让垂体瘤的治疗更趋完善

垂体瘤患者术后进行垂体功能的评估可以及时地对垂体功能减退者进行合适的替代治疗.但我们当前的临床现实是能够接受恰当的术后评估的患者还不到50％.只有加强内分泌科与神经外科医师的技术互补协作以及三级医院医师和基层医院医师的密切联系,提供以患者为中心的治疗才能弥补当前垂体瘤治疗存在的缺陷.     

老年垂体瘤患者术后垂体功能减退的高危因素

目的探讨老年垂体瘤患者术后垂体功能减退的高危因素。方法选择垂体瘤患者80例作为观察对象,观察患者术后垂体功能减退发生情况。多因素分析影响术后垂体功能减退高危因素,调查资料包括性别、术前垂体功能减退、合并高血压、合并糖尿病、合并高脂血症、吸烟史、术后肿瘤复发、肿瘤直径、手术入路。结果 80例垂体瘤患者出现垂体功能减退34例(42.5%);无垂体功能减退46例(57.5%)。经单因素分析表明,不同性别、合并高血压、合并糖尿病、合并高脂血症、吸烟史和手术入路术后垂体功能减退发生率比较差异无统计学意义(P0.05);术后垂体功能减退患者:术前垂体功能减退所占比例显著高于术后无垂体功能减退患者,术后肿瘤复发率显著高于术后无垂体功能减退患者,肿瘤直径30 mm所占比例显著高于术后无垂体功能减退患者,差异具有统计学意义(P0.05)。将上述单因素分析差异具有统计学意义的纳入多因素分析显示,术前垂体功能障碍、术后肿瘤复发和肿瘤直径30 mm为影响术后垂体功能减退高危因素。结论应对老年垂体瘤患者术后垂体功能减退的高危因素给予重点关注,早发现、早治疗。     

无功能性垂体腺瘤围手术期内分泌水平的变化及诊断进展

无功能性垂体腺瘤起源于垂体前叶上皮细胞,约占垂体腺瘤的1/3,大多数患者临床表现为头痛、视物模糊。但是部分患者术前及术后出现垂体功能减退。肿瘤对门静脉及垂体柄的压迫导致垂体前叶缺血坏死是引起垂体功能低下的主要机制,术中操作、肿瘤大小及残留都可导致新发垂体功能低下。术前主要以生长激素缺乏为主,而术后出现各个激素轴的改变。垂体功能减退容易被忽视,仅靠激素基础值的检测诊断远远不够,必要时需行刺激试验确诊。一旦明确垂体功能减退,充足的激素替代治疗能够提高患者的生活质量。     

垂体瘤切除术对垂体瘤并发心脏扩大患者心功能的影响

目的 回顾分析垂体瘤切除术对垂体瘤并发心脏扩大患者的心功能变化的影响.方法 收集解放军总医院2005 -2011年经垂体瘤切除术治疗的14例垂体腺瘤并发心脏扩大患者临床资料,对比分析手术前后患者心功能情况及术后恢复情况,利用超声心动图等无创检测手段检测患者术前及术后血清生长激素(GH)、左室舒张末期内径(LVEDD)、室间隔厚度(ST)、左室后壁厚度(LVPWT)和左室射血分数(LVEF),进行对比分析.结果 垂体瘤切除术后GH、ST、LVEF、LVPWT 平均值较术前均显著改善(分别为GH 93.89 μg/L比5.16 μg/L、ST 11.13 mm比10.64 mm、LVEF 43.92％比49.28％、LVPWT 10.53 mm比8.87 mm).手术前后GH差值与手术前后ST、LVEDD、LVEF差值呈线性关系,与手术前后LVEF差值呈正相关,与手术前后LVEDD和ST差值呈负相关.结论 垂体瘤切除术用于治疗垂体腺瘤并发心脏扩大可显著改善患者心功能,其心功能恢复程度和手术前后GH差值关系明显.     

内分泌激素水平监测对垂体瘤患者手术远期疗效的观察

目的 探讨内分泌激素水平监测对垂体瘤手术远期疗效观察的意义.方法 动态观察经显微外科手术治疗的137例垂体瘤患者手术前后血清泌乳素(PRL)、生长激素(GH)、甲状腺功能[T3、T4促甲状腺素(TSH)、血皮质醇(F)和促肾上腺皮质激素(ACTH)]的变化,并进行2年以上的随访和远期疗效评价.结果 术后1周内PRL、GH水平明显下降且与以后的PRL、GH水平基本一致,垂体GH瘤患者34例,术后GH降至0.34 nmol/L以下者11例,23例GH未降至0.34 nmol/L以下,其中13例术后5年内复发.结论 术后1周的PRL和GH水平可做为判断手术疗效的指标之一,术后GH降至0.34 nmol/L以下可做为判断临床治愈的标准.     

单纯性Rathke囊肿患者内分泌功能改变的初步研究

回顾性分析65例单纯性Rathke囊肿患者手术前后内分泌功能改变,术前存在的垂体激素分泌异常以垂体-性腺激素分泌受损和高催乳素血症多见,最常见症状女性为月经紊乱及溢乳、男性为性欲减退及勃起功能障碍,严重者可发生全垂体功能减退甚至危象.手术可以有效改善受损的垂体功能,也可能导致新的损害.     

