颅内肿瘤X刀治疗后再手术原因与对策

Causes and management of operation after X-knife on intracranial tumors

目的 探讨颅内肿瘤X刀治疗后再手术原因与预防、治疗方法。方法 总结 32例X刀治疗后再手术病例 ,含病变 49个 ,病变最大直径 4.0 1± 1.30cm ,体积 2 7.2 6± 2 1.6 8cm3 。取同期X刀治疗患者对比分析。结果 对 49个病变进行 38次X刀治疗 ,随访 42 .0 8± 19.82月 ,31例X刀后出现病情反复或加重 ,影像检查见瘤周水肿 30例 ,新生强化结节 5例 ,局部复发 10例 ,脑积水 6例。共接受 39次手术治疗 ,肿瘤切除 2 3例次 ,病变切除 8例次 ,去骨瓣减压 5例 ,腹腔分流 7例 ,囊肿穿刺 2例。病理见肿瘤中心及部分靶区脑组织坏死 ,伴灶性、陈旧性出血、胶质细胞增生、癍痕形成。结论 X刀治疗后再手术病残、死亡率高 ,顽固性水肿、新生强化结节、放射性坏死等脑迟发反应是X刀治疗后再手术和致残的主要原因 ,其次是肿瘤复发和脑积水等并发症。主张严格掌握X刀治疗适应证与照射剂量 ,合理使用多靶点、分次治疗 ,并有机结合传统放射与手术治疗。

Objective To study the causes,prevention and management of operation after X-knife on intracranial tumors.Method The treatment and follow-up data of 32 patients with operation after X-knife are summarized.Which included 49 lesions.The maximal diameter of the lesions was 4.01±1.30cm.The tumor volume was 27.26±21.68cm 3.And some non-operative X-knife patients were served as control for comparative study.Result Forty-nine lesions were treated with 80 targets in 38 X-knife treatments.They were followed up for 42.08±19.82 months.The symptoms were reappeared or deteriorated in 31 patients 11.93±16.95 months after the X-knife.Thirty cases of peripheral edema,5 of new enhanced neoplasm,10 of recurrence and 6 of hydrocephalus were discovered in the CT/MRI examination.Thirty-nine operations were performed,including 23 tumor resection,8 neoplasm resection,5 decompression,7 peritoneal shunt,2 cyst-puncture.The center tumor necrosis (some with cerebral necrosis in the focus),spots of old hemorrhage,gliosis and scar were revealed in the pathological study.Conclusion The findings showed high morbidity and mortality of the operative patients after X-knife.The delayed reaction as intractable edema,new enhanced neoplasm and radiation necrosis was the primary cause of dysfunction and operation after X-knife.The tumor recurrence and the complications such as hydrocephalus were the secondary cause.It is promoted that the indication and dose should be managed strictly and cautiously,the multi-target and fractionated stereotactic radiotherapy be handled rationally,and the traditional external radiation as well as the operation be combined with the X-knife.