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1 腦腫瘤手術 Neurosurgery for Brain tumour 朱獻倫醫生香港中文大學威爾斯亲王醫院神經外科 Dr Xianlun Zhu Neurosurgery PWH CUHK

2 腦瘤的神經外科治療 Brain tumour neurosurgical treatment 良性主要靠手術切除治愈机會較高惡性術后常需化學和放射治療复發机會較高少数惡性腦瘤对化療和放療高度敏感 Benign Mainly by excision Better chance of cure Malignant Often needs chemotherapy / radiotherapy More chance of recurrence Few types highly sensitive to chemotherapy and radiotherapy

by excision Better chance of cure Malignant Often needs chemotherapy / radiotherapy

3 并导致不同的發病表現 Lead to various presentation 局部表現 : 与受侵犯的部位有關顱內压力增高表现 : 肿瘤大直接引致, 或因阻塞性脑积水間接引致頭痛, 呕吐, 昏睡, 神志不清等 Focal signs according to the site Raise ICP: due to mass effect or obstructive hydrocephalus 小腦腫瘤是小儿常見腦瘤, 可引起反复呕吐与腸胃病相從, 亦可引起動作笨拙, 步态不稳 Cerebellar tumour: common in children. Recurrent vomiting may mimic GI disorders. Can cause ataxia

mass effect or obstructive hydrocephalus 小腦腫瘤是小儿常見腦瘤, 可引起反复呕吐与腸胃病相從, 亦可引起動作笨

4 目標腦瘤手術 Surgery for brain tumour [1] 获取肿瘤樣本從确立病理診断 ( 甚麼瘤? 良或惡性?), 進而指导下一步治療 [2] 全部或大部份切除肿瘤, 視乎手術的安全性 Purpose [1] Tumour biopsy for Histopathological diagnosis [2] Tumour excision or debulking depends on the safty.

5 腦瘤手術种類 Types of surgery for brain tumour 肿瘤活检手術 : 只获取肿瘤组織樣本适用於 : 位於要害部住, 切除手術高風險估計化療放射治療對该肿瘤很奏效协助寻找轉移瘤的源頭肿瘤切取并同時活檢适用於 : 肿瘤体积大, 需減壓估計是良性肿瘤, 若能切除则為优先考慮 Pure Biopsy Critical location, high risk for excision Estimated good response to chemotherapy / RT Metastatic tumour: Part of the investigation to look for primary tumour Biopsy + Resection Massive tumour requiring decompression Benign tumour: excision is the best treatment 大多数的腦瘤都需要先行手術切除, 因為 : 对化療放射治療高度敏感的腦瘤屬少数對大多数腦瘤来说, 即使不能全部切除, 減少肿瘤体积和细胞数量有助提高化療和放射治療的效果 Majority of the brain tumours need tumour resection: Only few types of brain tumour highly sensitive the chenotherapy / RT. Debulking and cytoreduction: better chemotherapy / RT effect

primary tumour Biopsy + Resection Massive tumour requiring decompression Benign tumour: excision is the best treatment 大多数的腦瘤都需要先行手術切除, 因為 : 对化療放射治療高度敏感的腦瘤屬少数對大多数腦

6 肿瘤活检手術 [1]: 导航指引针吸活检 Biopsy [1]: Navigation guided needle aspiration 顱骨鉆孔 Burr hole Ø 14mm 針粗 1.8mm

7 肿瘤活检手術 [2]: 內視镜活檢 ( 顱骨鉆孔 ) 适用于腦室內生長的肿瘤還可能同時進行解除阻塞性腦積水的手術 Tumour Biopsy [2]: Neuroendoscopy (burr hole) Indicated for intraventricular tumour. May perform 3 rd ventriculostomy for obstructive hydrocephalus at the same procedure as well

8 男 16 岁 M/16 多尿多饮水 ( 尿崩症表現 )1 年. 間歇性頭痛 3 個月, 复視步行不穏 2-3 個月頭痛加重反复呕吐 1 周 TCY, 2007 Polyuria, polydipsia 1 year, on and off heacahce 3 months, diploia unsteady gait 2-3 months, increasing headache and repeated vomiting 1 week. MRI: 松果体及鞍上區腫瘤 + 阻塞性腦積水年龄, 表現, 部位提示生殖细胞瘤, 可能化療放療有好效果 MRI: Pineal and suprasellar region tumour, with obstructive hydrocephalus. Ge, symptoms and site suggested germcell tumour which is sensitvie to chemotherapy and radiotherapy

diploia unsteady gait 2-3 months, increasing headache and repeated vomiting 1 week.

