower extremity scar is extensive and combined with severe deformity.
Objective: To summarize the clinical features of Marjolin's ulcers in lower limbs and the diagnosis and treatment meth ods for it.Methods: The clinical data of 89 patients with lower limbs Marjolin's ulcers, who were treated in Xiangya Hospital, Central South University from Jan 1998 to Dec 2017, were retrospectively analyzed, including demographics, injury factors, length of cancer incubation period, lesion location, ulcer area, path ological type, bone invasion, lymph node metastasis, surgical meth ods, repair methods and prognosis.Results: There were 70 males and 19 females among 89 patients with lower limbs Marjolin's ulcers. The most common injuries were flame burn(42 cases), trauma(19 cases), and burns(12 cases). The lesions were most common in the lower leg(31 cases), followed by the th igh(11 cases) and the heel(11 cases). The ulcer area was 1.5–600.0 cm2. There were 80 cases of squamous cell carcinoma, 8 cases of verrucous carcinoma, and 1 case of sarcoma. Before operation, 78 cases of inguinal lymphadenectasis were found, 49 cases of inguinal lymph node dissection, 29 cases of simple lymph node biopsy and resection, and 9 cases of lymph node metastasis and 8 cases of bone invasion were observed; 24 cases of amputation, 53 cases of extended resection and skin grafts, and 12 patients of extensive resection and flap transplantation were performed. Sixty-five cases were followed up, and 8 cases recurred, including 2 cases of amputation patients and 6 cases of extended resection patients. There was no relationship between recurrence of tumors and surgical meth ods(P>0.05).Conclusion: The recurrence and metastasis rate of Marjolin's ulcers in lower limbs is high, requiring early detection, early diagnosis, early surgical treatment and regular follow-up. Lnguinal lymphadenectasis is more common and requires lymph node biopsy and lymphadenectomy, or lymph node dissection. Extended local resection, skin graft or flap repair is the main treatment meth ods. However, amputation can be considered if the cancer is big, the invasion is deep, and the lower extremity scar is extensive and combined with severe deformity.
引文
[1]刘赞,周宇翔,张丕红,等.187例瘢痕癌患者临床特点分析[J].中华烧伤杂志,2016,32(5):293-298.LIU Zan,ZHOU Yuxiang,ZHANG Pihong,et al.Analysis of clinical characteristics of 187 patients with Marjolin’s ulcers[J].Chinese Journal of Burns,2016,32(5):293-298.
[2]Sharma A,Schwartz RA,Swan KG.Marjolin's warty ulcer[J].J Surg Oncol,2011,103(2):193-195.
[3]徐泽华,肖美萍,杨木兰,等.瘢痕溃疡34例临床分析[J].当代医学,2010,16(12):76.XU Zehua,XIAO Meiping,YANG Mulan,et al.Clinical analysis of34 cases of scar ulcers[J].Contemporary Medicine,2010,16(12):76.
[4]龙忠恒,谢卫国.瘢痕癌研究进展[J].中华烧伤杂志,2014,30(6):495-499.LONG Zhongheng,XIE Weiguo.Advances in the research of Marjolin’s ulcer[J].Chinese Journal of Burns,2014,30(6):495-499.
[5]Baskara A,Sikka L,Khan F,et al.Development of a Marjolin’s ulcer with in 9 month s in a plantar pressure ulcer[J].Eur J Dermatol,2010,20(2):225.
[6]Metwally IH,Roshdy A,Saleh SS,et al.Epidemiology and predictors of recurrence of Marjolin’s ulcer:experience from Mansoura University[J].Ann R Coll Surg Engl,2017,99(3):245-249.
[7]Venkatswami S,Anandan S,Krishna N,et al.Squamous cell carcinoma masquerading as a trophic ulcer in a patient with Hansen’s disease[J].Int J Low Extrem Wounds,2010,9(4):163-165.
[8]Pekarek B,Buck S,Osher L.A comprehensive review on Marjolin’s ulcers:Diagnosis and treatment[J].J Am Col Certif Wound Spec,2011,3(3):60-64.
[9]Kowal-Vern A,Criswell BK.Burn scar neoplasms:A literature review and statistical analysis[J].Burns,2005,31(4):403-413.
[10]叶子青,谢卫国,龙忠恒,等.21例瘢痕癌患者诊疗分析[J].中华烧伤杂志,2014,30(6):491-494.YE Ziqing,XIE Weiguo,LONG Zhongheng,et al.Analysis of diagnosis and management of 21 patients with Marjolin’s ulcers[J].Chinese Journal of Burns,2014,30(6):491-494.
[11]Saaiq M,Ashraf B.Marjolin’s ulcers in the post-burned lesions and scars[J].World J Clin Cases,2014,2(10):507-514.
[12]Chalya PL,Mabula JB,Rambau P,et al.Marjolin’s ulcers at a university teaching hospital in North western Tanzania:a retrospective review of 56 cases[J].World J Surg Oncol,2012,10:38.
[13]Bauer T,David T,Rimareix T,et al.Marjolin’s ulcer in chronic osteomyelitis:seven cases and a review of the literature[J].Rev Chir Orth op Reparatrice Appar Mot,2007,93(1):63-71.
