03-01-이승환

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1 대한골관절종양학회지 J. of Korean Bone & Joint Tumor Soc. Volume 14, Number 1, June, 2008 연골모세포종 - 골단과견인골단의비교 - 연세대학교의과대학정형외과학교실 이승환 이모세 신규호 한수봉 목적 : 연골모세포종은드문원발성양성골종양으로대부분이장관골의골단에호발하는것으로알려져있다. 본연구에서는 19 례의환자를대상으로골단과견인골단에발생한연골모세포종을비교분석하고자하였다. 대상및방법 : 1987년 8월부터 2005년 8월까지연골모세포종으로치료받은 19 례의환자를대상으로하였으며평균추시기간은 5년이었다. 발생연령은평균 17.6세였으며남자가 15 명, 여자가 4명이었다. 수술적치료로는소파술, 소파술및골이식술, 소파술및시멘트충전술을시행하였다. 후향적연구방법을통해골단과견인골단에발생한연골모세포종에서발생연령, 증상의기간, 종양의크기, 성장판의개폐여부, 병적골절여부, 재발여부및동맥류성골낭종의동반여부등의차이를분석하였다. 결과 : 발생부위는골단이 11 례, 견인골단이 8례였다. 골단에발생한경우는대퇴골원위부가, 견인골단은대퇴골대전자가가장많았다. 평균발생연령은골단이 14.2세, 견인골단이 22.3 세로통계적으로유의한차이를보였다. 골단에발생한 11 례중 3례에서는성장판유합후에발생하였으며, 견인골단에서는전례 (100%) 에서유합후에발생하여통계적으로유의한차이가있었다. 종양의크기는견인골단에발생한경우통계적으로유의하게큰것으로나타났다. 결론 : 연골모세포종은주로장관골의골단에호발하는것으로알려져있으나 20 세이상에서는견인골단에서주로발생하여진단에주의를요한다. 두그룹간발생연령, 성장판의개폐여부및종양의크기가통계적으로유의한차이가있었으며증상의기간, 병적골절, 재발, 동맥류성골낭종의동반여부에는차이가없는것으로나타났다. 색인단어 : 연골모세포종, 골단, 견인골단 통신저자 : 신규호서울특별시서대문구신촌동 134 연세대학교의과대학정형외과학교실 Tel: 02) , Fax: 02) , qshin@yuhs.ac * 본논문의요지는 2008 년도대한골관절종양학회춘계학술대회에서발표되었음. 17

2 대한골관절종양학회지 : 제 14 권제 1 호 2008 년 서론연골모세포종은전체골종양의 1~2% 를차지하는비교적드문양성골종양으로, 10대의남성에호발하는것으로알려져있다 2,4,5,7). 발생부위는연골내골화가일어나는이차골화중심이있는곳은어디나발생할수있으며주로장관골의골단에호발하나견인골단에는비교적드물게발생하는것으로알려져있다. 연골모세포종의국소재발및예후에관련된연구보고는많으나골단과견인골단의발생부위에따른임상적방사선학적특징을비교한연구는없었다. 본연구에서는 1987년 8월부터 2005년 8월까지연골모세포종으로수술적치료를시행받은 19 명의환자를대상으로골단및견인골단에발생한연골모세포종의임상적및방사선학적특징을비교하고자하였다. 연구대상및방법 1. 연구대상 1987년 8월부터 2005년 8월까지연골모세포종으로치료받은 26 명의환자중최소 2년이상추시관찰이가능했던 19 명의환자를대상으로하였다. 발생연령은평균 17.6 세 (5~32) 였으며남자가 15 명 (79%), 여자가 4명 (21%) 이었다. 19례중골단이 11 례 (58%), 견인골단이 8례 (42%) 였다. 2. 방법모든환자에대해의무기록을통해발병시의연 령, 성별, 내원시의증상및이환기간, 수술방법및재발여부를조사하였다. 내원시방사선학적검사를통해발생부위, 성장판의개폐여부, 종양의크기, 병적골절의동반여부를조사하였다. 종양의크기는자기공명영상에서가로, 세로및높이의최대길이 (cm) 를측정하여평균을낸값을세제곱하여부피 (cc) 를구하였다. 재발은수술후추시중에방사선학적으로골용해성병변이나타나재수술을시행하여병리학적으로증명된경우를국소재발로판정하였다. 전례의환자에서수술적치료를시행하였으며자기공명영상에서측정한평균직경이 2 cm 미만인경우단독소파술을, 5 cm 미만에서는소파술및골이식술을, 5 cm 이상에서는소파술및골시멘트삽입술을시행하였다. 소파술시행부위에는 high speed burring을시행하였으며, 성장판이폐쇄된후에발생한병변에대해서는전기소작술을추가로시행하였다. 병적골절이있는 3례의환자에서는내고정술을시행하였다. 통계학적분석은 Statistical Product and Service solution (SPSS, version 10) 를이용하여 Wilcoson rank sum test와 Fisher s exact test 를통해두그룹간에발생연령, 증상의기간, 종양의크기, 성장판의개폐여부, 병적골절여부, 재발여부및동맥류성골낭종의동반여부등의차이를분석하으며, P-value가 0.05 이하인경우통계적으로유의한것으로간주하였다. 결과평균발생연령은골단군에서 14.2 세, 견인골단군에서 22.3세로견인골단군에서유의하게높은것 Table 1. Comparison of chondroblastoma on epiphysis and apophysis Epiphysis Apophysis P-value Age (years) Volume of tumor (cc) Physeal closure (%) Duration of Symptom (months) >0.05 Pathologic Fracture 0 3 >0.05 Aneurysmal bone cyst 0 2 >0.05 Recurrence (%) >

