胼胝体胶质瘤的显微手术及综合治疗策略

Microsurgery and comprehensive treatment strategies for callosal gliomas

目的:探讨胼胝体胶质瘤的临床特点、显微手术可行性和术后综合治疗策略以改善预后。方法:回顾性分析1995年1月至2007年12月我院收治的82例胼胝体胶质瘤患者的临床特点、诊治经过及预后。术前根据影像特点选择最佳手术入路和切除的策略。术中应用神经导航8例,B超监测4例,超声吸引手术刀(CUSA)辅助切除肿瘤5例。术后病理学证实为胶质瘤且级别Ⅱ级以上者行放化疗。化疗方案:替尼泊苷(VM-26)+甲环亚硝脲(Me-CCNU)和(或)替莫唑胺。放疗方案:根据病理级别和胶质瘤范围,以普通外照射为主要方式进行个体化设定。采用门诊、电话及邮件等方式进行随访。结果:82例患者临床表现为头痛、呕吐44例,癫16例,精神症状12例,记忆力减退10例,轻偏瘫20例。显微手术经纵裂入路44例,经皮质入路24例,经纵裂-皮质联合入路5例,活检7例,仅放化疗2例。术中见肿瘤主体位于胼胝体嘴部6例,膝部36例,体部30例,压部10例;镜下全切除45例,次全切除13例,部分切除15例,活检7例。病理证实为星形胶质细胞瘤48例,少突胶质细胞瘤11例,室管膜瘤2例,胶质母细胞瘤19例。获得随访61例,临床症状改善45例,无明显变化9例,加重7例;1年生存率为89%,2年71%,3年62%,5年39%,最长生存期140个月,中位生存时间47个月。COX生存分析提示年龄大、肿瘤病理级别高、切除不完全是预后较差的相关因素。结论:胼胝体胶质瘤是位置特殊的肿瘤,术前应充分了解肿瘤解剖位置、毗邻关系、血供等,正确的手术入路和策略可降低致残率并取得良好疗效,经纵裂入路是常用入路,神经导航、术中超声监测结合显微技术可提高肿瘤切除程度和减少损伤及改善预后。

Objective：To investigate the clinical characteristics, microsurgery feasibility and postoperation comprehensive treatment strategy of callosal gliomas, so as to improve the prognosis of patients. Methods： The clinical manifestations,diagnoses, microsurgical approaches, chemotherapy and radiotherapy, and prognoses of 82 callosal gliomas patients, who were treated in our hospital during January 1995 and December 2007, were retrospectively analyzed. The optimal surgical approach and resection strategies were chosen preoperatively according to the imaging features of tumors. Resections were performed and the navigational orientation was used during operation in 8 cases, type-B ultrasonic supervision was used in 4 cases, and cavitron ultrasonic surgical aspirator （CUSA） was used in 5 cases. Patients with tumors above grade Ⅱ underwent chemotherapy （teniposide＋ semustine）and radiotherapy designated individually according to the pathological grades and involvement of gliomas. The follow-up study was conducted by telephone, mail or outpatient department visits. Results： The clinical manifestations of the 82 patients included headache and vomiting （n= 44）, epilepsy （n= 16）, mental symptoms （n= 12）, and mild plasy （n= 20）. Resections were performed via the longitudinal fissure approach in 44 cases, via the transcortical approach in 24 cases, and via the longitudinal fissure and transcortical combined approach in 5 patients; 7 patients received stereotactic biopsy and 2 patients only received chemotherapy and radiotherapy. Six patients had tumors found in the rostrum of corpus callosum, 36 in the genu of corpus callosum. 30 in the body of corpus callosum, and 10 in the splenium of corpus callosum.Total surgical resection was performed in 45 cases, subtotal in 13 cases,and partial in 15 case. Pathological findings confirmed astrocytoma in 48 cases, oligodendroglioma in 11 cases, ependymoma in 2 cases, and glioblastoma in 19 cases. The follow-up of 61 patients indicated that 89% patients survived for over 1 year, 71% survived for over 2 years, 62 % survived for over 3 years and 39% survived for over 5 years, with a median survival time being 47 months and the longest survival time being 140 months. COX regression analysis found that elder age, higher pathology grade and incomplete resection were associated with poor prognosis. Conclusion： The callosal gliomas locate at especial position, and the anatomic characteristic, adjacent structure, blood supply should be fully understood before operation. Accurate surgical approaches assisted by appropriate therapeutic strategies can improve the prognosis of the patients. The longitudinal fissure approach is commonly used. The proficient microsurgical technique combined with navigation and type-B ultrasonic can improve the resection outcome and prognosis of patients.