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首页> 外文期刊>Journal of neurosurgical sciences >Resecting diffuse low-grade gliomas to the boundaries of brain functions: a new concept in surgical neuro-oncology
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Resecting diffuse low-grade gliomas to the boundaries of brain functions: a new concept in surgical neuro-oncology

机译：将弥漫性低级神经胶质瘤切除到脑功能的边界：外科神经肿瘤学的新概念

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The traditional dilemma making surgery for diffuse low-grade gliomas (DLGGs) challenging is underlain by the need to optimize tumor resection in order to significantly increase survival versus the risk of permanent neurological morbidity. Development of neuroimaging led neurosurgeons to achieve tumorectomy according to the oncological limits provided by preoperative or intraoperative structural and metabolic imaging. However, this principle is not coherent, neither with the infiltrative nature of DLGGs nor with the limited resolution of current neuroitnaging. Indeed, despite technical advances, MRI still underestimates the actual spatial extent of gliomas, since tumoral cells are present several millimeters to centimeters beyond the area of signal abnormalities. Furthermore, cortical and sub cortical structures may be still crucial for brain functions despite their invasion by this diffuse tumoral disease. Finally, the lack of reliability of functional MRI has also been demonstrated. Therefore, to talk about "maximal safe resection" based upon neuroimaging is a non -sense, because oncological MRI does not show the tumor and functional MRI does not show critical neural pathways. This review proposes an original concept in neuro-oncological surgery, i.e. to resect DLGG to the boundaries of brain functions, thanks to intraoperative electrical mapping performed in awake patients. This paradigmatic shift from image -guided resection to functional mapping -guided resection, based upon an accurate study of brain connectomics and neuroplasticity in each patient throughout tumor removal has permitted to solve the classical dilemma, by increasing both survival and quality of life in DLGG patients. With this in mind, brain surgeons should also be neuroscientists.
机译：弥漫性低度神经胶质瘤（DLGGs）挑战的传统两难选择手术是需要优化肿瘤切除以显着提高生存率和永久性神经系统疾病风险的基础。神经影像学的发展导致神经外科医生根据术前或术中结构和代谢成像所提供的肿瘤学限制实现肿瘤切除。但是，该原理既不与DLGG的浸润性无关，也不与目前的神经刺激治疗的分辨率有限相一致。确实，尽管技术进步，但MRI仍低估了神经胶质瘤的实际空间范围，因为肿瘤细胞的存在范围超出信号异常区域几毫米到几厘米。此外，皮质和皮质下结构尽管对这种弥漫性肿瘤疾病有侵害，但对大脑功能仍然可能至关重要。最后，还证实了功能性MRI的可靠性不足。因此，谈论基于神经影像的“最大安全切除”是无稽之谈，因为肿瘤MRI不能显示肿瘤，功能MRI不能显示关键的神经通路。这篇综述提出了神经肿瘤外科手术的原始概念，即由于清醒患者进行了术中电图绘制，因此将DLGG切除至脑功能的边界。这种从影像引导切除到功能映射引导切除的范式转变，是基于对整个肿瘤切除过程中每位患者的大脑结缔组织学和神经可塑性的精确研究，通过增加DLGG患者的生存率和生活质量，解决了经典难题。 。考虑到这一点，脑外科医师也应该是神经科学家。

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