Department of Neurosurgery, University of Toyama, Sugitani, Toyama 930-0194, Japan.
J Neurosurg. 2011 Dec;115(6):1147-57. doi: 10.3171/2011.7.JNS101976. Epub 2011 Aug 12.
The authors report their investigation on the current status of neuroendoscopic biopsy for ventricular and paraventricular tumors as well as treatment for associated hydrocephalus in Japan.
Patients who had undergone therapeutic neuroendoscopy between 2005 and 2009 were included in this study. The main items examined were age; sex; localization of tumor; pathological diagnosis using biopsy; the presence, treatment, and efficacy of treatment of associated hydrocephalus; perioperative complications; activities of daily living (ADL) before and after therapeutic neuroendoscopy; and the presence of dissemination during the postoperative course.
Seven hundred fourteen patients from 123 sites (462 male and 252 female patients, mean age 33.3 years) were enrolled. Localization of the tumor was mainly classified into the lateral ventricle in 91 patients, the third ventricle in 339, the fourth ventricle in 18, the suprasellar region in 75, and other paraventricular areas in 191 patients. The most commonly observed tumors were germ cell tumors in the third ventricle (177 cases [39%]), cystic lesions in the suprasellar region (56 cases [75%]), and astrocytic tumors in the thalamus-basal ganglia (71 cases [38%]). Although 641 (92.8%) of 691 patients could receive neuroendoscopic diagnosis using biopsy, the diagnosis obtained with endoscopic biopsy differed from the final diagnosis based on subsequent craniotomy in 18 patients and clinical course in 3 patients. Of these 21 patients, 7 had astrocytic tumors, 4 had pineal tumors, 6 had germ cell tumors, and 4 had other tumors. The final diagnostic accuracy rate was 89.7%. Associated hydrocephalus was observed in 517 patients (72.4%), of whom 316 and 39 underwent third ventriculostomy and fenestration of the septum, respectively. The response rates were 96.2% and 89.7%, respectively. Third ventriculostomy was required for recurrence of hydrocephalus in 41 patients (13.0%), and the long-term response rate was therefore 83.2% (263 of 316 patients). Perioperative complications other than fever, such as new onset of or progressive hydrocephalus, infection due to CSF leakage, and bleeding in the ventricle or tumor, were found in 81 patients (11.3%). The median Karnofsky Performance Scale score before endoscopic surgery was 80, but it increased to 90 after surgery. The score was thus significantly increased after surgery (p < 0.0001, Mann-Whitney U-test). Activities of daily living after surgery decreased due to perioperative complications in 15 patients (2.1%). The incidence of new dissemination after endoscopic biopsy was 6.8% and not high compared with routine surgical treatment.
The authors concluded that neuroendoscopic diagnosis using biopsy for ventricular and paraventricular tumors is adequately accurate and safe. It was demonstrated that endoscopic procedures play important roles not only in the treatment of hydrocephalus associated with intra- and paraventricular tumors but also in significantly improving ADL. Furthermore, the long-term outcome of endoscopic third ventriculostomy was clearly favorable.
作者报告了他们在日本对脑室和室周肿瘤的神经内镜活检现状以及相关脑积水治疗的研究结果。
本研究纳入了 2005 年至 2009 年间接受治疗性神经内镜检查的患者。主要检查项目包括年龄、性别、肿瘤定位、活检的病理诊断、相关脑积水的存在、治疗及疗效、围手术期并发症、治疗前后日常生活活动(ADL)以及术后是否有肿瘤播散。
共纳入 123 个部位的 714 例患者(462 例男性和 252 例女性,平均年龄 33.3 岁)。肿瘤定位主要分为侧脑室 91 例、第三脑室 339 例、第四脑室 18 例、鞍上区 75 例和其他室周区 191 例。最常见的肿瘤为第三脑室的生殖细胞瘤(177 例[39%])、鞍上区的囊性病变(56 例[75%])和丘脑-基底节区的星形细胞瘤(71 例[38%])。尽管 691 例患者中有 641 例(92.8%)能够通过神经内镜活检进行诊断,但内镜活检的诊断与后续开颅手术的最终诊断在 18 例患者和 3 例患者的临床病程中存在差异。这 21 例患者中,7 例为星形细胞瘤,4 例为松果体瘤,6 例为生殖细胞瘤,4 例为其他肿瘤。最终诊断准确率为 89.7%。517 例(72.4%)患者存在相关脑积水,其中 316 例行第三脑室造瘘术,39 例行中隔造瘘术。其有效率分别为 96.2%和 89.7%。41 例(13.0%)患者因脑积水复发需要再次行第三脑室造瘘术,因此长期有效率为 83.2%(263 例患者)。除发热外,还发现了 81 例(11.3%)患者存在新出现或进展性脑积水、CSF 漏导致的感染、脑室或肿瘤内出血等围手术期并发症。内镜手术前,Karnofsky 表现状态评分中位数为 80,术后增加至 90。因此,术后评分明显升高(p < 0.0001,Mann-Whitney U 检验)。15 例(2.1%)患者因围手术期并发症导致术后日常生活活动能力下降。内镜活检后新发生肿瘤播散的发生率为 6.8%,与常规手术治疗相比并不高。
作者认为,脑室和室周肿瘤的神经内镜活检诊断准确率高且安全。研究表明,内镜手术不仅在治疗脑室和室周肿瘤相关的脑积水方面发挥了重要作用,而且显著改善了 ADL。此外,内镜第三脑室造瘘术的长期效果明显良好。