经蝶窦垂体瘤显微切除术治疗Cushing病的疗效分析

总结了自1980年初至1992年底经蝶显微外科手术治疗Cushing病103例的手术疗效。其中41例进行了选择性垂体腺瘤切除术,62例行垂体瘤及瘤周垂体前叶组织大部切除术。结果:近期有效率为83.5％,远期痊愈率为60.2％,复发率为11.4％。术后病理发现肿瘤者痊愈率为63.1％,而未见肿瘤者痊愈率为48.1％。垂体瘤及瘤周垂体前叶组织大部切除术的痊愈率72.6％,明显高于选择性肿瘤切除术的41.5％（P<0.001）。痊愈者术后48小时内血浆皮质醇水平即降至正常或低于正常,术后好转和无效者,其水平一般仍明显高于正常。术后有1.6％的病例（1/60例）出现继发性甲减,62.5％（30/48例）术前月经紊乱者在术后恢复正常。垂体瘤及瘤周垂体前叶组织大部切除术的疗效优于选择性肿瘤切除术;术后病理检查发现肿瘤者及术后48小时内血浆皮质醇水平明显下降或低于正常者预后良好。     

16例老年颅咽管瘤手术前后内分泌功能变化及相关因素分析

目的 分析老年颅咽管瘤患者手术治疗前后激素水平变化情况,总结此类患者垂体功能低下的特点,为手术前后激素替代治疗提供依据.方法 回顾性分析我院2008年4月～2011年12月收治的16例60岁以上颅咽管瘤老年患者的临床资料.结果 16例患者治疗前以垂体功能低下为突出表现及以此就诊的比例分别为12.5％(2/16)、6.25％ (1/16),术前实验室检查证实有内分泌功能低下的比例为93.8％.所有患者手术后短期内激素功能下降到低点,血清皮质醇、甲状腺素水平低下和尿崩的出现率明显高于术前.但内分泌功能达到低点后尚可改善,随访时内分泌功能恢复正常1例(6.25％),于术后3个月内恢复;9例存在永久垂体功能低下,其中初次手术后永久性功能低下占77.8％ (7/9),再次手术后比例为100％(2例).结论 老年颅咽管瘤患者治疗前内分泌功能低下较为常见,但被严重低估,术后继发内分泌功能紊乱较术前更为常见,特别是复发者,加强监测评估、及早给予激素替代治疗,对减少手术风险、改善老年患者预后有重要意义.     

垂体前叶功能减退症88例回顾性分析

目的 探讨垂体前叶功能低下的临床表现，诊断和治疗，方法 回顾性分析８８例垂体前叶功能低下患者的临床资料。结果 男性２７例，女性５１例，平均病程４．８年，席汉综合征３８例，垂体瘤３２例，颅咽管瘤４例，生殖细胞瘤３例，特发性垂体功能减退６例，空泡蝶鞍２例，脊索瘤，垂体囊肿和隐球菌性脑膜炎各１例，８０％以上患者有性腺功能低下表现，甲状腺功能低下占３３．３％，严重的上腺皮质功能低下者较少，发生低血压，低血     

五例垂体柄中断综合征的临床诊断

目的 提高对垂体柄中断综合征(PSIS)的认识和诊断水平.方法 回顾分析5例PSIS患者的临床表现、垂体前叶及各靶腺轴和垂体后叶功能、影像学表现.结果 PSIS患者5例,其中男性4例,年龄17～21岁,3例有难产史,1例有头颅外伤史,均表现为不同程度的生长发育障碍,1例有畏寒、反应迟钝等甲状腺功能减退症状,均无多饮和低比重尿.所有患者存在生长激素缺乏、低促性腺激素性性腺功能减退和肾上腺皮质储备功能不足,4例患者同时存在中枢性甲状腺功能减退,3例临床并无相应表现.磁共振检查显示所有患者垂体柄和垂体后叶正常高信号消失,而在视交叉下(4例)、蝶窦内(1例)见到点状异常高信号,伴部分空蝶鞍.结论 PSIS以生长发育迟缓为主要临床表现,部分性或完全性垂体前叶功能减退而垂体后叶功能正常,磁共振检查呈现的特征性改变为重要诊断依据.     

