囊性、囊实性颅咽管瘤的立体定向囊内放疗

目的研究CT、MRI引导立体定向囊内放射治疗囊性和囊实性颅咽管瘤的疗效。方法对100例囊性和囊实性颅咽管瘤的囊性部分行CT、MRI引导立体定向囊腔内置入Ommaya,吸除囊液、注入胶体磷酸铬,对囊实性颅咽管瘤的实质部分行伽玛刀治疗。结果全部病例经手术排出囊液后临床症状迅速改善,经囊腔内放疗后6～84个月随访90例病人,CT及MRI扫描显示42例瘤腔持续消失,临床症状消失,恢复正常工作和学习;18例肿瘤显著缩小,症状持续改善;20例肿瘤无明显改变;复发10例,其中再手术6例;死亡7例。结论CT、MRI引导立体定向放射治疗囊性颅咽管瘤安全、有效。     

囊性颅咽管瘤内置管囊小剂量多次化疗的疗效观察

目的探索神经外科综合治疗位于视丘下部附近区域的囊性颅咽管瘤之方法。方法选择16例囊性或以囊性为主的颅咽管瘤,在CT介导立体定向内窥镜下切除部分囊壁或肿瘤实质,排除囊液减压后囊内置入Ommaya管,术后经反复抽吸囊液,并反复注入小剂量博来霉素30～40次。结果16例经治疗后视力、视野障碍明显好转,7例有颅内压增高者术后缓解。CT显示瘤腔缩小,无手术死亡,术后视丘下部功能紊乱反应轻。14例获随访2～3年,临床症状明显改善。结论该疗法安全、简便、有效,是采用微侵袭神经外科手段治疗颅咽管瘤的有效方法,有一定的临床应用价值。     

囊性颅咽管瘤Ommaya囊留置加放射治疗与开颅手术切除的术后对照分析

目的 探索神经外科综合治疗囊性颅咽管瘤之方法.方法 选择7例囊性或以囊性为主的颅咽管瘤,在MRI CT引导下立体定向穿刺囊壁,置管冲洗后Ommaya囊留置,术后可抽吸囊液并行放射治疗或x-刀、r-刀治疗.12例囊性或以囊性为主的颅咽管瘤选择经采用多种开颅手术入路显微镜下肿瘤切除术,术后常规行放射治疗.结果 7例经立体定向置管Ommaya囊留置加放射或x-刀治疗后视力、视野障碍明显好转,6例有颅内压增高者术后均有显著缓解.术后3个月～3年复查MRI/ CT显示瘤腔缩小,无手术死亡,术后视丘下部功能紊乱反应轻.12例手术切除(全切除4例;次全切除3例;大部分切除5例)病例,术后视神经减压效果明显,颅高压症状改善显著,但术后视丘下部功能紊乱反应较重,2例需终身激素替代治疗.结论 对比开颅手术切除,囊性颅咽管瘤的Ommaya囊留置加放射治疗,该疗法安全、简便、有效,术后反应轻,可达到较为理想的治疗效果.     

CT立体定向囊腔内放疗治疗囊性颅咽管瘤

目的：研究治疗囊性颅咽管瘤最佳治疗方法。方法：对３４例囊性颅咽管瘤进行ＣＴ立体定向囊腔内胶体磷酸铬内放疗。结果：全部病例经手术排除囊液后临床症状迅速改善，经囊腔内放疗后１２～６６个月随访，ＣＴ扫描显示２８例（８２．５％）瘤腔持续消失，３例（８．８％）瘤腔显著缩小，症状持续改善。３例（８．８％）分别于１９、２５、３６个月后因瘤实质部分增大，症状恶化而相继死亡。无手术死亡率和严重并发症。结论：ＣＴ立体定向囊腔内放疗治疗囊性颅咽管瘤十分安全、有效，应作为治疗囊性颅咽管瘤首选的方法。     