[14]Ogawa B,Chen M,Margolis J,et al.Marjolin’s ulcer arising at the elbow:A case report and literature review[J].Hand,2016,1(2):89-93.
[15]Aydo?du E,Yildirim S,Ak?z T.Is surgery an effective and adequate treatment in advanced Marjolin’s ulcer?[J].Burns,2005,31(4):421-431.
[16]沈锐,张金明,张凤刚,等.51例Marjolin’s溃疡临床特点与治疗分析[J].中华损伤与修复杂志(电子版),2015,10(5):32-37.SHEN Rui,ZHANG Jinming,ZHANG Fenggang,et al.Clinical characteristics and therapeutic analysis of 51 patients with Marjolin’s ulcers[J].Chinese Journal of Injury Repair and Wound Healing.Electronic Edition,2015,10(5):32-37.
[17]Agale SV,Kulkarni DR,Valand AG,et al.Marjolin’s ulcer:Adiagnostic dilemma[R].J Asso Physicians India,2009,57(8):593-594.
[18]Das KK,Chakaraborty A,Rahman A,et al.Incidences of malignancy in chronic burn scar ulcers:experience from Bangladesh[J].Burns,2015,41(5):1315-1321.
[2]Sharma A,Schwartz RA,Swan KG.Marjolin's warty ulcer[J].J Surg Oncol,2011,103(2):193-195.
[3]徐泽华,肖美萍,杨木兰,等.瘢痕溃疡34例临床分析[J].当代医学,2010,16(12):76.XU Zehua,XIAO Meiping,YANG Mulan,et al.Clinical analysis of34 cases of scar ulcers[J].Contemporary Medicine,2010,16(12):76.
[4]龙忠恒,谢卫国.瘢痕癌研究进展[J].中华烧伤杂志,2014,30(6):495-499.LONG Zhongheng,XIE Weiguo.Advances in the research of Marjolin’s ulcer[J].Chinese Journal of Burns,2014,30(6):495-499.
[5]Baskara A,Sikka L,Khan F,et al.Development of a Marjolin’s ulcer with in 9 month s in a plantar pressure ulcer[J].Eur J Dermatol,2010,20(2):225.
[6]Metwally IH,Roshdy A,Saleh SS,et al.Epidemiology and predictors of recurrence of Marjolin’s ulcer:experience from Mansoura University[J].Ann R Coll Surg Engl,2017,99(3):245-249.
[7]Venkatswami S,Anandan S,Krishna N,et al.Squamous cell carcinoma masquerading as a trophic ulcer in a patient with Hansen’s disease[J].Int J Low Extrem Wounds,2010,9(4):163-165.
[8]Pekarek B,Buck S,Osher L.A comprehensive review on Marjolin’s ulcers:Diagnosis and treatment[J].J Am Col Certif Wound Spec,2011,3(3):60-64.
[9]Kowal-Vern A,Criswell BK.Burn scar neoplasms:A literature review and statistical analysis[J].Burns,2005,31(4):403-413.
[10]叶子青,谢卫国,龙忠恒,等.21例瘢痕癌患者诊疗分析[J].中华烧伤杂志,2014,30(6):491-494.YE Ziqing,XIE Weiguo,LONG Zhongheng,et al.Analysis of diagnosis and management of 21 patients with Marjolin’s ulcers[J].Chinese Journal of Burns,2014,30(6):491-494.
[11]Saaiq M,Ashraf B.Marjolin’s ulcers in the post-burned lesions and scars[J].World J Clin Cases,2014,2(10):507-514.
[12]Chalya PL,Mabula JB,Rambau P,et al.Marjolin’s ulcers at a university teaching hospital in North western Tanzania:a retrospective review of 56 cases[J].World J Surg Oncol,2012,10:38.
[13]Bauer T,David T,Rimareix T,et al.Marjolin’s ulcer in chronic osteomyelitis:seven cases and a review of the literature[J].Rev Chir Orth op Reparatrice Appar Mot,2007,93(1):63-71.
[14]Ogawa B,Chen M,Margolis J,et al.Marjolin’s ulcer arising at the elbow:A case report and literature review[J].Hand,2016,1(2):89-93.
[15]Aydo?du E,Yildirim S,Ak?z T.Is surgery an effective and adequate treatment in advanced Marjolin’s ulcer?[J].Burns,2005,31(4):421-431.
[16]沈锐,张金明,张凤刚,等.51例Marjolin’s溃疡临床特点与治疗分析[J].中华损伤与修复杂志(电子版),2015,10(5):32-37.SHEN Rui,ZHANG Jinming,ZHANG Fenggang,et al.Clinical characteristics and therapeutic analysis of 51 patients with Marjolin’s ulcers[J].Chinese Journal of Injury Repair and Wound Healing.Electronic Edition,2015,10(5):32-37.
[17]Agale SV,Kulkarni DR,Valand AG,et al.Marjolin’s ulcer:Adiagnostic dilemma[R].J Asso Physicians India,2009,57(8):593-594.
[18]Das KK,Chakaraborty A,Rahman A,et al.Incidences of malignancy in chronic burn scar ulcers:experience from Bangladesh[J].Burns,2015,41(5):1315-1321.