Analysis of clinical characteristics of 187 patients with Marjolin's ulcers
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摘要: 目的 分析瘢痕癌的病因学及临床特征,并探讨其防治方法。 方法 回顾性分析1998年1月—2015年5月中南大学湘雅医院烧伤重建外科收治的187例瘢痕癌患者的病历资料。统计患者性别、初始伤或原发病发生年龄、瘢痕癌发生年龄,初始伤或原发病、潜伏期长短、溃疡前期长短、溃疡后期长短、病变部位、病灶类型、病灶面积、局部瘢痕张力情况,组织病理学类型、细胞分化程度,骨侵犯及淋巴结病变情况,治疗方法及预后。对初始伤或原发病发生年龄与潜伏期长短、溃疡前期长短与溃疡后期长短进行Spearman相关分析,对复发情况行Fisher确切概率法检验。 结果 (1)本组患者男女比例约1.6∶1.0,初始伤或原发病发生年龄为0.17~78.00(17±18)岁,瘢痕癌发生年龄为18~84(49±14)岁。(2)本组患者初始伤最常见的为火焰烧伤。潜伏期0.25~74.00(32±16)年,溃疡前期0~73.00(26±19)年、溃疡后期0.08~59.00(6±11)年。病变部位常见于下肢及头面部,病灶类型以侵蚀性溃疡最为常见,病灶面积为1~625(69±110)cm2。初始伤或原发病发生年龄与潜伏期长短、溃疡前期长短与溃疡后期长短均呈明显负相关(
r 值分别为-0.71、-0.50,P 值均小于0.01)。176例患者病变周围存在张力较大的病理性瘢痕。(3)组织病理学类型以鳞状细胞癌为主,细胞高分化者居多。(4)本组患者有59例出现癌细胞骨侵犯,100例出现淋巴结肿大,18例出现癌细胞淋巴结转移。(5)本组患者中20例未行手术;167例采用手术治疗,以病灶扩大切除术为主。根据病灶扩大切除术后的创面情况,主要行皮片移植修复和局部皮瓣转移修复。139例行病灶扩大切除术患者创面绝大部分为一次性修复。104例随访患者中28例术后复发,头面部、上肢、下肢、臀部复发情况差异不明显(P >0.05),复发时间以愈后6个月以上为主。 结论 瘢痕癌患者初始伤或原发病发生年龄越小,经历的潜伏期越长;潜伏期内溃疡前期越短,溃疡后期则越长。瘢痕癌可能多发生于张力较大的瘢痕部位,提示尽早治疗高张力瘢痕与瘢痕溃疡是重要预防措施。手术扩大切除是治疗瘢痕癌的首选方法,术后有一定的复发率,应定期随访。Abstract: Objective To analyze the etiology and clinical characteristics of Marjolin's ulcer, and to explore its prevention and treatment. Methods Medical records of 187 patients with Marjolin's ulcers admitted to the Department of Burns and Reconstructive Surgery of Xiangya Hospital of Central South University from January 1998 to May 2015 were retrospectively analyzed, including gender, age of onset of initial injury or primary disease, age of onset of Marjolin's ulcer, initial injury or primary disease, length of latency, lengths of pre- and post-ulceration periods, lesion site, lesion type, lesion area, local scar tension, histopathological type, degree of carcinoma cell differentiation, bone invasion and lymphadenopathy, treatment, and prognosis. The relationships between the age of onset of initial injury or primary disease and the length of latency, and the length of pre-ulceration period and the length of post-ulceration period were assessed by Spearman correlation analysis. The recurrence rates were processed with Fisher's exact test. Results (1) Among the patients, the ratio of male to female was nearly 1.6∶1.0. The age of onset of initial injury or primary disease was 0.17-78.00 (17±18) years, and the age of onset of Marjolin's ulcers was 18-84 (49±14) years. (2) The most common initial injury among the patients was flame burn. The length of latency was 0.25-74.00 (32±16) years, and the lengths of pre- and post-ulceration periods were 0-73.00 (26±19) years and 0.08-59.00 (6±11) years respectively. The common lesion sites were the lower limbs and head and face. The rodent ulcer was the most common lesion type, and the lesion area was 1-625 (69±110) cm2. There were obviously negative correlations between the age of onset of initial injury or primary disease and the length of latency, as well as the length of pre-ulceration period and the length of post-ulceration period (withr values respectively -0.71 and -0.50,P values below 0.01). The pathological scars of strong tension around lesions were seen in 176 cases. (3) The major histopathological type was squamous cell carcinoma, with high cell differentiation in most cases. (4) Bone invasion of carcinoma cells was observed in 59 cases. Lymph node enlargement was observed in 100 cases, and lymph node metastasis was observed in 18 cases. (5) Twenty patients did not receive any surgery, while 167 patients were treated by surgery with lesion extended resection as the main method. According to the condition of wound after the lesion extended resection, the wounds were mainly repaired by skin grafting and transplantation of local skin flap. The majority of wounds in 139 patients who underwent lesion extended resection were repaired in one surgery. Twenty-eight patients out of 104 followed-up cases had recurrence after surgery, mainly seen on head and face, upper limb, lower limb, and buttock, and there was no significant difference among them (P >0.05). The recurrence time of most patients was longer than 6 months after cure. Conclusions Patients with Marjolin's ulcers in younger age of onset of initial injury or primary disease tend to have longer latency, during which the shorter the pre-ulceration period is, the longer the post-ulceration period will be. Marjolin's ulcers are prone to occur in scar sites with large tension. Early treatment of high tension scar and scar ulcer is important in prevention, and surgery is the optimal treatment for Marjolin's ulcers. Regular follow-up should be carried out owning to recurrence rate in certain degree after surgery.
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