光动力诊断和荧光指导切除脑恶性胶质瘤15例

目的研究光动力诊断(PDD)和荧光指导的肿瘤切除在脑恶性胶质瘤治疗中的作用。方法对手术治疗的原发和复发的15例恶性脑胶质瘤患者,在手术中进行荧光波谱诊断及其指导下的肿瘤切除。光敏剂为血卟啉衍生物,剂量为2mg/kg体重。应用激光电子波谱分析系统,光纤尖端激发激光波长632．5nm。手术前48h静脉注射光敏剂,注射后患者进行避光。手术为常规开颅手术,显微镜下切除肿瘤,在手术医师认为肿瘤完全切除后用光纤探头在瘤腔各壁进行多于4个点的光动力诊断,同时取该点样本送常规病理。如光动力诊断发现肉眼未发现的肿瘤则进一步切除。直至瘤腔各壁均确认为正常脑组织。分别记录肉眼辨别,光动力诊断和病理诊断结果,计算光动力诊断的敏感率,特异率和准确率。术后复查CT或MRI确定切除程度,记录手术死亡率和致残率。结果15例肿瘤标本均表现特异肿瘤波谱图形,其中有2例患者在光动力诊断后发现肿瘤,继续切除肿瘤。有1例显微镜下可疑肿瘤组织,经光动力诊断为脑组织,未切除,取病理证实为脑组织。2例(胶质肉瘤和胶质母细胞瘤)离体肿瘤组织和正常脑组织进行光动力诊断,均获得和术后病理诊断相一致的诊断。在瘤腔各壁取样标本106份,根据病理诊断,光动力诊断的敏感率90．60%,特异率96．8％,准确率94．3％。15例患者无手术死亡,1例术后偏瘫失语加重。9例患者肿瘤全切,6例患者肿瘤未全切,其中5例患者因肿瘤位于功能区,为保护功能未能全切肿瘤,并被手术后．MRI或CT证实。有1例术中肉眼辨认和PDD均未提示肿瘤,但样本病理提示仍为肿瘤边缘组织。结论荧光波谱分析的光动力诊断具有比较快速准确、简单客观等特点,对于提高脑恶性胶质瘤的切除程度和减少手术损伤具有积极意义。

Photodynamic diagnosis and fluorescence-guided resection of malignant gliomas: a report of 15 cases

Objective To study the usefulness of the intraoperative photodynamic diagnosis (PDD) and fluorescence-guided resection of malignant gliomas. Methods Fifteen consecutive patients with malignant gliomas received doses of hematoporphyrin derivative (HPD, 2 mg/kg body weight) 48 hours before induction of anesthesia. After the tumors recognized by bare eyes they were removed routinely. The fluorescence around 690 nm excited by laser beam (wavelength 632.5 nm) was detected by laser electronic spectrum analyzer and then fluorescing tissue was removed whenever it was considered safel. Tissue samples derived from the walls of tumor cavities after resection and PDD were sent for histological examination. Compared with the result of the histological examination, the sensitivity and specificity of PDD were calculated and recorded. Early postoperative MRI or CT were done to determine the extend of the resection of the tumors. Surgical mortality and morbidity were also recorded. Results Intraoperatively, in all of 15 cases tumor areas with HPD fluorescence could be recognized by laser electronic spectrum analyzer . On the basis of 106 tissue samples derived from 15 tumors, a sensitivity of 90.6%, a specificity of 96.8% and an accuracy of 94.3% of PDD were achieved. In 2 cases the resection of residual tumor were performed after finding left tumors by PDD. Complete resection of contrast-enhancing tumor was accomplished in 9 patients (60%). Residual intraoperative tissue fluorescence left unresected for safety reasons predicted residual enhancement on MR images in 5 of the 6 remaining patients. No perioperative deaths and one case of morbidity were encountered. Conclusions Intraoperative photodynamic diagnosis following resection of malignant gliomas can detect residual tumor tissue with high accuracy. Photodynamic dianosis and fluorescence-guided resection of malignant gliomas have a positive role in improving the radicality of malignant glioma resection.