垂体TSH细胞腺瘤致中枢性甲状腺功能亢进的诊断和处理

目的 前瞻性研究分析7例垂体促甲状腺激素(thyroid-stimulating hormone，TSH)腺瘤所致中枢性甲状腺功能亢进患的临床资料：方法 男性6例，女性1例，平均年龄42．7岁，平均病程3．1年，平均延误诊断1．5年。7例均有不同程度的甲状腺增大和甲状腺功能亢进症状，4例有视野缺损。7例均有血浆游离T3、游离T4、T3和T4增高，TSH不被抑制，其中，4例TSH增高，3例TSH正常；3例行促甲状腺释放激素(thyrotropin releasing hormone，TRH)试验、2例无反应，1例有反应。7例均行蝶鞍MRI检查，均为垂体大腺瘤和巨大腺瘤，直径2～5cm；7例对海绵窦均有不同程度的挤压或包绕，2例侵犯蝶窦。7例均行经口鼻蝶窦显微外科垂体腺瘤切除术，其中，1例术前外院曾行γ-刀治疗，1例行二期开颅垂体腺瘤切除术，3例术后辅以放疗：结果 术后病理均为垂体TSH细胞腺瘤。随访3个月～1年，甲状腺功能正常5例，蝶鞍MRI检查末见肿瘤6例。结论 垂体TSH细胞腺瘤首选手术治疗，术后密切随访甲状腺功能和影像学检查，若发现异常，及时辅以放疗。早期诊断和治疗是预后的关键。     

垂体腺瘤经蝶窦手术中垂体柄和垂体组织的辨认与保护效果

目的分析采用经蝶窦手术治疗垂体腺瘤对垂体柄和垂体组织的辨认和保护,以改善治疗效果。方法对我院收治的35例经蝶窦手术治疗垂体腺瘤的患者进行回顾性分析,统计肿瘤切除率、FT3、FT4、TSH、ACTH 4种激素在手术前后和随访期的水平,及术后并发症。结果垂体腺瘤全切除和次全切除患者共34例,占97.1%;激素检测显示手术对FT3、ACTH并无显著性影响(P0.05),而FT4和TSH在术后及随访期的正常人数显著增加(P0.05);此外,手术后的并发症主要包括尿崩(22.8%)、电解质紊乱(8.6%)、脑脊液漏(2.8%)及垂体功能低下(2.8%)。结论采用经蝶窦入路手术切除垂体腺瘤具有较高的安全性和切除率,且对剩余的垂体组织损伤较小,能很好保护垂体组织的正常生理功能,并发症发生率较低,是一种有效治疗垂体腺瘤的手段。     

经蝶窦垂体腺瘤切除术中鞍底的处理

目的 探索改进经蝶窦垂体腺瘤切除术中的鞍底处理方法。方法 对本院1995年以来82例经蝶窦显微手术的体腺瘤患,按鞍底处理分为三类。术中满意切除腺瘤,鞍隔蛛网膜囊满意贴向鞍底,用明胶海绵加EC胶单纯封闭鞍底（29例）;术中蛛网膜破损有脑脊液漏出,用明胶海绵加EC胶封堵（37例）;对肿瘤刮除不满意或刮除肿瘤后鞍隔蛛网膜下降不满意,鞍内填入明胶海绵或速即沙等止血物质,鞍底敞开不封闭（16例）。结果 患术后均无不良反应,也没有并发症。结论 本方法与目前传统方法的最大区别在于处理鞍底不用自体游离组织,而用明胶海绵、EC胶、其方法简便、安全、疗效可靠,且减少患的痛苦。     

儿童和青春期垂体促肾上腺皮质激素腺瘤的诊断和治疗

目的　讨论儿童和青春期垂体促肾上腺皮质激素 (ACTH)腺瘤的诊断和治疗。方法　回顾性分析经手术后病理证实为垂体腺瘤的 2 8例患者临床资料。结果　男 8例 ,女 2 0例 ,平均年龄 15 7岁。 2 6例有表现为典型的库欣病 (Cushing sdisease) ,10例有发育迟缓。均行经蝶窦显微外科垂体腺瘤切除术 ,2 6例行瘤周垂体切除。本组无死亡。随诊 1～ 10年 ,复发 5例 ,其中 3例再经蝶窦手术 ,2例行垂体放疗后 7年再次复发行肾上腺切除术 ,术后垂体功能低下 ,用强的松替代治疗。结论　儿童和青春期ACTH腺瘤大多数为垂体微腺瘤 ,发病年龄较小 ,可引起生长发育迟缓 ,经蝶窦显微外科垂体腺瘤切除术是最佳治疗方法 ,术中行瘤周垂体切除可提高疗效。对于临床症状复发 ,影像学检查有明显肿瘤复发者应再次经蝶窦手术治疗 ,而症状复发但影像学检查无明显肿瘤者 ,行蝶鞍区放疗或肾上腺切除手术。     