颅咽管瘤的微侵袭外科治疗

目的探讨颅咽管瘤的微侵袭治疗方法的选择及并发症。方法46例颅咽管瘤患者,30例行显微手术切除,其中25例行全切除,5例行大部分切除后予r刀治疗;6例行单纯r刀治疗;10例行MRI立体定向囊内放射治疗。结果手术组25例全切除患者,术后21例恢复正常工作,2例需生活照顾,2例死于下丘脑损害;随访2年以上16例,CT或MRI检查未见肿瘤复发。r刀治疗组11例患者临床症状明显改善,随访6～30个月,MRI检查显示4例肿瘤完全消失,5例缩小,2例无变化,无术后并发症。囊腔放疗组10例经手术排除囊液后临床症状明显改善,随访3～30个月,MRI显示3例肿瘤完全消失,7例瘤腔明显缩小,无手术死亡率及严重并发症。结论显微手术全切除颅咽管瘤仍是目前理想的治疗方法,r刀治疗适用实质性和部分实质性,体积较小(<3～4cm)的肿瘤。对囊性体积较大的颅咽管瘤行立体定向囊腔内放疗是一种十分安全有效的方法。     

立体定向Ommaya管置入并~(32)P内放疗治疗术后复发囊性颅咽管瘤(附13例临床分析)

目的探讨开颅术后复发囊性颅咽管瘤的治疗方法。方法对我科13例复发囊性颅咽管瘤患者应用立体定向穿刺、Ommaya管置入反复抽吸囊液,配合32P内放疗治疗。术后长期随访观察疗效。结果在手术抽出囊液后,大多数患者临床症状和体征迅速改善。全部患者术后随访6～60个月,平均32.4个月。经影像学检查证实,术后囊腔消失、肿瘤无复发8例;肿瘤明显缩小、囊腔不足5ml者4例;1例多囊性肿瘤控制不理想,囊腔反复增大,多次门诊穿刺抽液,仅能控制症状。肿瘤总的有效控制率为92.3%。无手术相关死亡及严重并发症发生。结论联合应用立体定向Ommaya管置入反复抽吸囊液,配合32P内放疗的方法,可以安全有效的治疗复发囊性颅咽管瘤。     

CT脑立体定向手术治疗复发性囊性颅咽管瘤（附18例报告）

关于颅咽管瘤的治疗,多数学者主张行根治术。对于较大的囊性及复发性囊性肿瘤手术全切除,往往伴有很高的复发率和死亡率。我们从1994年5月至1997年12月先后对18例复发性囊性颅咽管瘤进行CT定向瘤腔置管,Ommaya囊头皮下埋置,定期抽吸囊液,取得了较好疗效。报道如下。     

颅咽管瘤的个体化治疗分析

目的 探讨颅咽管瘤个体化治疗方法以及不同治疗方法的适应症。方法 2011~2013年收治颅咽管瘤83例,首次发病者行手术切除,不能耐受开颅手术者行立体定向囊液抽吸+32P囊内放疗或伽玛刀治疗;囊性为主复发者行立体定向囊液抽吸+32P囊内放疗,合并实体病变者结合伽玛刀治疗;病变体积小,未侵及下丘脑以及第三脑室的实体复发者采取开颅手术治疗;术后残余、复发实体病灶无法实施手术切除者行伽玛刀治疗。结果 开颅手术切除46例;采取立体定向囊液抽吸+32P囊内放疗32例,其中11例同时接受伽玛刀治疗;单独接受伽玛刀治疗5例。所有患者随访11~40个月,治疗有效75例,稳定4例,进展4例。并发症发生率为45.8%。结论 颅咽管瘤患者的治疗方案,应根据患者具体临床表现及影像学特征,个体化制定、实施。     

立体定向间质放疗治疗囊性颅咽管瘤

目的探讨采用立体定向和间质放疗技术,治疗颅咽管瘤的方法和预后.方法对23例囊性颅咽管瘤采用CT引导立体定向技术,肿瘤囊腔内放置贮液囊导管,按3.7-7.4MBq/克肿瘤组织注入Cr32po4进行内放疗.结果16例获得逐渐改善,3例恶化,2例偏瘫恢复正常,所有内分泌功能障碍,均获得稳定或不同程度好转,复查CT或MT示1例瘤体增大,1例新的囊腔形成,1例导管在脑室内,其余囊腔均明显缩小,其中9例囊腔几乎消失.结论立体定向间质放疗对囊性颅咽管瘤可以起到很好的控制作用.     

