Department of Neurosurgery, Hospital Garcia de Orta, Almada, Portugal.
Acta Neurochir (Wien). 2011 Oct;153(10):1907-17; discussion 1917. doi: 10.1007/s00701-011-1125-z. Epub 2011 Aug 14.
Diffuse WHO grade II glioma (GIIG) involving the occipital lobe is a rare entity. Its surgical resection remains controversial as it implies inducing a permanent visual deficit. For the first time to our knowledge, we report a consecutive surgical series of patients who underwent an occipital lobectomy for an LGG invading visual structures.
Six right-handed patients harboring a GIIG revealed by seizures (normal examination except a quadrantanopsia in one case) and located within the occipital lobe (4 left and 2 right tumors) were submitted to surgery. Before making this decision, the benefit-to-risk ratio of the resection was extensively discussed with the patient and his/her family, especially concerning the price to pay to remove the tumor, that is, to voluntarily generate a permanent hemianopsia. All the procedures were performed under awake condition using intraoperative electrostimulation, in order to pursue the resection until sensory-motor and/or language structures were encountered.
An extensive occipital lobectomy was achieved in the six patients, with identification and preservation of sensory-motor pathways in the two cases with a right tumor and detection of language pathways in the four cases with a left tumor. The mean extent of resection was 93% (range: 91-100%). All patients experienced an expected postoperative deficit of the visual field (homonymous hemianopsia). Nonetheless, the six patients resumed a normal social and professional life (KPS at 90 in the 6 cases) with a mean follow-up of 58 months (range: 3-147 months)--with adjuvant treatment in three cases (in addition to a reoperation in two of them).
Our findings suggest that, despite a definitive hemianopsia, an extensive surgical resection can be considered in the rare cases of occipital GIIG involving the primary visual structures, with patients able to maintain a normal life--except regarding the medico-legal problem of driving.
累及枕叶的弥漫性世界卫生组织 2 级胶质瘤（GIIG）较为罕见。由于手术切除可能导致永久性视力缺损，因此其手术切除一直存在争议。据我们所知，这是首次报道一系列连续的患者接受枕叶切除术以切除侵犯视觉结构的低级别胶质瘤。
6 名右手习惯患者因癫痫发作（除 1 例象限盲外，检查均正常）且位于枕叶内（4 例左侧肿瘤，2 例右侧肿瘤）被诊断为 GIIG，接受手术治疗。在做出这一决定之前，与患者及其家属充分讨论了切除的获益与风险比，尤其是为了切除肿瘤而必须付出的代价，即自愿产生永久性偏盲。所有手术均在清醒状态下进行，术中采用电刺激，以继续切除直至遇到感觉运动和/或语言结构。
6 例患者均行广泛的枕叶切除术，其中 2 例右侧肿瘤患者识别和保留了感觉运动通路，4 例左侧肿瘤患者检测到语言通路。平均切除范围为 93%（范围：91-100%）。所有患者术后均出现预期的视野缺损（同向偏盲）。尽管如此，6 例患者在术后平均随访 58 个月（范围：3-147 个月）中均恢复了正常的社会和职业生活（6 例患者的 KPS 均为 90）——其中 3 例接受了辅助治疗（其中 2 例患者还进行了再次手术）。
尽管存在永久性偏盲，但对于罕见的累及初级视觉结构的枕叶 GIIG，广泛的手术切除是可以考虑的，患者能够维持正常的生活——除了涉及到驾驶的医学法律问题。