经蝶窦手术治疗巨大垂体腺瘤

目的探讨经蝶窦手术治疗巨大垂体腺瘤的临床效果。方法从2005年3月至2008年12月,采用经蝶窦分次手术治疗直径大于4cm的巨大垂体腺瘤46例,其中无功能腺瘤24例,泌乳素腺瘤9例,生长激素瘤10例,促肾上腺皮质激素腺瘤1例,混合性腺瘤2例。结果本组患者1次手术31例,2次手术12例,3次手术3例。分次手术间隔为6～8W。全切除26例,次全切除20例。术后并发垂体功能低下2例,脑脊液漏2例,术后肢体偏瘫1例。无死亡病例。l例在手术后2年肿瘤复发。结论经蝶窦手术能有效治疗巨大垂体腺瘤。分次经蝶窦手术能有效提高手术全切除率并减少术后并发症。     

部分空蝶鞍合并垂体腺瘤诊断和手术治疗

报道１９７９年４月至１９９５年２月经手术和（或）影像学证实的１５例，部分空泡蝶鞍（ＰＥＳ）合并垂体腺瘤，占同期垂体腺瘤的１．６％，其中合并肢端肥大症６例，柯兴氏病５例，泌乳素腺瘤３例，无功能腺瘤合并自发性脑脊液鼻漏１例。本组１４例经蝶窦显微外科手术切除垂体腺瘤，术后均达到治愈和缓解，无１例发生术后脑脊鼻漏。本文就其病因、发病机制、诊断、处理原则和手术技巧等进行了较详细的讨论。     

巨型垂体腺瘤经蝶窦显微手术

目的:探讨治疗巨型垂体腺瘤的有效方法。方法:采用经蝶窦显微手术治疗7例直径大于4cm的巨型垂体腺瘤,介绍手术的适应证和显微手术的技术。结果:本组肿瘤全切除6例,次全切除1例,无手术死亡及严重的手术并发症。结论:经蝶窦显微手术治疗巨型垂体腺瘤是一种有效的方法。     

经蝶显微手术治疗老年垂体腺瘤19例报告

目的：报告19例老年垂体腺瘤的经蝶显微手术治疗,探讨老年垂体腺瘤的临床特点及治疗原则。方法：分析19例老年垂体腺瘤的临床及影像学特征,显微手术疗法、手术结果、术后并发症及治疗。结果：肿瘤全切12例,次全切5例,大部分切除2例,无手术死亡,无严重并发症;手术效果满意,临床症状改善90％;在平均3年随访中,2例临床症状复发。结论：老年垂体腺瘤经蝶入路显微手术切除是一种安全有效的方法。     

垂体促甲状腺激素腺瘤的诊断和治疗(三例报告并文献复习)

自2000年1月至2004年12月手术治疗垂体腺瘤152例，发现5例垂体促甲状腺激素（TSH）阳性，其中3例符合TSH细胞腺瘤诊断，现报告如下。     

经蝶窦垂体腺瘤手术中发生脑脊液漏的原因和防治

目的 探讨经蝶窦入路垂体腺瘤手术中发生脑脊液漏的常见原因及其防治方法.方法 回顾性分析260例显微镜下、274例神经内镜下经蝶窦垂体腺瘤切除术中,46例术中发生脑脊液漏,其中显微镜手术24例,神经内镜手术22例.术中多用人工干燥硬脑膜或自体脂肪及纤维蛋白胶修补,蝶窦内填明胶海绵,对于肿瘤体积巨大,鞍底骨质广泛破坏甚至消失者,用骨片填放于蝶窦内固定填塞的软组织.根据术中修补情况36例术后即刻行腰大池置管持续引流.结果 术中修补46例脑脊液漏,术后13例发生脑脊液漏,经腰大池引流3-6 d愈合;6例发生细菌性脑膜炎,经腰大池引流治愈.结论 术前应充分估计容易发生脑脊液漏的患者,手术操作格外小心,并准备好修补措施;应用自体脂肪及纤维蛋白胶修补经蝶窦垂体腺瘤术中脑脊液漏是有效的方法;如果术后发生脑脊液漏或细菌性脑膜炎,则需要腰大池置管持续引流.