垂体腺瘤患者的围手术期垂体激素监测及临床意义

为了对垂体腺瘤患者进行手术前后激素测定、分型、并监测术后垂体功能以及寻求一种判断手术切除程度及术后有无复发的方法，对50例垂体腺瘤手术患者采用放免法测定手术前、后激素水平，对测定值进行回顾性分析，判断检测结果的相互关系并分析其临床意义。结果：泌乳素(PRL)腺瘤及生长激素(GH)腺瘤全切组及末全切组术后激素水平均较术前明显降低(P＜0．05)，全切组术后激素水平与末全切组比较有明显差异(P＜0．05)。认为手术治疗可以明显改善垂体瘤患者术前高激素水平状态，手术治疗有着肯定的治疗价值。其切除程度将决定着术后内分泌的改善水平，应在不损害正常垂体前提下争取全切肿瘤。     

垂体瘤伽玛刀治疗前后的内分泌改变

报导１９９３年１０月至１９９５年５月，经伽玛刀治疗的垂体瘤２７２例，其中对２０３例病人的ＰＲＬ、ＧＨ水平进行治疗前后的比较。结果表明，治疗后１２个月血中ＰＲＬ、ＧＨ与治疗前相比明显下降，且下降程度受治疗前激素水平的影响，治疗前水平越高，治疗后下降越慢。     

The GnRH test in the assessment of patients with pituitary and parapituitary lesions: results of a 5-year retrospective study

OBJECTIVE: To examine the utility of the GnRH (gonadotrophin-releasing hormone) test in the management of patients with pituitary and parapituitary lesions. PATIENTS AND METHODS: A 5-year retrospective study of LH (luteinizing hormone) and FSH (follicle stimulating hormone) responses to GnRH test in patients with HP (hypothalamic-pituitary) disease in a regional endocrine centre. Serum LH and FSH concentrations were measured at baseline and at 20 and 60 min after an intravenous bolus of 100 mcg (micrograms) of GnRH. The GnRH responses were categorised by tumour size, tumour type, and gonadal status. RESULTS: Of the 104 patients studied, 46 were male and 58 were female. There were 50 normal, 38 subnormal and 16 exaggerated LH responses compared with 34 normal 67 subnormal and three exaggerated responses for FSH. Seventy-four patients (71.2%) were hypogonadal. Normal LH responses were achieved in half of the hypogonadal subjects and normal FSH responses in more than a third. Furthermore, the LH responses were exaggerated in nine hypogonadal patients compared with three for FSH. The GnRH test could not differentiate between pituitary or parapituitary lesions either by size or type of lesion. An exception was the male non-functioning adenoma (NFA) sub-group (10 patients, all were hypopituitary, seven were hypogonadal), which demonstrated significant subnormal LH and FSH responses compared with other male and female tumour type sub-groups. CONCLUSIONS: The data from this study indicate that the GnRH test is unhelpful in the clinical assessment of the HP axis in patients with HP disease.     

The evolution of extracranial approaches to the pituitary and anterior skull base

The development of extracranial approaches to the anterior skull base has been a process in development for over a 100 years. Many neurosurgical (and non-neurosurgical) pioneers have contributed to its evolution. In this paper, we will review the major contributors and contributions to this evolving field.     

Pituitary abscess: our experience with a case and a review of the literature

Pituitary abscess is a rare disease. Due to its potentially high mortality and morbidity rate, it should be considered in the differential diagnosis of sellar masses. Despite recent advances in radiological investigations, making a definitive diagnosis preoperatively remains challenging. This 45-year-old Indian gentleman presented with severe throbbing headache for six months. Magnetic resonance imaging of the brain revealed a sellar mass with peripheral enhancement that was misdiagnosed as a pituitary macroadenoma. A trans-sphenoidal excision was done, which surprisingly yielded only pus that was drained accordingly from the lesion. Fungal and bacterial cultures were negative. However this patient subsequently lost complete function of the pituitary gland, resulting in central diabetes insipidus and required permanent hormonal replacement therapy in the deficient endocrine axes. A Medline search was conducted and a review of 24 cases reported in the last 5 years discussed.     

Treatment of acromegaly: is there still a place for radiotherapy?

Objective To evaluate efficacy and safety of radiotherapy on acromegaly treatment. Design and patients We followed retrospectively 99 acromegalic patients for at least one year after radiotherapy (RT). RT had been performed after unsuccessful surgery in 91 patients and as primary treatment in eight. Time elapsed between surgery and RT was 1.4 ± 2.4 years. Mean follow-up after RT was 5.9 ± 4.7 years (1–16 years). All patients were treated with linear accelerator, 89 by conventional (3240–6000 cGY) and ten by stereotactic RT. Measurements Biochemical remission was defined as GH < 2.5 ng/ml and IGF-I normalization. Results At latest follow-up, 54% of patients had serum GH level <2.5 ng/ml; 42% had normal IGF-I and 38% of patients achieved normalization of both. Controlled patients had lower baseline GH and IGF-I levels compared to uncontrolled ones. They achieved remission after 3.8 ± 2.4 years, a significantly lower time length compared to maximum follow-up of uncontrolled (6.0 ± 4.9 year). Results regarding GH and IGF-I levels were similar in patients treated either primarily or after surgery. No patient showed tumor growth. Visual field defects were observed in four, seizures in one, and mental disorders in two patients, although cognitive function were not properly assessed. At the last follow-up, 47% of patients had acquired at least one hormonal deficiency. Conclusions There is still a place for RT in acromegaly treatment, mainly for: after non-curative surgery and poor response or inaccessibility to medical treatment; growth restraining of aggressive macroadenomas; co-morbidities that contraindicate surgery and surgery refusal. However, side effects and latency period to achieve disease control should be kept in mind.