ulnar 1 Total 8 A Fig. 1. A 5-year-old girl with left hip pain. (A) Preoperative hip anterior-posterior view and axial view shows chondroblastoma at epiphysis of the femoral head.

3 이승환외 : 연골모세포종 - 골단과견인골단의비교 - Table 2. Site of chondroblastoma of epiphyseal origin Table 3. Site of chondroblastoma of apophyseal origin Site Number Site Number Proximal tibia 4 Distal femur 4 Proximal femur 2 Proximal humerus 1 Total 11 Greater trochanter of femur 6 Calcaneus 1 Proximal ulnar 1 Total 8 A Fig. 1. A 5-year-old girl with left hip pain. (A) Preoperative hip anterior-posterior view and axial view shows chondroblastoma at epiphysis of the femoral head. (B) Postoperative hip anterior-posterior view and axial view after 3 years shows healing status of chondroblastoma after curettage and bone grafting. B A Fig. 2. A 10-year-old boy with right knee pain. (A) Preoperative knee anterior-posterior view and lateral view shows chondroblastoma at epiphysis of the distal femur. (B) Postoperative knee anterior-posterior view and lateral view after 3 years shows healing status of chondroblastoma after curettage. B 으로나타났다. 20세이상의환자의경우에도골단군에서 18%, 견인골단군에서 75% 를차지하여통 계적으로유의한차이가있었다. 성장판의경우골단군은 3례 (27%) 에서폐쇄후에발생하였으나견인 19

대한골관절종양학회지 : 제 14 권제 1 호 2008 년 골단군의경우전례에서성장판폐쇄후에발생하여통계적으로유의한차이가있었다. 종양의크기는견인골단군에서통계적으로유의하게큰것으로나타났다. 병적골절의경우견인골단군에서 3례있었으나통계적으로유의한차이는없었다. 그외에증상의이환기간, 재발및동맥류성골낭종의동반여부는통계적으로유의한차이는없었다 (Table 1).

수술방법은골단군은 4례에서단독소파술로치료하였으며, 6례에서소파술및골이식술을, 1례에서소파술및골시멘트삽입술을시행하였다. 성장판폐쇄후에대퇴골두골단에발생한 1례에서소파술 A B C D Fig. 3. A 25-year-old woman with right hip pain.

