Wright James, Chugh Jessey, Wright Christina Huang, Alonso Fernando, Hdeib Alia, Gittleman Haley, Barnholtz-Sloan Jill, Sloan Andrew E
Department of Neurological Surgery, University Hospitals Case Medical Center.
Case Western Reserve University School of Medicine; and.
Neurosurg Focus. 2016 Oct;41(4):E14. doi: 10.3171/2016.8.FOCUS16233.
OBJECTIVE Laser interstitial thermal therapy (LITT), sometimes referred to as "stereotactic laser ablation," has demonstrated utility in a subset of high-risk surgical patients with difficult to access (DTA) intracranial neoplasms. However, the treatment of tumors larger than 10 cm is associated with suboptimal outcomes and morbidity. This may limit the utility of LITT in dealing with precisely those large or deep tumors that are most difficult to treat with conventional approaches. Recently, several groups have reported on minimally invasive transsulcal approaches utilizing tubular retracting systems. However, these approaches have been primarily used for intraventricular or paraventricular lesions, and subtotal resections have been reported for intraparenchymal lesions. Here, the authors describe a combined approach of LITT followed by minimally invasive transsulcal resection for large and DTA tumors. METHODS The authors retrospectively reviewed the results of LITT immediately followed by minimally invasive, transsulcal, transportal resection in 10 consecutive patients with unilateral, DTA malignant tumors > 10 cm. The patients, 5 males and 5 females, had a median age of 65 years. Eight patients had glioblastoma multiforme (GBM), 1 had a previously treated GBM with radiation necrosis, and 1 had a melanoma brain metastasis. The median tumor volume treated was 38.0 cm. RESULTS The median tumor volume treated to the yellow thermal dose threshold (TDT) line was 83% (range 76%-92%), the median tumor volume treated to the blue TDT line was 73% (range 60%-87%), and the median extent of resection was 93% (range 84%-100%). Two patients suffered mild postoperative neurological deficits, one transiently. Four patients have died since this analysis and 6 remain alive. Median progression-free survival was 280 days, and median overall survival was 482 days. CONCLUSIONS Laser interstitial thermal therapy followed by minimally invasive transsulcal resection, reported here for the first time, is a novel option for patients with large, DTA, malignant brain neoplasms. There were no unexpected neurological complications in this series, and operative characteristics improved as surgeon experience increased. Further studies are needed to elucidate any differences in survival or quality of life metrics.
目的 激光间质热疗（LITT），有时也被称为“立体定向激光消融”，已在一部分难以手术切除（DTA）的高危颅内肿瘤患者中显示出其效用。然而，治疗大于10厘米的肿瘤与欠佳的治疗效果及发病率相关。这可能会限制LITT在处理那些传统方法最难治疗的大肿瘤或深部肿瘤时的效用。最近，有几个研究小组报道了利用管状牵开系统的微创经脑沟入路。然而，这些入路主要用于脑室内或脑室旁病变，对于脑实质内病变则报道为次全切除。在此，作者描述了一种针对大的和DTA肿瘤的联合治疗方法，即先进行LITT，然后进行微创经脑沟切除术。方法 作者回顾性分析了连续10例单侧、DTA恶性肿瘤大于10厘米患者，在接受LITT后立即进行微创经脑沟、经通道切除术的结果。患者中5例男性和5例女性，中位年龄为65岁。8例患有多形性胶质母细胞瘤（GBM），1例为先前接受过治疗的GBM伴放射性坏死，1例为黑色素瘤脑转移。治疗的中位肿瘤体积为38.0立方厘米。结果 达到黄色热剂量阈值（TDT）线的治疗中位肿瘤体积为83%（范围76%-92%），达到蓝色TDT线的治疗中位肿瘤体积为73%（范围60%-87%），中位切除范围为93%（范围84%-100%）。2例患者出现轻度术后神经功能缺损，其中1例为短暂性。自本次分析以来，4例患者死亡，6例仍存活。中位无进展生存期为280天，中位总生存期为482天。结论 本文首次报道的先进行激光间质热疗然后进行微创经脑沟切除术，是治疗大的、DTA恶性脑肿瘤患者的一种新选择。本系列中未出现意外的神经并发症，且随着外科医生经验的增加，手术效果得到改善。需要进一步研究以阐明生存或生活质量指标方面的任何差异。
