Coburger Jan, Merkel Andreas, Scherer Moritz, Schwartz Felix, Gessler Florian, Roder Constantin, Pala Andrej, König Ralph, Bullinger Lars, Nagel Gabriele, Jungk Christine, Bisdas Sotirios, Nabavi Arya, Ganslandt Oliver, Seifert Volker, Tatagiba Marcos, Senft Christian, Mehdorn Maximilian, Unterberg Andreas W, Rössler Karl, Wirtz Christian Rainer
‡Department of Neurosurgery, University of Ulm, Günzburg, Germany; §Department of Neurosurgery, University of Erlangen, Erlangen, Germany; ¶Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany; ‖Department of Neurosurgery, University of Schleswig-Holstein, Kiel, Germany; #Department of Neurosurgery, University of Frankfurt, Frankfurt, Germany; **Department of Neurosurgery, University of Tübingen, Tübingen, Germany; ‡‡Department of Internal Medicine III, University of Ulm, Ulm, Germany; §§Institute for Epidemiology and Medical Biometrics, University of Ulm, Ulm, Germany; ¶¶Department of Neuroradiology, University of Tübingen, Tübingen, Germany; ‖‖Department of Neurosurgery, International Neuroscience Institute Hannover, Hannover, Germany; ##Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany.
Neurosurgery. 2016 Jun;78(6):775-86. doi: 10.1227/NEU.0000000000001081.
The ideal treatment strategy for low-grade gliomas (LGGs) is a controversial topic. Additionally, only smaller single-center series dealing with the concept of intraoperative magnetic resonance imaging (iMRI) have been published.
To investigate determinants for patient outcome and progression-free-survival (PFS) after iMRI-guided surgery for LGGs in a multicenter retrospective study initiated by the German Study Group for Intraoperative Magnetic Resonance Imaging.
A retrospective consecutive assessment of patients treated for LGGs (World Health Organization grade II) with iMRI-guided resection at 6 neurosurgical centers was performed. Eloquent location, extent of resection, first-line adjuvant treatment, neurophysiological monitoring, awake brain surgery, intraoperative ultrasound, and field-strength of iMRI were analyzed, as well as progression-free survival (PFS), new permanent neurological deficits, and complications. Multivariate binary logistic and Cox regression models were calculated to evaluate determinants of PFS, gross total resection (GTR), and adjuvant treatment.
A total of 288 patients met the inclusion criteria. On multivariate analysis, GTR significantly increased PFS (hazard ratio, 0.44; P < .01), whereas "failed" GTR did not differ significantly from intended subtotal-resection. Combined radiochemotherapy as adjuvant therapy was a negative prognostic factor (hazard ratio: 2.84, P < .01). Field strength of iMRI was not associated with PFS. In the binary logistic regression model, use of high-field iMRI (odds ratio: 0.51, P < .01) was positively and eloquent location (odds ratio: 1.99, P < .01) was negatively associated with GTR. GTR was not associated with increased rates of new permanent neurological deficits.
GTR was an independent positive prognostic factor for PFS in LGG surgery. Patients with accidentally left tumor remnants showed a similar prognosis compared with patients harboring only partially resectable tumors. Use of high-field iMRI was significantly associated with GTR. However, the field strength of iMRI did not affect PFS.
EoR, extent of resectionFLAIR, fluid-attenuated inversion recoveryGTR, gross total resectionIDH1, isocitrate dehydrogenase 1iMRI, intraoperative magnetic resonance imagingLGG, low-grade gliomaMGMT, methylguanine-deoxyribonucleic acid methyltransferasenPND, new permanent neurological deficitOS, overall survivalPFS, progression-free survivalSTR, subtotal resectionWHO, World Health Organization.
低级别胶质瘤（LGGs）的理想治疗策略是一个存在争议的话题。此外，仅有涉及术中磁共振成像（iMRI）概念的较小规模单中心系列研究发表。
在德国术中磁共振成像研究组发起的一项多中心回顾性研究中，调查iMRI引导下手术治疗LGGs后患者预后和无进展生存期（PFS）的决定因素。
对6个神经外科中心接受iMRI引导下切除LGGs（世界卫生组织二级）治疗的患者进行回顾性连续评估。分析了功能区位置、切除范围、一线辅助治疗、神经生理监测、清醒开颅手术、术中超声和iMRI场强，以及无进展生存期（PFS）、新的永久性神经功能缺损和并发症。计算多变量二元逻辑回归和Cox回归模型，以评估PFS、全切除（GTR）和辅助治疗的决定因素。
共有288例患者符合纳入标准。多变量分析显示，GTR显著提高了PFS（风险比，0.44；P <.01），而“未成功”的GTR与预期的次全切除无显著差异。联合放化疗作为辅助治疗是一个不良预后因素（风险比：2.84，P <.01）。iMRI的场强与PFS无关。在二元逻辑回归模型中，使用高场iMRI（优势比：0.51，P <.01）与GTR呈正相关，而功能区位置（优势比：1.99，P <.01）与GTR呈负相关。GTR与新的永久性神经功能缺损发生率增加无关。
GTR是LGG手术中PFS的独立阳性预后因素。意外遗留肿瘤残余的患者与仅部分可切除肿瘤的患者预后相似。使用高场iMRI与GTR显著相关。然而，iMRI的场强不影响PFS。
EoR，切除范围；FLAIR，液体衰减反转恢复；GTR，全切除；IDH1，异柠檬酸脱氢酶1；iMRI，术中磁共振成像；LGG，低级别胶质瘤；MGMT，甲基鸟嘌呤脱氧核糖核酸甲基转移酶；nPND，新的永久性神经功能缺损；OS，总生存期；PFS，无进展生存期；STR，次全切除；WHO；世界卫生组织