4 대한골관절종양학회지 : 제 14 권제 1 호 2008 년 골단군의경우전례에서성장판폐쇄후에발생하여통계적으로유의한차이가있었다. 종양의크기는견인골단군에서통계적으로유의하게큰것으로나타났다. 병적골절의경우견인골단군에서 3례있었으나통계적으로유의한차이는없었다. 그외에증상의이환기간, 재발및동맥류성골낭종의동반여부는통계적으로유의한차이는없었다 (Table 1). 재발은견인골단및골단군에각각 1례씩있었으며, 동맥류성골낭종은대퇴골대전자부및종골에발생한연골모세포종에서각각 1례씩동반되었다. 발생부위는골단군에서는대퇴골원위부및경골근위부에각각 4례로가장많이발생하였으며대퇴골근위부골단에 2례, 상완골근위부에 1례가있었다. 견인골단군의경우대퇴골대전자부위가 6례로가장많았으며종골에 1례, 척골근위부에 1례가있었다 (Table 2,3). 수술방법은골단군은 4례에서단독소파술로치료하였으며, 6례에서소파술및골이식술을, 1례에서소파술및골시멘트삽입술을시행하였다. 성장판폐쇄후에대퇴골두골단에발생한 1례에서소파술 A B C D Fig. 3. A 25-year-old woman with right hip pain. (A) Preoperative hip anterior-posterior view shows chondroblastoma at epiphysis of the femoral head. (B) Postoperative hip anterior-posterior view after 12 months shows healing status of chondroblastoma after curettage and bone graft. (C) Postoperative hip anterior-posterior view after 27 months shows newly developed radiolucent lesion at the femoral neck. (D) Postoperative hip anteriorposterior view after 5 years shows healing status of chondroblastoma after curettage, cementation and internal fixation with dynamic hip screw. A Fig. 4. A 28-year-old man with left hip pain. (A) Preoperative hip anterior-posterior view and axial view shows chondroblastoma at greater trochanter of the femur. (B) Postoperative hip anterior-posterior view and axial view after 6 years shows healing status of chondroblastoma after curettage, cementation and internal fixation with proximal femoral intramedullary nail. B 20

$(B) Preoperative calcaneal lateral view shows pathologic fracture of calcaneal tuberosity.$ (C) Postoperative calcaneal lateral view shows reduction status of calcaneus after curettage, bone grafting and percutaneous pinning with 2 Kirschner s wires.

(C) Postoperative calcaneal lateral view shows reduction status of calcaneus after curettage, bone grafting and percutaneous pinning with 2 Kirschner s wires.

5 이승환외 : 연골모세포종 - 골단과견인골단의비교 - A B C D Fig. 5. A 15-year-old man with left heel pain. (A) Preoperative calcaneal lateral view shows chondroblastoma at apophysis of the calcaneus. (B) Preoperative calcaneal lateral view shows pathologic fracture of calcaneal tuberosity. (C) Postoperative calcaneal lateral view shows reduction status of calcaneus after curettage, bone grafting and percutaneous pinning with 2 Kirschner s wires. (D) Postoperative calcaneal lateral view after 3 years shows healing status of chondroblastma. 하였으며대퇴골대전자에발생한 1례에서는예방적으로내고정술을시행하였다 (Fig 4,5,6). 대퇴골대전자부에발생한 1례에서소파술및골이식술로치료후 50 개월째에재발하여철저한소파술및골시멘트삽입술을시행하였다 (Table 4). A Fig. 6. A 16-year-old woman with left elbow pain. (A) Preoperative elbow lateral view shows chondroblastoma at apophysis of the proximal ulnar. (B) Postoperative elbow lateral view after 3 years shows healing status of chondroblastoma. Table 4. Operative methods 및골이식술로치료후 27 개월째에재발하였으며, 병변이대퇴경부까지확장되어철저한소파술, 골시멘트삽입술및내고정술을시행하였다 (Fig. 1,2,3). 견인골단군의경우비교적종양의크기가커서단독소파술만시행한환자는없었고, 소파술및골이식술을 4례, 소파술및골시멘트삽입술을 4 례에서시행하였다. 대퇴골대전자부위에발생한환자중 2례에서, 그리고종골에서발생한 1례에서병적골절이동반되어추가적으로내고정술을시행 B Methods Epiphysis Apophysis Curettage only 4 0 Curettage and bone graft 5 4 Curettage and cementation 2 4 Total 11 8 고찰연골모세포종은장관골의골단에 10대의남성에서호발하는것으로알려져있다. 그러나최근국내의보고에서이등 11) 은우리나라의경우연골모세포종의발생연령이평균 20 세였고 67% 에서성장판유합후에발생하였다고보고한바있다. 본연구에서는전체환자에서평균발생연령은 17.6세였으며, 58% 정도에서성장판유합후에발생하였다. 골단에발생한연골모세포종의경우평균발생연령이 14.2 세였으며대부분이남자에서, 72% 가성장판유합전에발생하였다. 발생부위는상완골근위부, 대퇴골근위부및대퇴골원위부가호발부위로알려져있으나 2) 본연구에서는상완골근위부의발생빈도가타부위에비해낮았다. 견인골단에발생한연골모세포종의경우평균발생연령이 22.3 세로골단에발생한경우와비교하여통계적으로유의하게연령이높았으며모든예에서성장판유합후에발생하였다. 대부분남자에서발생하여성별에유의한차이는없었다. 골단에발생한연골모세포종은 10 대에서성장판유합전에주로발생하나견인골단에발생하는경우발생연령이높고대부분성장판유합후에발생하여두군간의 21

