Veeravagu Anand, Jiang Bowen, Ludwig Cassie, Chang Steven D, Black Keith L, Patil Chirag G
Department of Neurosurgery, Stanford School of Medicine, Palo Alto, CA, USA.
Cochrane Database Syst Rev. 2013 Apr 30(4):CD009319. doi: 10.1002/14651858.CD009319.pub2.
Low-grade gliomas (LGG) constitute a class of slow-growing primary brain neoplasms. Patients with clinically and radiographically suspected LGG have two initial surgical options, biopsy or resection. Biopsy can provide a histological diagnosis with minimal risk but does not offer a direct treatment. Resection may have additional benefits such as increasing survival and delaying recurrence, but is associated with a higher risk for surgical morbidity. There remains controversy about the role of biopsy versus resection and the relative clinical outcomes for the management of LGG.
To assess the clinical effectiveness of biopsy compared to surgical resection in patients with a new lesion suspected to be a LGG.
The following electronic databases were searched: Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11), MEDLINE (1950 to week 3 November 2012), EMBASE (1980 to Week 46 2012). Unpublished and grey literature including Metaregister, Physicians Data Query, www.controlled-trials.com/rct, www.clinicaltrials.gov, and www.cancer.gov/clinicaltrials were also queried for ongoing trials.
Patients of any age with a suspected intracranial LGG receiving biopsy or resection within a randomized clinical trial (RCT) or controlled clinical trial (CCT) were included. Patients with prior resections, radiation therapy, or chemotherapy for LGG were excluded. Outcome measures included overall survival (OS), progression free survival (PFS), functionally independent survival (FIS), adverse events, symptom control, and quality of life (QoL).
A total of 2764 citations were searched and critically analyzed for relevance. This effort was undertaken by three independent review authors.
No RCTs of biopsy or resection for LGG were identified. Twenty other studies were retrieved for analysis based on pre-specified selection criteria. Ten studies were retrospective or literature reviews. Three studies were prospective but were limited to tumor recurrence or the extent of resection. One study was a population-based parallel cohort and not an RCT. Four studies were RCTs, however patients were randomized with respect to varying radiotherapy regimens to assess timing and dose of radiation. One RCT was focused on high-grade gliomas and not LGG. One last RCT evaluated diffusion tensor imaging (DTI)-based neuro-navigation for surgical resection.
AUTHORS' CONCLUSIONS: Currently there are no randomized clinical trials or controlled clinical trials available on which to base clinical decisions. Therefore, physicians must approach each case individually and weigh the risks and benefits of each intervention until further evidence is available. Future research could focus on randomized clinical trials to determine outcomes benefits for biopsy versus resection.
低级别胶质瘤（LGG）是一类生长缓慢的原发性脑肿瘤。临床和影像学怀疑为LGG的患者有两种初始手术选择，即活检或切除。活检能以最小风险提供组织学诊断，但不能提供直接治疗。切除可能有额外益处，如延长生存期和延缓复发，但手术并发症风险较高。关于活检与切除在LGG治疗中的作用以及相对临床结局仍存在争议。
评估对于疑似为LGG的新病灶患者，活检与手术切除相比的临床效果。
检索了以下电子数据库：Cochrane对照试验中心注册库（CENTRAL）（2012年第11期）、医学期刊数据库（MEDLINE）（1950年至2012年11月第3周）、荷兰医学文摘数据库（EMBASE）（1980年至2012年第46周）。还查询了未发表文献和灰色文献，包括Meta注册库、医师数据查询库、www.controlled-trials.com/rct、www.clinicaltrials.gov和www.cancer.gov/clinicaltrials，以获取正在进行的试验。
纳入在随机临床试验（RCT）或对照临床试验（CCT）中接受活检或切除的任何年龄疑似颅内LGG患者。排除既往有LGG切除、放疗或化疗史的患者。结局指标包括总生存期（OS）、无进展生存期（PFS）、功能独立生存期（FIS）、不良事件、症状控制和生活质量（QoL）。
共检索并严格分析了2764条引文的相关性。这项工作由三位独立的综述作者完成。
未找到关于LGG活检或切除的RCT。根据预先设定的入选标准检索了另外20项研究进行分析。10项研究为回顾性研究或文献综述。3项研究为前瞻性研究，但仅限于肿瘤复发或切除范围。1项研究是基于人群的平行队列研究，而非RCT。4项研究为RCT，然而患者是就不同放疗方案进行随机分组，以评估放疗时机和剂量。1项RCT关注的是高级别胶质瘤而非LGG。最后1项RCT评估了基于扩散张量成像（DTI）的神经导航用于手术切除。
目前尚无随机临床试验或对照临床试验可作为临床决策的依据。因此，医生必须对每个病例进行个体化处理，权衡每种干预措施的风险和益处，直至获得更多证据。未来研究可聚焦于随机临床试验，以确定活检与切除的结局获益情况。
