CAJ | 학술논문

目的：探讨不同组织学类型骨肉瘤应用不同穿刺活检方法行术前病理诊断的确切程度的差异，以及术前穿刺活检病理诊断准确性对骨肉瘤患者预后的影响。方法收集347例术前曾行穿刺活检、术后病理诊断证实为骨肉瘤，且临床、影像学资料完整的病例。参照病理诊断与技术规范，将术前穿刺活检病理诊断的确切程度分为6级，1级：明确病理诊断；2级：基本明确病理诊断；3级：具重要参考意义的病理诊断；4级：描述性病理诊断；5级：未穿刺到有效成分；6级：病理误诊。1～3级为诊断准确，4～6级为诊断不准确。结果347例骨肉瘤患者，术前252例由放射科医师在CT引导下行穿刺活检，95例由骨科医师在麻醉后目视下行粗针穿刺活检。目视下行粗针穿刺活检病理诊断的准确率（97.9％）高于CT引导下行穿刺活检（91.7％）。普通型骨肉瘤穿刺活检病理诊断准确率较高（95.4％），血管扩张型骨肉瘤和髓内高分化骨肉瘤穿刺活检准确率较低（55.6％和63.7％）。穿刺活检病理诊断确切程度与患者年龄、血清碱性磷酸酶水平、影像学诊断、穿刺方式和骨肉瘤组织学类型相关。随访结果表明术前穿刺活检病理诊断准确和不准确病例组相比，术后复发率和病死率差异有统计学意义（ P＜0.01）。结论穿刺活检病理诊断的确切程度关系到骨肉瘤患者术后病死率和复发率，位于四肢长骨的骨肉瘤，医师目视下粗针穿刺活检＋冷冻切片初诊＋常规病理复诊是可靠而安全的方法。穿刺活检的病理诊断如能密切结合临床和影像学资料能将病理诊断确切程度提升1～3级。
목적：탐토불동조직학류형골육류응용불동천자활검방법행술전병리진단적학절정도적차이，이급술전천자활검병리진단준학성대골육류환자예후적영향。방법수집347례술전증행천자활검、술후병리진단증실위골육류，차림상、영상학자료완정적병례。삼조병리진단여기술규범，장술전천자활검병리진단적학절정도분위6급，1급：명학병리진단；2급：기본명학병리진단；3급：구중요삼고의의적병리진단；4급：묘술성병리진단；5급：미천자도유효성분；6급：병리오진。1～3급위진단준학，4～6급위진단불준학。결과347례골육류환자，술전252례유방사과의사재CT인도하행천자활검，95례유골과의사재마취후목시하행조침천자활검。목시하행조침천자활검병리진단적준학솔（97.9％）고우CT인도하행천자활검（91.7％）。보통형골육류천자활검병리진단준학솔교고（95.4％），혈관확장형골육류화수내고분화골육류천자활검준학솔교저（55.6％화63.7％）。천자활검병리진단학절정도여환자년령、혈청감성린산매수평、영상학진단、천자방식화골육류조직학류형상관。수방결과표명술전천자활검병리진단준학화불준학병례조상비，술후복발솔화병사솔차이유통계학의의（ P＜0.01）。결론천자활검병리진단적학절정도관계도골육류환자술후병사솔화복발솔，위우사지장골적골육류，의사목시하조침천자활검＋냉동절편초진＋상규병리복진시가고이안전적방법。천자활검적병리진단여능밀절결합림상화영상학자료능장병리진단학절정도제승1～3급。
Objective To study the difference in pathologic diagnostic accuracy among different histologic subtypes of osteosarcoma and different methods of preoperative biopsy, and the influence of diagnostic accuracy on prognosis of osteosarcoma.Methods The preoperative biopsies, complete clinical, radiological and pathological data of 347 pathologically confirmed osteosarcomas were evaluated.According to the Pathological Diagnostic and Technical Specifications, the accuracy of preoperative biopsies was divided into 6 grades.1:definite diagnosis, 2:basically definite diagnosis, 3:significant diagnosis, 4:descriptive diagnosis, 5:inadequate sampling, 6:misdiagnosis.1 to 3 were defined as successful diagnosis,while 4 to 6 were defined as unsuccessful diagnosis.Results Of the 347 biopsies, 252 were CT-guided needle biopsies by the radiologists, and 95 were core-needle biopsies by orthopedic surgeons without CT-guidance.The latter showed a higher overall biopsy success rate (97.9%) in all osteosarcomas.Biopsies by surgeons showed a higher biopsy success rate (95.4%) in conventional osteosarcoma, but lower success rate in telangiectatic ( 55.6%) and low-grade central osteosarcomas ( 63.7%) . The accuracy of pathologic diagnosis of preoperative biopsy was related to patients′age, serum AKP level, imaging diagnosis, method of biopsy and the subtype of osteosarcoma.Comparing the groups with successful and unsuccessful diagnosis, there were significant differences in recurrence rate and mortality after operation ( P <0.01 ) .Conclusions The accuracy of pathologic diagnosis of preoperative biopsy are related to recurrence rate and mortality after operation.Biopsy by orthopedic surgeons without CT-guidance is reliable and safe, followed by primary diagnosis at frozen section and final diagnosis by routine pathologic sections for osteosarcomas located in the long bones of the extremities.Close integration of the preoperative pathologic diagnosis with clinical and radiological data will improve the accuracy of diagnosis.