6 대한골관절종양학회지 : 제 14 권제 1 호 2008 년 다른특징을보였다. 연골모세포종은상완골근위부, 대퇴골근위부및대퇴골원위부에서가장호발하는것으로알려져있으며 2), 비전형적인발생부위에대한연구보고중 Zhonghua 12) 는장관골이외의부위는족부가가장흔하며평균발병연령이 27.8세로높았으며절반이상에서골낭종성변화가동반되어발병연령, 방사선학적및병리학적소견이전형적인부위에생긴예와다르다고보고한바있다. 본연구에서는견인골단군에서대퇴골대전자부위가가장흔한것으로나타났으며방사선학적으로종양의크기가골단군보다유의하게큰것으로나타났다. 견인골단군에서는대부분이성장판유합후에발생하여종양성장의방어벽으로작용하는성장판이없어나타난결과로생각되나이에대한병리학적연구가필요할것으로사료된다. 국소재발의경우 10~35% 정도로보고되고있으며 1,8,10), 본연구에서는전체환자 19 례중 2례, 11% 로다른보고들과유사한결과를보였으며원격전이는없었다. 성장판이열려있는경우재발률이높다는보고도있었는데 2,3,4), 이는성장판에손상위험때문에충분한소파술을시행할수없기때문이라는가설이제시된바있다 9). 본연구에서는대부분성장판이열려있을때연골모세포종이발생한골단군 (11 례중 8례 ) 과성장판이모두폐쇄후에발생한견인골단군간에재발률에유의한차이는없는것으로나타났다. 동맥류성골낭종은연골모세포종의 10~15% 정도에서동반되는것으로보고되고있으며 3,4), 이경우재발의위험이높다는보고가있으나이에대해서는논란의여지가있었다 6,8). 본연구에서는동맥류성골낭종이 19 례중 2례 (11%) 에서동반되었으며모두견인골단군에서발생하였으나두군간의통계적인차이는없었으며, 위의 2례에서재발은없었다. 견인골단에발생하는연골모세포종은골단의연골모세포종에비하여비교적늦은나이에발생하고, 대부분이성장판의유합후에생기고, 종양의크기가비교적큰것으로나타나임상적및방사선학적으로다른특징을보였다. 국소재발등의치료결과에유의한차이는없었으나견인골단에골종양병변이발생시에는연골모세포종의가능성을고려하여이에대한적절한진단과치료가필요할것으로 생각된다. 결 연골모세포종은주로장관골의골단에호발하는것으로알려져있으나 20 세이상의비교적고연령에서는견인골단에서주로발생하여진단에주의를요한다. 두그룹간에는발생연령, 성장판의개폐여부및종양의크기가통계적으로차이가있었으며증상의기간, 병적골절, 재발, 동맥류성골낭종의동반여부에는차이가없는것으로나타났다. 론 REFERENCES 01) Bloem JL, Mulder JD: Chondroblastoma: a clinical and radiological study of 104 cases. Skeletal Radiol, 14:1-9, ) Campanacci, M: Bone and Soft Tissue Tumors: Clinical Features, Imaging, Pathology and Treatment. 2nd ed, New York, , Springer, ) Crim JR, Gold RH, Mirra JM and Eckardt J: Case report 748: chondroblastoma of the femur with an aneurysmal bone cyst. Skel Radiol, 21: , ) Dahlin DC and Ivins JC: Benign chondroblastoma. A study of 125 cases. Cancer, 30: , ) Fink BR, Temple HT, Chiricosta FM, Mizel MS and Murphey MD: Chondroblas-toma of the foot. Foot and Ankle Internat, 18: , ) Huvos AG, Marcove RC: Chondroblastoma of bone. A critical review. Clin Orthop Relat Res, , ) Jaffe HL and Lichtenstein L: Benign chondroblastoma of bone. A reinterpretation of the so-called calcifying or chondromatous giant cell tumor. Am J Pathol, 18: , ) Ramappa AJ, Lee FY, Tang P, Carlson JR, Gebhardt MC, Mankin HJ: Chondroblastoma of bone. J Bone Joint Surg Am, 82-A: , ) Springfield DS, Capanna R, Gherlinzoni F, Picci P and Campanacci M: Chondroblastoma. A review of seventy cases. J Bone and Joint Surg, 67- A: , June ) Turcotte RE, Kurt AM, Sim FH, Unni KK,McLeod RA: Chondroblastoma. Hum Pathol, 22