Abstract：

Objective To analyze the causes and prevention and treatment of cerebrospinal fluid leak during transsphenoidal pituitary adenoma surgery.Methods Retrospective study of 260 cases of microscopic transsphenoidal surgery and 274 cases of endoscopic surgery for resection of the pituitary adenomas was performed.CSF leak occurred in 24 cases with microscopic surgery and in 22 cases with endoscopic surgery during operation.The sellar floors were sealed by artificial dried dura or free autogenic fat and fibrin glue for the CSF leakage during surgery.For giant tumors which extensively destroyed sella floor,we put bony plates in sphenoid sinus to support the crammed tissue.Lumber drainage was performed immediately after operation in 36 cases.Methods In the 46 patients with CSF leakage during surgery,13 cases occurred CSF leakage postoperatively,cured in 3-6 days after lumber drainage.6 patients occurred bacterial meningitis,cured after long term lumber drainage.Conclusion Probability of CSF leak before transsphenoidal surgery should be estimated,and preparation for the fixing up the leak is necessary.Using free autogenic fat and ebonite to repaired the sellar floors in case of CSF leakage during surgery is a effective measurement.Patients with CSF leakage or bacterial meningitis after surgery require lumber drainage.     

垂体促甲状腺激素腺瘤的诊断和治疗(附12例报告)

目的 探讨垂体促甲状腺激素(TSH)腺瘤所致中枢性甲状腺功能亢进症的诊断和处理.方法 同顾性总结12例垂体TSH腺瘤临床资料和经蝶窦手术切除的疗效.主要症状为甲状腺肿人和中楸性甲状腺功能亢进症.CT和MRI显示均为大腺瘤或巨大腺瘤.所有患者均接受经蝶窦外科手术治疗,其中6例患者术后辅以放射治疗,2例患者术后辅以约物治疗.结果 显微镜下全切除8例;次全切除2例;部分或大部分切除2例.术后病理均为TSH腺瘤.随访半年-3年期间,甲状腺功能亢进症状恢复10例,复发2例.结论 垂体TSH腺瘤经蝶窦外科治疗可取得良好的长期预后,早期诊断和综合治疗是治愈的关键,术后定期随诊至关重要,术后如出现症状复发,根据具体情况再次手术和(或)辅以放疗和药物治疗.     

Manifestation, management and outcome of subclinical pituitary adenoma apoplexy

The objective of this study was to investigate the clinical features, diagnosis, treatment and outcomes of subclinical pituitary adenoma apoplexy (SPAA) in 185 consecutive patients between January 1990 and May 2007. Of the 185 patients, 133 (71.89%) underwent transsphenoidal tumor decompression and the remaining 52 patients (28.11%) underwent transcranial surgery. Preoperative and postoperative endocrinological hormone concentrations were measured in all patients. Pituitary imaging was obtained by CT scans or MRI. Follow-up outcomes were obtained from the records of outpatient visits and by telephone interviews. Visual disturbance, headache and pituitary function impairment improved significantly in all patients. Prolactinoma was the most frequent type of pituitary adenoma in our series (51.89%). SPAA usually occurred in patients with large or giant adenomas (85.95%). Postoperative follow-up ranged from 1 year to 17 years with a mean of 7.4 ± 1.6 years. The tumor recurred in 23 patients, 18 of whom were treated with postoperative radiotherapy for either residual tumors (n = 8) or recurrence (n = 10). Long-term thyroid hormone replacement was necessary in eight patients and steroid hormone replacement in six patients. The incidence of SPAA is relatively high compared with that of acute pituitary apoplexy. The exact pathogenic mechanism of SPAA remains unknown. MRI is significantly better than CT scans for detection of SPAA. Transsphenoidal decompression is safe and effective. Surgical decompression should be performed as early as possible.     

亚临床型垂体腺瘤卒中的诊治

目的总结203例亚临床型垂体腺瘤卒中患者临床特点、诊断、处理与结果。方法回顾性分析亚临床型垂体腺瘤卒中病人203例,149例行经鼻蝶垂体腺瘤切除术,54例行开颅切除手术。患者术前术后均作内分泌学检查,影像学检查为cT或MRI。结果所有病人视觉损害、头痛或垂体功能得到不同程度改善。泌乳素腺瘤是本组病例中最常见病理类型。大腺瘤及巨腺瘤患者容易发生亚临床型垂体腺瘤卒中。术后随访有24例垂体腺瘤复发。19例接受放疗。9例术后长期服用甲状腺素替代药物,8例服用类固醇激素。结论亚临床型垂体腺瘤卒中的发病率比急性卒中高。亚临床型垂体腺瘤卒中的发病机制尚不清楚。磁共振优于cT诊断亚临床型垂体腺瘤卒中。经鼻蝶手术治疗亚临床型垂体腺瘤卒中安全有效。     

