松果体区肿瘤的外科治疗策略探讨

Analysis of the surgical strategy for the treatment of pineal region tumors

目的 探讨松果体区肿瘤的规范化外科治疗策略.方法 回顾性分析2007年9月至2012年2月解放军总医院神经外科治疗的43例伴有梗阻性脑积水的松果体区肿瘤患者资料,其中男性30例,女性13例;年龄1 -52岁,平均（27±4）岁.所有病例均先接受脑室镜下第三脑室底造瘘及肿瘤活检术,27例（62.8％）患者活检病理诊断包括生殖细胞瘤23例、松果体母细胞瘤4例,随后接受了药物化疗和（或）放疗（单纯脑室镜手术组）.16例（37.2％）患者活检病理诊断包括星形细胞瘤5例、松果体细胞瘤4例、畸胎瘤4例、室管膜瘤2例、松果体乳头状瘤1例,二期接受了开颅病变切除术（开颅手术组）.本组病例均定期于术后1、3、6个月随访.随访时常规进行临床、影像学及血清肿瘤标志物检查.结果 单纯脑室镜治疗组中1例患者术后因脑室内出血而行脑室外引流术后1周好转,术后短期并发症发生率为2.3％（1/43）,无术后长期并发症发生.术后经辅助化疗和（或）放疗,长期随访均治愈或无进展生存.而开颅手术治疗组中,2例患者出现术后颅内血肿,再次开颅行血肿清除术（2/16）.术后短期并发症发生率为6/16,长期并发症发生率为1/16.结论 合并梗阻性脑积水的松果体区肿瘤可首先选择脑室镜下第三脑室底造瘘,行肿瘤组织活检术,待病理检查明确后根据肿瘤实际病理类型制定下一步治疗方案,以使大部分患者避免进行开颅手术和分流术.

Objective To evaluate and explore the optimal surgical strategy for the normalized treatment of pineal region tumors.Methods From September 2007 to February 2012,43 patients were treated in Chinese People＇s Liberation Army General Hospital,including 30 male and 14 female patients,with pineal region tumors and non-communicating hydrocephalus were enrolled,who were 1-52 years old,mean age was （27 ± 4） years.The clinical records,treatment strategy,and prognosis were retrospectively analyzed.All the patients routinely underwent endoscopic third ventriculostomy （ETV） and tumor biopsy as the initial treatment.Twenty-seven cases （62.8％,pure endoscopic group） with histological diagnosis of germinoma（23 cases） or pineoblastoma （4 cases） were treated with chemotherapy with/without radiation therapy after ETV.The rest 16 cases （37.2％,craniotomy group） with histological diagnosis of nongerminoma and non-pineoblastoma （5 astrocytomas,4 pineocytomas,4 teratomas,2 ependymomas,and 1 pineopappiloma） had craniotomy and tumor resection after ETV.All the cases had routine follow-up at 1,3,and 6 months after the final surgery.The clinical,imaging,and tumor markers analysis were routinely examined at follow-up.Results In the pure endoscopic group,1 case had intra-ventricular hemorrhage after ETV,followed by external ventricular drainage and recovered after 1 week.Endoscopic procedure related short-term （＜ 3 months） complication rate was 2.3 ％ （1/43）,while long-term morbidity was 0.All cases in the pure endoscopic group had chemotherapy with/without radiation therapy.Long-term follow-up results showed that all cases were cured or had progression free survival （PFS）.In the craniotomy group,2 cases （2/16） developed intra-cranial hemorrhage after surgery,and had to be operated again for hematoma evacuation.In the craniotomy group,the short-term （＜ 3 months） morbidity rate was 6/16.At 3 months follow-up,1 case still had homonymous hemianopia,which made the long-term morbidity rate was 1/16.Conclusions For pineal region tumors with non-communicating hydrocephalus,simultaneous ETV with tumor biopsy can be the most favorable initial diagnostic and therapeutic treatment.Second-stage treatment （chemotherapy,radiation therapy,or craniotomy with tumor resection） can be selected according to the histological diagnosis.