Cohen-Inbar Or, Sviri Gil E
Department of Neurological Surgery, Rambam Maimonides Health Care Campus, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Department of Neurological Surgery and Gamma-Knife Center, University of Virginia Health Care Campus, Charlottesville, VA, USA.
Rambam Maimonides Med J. 2018 Jul 30;9(3):e0025. doi: 10.5041/RMMJ.10346.
The surgical management of cerebral and skull base lesions has evolved greatly in the last few decades. Still, a complete resection of lesions abutting critical neurovascular structures carries significant morbidity. Stereotactic radiosurgery (SRS) has emerged as an increasingly accepted treatment option. Minimally invasive, SRS results in excellent tumor control and low complication rates in patients with moderate-size tumors. The management of large cerebral and skull base tumors remains a formidable challenge. In such large tumors, radical surgical extirpation offers a significantly higher risk of neurological deficit, and SRS alone cannot be used because of the elevated incidence of radiation-induced complications known to be associated with large-volume tumors. With increasing treatment volumes, SRS-associated tumor control rates decrease and complication rates increase. Planned subtotal resection (STR) with adjuvant SRS (adaptive hybrid surgery [AHS]) has gained increasing interest in recent years as a multimodal approach. In AHS, a planned STR (aimed at decreasing surgical morbidity) followed by SRS to a preplanned residual tumor aids in harnessing advantages offered by both approaches. Although intuitive and reasonable, this paradigm shift from maximal resection at all cost has not been adopted widely. Combining open microsurgery with SRS requires a good understanding of both surgical and SRS modalities and their respective safety-efficacy features. We present a review and discussion on AHS as a modern, multidisciplinary treatment approach. Available data and views are discussed for vestibular schwannoma (VS) as a sample tumor. Other indications for AHS are mentioned in brief.
在过去几十年中，脑和颅底病变的外科治疗有了很大发展。然而，完全切除毗邻关键神经血管结构的病变仍会带来显著的发病率。立体定向放射外科（SRS）已成为越来越被接受的治疗选择。SRS具有微创性，在治疗中等大小肿瘤的患者中能实现出色的肿瘤控制且并发症发生率低。大脑和颅底大肿瘤的治疗仍然是一项艰巨的挑战。对于此类大肿瘤，根治性手术切除导致神经功能缺损的风险显著更高，而且由于已知与大体积肿瘤相关的放射诱导并发症发生率升高，不能单独使用SRS。随着治疗体积的增加，SRS相关的肿瘤控制率下降，并发症发生率上升。近年来，计划次全切除（STR）联合辅助SRS（适应性混合手术[AHS]）作为一种多模式方法越来越受到关注。在AHS中，先进行计划STR（旨在降低手术发病率），然后对预先计划的残留肿瘤进行SRS，有助于利用两种方法的优势。尽管这种从不惜一切代价进行最大程度切除的模式转变直观且合理，但尚未被广泛采用。将开放显微手术与SRS相结合需要对手术和SRS模式及其各自的安全有效性特征有很好的理解。我们对AHS作为一种现代多学科治疗方法进行综述和讨论。以听神经瘤（VS）作为样本肿瘤讨论现有数据和观点。简要提及AHS的其他适应证。
