Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data.
Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data.
复制标题
内窥镜上脑脑脑膜瘤的内窥镜鼻鼻方法：引入一种新的评分系统，以预测切除程度并帮助选择长期结果数据。
DOI：
10.3171/2020.4.jns20475
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发表时间：
2021-07-01
影响因子：
4.1
通讯作者：
Schwartz TH
中科院分区：
文献类型：
--
作者：
Youngerman BE;Banu MA;Gerges MM;Odigie E;Tabaee A;Kacker A;Anand VK;Schwartz TH
鼻内窥镜入路（EEA）在鞍上脑膜瘤（SSMs）切除术中越来越受欢迎。适当的病例选择是优化患者预后的关键。缺乏长期结果数据。作者系统地确定了术前与切除程度（EOR）相关的因素，并确定了EOR与SSMs EEA后长期复发的关系。在这项回顾性队列研究中，作者确定了与EOR相关的术前临床和影像学特征，并以加州大学旧金山分校最近发表的可切除性评分为基础，提出了一个更针对EEA的评分。然后，他们用Kaplan-Meier生存分析检查了总全切除（GTR; 100%）、近全切除（NTR; 95% - 99%）和次全切除（STR; < 95%）与复发或进展的关系。共确定了51例患者。47例（85%）以手术为目标的患者中有40例实现了影像学GTR。不完全切除的重要独立危险因素为手术前（OR 25.94, 95% CI < 2.00 ~ 336.49, p = 0.013）；视神经外侧肿瘤（OR 13.41, 95% CI 1.82 ~ 98.99, p = 0.011）；颈内动脉（ICA）完全闭塞（OR 15.12, 95% CI 1.17-194.08, p = 0.037）。在校正其他变量后，肿瘤大小和视神经管侵犯不是显著的危险因素。基于多变量模型的可切除性评分成功预测了GTR的可能性；0分对GTR的阳性预测值为97%，而2分对不完全切除的阴性预测值为87.5%。平均随访40.6±32.4个月（平均±SD）， GTR术后复发率为2.7%（1例组织学不典型），NTR术后复发率为44.4%，STR术后复发率为80% （p < 0.0001）。93.5%的患者视力稳定或改善，67.4%的患者术前视力有改善。术后脑脊液渗漏5例（9.8%），其中4例经腰椎引流管处理，1例需再次手术。EEA是一种安全有效的治疗ssm的方法，在精心挑选的病例中具有良好的视觉效果。术后基于mri的EOR与直接内镜检查相结合可以代替Simpson分级预测复发。GTR可显著降低复发率，无论肿瘤大小、靠近或包裹大脑前动脉、或侵犯内侧视神经管均可实现。不完全切除的危险因素包括既往手术、肿瘤位于视神经外侧和ICA完全包膜。
The endoscopic endonasal approach (EEA) has gained increasing popularity for the resection of suprasellar meningiomas (SSMs). Appropriate case selection is critical in optimizing patient outcome. Long-term outcome data are lacking. The authors systematically identified preoperative factors associated with extent of resection (EOR) and determined the relationship between EOR and long-term recurrence after EEA for SSMs. In this retrospective cohort study, the authors identified preoperative clinical and imaging characteristics associated with EOR and built on the recently published University of California, San Francisco resectability score to propose a score more specific to the EEA. They then examined the relationship between gross-total resection (GTR; 100%), near-total resection (NTR; 95%–99%), and subtotal resection (STR; < 95%) and recurrence or progression with Kaplan-Meier survival analysis. A total of 51 patients were identified. Radiographic GTR was achieved in 40 of 47 (85%) patients in whom it was the surgical goal. Significant independent risk factors for incomplete resection were prior surgery (OR 25.94, 95% CI < 2.00 to 336.49, p = 0.013); tumor lateral to the optic nerve (OR 13.41, 95% CI 1.82–98.99, p = 0.011); and complete internal carotid artery (ICA) encasement (OR 15.12, 95% CI 1.17–194.08, p = 0.037). Tumor size and optic canal invasion were not significant risk factors after adjustment for other variables. A resectability score based on the multivariable model successfully predicted the likelihood of GTR; a score of 0 had a positive predictive value of 97% for GTR, whereas a score of 2 had a negative predictive value of 87.5% for incomplete resection. After a mean follow-up of 40.6 ± 32.4 months (mean ± SD), recurrence was 2.7% after GTR (1 patient with atypical histology), 44.4% after NTR, and 80% after STR (p < 0.0001). Vision was stable or improved in 93.5% and improved in 67.4% of patients with a preoperative deficit. There were 5 (9.8%) postoperative CSF leaks, of which 4 were managed with lumbar drains and 1 required a reoperation. The EEA is a safe and effective approach to SSMs, with favorable visual outcomes in well-selected cases. The combination of postoperative MRI-based EOR with direct endoscopic inspection can be used in lieu of Simpson grade to predict recurrence. GTR dramatically reduces recurrence and can be achieved regardless of tumor size, proximity or encasement of the anterior cerebral artery, or medial optic canal invasion. Risk factors for incomplete resection include prior surgery, tumor lateral to the optic nerve, and complete ICA encasement.