Duffau Hugues
Department of Neurosurgery, UMR-S678 Inserm, Hôpital Salpêtrière, Paris, France.
J Neurooncol. 2006 Aug;79(1):77-115. doi: 10.1007/s11060-005-9109-6. Epub 2006 Apr 11.
Despite a recent literature supporting the impact of surgery on the natural history of low-grade glioma (LGG), the indications of resection still remain a matter of debate, especially because of the frequent location of these tumors within eloquent brain areas - thus with a risk to induce a permanent postoperative deficit. Therefore, since the antagonist nature of this surgery is to perform the most extensive glioma removal possible, while preserving the function and the quality of life, new concepts were recently applied to LGG resection in order to optimize the benefit/risk ratio of the surgery.First, due to the development of functional mapping methods, namely perioperative neurofunctional imaging and intrasurgical direct electrical stimulation, the study of cortical functional organization is currently possible for each patient - in addition to an extensive neuropsychological assessment. Such knowledge is essential because of the inter-individual anatomo-functional variability, increased in tumors due to cerebral plasticity phenomena. Thus, brain mapping enables to envision and perform a resection according to individual functional boundaries.Second, since LGG invades not only cortical but also subcortical structures, and shows an infiltrative progression along the white matter tracts, new techniques of anatomical tracking and functional mapping of the subcortical white matter pathways were also used with the goal to study the individual effective connectivity - which needs imperatively to be preserved during the resection.Third, the better understanding of brain plasticity mechanisms, induced both by the slow-growing LGG and by the surgery itself, were equally studied in each patient and applied to the surgical strategy by incorporating individual dynamic potential of reorganization into the operative planning. The integration of these new concepts of individual functional mapping, connectivity and plastic potential to the surgery of LGG has allowed an extent of surgical indications, an optimization of the quality of resection (neuro-oncological benefit), and a minimization of the risk of sequelae (benefit on the quality of life). In addition, such a strategy has also fundamental applications, since it represents a new door to the connectionism and cerebral plasticity.
尽管近期有文献支持手术对低级别胶质瘤（LGG）自然病程的影响，但手术指征仍存在争议，尤其是因为这些肿瘤常位于脑功能区，因此有导致永久性术后功能缺损的风险。所以，鉴于该手术的矛盾性质是在保留功能和生活质量的同时尽可能广泛地切除胶质瘤，最近一些新的理念被应用于LGG切除手术，以优化手术的获益/风险比。
首先，由于功能定位方法的发展，即围手术期神经功能成像和术中直接电刺激，目前除了进行广泛的神经心理学评估外，还能够针对每位患者研究皮质功能组织。由于个体间解剖功能的变异性，以及肿瘤导致的大脑可塑性现象使这种变异性增加，此类知识至关重要。因此，脑图谱能够根据个体功能边界来规划和实施切除手术。
其次，由于LGG不仅侵犯皮质结构，还侵犯皮质下结构，并沿白质束呈浸润性进展，因此也采用了新的解剖追踪和皮质下白质通路功能定位技术，目的是研究个体的有效连接性，而在切除过程中必须保留这种连接性。
第三，对由生长缓慢的LGG以及手术本身所诱导的脑可塑性机制的更好理解，也在每位患者中进行了研究，并通过将个体动态重组潜能纳入手术规划而应用于手术策略。将这些个体功能定位、连接性和可塑性潜能的新概念整合到LGG手术中，扩大了手术指征，优化了切除质量（神经肿瘤学获益），并将后遗症风险降至最低（对生活质量有益）。此外，这样的策略还具有重要的基础应用价值，因为它为连接主义和大脑可塑性打开了一扇新的大门。