9 紧急手術 : 內視镜 3 腦室底部穿通術 ( 解除腦積水 ) 內視镜肿瘤活檢術 Emergency operation Endoscopic 3 rd ventriculostomy( to relive the obstructive hydrocephalus) Endoscopic tumour biopsy Pathology: Germinoma 病理診断 : 単纯生殖细胞瘤手術設計 Surgical strategy

the obstructive hydrocephalus) Endoscopic tumour biopsy

10 術后頭痛嘔吐消失接受化療和放療 After the operation, headache and vomiting subsided. Further treatment: chemotherapy and radiotherapy Pre-op week post-op 2 years post-op 2009

11 肿瘤活检手術 [3]: 立体定向框架針吸活检 ( 顱骨鉆孔 ) Tumour biopsy (3): Frame based Stereotactic needle biopsy (burr hole) 精确度在几毫米之內 Accuracy with few mm 頭架固定 Fix the frame to the head 手術計劃 Surgical plan 掃描 CT or MRI scan 顱骨鑽孔针吸活检 Burr hole beedle biopsy 术中靶點确定 X-Ray confirm the target

few mm 頭架固定 Fix the frame to the head 手術計劃 Surgical plan 掃描 CT or MRI

12 肿瘤活检手術 [4]: 術中超音波引導針吸活检 ( 顱骨鉆孔 ) Tumour biopsy (4): USG guided needle biopsy (burr hole) 适合体積大表淺病灶 Useful for superficial large lesion 超音波探頭 USG probe 術中實時影像和針道 Intra-Op real time image and needle track

13 腦瘤切除手術 Tumor excision 开顱手術 Craniotomy 手術完成它骨辨回复原位并用钛手屬固定 The bone flap will be replaced and fixed with titanium plates after tumour excision 显微手術, 并應用导航, 超聲波探測, 超聲波吸引器等 Microsurgery together with navigation, USG, USG aspirator etc.

plates after tumour excision 显微手術, 并應用导航, 超聲波探測, 超聲波吸

14 2004 年 : 無复發, 正常成長發育 2004: No recurrent Normal development 年, 年纪 4 個月. 手術切除 Year 2000: 4 months, Surgical excision 脈络丛瘤 ( 良性 ) Pathology: Choroidal papilloma (benign)

15 小腦肿瘤伴阻塞性腦积水 Cerebellar tumour with obstructive hydrocephalus 術前 Pre-Op 術后 Post-Op

16 併發症 - 針吸活檢文獻記載 : 成功診断率 : 平均 95% ( %) 併發症率 ( 有症状的出血 ): 1-5% 威爾斯亲王醫院 *: 成功診断率 : 平均 93% (50/54) 併發症率 ( 有症状的出血 ): 2% (1/54) Complication: Needle biopsy Literature: Diagnostic yield: 95% in average ( %) Complication (symptomatic haemorrahge): 1-5% Prince of Wales Hospital*: Diagnostic yield 93% (50/54), Complication (symptomatic haemorrhage) 2% (1/54) 術后左手力弱 Post-Op Lt hand weakness (Yuen et al, Stereotactic & Functional Neurosurgery 2014)

Complication: Needle biopsy Literature: Diagnostic yield: 95% in average (83.

17 併發症开顱手術腦瘤切除腦 / 神經 / 血管損傷術中失血, 尤其是小儿術后顱內血肿 / 感染 Complication Craniotomy tumour excision Brain/nerve/vessel injury, Blood lost, especially in children. Post-Op haematoma and infection

18 小腦缄黙症候群小儿, 小腦中線肿瘤切除術后几天后發生清醒, 明白, 但不說話煩躁, 哭, 常伴小腦共濟失調原因不完全清楚文獻回顧性研究 : 2-29%. 前瞻性研究 : 24% (107/450), 髓母細胞瘤術后 (Robertson et al, JNS 2006) 威爾斯亲王醫院 : 4/40 (10%): 3 例 : 3 周至 6 個月完全康复 [ 男 9 岁, 男 8 岁, 男 5 岁 ] 1 例 : 1 年后恢复說話長期隨訪 : 共濟失調, 认知功能缺陷和精神疾患 Cerebellar mutism children, few days after cerebellar midline tumour excision. Conscious and understanding but not speak, irritable, often with ataxia. Cause not well understood. Literature Retrospective series: 2-29%. Prospective study: 107/450 (24%) among childre with Medulloblastoma after tumour excision. (Robertson et al, JNS 2006) PWH: 4/40 (10%): 3 cases: well recovered 3w-6m [M/9, M/8, M/5. 1: speech recovered in a year. Long term survivor but with ataxia, cognitive deficit and psychiatric disorders.

精神疾患 Cerebellar mutism children, few days after cerebellar midline tumour excision. Conscious and understanding but not speak, irritable, often with ataxia. Cause not well understood.

