Gogos Andrew J, Young Jacob S, Pereira Matheus P, Morshed Ramin A, Potts Matthew B, Hervey-Jumper Shawn L, Berger Mitchel S
1Department of Neurological Surgery, University of California, San Francisco.
2School of Medicine, University of California, San Francisco, California; and.
J Neurosurg. 2020 Oct 2;135(2):480-487. doi: 10.3171/2020.6.JNS201296. Print 2021 Aug 1.
Although most patients with low-grade glioma (LGG) present after a seizure, a small proportion is diagnosed after neuroimaging is performed for a sign or symptom unrelated to the tumor. While these tumors invariably grow, some surgeons argue for a watchful waiting approach. Here, the authors report on their experience in the surgical treatment of patients with incidental LGG (iLGG) and describe the neurological outcomes, survival, and complications.
Relevant cases were identified from a prospective registry of patients undergoing glioma resection at the University of California, San Francisco, between 1997 and 2019. Cases were considered iLGG when the lesion was noted on imaging performed for a reason unrelated to the tumor. Demographic, clinical, pathological, and imaging data were extracted from the electronic medical record. Tumor volumes, growth, and extent of resection were calculated from pre- and postoperative volumetric FLAIR sequences.
One hundred thirteen of 657 (17.2%) first-time resections for LGG were for incidental lesions. The most common reasons for the discovery of an iLGG were headaches (without mass effect, 34.5%) or trauma (16.8%). Incidental tumors were no different from symptomatic lesions in terms of laterality or location, but they were significantly smaller (22.5 vs 57.5 cm3, p < 0.0001). There was no difference in diagnosis between patients with iLGG and those with symptomatic LGG (sLGG), incorporating both molecular and pathological data. The median preoperative observation time for iLGG was 3.1 months (range 1 month-12 years), and there was a median growth rate of 3.9 cm3/year. Complete resection of the FLAIR abnormality was achieved in 57% of patients with incidental lesions but only 23.8% of symptomatic lesions (p < 0.001), and the residual volumes were smaller for iLGGs (2.9 vs 13.5 cm3, p < 0.0001). Overall survival was significantly longer for patients with incidental tumors (median survival not reached for patients with iLGG vs 14.6 years for those with sLGG, p < 0.0001). There was a 4.4% rate of neurological deficits at 6 months.
The authors present the largest cohort of iLGGs. Patient age, tumor location, and molecular genetics were not different between iLGGs and sLGGs. Incidental tumors were smaller, a greater extent of resection could be achieved, and overall survival was improved compared to those for patients with sLGG. Operative morbidity and rates of neurological deficit were acceptably low; thus, the authors advocate upfront surgical intervention aimed at maximal safe resection for these incidentally discovered lesions.
尽管大多数低级别胶质瘤（LGG）患者是在癫痫发作后就诊，但仍有一小部分是在因与肿瘤无关的体征或症状进行神经影像学检查后被诊断出来的。虽然这些肿瘤最终都会生长，但一些外科医生主张采取观察等待的方法。在此，作者报告了他们对偶然发现的LGG（iLGG）患者进行手术治疗的经验，并描述了神经学结果、生存率和并发症情况。
从1997年至2019年在加利福尼亚大学旧金山分校进行胶质瘤切除术的患者前瞻性登记中识别出相关病例。当病变是在因与肿瘤无关的原因进行的影像学检查中被发现时，这些病例被视为iLGG。从电子病历中提取人口统计学、临床、病理和影像学数据。根据术前和术后的液体衰减反转恢复（FLAIR）序列计算肿瘤体积、生长情况和切除范围。
657例首次进行LGG切除术的患者中有113例（17.2%）是针对偶然发现的病变。发现iLGG最常见的原因是头痛（无占位效应，34.5%）或外伤（16.8%）。偶然发现的肿瘤在左右侧或位置方面与有症状的病变没有差异，但它们明显更小（22.5 vs 57.5 cm³，p < 0.0001）。纳入分子和病理数据后，iLGG患者与有症状的LGG（sLGG）患者在诊断方面没有差异。iLGG患者术前的中位观察时间为3.1个月（范围1个月至12年），中位生长速度为3.9 cm³/年。57%的偶然发现病变患者实现了FLAIR异常的完全切除，而有症状病变患者仅为23.8%（p < 0.001），iLGG的残留体积更小（2.9 vs 13.5 cm³，p < 0.0001）。偶然发现肿瘤的患者总体生存期明显更长（iLGG患者中位生存期未达到，而sLGG患者为14.6年，p < 0.0001）。6个月时神经功能缺损发生率为4.4%。
作者展示了最大规模的iLGG队列。iLGG和sLGG在患者年龄、肿瘤位置和分子遗传学方面没有差异。偶然发现的肿瘤更小，可以实现更大范围的切除，与sLGG患者相比总体生存期得到改善。手术发病率和神经功能缺损发生率低至可接受水平；因此，作者主张对这些偶然发现的病变进行旨在最大程度安全切除的早期手术干预。
