Departments of1Neurosurgery and.
2The City University of New York (CUNY) School of Medicine, New York, New York.
J Neurosurg. 2022 Nov 4;139(1):73-84. doi: 10.3171/2022.9.JNS22842. Print 2023 Jul 1.
Maximal safe resection is the goal of surgical treatment for high-grade glioma (HGG). Deep-seated hemispheric gliomas present a surgical challenge due to safety concerns and previously were often considered inoperable. The authors hypothesized that use of tubular retractors would allow resection of deep-seated gliomas with an acceptable safety profile. The purpose of this study was to describe surgical outcomes and survival data after resection of deep-seated HGG with stereotactically placed tubular retractors, as well as to discuss the technical advances that enable such procedures.
This is a retrospective review of 20 consecutive patients who underwent 22 resections of deep-seated hemispheric HGG with the Viewsite Brain Access System by a single surgeon. Patient demographics, survival, tumor characteristics, extent of resection (EOR), and neurological outcomes were recorded. Cannulation trajectories and planned resection volumes depended on the relative location of white matter tracts extracted from diffusion tractography. The surgical plans were designed on the Brainlab system and preoperatively visualized on the Surgical Theater virtual reality SNAP platform. Volumetric assessment of EOR was obtained on the Brainlab platform and confirmed by a board-certified neuroradiologist.
Twenty adult patients (18 with IDH-wild-type glioblastomas and 2 with IDH-mutant grade IV astrocytomas) and 22 surgeries were included in the study. The cohort included both newly diagnosed (n = 17; 77%) and recurrent (n = 5; 23%) tumors. Most tumors (64%) abutted the ventricular system. The average preoperative and postoperative tumor volumes measured 33.1 ± 5.3 cm3 and 15.2 ± 5.1 cm3, respectively. The median EOR was 93%. Surgical complications included 2 patients (10%) who developed entrapment of the temporal horn, necessitating placement of a ventriculoperitoneal shunt; 1 patient (5%) who suffered a wound infection and pulmonary embolus; and 1 patient (5%) who developed pneumonia. In 2 cases (9%) patients developed new permanent visual field deficits, and in 5 cases (23%) patients experienced worsening of preoperative deficits. Preoperative neurological or cognitive deficits remained the same in 9 cases (41%) and improved in 7 (32%). The median overall survival was 14.4 months in all patients (n = 20) and in the newly diagnosed IDH-wild-type glioblastoma group (n = 16).
Deep-seated HGGs, which are surgically challenging and frequently considered inoperable, are amenable to resection through tubular retractors, with an acceptable safety profile. Such cytoreductive surgery may allow these patients to experience an overall survival comparable to those with more superficial tumors.
最大限度地安全切除是高级别胶质瘤（HGG）手术治疗的目标。由于安全问题，深部脑半球胶质瘤的手术具有挑战性，以前通常被认为无法手术。作者假设使用管状牵开器可以以可接受的安全性切除深部脑胶质瘤。本研究的目的是描述使用立体定向放置的管状牵开器切除深部 HGG 的手术结果和生存数据，并讨论实现这些手术的技术进步。
这是对 20 名连续患者的回顾性研究，这些患者由一名外科医生进行了 22 例深部半球 HGG 的切除手术，使用的是 Viewsite Brain Access System。记录患者的人口统计学数据、生存情况、肿瘤特征、切除程度（EOR）和神经学结果。套管的轨迹和计划切除的体积取决于从弥散张量成像中提取的白质束的相对位置。手术计划在 Brainlab 系统上设计，并在 Surgical Theater 虚拟现实 SNAP 平台上进行术前可视化。EOR 的体积评估是在 Brainlab 平台上获得的，并由经过董事会认证的神经放射科医生确认。
本研究纳入了 20 名成年患者（18 名 IDH 野生型胶质母细胞瘤患者和 2 名 IDH 突变型 4 级星形细胞瘤患者）和 22 例手术。该队列包括新诊断的肿瘤（n=17；77%）和复发性肿瘤（n=5；23%）。大多数肿瘤（64%）紧贴脑室系统。术前和术后平均肿瘤体积分别为 33.1±5.3cm3 和 15.2±5.1cm3。中位 EOR 为 93%。手术并发症包括 2 名（10%）患者出现颞角嵌顿，需要放置脑室-腹腔分流管；1 名（5%）患者发生伤口感染和肺栓塞；1 名（5%）患者发生肺炎。2 例（9%）患者出现新的永久性视野缺损，5 例（23%）患者术前缺损恶化。9 例（41%）患者术前神经或认知功能缺损保持不变，7 例（32%）患者改善。所有患者（n=20）和新诊断的 IDH 野生型胶质母细胞瘤患者（n=16）的总生存中位数为 14.4 个月。
深部 HGG 手术具有挑战性，通常被认为无法手术，但通过管状牵开器可以切除，安全性可接受。这种细胞减容手术可能使这些患者的总生存时间与肿瘤较浅的患者相当。