19 病理腦瘤治疗預后 ( 治療結果 ) 良性或惡性对化學和放射治療的有效敏感程度能否全部切除 Pathology: Outcome Benign or malignant Responsive to chemotherapy / radiotherapy Complete excision or not

20 腫瘤全部切除與併發症的關係 Complete excision Vs Complication 如果腦瘤與重要结构例如血管神經等關系密切, 或者邊界不清, 切除过程可能造成損傷, 导致危險或后遺症總的來說, 醫生和病人及家人都希望以安全為上對某些類型的腦瘤, 術后安排早期 MRI 如發現有殘余腫瘤而且可以切除, 則進行二期手術全切併發症 If the tumour has a close relationship with critical brain structure such as nerves and vessels, or a unclear margine, damage may occur during the excision leading to complication, neurological deficit and disability. Overal, the doctor and the patient and the relatives will take safety as high priority For certain types of tumour, early post-op MRI is needed. If residual tumour is found and can be further exercised, 2 nd stage operation will be carried out.

vessels, or a unclear margine, damage may occur during the excision leading to complication, neurological deficit and disability.

21 如何尽量安全切除腦腫瘤? How to maximize a safe brain tumour excision? 除了外科醫生的經验和技巧, 很多現代技術都有助于提高腦肿瘤的切除率及安全性例如 : 功能性影像 ( 功能性 MRI, 神經纤维成像 ), 神經導航, 術中電生理監測, 術中腦功能探測, 清醒开顱手術, 術中影像 (USG, CT, MRI), 術中螢光剂引導惡性膠質瘤切除, 超聲波吸引器.. 微創手術? Minimally invasive surgery? Apart from the skill and experience of the surgeon, some modern technologies are useful, such as: functional imaging (fmri, DTI), neuro-navigation, intra-operative electrical physiological monitoring, functional brain mapping, awake craniotomy, Intra-operative imaging (USG, CT and MRI), Fluoresence guided resection of malignant glioma USG aspirator etc.

22 女, 48 岁, 左腿局灶性抽搐癲癇症 MRI: 腫瘤侵犯右腦運動功能區. F48, Left foot focal seizures MRI: tumour involed the Rt motor cortex foot function region 手術切除肿瘤會令左腳瘫痪嗎? 肿瘤 Tumour Will Lt foot become palsy after tumour excision? CW 2010

23 开顱手術 : 睡眠喚醒 - 睡眠 Craniotomy: Sleep Awake - Sleep 导航系統下开顱并确定肿瘤位置 Navigation guided craniotomy and lesion localization

24 开顱手術 : 睡眠喚醒 - 睡眠 Awake craniotomy: Sleep Awake - Sleep 應用電刺激寻找下肤功能部位 To map the lower limb functional area by electrical stimulation

25 超聲探测証實肿瘤在皮层下方 USG confirms the tumour underneath the cortex 探測结果显示肿瘤為下肢功能區所复蓋如何做? Mapping result: The tumour is underneath the foot function area! How to do? 导航指示肿瘤部 Navigation pointing to the tumour 腿活動 leg Motor 腿感觉 Leg sensation

26 微創手術? Minimally invasive surgery? 經腦溝, 在手术显微镜下切除肿瘤, 術中不断檢查下肢功能 ( 术中清醒的好處 ) Sulcal approach microsurgery. Repeated examination the limb function during resection ( it requires patient awake and copperation)

27 肿瘤全部切除術后無神經功能缺損病理 : 恶性膠质瘤 ( 三级 ) 隨即接受放療和化療 Gross total excision No neurological deficit Pathology: malignant glioma (Grade III) Received radiotherapy and Chemotherapy

28 治療后探查手術 Second look operation 做了第一次手术并接受了化療或放療后, 如果肿瘤反應与预期不相符, 例如体積缩小不如理想, 怀疑病理性质有改變, 则有需要進行手術探查以明确原因以指导進一步治療这种探查手術可能是单纯活檢術, 亦可以是切除手術, 視乎個案而定 After the 1 st operation and sbusequent chemotherapy or radiotherapy, sometimes surgery may be needed if the tumour s response is not as expected, such as unsatisfactory size reduction, suspected change of pathology. The surgery is to answer the question. The surgery can be biopsy only, or a excision operation, depends on the condition of individual case.

29 然而, 令人心痛悲傷的是見到有的病入盡管反复手術, 接受化療和放療, 肿瘤仍复發, 轉移. Yet, Yet, it is sad and heart breaking to see some patients, in spite of repeated operations, chemotherapy and radiotherapy, still developed recurrence, and even metastasis..

30 结語当今, 神經外科己有很大的發展, 让我们能采用各种不同的方法去治療各類腦瘤. 对於漫長艰辛的腦瘤治疗过程, 外科手術只是其中一环. 神經外科需要和各學科尃家紧密合作, 包括肿瘤學家, 病理學家, 影像學家, 心理學家, 基础研究科學家. 与腦腫瘤博斗, 我们需要病人的坚強意志和家入的理解支持 Closing remark Great advance has been made in neurosurgery for brain tumour enable us to tackle the tumour in various way. It is only a part of the long journey for brain tumour treatment. Neurosurgeon need to work closely with different disciplines including neuro-oncologist, pathologist, radiologist, neuropsychologist, and basic scientist. To fight against brain tumour, we need the patient s strong will to live, the understanding and support from the relatives

6-1-1極限的概念

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