MGMT在TSH腺瘤中的表达及临床意义

目的促甲状腺激素腺瘤(TSH腺瘤)约占垂体腺瘤总数的2%,一线的治疗方式是手术治疗,但手术治疗面临许多困难并且效果一般。有研究表明:TMZ的疗效和O-6甲基鸟嘌呤-DNA甲基转移酶(MGMT)密切相关。因此,本研究拟通过检测TSH腺瘤标本中MGMT的表达来评估TMZ对TSH腺瘤的治疗价值。方法本研究所用15例TSH腺瘤标本均来自南京军区南京总医院神经外科手术病例。采用SP免疫组织化学染色法检测15例TSH腺瘤中MGMT表达;在光镜下用半定量方法分析标本中阳性细胞核的表达情况来评分。结果本研究15例TSH腺瘤中女性8例,男性7例,平均年龄(53.2±15.9)岁。超过一半(53.3%)TSH腺瘤的MGMT表达25%,绝大多数(93.3%)TSH腺瘤的MGMT低表达(≤50%)。结论大部分TSH腺瘤低表达MGMT,可能适合TMZ治疗。     

Surgical outcome of the endoscopic endonasal approach for non-functioning giant pituitary adenoma

Pituitary adenomas with extensive suprasellar extension are a therapeutic challenge. The efficacy and safety of the endoscopic endonasal approach for non-functioning giant pituitary adenoma was evaluated retrospectively. A total of 43 consecutive patients with pituitary adenomas with a suprasellar extension of >20 mm underwent tumor resection with a purely endoscopic endonasal approach, and their surgical outcomes were analyzed. At surgery, irrespective of the size and shape of the adenoma, every effort was made to perform intracapsular resection under direct visual control using an angled-lens endoscope. Gross total removal was achieved in 20 out of 43 patients. Postoperatively, 42 patients showed varying improvement of both visual field defects and impaired visual acuity. In two patients who presented with gait disturbance and cognitive dysfunction due to obstructive hydrocephalus, these symptoms were completely resolved. There were no serious operative complications. The results indicate that intracapsular resection via the endoscopic approach can be a safe and effective treatment for giant pituitary adenomas.     

经蝶窦入路手术治疗垂体生长激素腺瘤

目的 探讨垂体生长激素(GH)腺瘤患者的肿瘤大小、术前GH水平、术中GH的动态变化对手术效果的影响.方法 回顾分析47例垂体GH腺瘤,18例术前行口服糖耐量试验(OGTT);均采用经蝶窦入路手术,19例术中检测GH水平,21例术后1个月行OGTT试验.结果 术后随访期内临床症状明显缓解的30例,随访期内GH<2.0.g/ml的有29例,总的缓解率61.7%,其中微腺瘤77.7%、大腺瘤的缓解率是51.7%.结论 垂体GH腺瘤患者的早期诊断是提高手术效果的关键,OGTT抑制试验有助于早期诊断;经鼻蝶入路手术是治疗首选,术中GH的动态观察有助于早期判断手术效果,若能及时快速测定GH,将有助于提高缓解率.     

神经内镜下经单鼻孔蝶窦垂体腺瘤切除术

目的探讨神经内镜下经单鼻孔蝶窦切除垂体腺瘤的技术方法和疗效。方法 2006年8月至2009年5月在神经内镜下经单鼻孔蝶窦切除垂体腺瘤202例。结果肿瘤全切除171例(84.65%),次全切除22例(10.89%),部分切除9例(4.46%),术后临床症状改善196例(97.02%)。术后血清内分泌激素较术前有所改善173例(85.64%)。28例(13.86%)出现术后并发症,包括尿崩症、鼻腔出血和脑脊液漏。结论神经内镜下经单鼻孔蝶窦垂体腺瘤切除术具有手术创伤小、术后并发症少等优点,是一种安全、有效的治疗方法。     

儿童和青春期垂体腺瘤的诊断和治疗

儿章和青春期垂体腺瘤多数指16或18岁以前经手术证实的病例。全面评估内分泌、影像学改变是诊断的关键、治疗的基础。儿童和青春期PRL腺瘤与成人PRL腺瘤在对溴隐停有效性方面相同。甲介型或气化不良的经窦并不是经蝶手术的禁忌症。关于Cushing’s病的治疗，首选经蝶手术，治愈率可达80％～98％．放射治疗应严格掌握适应症，尽可能减少延迟性的垂体功能低下的发生。术后可以发生各种垂体和下丘脑功能障碍，长期、正规的随访具有特别重要的意义。     

Transsphenoidal surgery for visual loss in patients with pituitary adenomas

This paper presents the results of transsphenoidal surgery in 41 consecutive patients with visual loss from pituitary adenomas. The most common pattern of loss was bitemporal hemianopia. Transsphenoidal decompression resulted in visual improvement in 78% of patients. If patients with optic atrophy and pre-operative complete blindness were excluded, improvement extended to 94% of patients. Because of its efficacy and low morbidity, transsphenoidal resection of pituitary tumours is the procedure of choice for most adenomas with extrasellar extension and visual field loss.