【作者】 比得戈·阿兰（Biteghe-bi-Nzeng Alain-Pascal）；

【导师】 王运杰；

【作者基本信息】 中国医科大学 ， 外科学， 2009， 博士

【摘要】 目的通过对4年临床资料的回顾性研究及随访,分析手术治疗垂体腺瘤的疗效。材料收集从2004年一月至2008年四月,四年间561例垂体腺瘤患者的病例。方法统计回顾从2004年一月至2008年四年间561例垂体腺瘤患者的临床特点、手术方式、治疗效果及随访观察。结果脑垂体腺瘤占我科全部颅脑手术例的10.66±2.93%,统计561例患者中共有338例女患和223例男患,平均年龄为44.02岁。主要症状表现为:视力视野缺损者占51.51%,头疼者占34.76%,闭经者占22.64%,泌乳者占13.9%,肢端肥大症者占11.76%。术前内分泌检查发现52.84%的病人患有高泌乳素血症,18.23%有高生长激素血症,有25.4%的患者表现为ACTH增高,5.9%的患者表现为皮质醇增高,3.9%的患者表现为TSH增高。根据Hardy’s分类法,垂体微腺瘤占3.3%,鞍内垂体大腺瘤占38.2%,鞍上垂体大腺瘤占48.7%,垂体巨腺瘤占9.31%。在手术入路方式中,经鼻蝶入路手术占77%,开颅手术占23%。根据垂体腺瘤的功能分类,无功能型垂体瘤占53.47%,在有内分泌功能的垂体瘤中,泌乳素型腺瘤占19.78%,生长激素型腺瘤占9.62%,促肾上腺皮质激素型腺瘤占4.63%,混合型腺瘤占5.52%,侵袭性腺瘤占1.24%,另外垂体癌占0.39%。手术后主要并发症为22.10%的患者存在电解质紊乱,11.59%的患者存在术后血糖升高,4.46%的患者出现尿崩症。根据术后治疗效果统计,在肢端肥大症病人中有36.1%治愈,高促肾上腺皮质激素血症病人中有41.25%治愈,高皮质醇血症病人中有16.54%治愈,在高泌乳素血症病人中有28.62%治愈,另外有0.71%的死亡率和5.35%的复发率。从手术后常规放疗的治疗原则后,有学者提出应该进行选择性放疗。我科的治疗方案为争取术中全部切除,若患者激素降至正常水平并且术后影像学检查未发现肿瘤残留,不用放疗;但是如果手术后患者激素水平没降至正常水平或术后影像学检查发现肿瘤残留应该进行放疗,通过随访发现236病人中有7.20%的病人行放射治疗。结论垂体腺瘤为常见的颅脑良性肿瘤,多见于中年女性。患者术前的症状持续时间较长。鞍上及鞍内垂体大腺瘤占多数。无功能型垂体腺瘤占53.47%,在有分泌功能的垂体腺瘤中,泌乳素腺型腺瘤占19.78%,生长激素型腺瘤占9.62%。在病理诊断为泌乳素腺瘤的患者中,82.1%的患者泌乳素水平高于1200mUI/L(P.000),但明显低于目前临床常用的泌乳素腺型垂体腺瘤的诊断标准:高于正常高值得四到五倍[200ng/ml(4240 mIU/L)】。对病理诊断为生长激素型腺瘤的患者中,62.96%的患者生长激素水平高于26mUI/L(P.000)。但是在促肾上腺皮质激素中,30.77%的患者有低皮质醇血症,42.31%的患者皮质醇正常,只有26.92%的患者有高皮质醇血症,血清皮质醇水平与病理诊断无相关性,这需要在临床诊断促肾上腺皮质激素型腺瘤的激素依据上引起注意。垂体腺瘤手术主要采用经蝶和经颅两种方式,具体采用哪一种入路应该根据患者具体情况,肿瘤部位,大小,质地,形状及蝶窦发育状况进行个体化设计。经蝶手术,手术时间短,并发症较少,患者住院时间与开颅手术相比明显缩短。比较适合垂体微腺瘤和垂体大腺瘤。对垂体巨大腺瘤,大脑开颅手术为主要手术方式。经鼻蝶手术治疗尽管术后死亡率和并发症均较低,但并不应因此而减少术后病人参加定期随访和放射治疗的比例,这样不利于降低垂体大腺瘤和垂体巨大腺瘤的复发率。更多还原

【Abstract】 ObjectivesWe report the clinical characteristic and surgical outcome in four years of retrospective study of patients with pituitary adenomas who attended surgical treatment from 2004 january to 2008 april,and the survey result among them for 4 years.MethodsThe retrospective clinical study found 561 patients in four years analysis and the pituitary adenomas account for 10.66±2.93%of the intracranial surgery.Among 561 patients,338 females and 223 males,the mean age were 44.02 years old.The main presenting symptoms were acuity deficiency 51.51%,headaches 34.76%, amenorrhea 22.64%,galactorrhea 13.9%,acromegaly 11.76%.The preoperative hormonal examinations showed 52.84%of hyper prolactinemia,18.23%of hyper serum HGH,25.4%hyper serum ACTH,5.9%hyper cortisolemia,3.9%of hyper serum TSH.According to Hardy’s classification,microadenoma accounted for 3.3%, intrasellar macroadenomas 38.2%,extrasellar macroadenomas 48.7%,and giants adenomas 9.31%.For the surgical approaches,transnazal transsphenoidal took 77% and transcranial 23%.The pituitary types were 53.47%for the non-functionning adenoma,19.78%PRL,9.62%GH,4.63%ACTH,5.52%for the mixed adenomas, 1.24%of invasive and 0.39%of carcinomas.The main complications were the hydroelectrolytics instability 22.10%,diabetes 11.59%and diabetes insipidus 4.46%. The surgical cure rate reached 36.1%in Acromegaly,41.25%in Acth,16.54%in Cortisol and 28.62%in PRL.With 0.71%of mortality and recurrence rate of 5.35%.We found 236 patients for the follow up.7/236(7.20%) of patients attended the radiotherapy treatment when 96%of the patient had a microscopic potential dural invasion. Conclusion.Our study corroborates the previous results that the pituitary adenoma is principally a benign tumor of young adults and more older people’s disease,with high female tendancy.The long duration of the symptoms in the patients in our study complicated the surgical treatment,finding more macroadenomas in all types of adenomas.We suggest to reconsider the serological value suspecting the pituitary adenomas,by 1200 mIU/L(P.000) for prolactinomas,26 mg/ml(P.000) for somatotroph adenoma.But no significant hormonal value in ACTH or CORT for corticotroph adenomas lead us to reconsider the diagnosis of corticotroph adenoma.The choice of the approach depends on the tumor size,the localisation,the nature of the tumor tissue and the general condition of the patient.Compared to the transcranial approach,the transsphenoidal approach took less time during operation, was less invasive,less hospital duration,less postoperative complications,less expenditures and no external scarification.It gave better results for the microadenomas and macroadenomas surgery but had a lot of limits for patients with giant adenomas who still needed craniotomy surgery.The surgical treatment by the transsphenoidal approach gave low mortality and morbidity compare to the transcranial approach.Despite the total excision,adjunctive postoperative radiotherapy coverage did not help for the long term remission of invasive intrasellar and extrasellar adenomas.更多还原