目标:如本系列的第1部分所述,丘脑胶质瘤(TG)是根深蒂固的,难以进入的肿瘤被重要的神经血管结构包围。鉴于他们的高手术发病率,TG历来被认为是不可手术的病变。尽管最大安全切除(MSR)已成为大叶甚至深部中叶颞叶和岛叶胶质瘤的治疗标准,TG雄辩的位置排除了这种管理策略,以活检和辅助治疗为主.作者假设MSR可以实现低发病率和死亡率的TG,从而改善结果。
方法:对2006年至2020年的所有TG患者进行了回顾性单中心研究。临床,成像,并获得病理报告。进行单变量和多变量分析以确定预后变量。案例示例说明了对更复杂的TG进行分期切除的各种方法和基本原理。
结果:共有42例患者(26例男性,16名女性),其中12例儿科(29%),包括在内。他们的平均年龄为36.0±21.4(中位数30,范围3-73)岁。中位最大肿瘤直径为45(范围19-70)mm。18例患者(43%)曾进行过立体定向针吸肿瘤活检,最终诊断改变了7例(39%)的显微外科手术切除后。最常见的手术方法是经经胸(29%),前半球形经call骨(29%),和上顶叶小叶(25%)。总的来说,合并次全切除率和总切除率为95%(n=40).低度胶质瘤(LGG;I级和II级)占该组的三分之一,而一半的患者患有多形性胶质母细胞瘤。没有手术死亡。尽管在12例患者中观察到暂时性的术后运动障碍(28.6%),除1例(2.4%)外,术后早期均有改善,有轻度残余偏瘫.两名患者因脑积水需要分流脑脊液。LGG患者的2年总生存率为90%,高级别神经胶质瘤(HGG)患者为15%。多变量分析显示,组织学分级,年龄,和切除程度是与生存相关的独立预后因素。
结论:TG的管理具有挑战性,许多人避免切除,如果不是大多数,神经外科医生,特别是对于HGG。此处报告的结果表明,切除后的结果有所改善,尤其是年轻的LGG患者。因此,作者提倡使用精心计划的手术方法对一组TG患者进行MSR。当代术中辅助手段,细致的显微外科技术。
OBJECTIVE: As presented in Part 1 of this series, thalamic gliomas (TGs) are deep-seated, difficult-to-access tumors surrounded by vital neurovascular structures. Given their high operative morbidity, TGs have historically been considered inoperable lesions. Although maximal safe resection (MSR) has become the treatment standard for lobar and even deep-seated mediobasal temporal and insular gliomas, the eloquent location of TGs has precluded this management strategy, with biopsy and adjuvant treatment being the mainstay. The authors hypothesized that MSR can be achieved with low morbidity and mortality for TGs, thus resulting in improved outcomes.
METHODS: A retrospective single-center study was performed on all TG patients from 2006 to 2020. Clinical, imaging, and pathology reports were obtained. Univariate and multivariate analyses were performed to determine prognostic variables. Case examples illustrate various approaches and the rationale for staging resections of more complex TGs.
RESULTS: A total of 42 patients (26 males, 16 females), among them 12 pediatric (29%) cases, were included. Their mean age was 36.0 ± 21.4 (median 30, range 3-73) years. The median maximal tumor diameter was 45 (range 19-70) mm. Eighteen patients (43%) had a prior stereotactic needle tumor biopsy, with the ultimate diagnosis changed for 7 patients (39%) following microsurgical resection. The most common surgical approaches were transtemporal (29%), anterior interhemispheric transcallosal (29%), and superior parietal lobule (25%). Overall, the combined subtotal and gross-total resection rate was 95% (n = 40). Low-grade gliomas (LGGs; grades I and II) comprised one-third of the group, whereas half of the patients had glioblastoma multiforme. There were no operative mortalities. Although temporary postoperative motor deficits were observed in 12 patients (28.6%), all improved during the early postoperative period except 1 (2.4%), who had mild residual hemiparesis. Two patients required CSF diversion for hydrocephalus. The 2-year overall survival rate was 90% for LGG patients and 15% for high-grade glioma (HGG) patients. Multivariate analysis revealed that histological grade, age, and extent of resection were independent prognostic factors associated with survival.
CONCLUSIONS: Management of TGs is challenging, with resection avoided by many, if not most, neurosurgeons, especially for HGGs. The results reported here demonstrate improved outcomes with resection, particularly in younger LGG patients. The authors therefore advocate for MSR for a select cohort of TG patients using carefully planned surgical approaches, contemporary intraoperative adjuncts, and meticulous microsurgical techniques.