7 이승환외 : 연골모세포종 - 골단과견인골단의비교 - 24: , ) Lee YK, Han IK, Oh JH, Lee SH, Kim HS: Treatment and prognosis of chondroblastoma. J of Korean Bone &Joint Tumor Soc, 13: 81-87, ) Zhonghua Bing Li Xue Za Zhi.: Chondroblastoma occurring in atypical site. Chinese J of Pathol, Dec;33(6):

8 대한골관절종양학회지 : 제 14 권제 1 호 2008 년 Abstract Chondroblastoma of Bone - Comparison of Epiphysis and Apophysis - Seung-Hwan Lee, M.D., Mo-Ses Lee, M.D., Kyoo-Ho Shin, M.D., Soo-Bong Hahn, M.D. Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea Purpose: Chondroblastoma is a rare benign bone tumor which occurs most frequently at epiphysis of long bones. This study analyzed the difference between patients with chondroblastoma either on their epiphysis or apophysis. Materials and Methods: We reviewed 19 patients with chondroblastoma who visited our hospital from August 1987 to August The mean follow up period was five years. Fifteen patients were male and 4 patients were female. The mean age of the patients was 17.6 years. The treatment consisted of either curettage alone, curettage with bone graft or curettage with cementation. We retrospectively compared the difference between one chondroblastoma originating from the epiphysis and the other chondroblastoma originating from the apophysis in terms of age predilection, duration of symptoms, size of tumor, status of the physis, presence of pathologic fracture, recurrence rate and accompanying aneurismal bone cyst. Results: Among the 19 patients, 11 patients had chondroblastoma at the epiphysis, and 8 at the apophysis. Distal femur was the most common site for epiphysis lesions while the greater trochanter was the most common site for lesions arising at the apophysis. The mean age was 14.2 years in the epiphysis group and 22.3 years in the apophysis group. Chondroblastoma occurred after closure of the physis in 3 out of 11 cases in the epiphysis group and in all 8 cases in the apophysis group showing a statistical significance between the groups in terms of status of the physis at onset. Size of the lesion was bigger in the apophysis group with statistical significance. Conclusion: Chondroblastoma is known to occur frequently at the epiphysis of long bones, but our study shows that in patients over 20 years old it occurs more frequently at the apophysis which needs to be considered when making the proper diagnosis. There was a significant difference between the two groups in terms of the age of occurrence, status of physis and size of tumor while there was none in terms of the duration of symptoms, presence of pathologic fracture, recurrence rate and presence of accompanying aneurismal bone cyst. Key Words: Chondroblastoma, Epiphysis, Apophysis Address reprint requests to Kyoo-Ho Shin, M.D. Department of Orthopaedic Surgery, Yonsei University College of Medicine, 134, Sinchon-dong, Seodaemun-gu, Seoul , Korea TEL: , FAX: , qshin@yuhs.ac 24

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical