目的:手术治疗中脑毛细胞星形细胞瘤(PA)仍然是一个巨大的挑战。为了促进决策并在中脑PA患者的管理中获得更好的结果,作者提出了一种新的中脑PAs的放射学分类,并进行了长期随访。
方法:57例于北京天坛医院接受手术治疗的中脑PA患者,首都医科大学,从2008年1月到2021年6月,进行了审查。根据MRI上确定的肿瘤位置和拓扑解剖变化,中脑PAs分为四种类型:硬(12/57,21.1%),tegmental(25/57,43.9%),导水管(5/57,8.8%),和tectal(15/57,26.3%)PA。相关的临床,放射学,收集和分析病理数据;手术程序和结果;以及长期结局.
结果:1-,3-,5年生存率达到98%,96%,96%,分别,66.7%的病例实现了全切除,随后在17.5%的病例中几乎全部切除。临床和放射学特征,手术方法的选择,每种类型之间的长期术后缺陷不同。农村PA与年轻年龄相关(中位数为9岁,IQR5.0-12.8年);最大的肿瘤体积(中位数31.9cm3,IQR17.2-42.6cm3);术前最低的Karnofsky性能量表(KPS)评分(中位数65,IQR50-70);术前最常见的运动缺陷(91.7%);混合的固体-囊性成分(75%);占据脚入池;丘脑抬高和前室(内侧和/或外侧移位);uncus,和前连合;最多样化的手术入路;更频繁地使用多模式图像引导手术(58.3%);并且在长期随访中KPS评分的改善最显着。TegmentalPA与青少年和年轻人相关(中位年龄21岁,IQR8-33年);肿瘤体积(中位数13.9cm3,IQR9.5-20.5cm3);良好的术前KPS评分(中位数80,IQR70-80);混合的实囊成分(72%);占用环境水箱和小脑中脑裂;与背桥关系密切,小脑上花梗,和后下第三脑室;永久性术后感觉障碍的可能性更高(40%)。导水管和顶管PAs与小肿瘤体积相关(分别为中位数9.14cm3,IQR5.1-17.4cm3和中位数11.84cm3,IQR5.7-18.3cm3),脑积水的比例更高(80%和86.7%,分别),和简单选择有限的手术方法。
结论:建立了中脑PAs的新颖而全面的放射学分类,这将成为患者管理的宝贵工具,并促进不同研究和出版物之间的统一沟通和比较。
OBJECTIVE: Surgery for midbrain pilocytic astrocytoma (PA) remains a formidable challenge. To facilitate decision-making and achieve a better outcome in the management of patients with midbrain PA, the authors have proposed a novel radiological classification of midbrain PAs with long-term follow-up.
METHODS: Fifty-seven midbrain PA patients who underwent surgery at Beijing Tiantan Hospital, Capital Medical University, from January 2008 to June 2021, were reviewed. Based on tumor location and the topological anatomical change identified on MRI, midbrain PAs were categorized into four types: crural (12/57, 21.1%), tegmental (25/57, 43.9%), aqueductal (5/57, 8.8%), and tectal (15/57, 26.3%) PAs. The relevant clinical, radiological, and pathological data; surgical procedures and results; and long-term outcomes were collected and analyzed.
RESULTS: The 1-, 3-, and 5-year survival rates reached 98%, 96%, and 96%, respectively, with gross-total resection achieved in 66.7% of cases, followed by near-total resection in 17.5% cases. The clinical and radiological features, selection of surgical approaches, and long-term postoperative deficits were distinct among each type. Crural PAs were associated with younger age (median 9 years, IQR 5.0-12.8 years); the largest tumor volume (median 31.9 cm3, IQR 17.2-42.6 cm3); the lowest preoperative Karnofsky Performance Scale (KPS) score (median 65, IQR 50-70); the most frequent preoperative motor deficit (91.7%); a mixed solid-cystic component (75%); occupation of the crural cistern; elevation and rotation of the thalamus (medial and/or lateral); displacement of the anterior third ventricle, uncus, and anterior commissure; the most diverse surgical approaches; more frequent use of multimodality image-guided surgery (58.3%); and the most remarkable improvement in KPS score at long-term follow-up. Tegmental PAs were associated with adolescents and young adults (median age 21 years, IQR 8-33 years); tumor volume (median 13.9 cm3, IQR 9.5-20.5 cm3); a good preoperative KPS score (median 80, IQR 70-80); a mixed solid-cystic component (72%); occupation of the ambient cistern and cerebellomesencephalic fissure; a close relationship with the dorsal pons, superior cerebellar peduncle, and posterior inferior third ventricle; and a higher probability of permanent postoperative sensory deficits (40%). Aqueductal and tectal PAs were associated with small tumor volume (median 9.14 cm3, IQR 5.1-17.4 cm3 and median 11.84 cm3, IQR 5.7-18.3 cm3, respectively), a higher percentage of hydrocephalus (80% and 86.7%, respectively), and a straightforward selection of limited surgical approaches.
CONCLUSIONS: A novel and comprehensive radiological classification of midbrain PAs was established, which will serve as a valuable tool in patient management and promote uniform communication and comparison across different studies and publications.