神经内镜手术治疗脑室内肿瘤

目的探讨神经内镜手术治疗脑室内肿瘤的临床疗效及经验.方法回顾性分析16例经神经内镜手术治疗的脑室内肿瘤的临床资料,其中肿瘤单纯位于侧脑室8例,第三脑室6例,同时位于侧脑室和第三脑室2例.结果肿瘤全切除4例,部分切除8例,囊性颅咽管瘤经囊腔内置Ommaya管术后囊腔明显缩小4例.术后根据病理检查对部分病例进行放射治疗.均无明显手术并发症.随访2～36个月,平均15.7个月,无死亡病例,第三脑室内生殖细胞瘤复发1例,第三脑室内囊性颅咽管瘤囊腔扩大1例.结论神经内镜手术治疗脑室内肿瘤具有微创、手术视野好、并发症少等优点,是一种有效的诊疗手段.     

Radiological findings following postsurgical intratumoral bleomycin injection for cystic craniopharyngioma

OBJECTIVES: The purpose of this study was to compare the radiological findings before and after intratumoral bleomycin injection in patients with cystic craniopharyngioma so as to define the role of adjuvant intracavitary bleomycin chemotherapy for cystic craniopharyngiomas. PATIENTS AND METHODS: Eleven patients whose craniopharyngioma was confirmed cytologically and/or histologically were retrospectively reviewed. The follow-up duration ranged from 9 to 79 months (mean, 31.6 months). Only the solid portion of the cystic craniopharyngiomas was excised before repeated injections of bleomycin (15-180 mg in total) into the cystic portion through an Ommaya reservoir were given. The patients were evaluated neuroradiologically before and after bleomycin administration. RESULTS: After the completion of all treatment cycles, the disappearance or shrinkage of the tumor was initially noted in all cases on follow-up CT and/or MR imaging studies. However, tumor recurrence was seen in four cases with a mixed tumor type. CONCLUSION: Postoperative bleomycin injection in cystic craniopharyngioma does not appear to totally eradicate the tumor and does not stop tumor recurrence unless the cyst is the only portion of the craniopharyngioma that is left. Nevertheless, postoperative bleomycin injection decreases and stabilizes tumor size, and thus may be considered as an option of treatment modalities in patients with predominantly cystic craniopharyngiomas.     

Long term results of multimodality treatment of craniopharyngioma in children

The management of craniopharyngioma has been controversial for years. We review our 20 year experience in the treatment of paediatric craniopharyngioma. Twenty-five patients were treated for craniopharyngioma at The Montreal Children's Hospital from 1972 to 1991. They included 15 males and 10 females whose median age was 10 years. The initial clinical manifestations were remarkable for a predominance of symptoms and signs related to intracranial hypertension, followed in frequency by visual and endocrinological deficits. Radiologically, there were five cystic craniopharyngiomas, one solid and 19 mixed. Several therapeutic approaches were used including stereotactic drainage followed by radiotherapy or radiosurgery (three cases), transsphenoidal removal (six cases) and subfrontal and/or pterional craniotomy for total (three cases) or partial (13 cases) removal, followed by radiotherapy in 10 cases. The follow up period averaged 11 years. Eight patients recurred, three after total and three after partial removal; none of these six patients had received radiotherapy. Two cases treated by stereotactic drainage recurred, one received adjuvant radiosurgery and the other conventional radiotherapy. Morbidity was lower, and quality of survival better, with more conservative approaches. More conservative approaches in the management of craniopharyngioma are reasonable alternatives for treatment. Similar rates of disease control are observed with less morbidity and better quality of survival.     

Isolated primary craniopharyngioma in the cerebellopontine angle

Between January 2000 and January 2011, we diagnosed three patients with isolated craniopharyngioma in the cerebellopontine angle (CPA). Brain MRI revealed cystic lesions with various imaging characteristics, including hypointensity on T1-weighted (T1W) images and hyperintensity on T2-weighted (T2W) images. The first patient's lesion showed rim enhancement after gadolinium administration. The second patient's lesion showed mixed signal intensity on both T1W and T2W images. The third patient's MRI showed a well-defined cystic lesion in the right CPA that compressed the brainstem. This lesion was hyperintense on T1W images and hypointense relative to cerebrospinal fluid on T2W images, and was peripherally enhanced after gadolinium administration. All three patients underwent surgical intervention through a suboccipital retrosigmoid craniotomy/craniectomy and lesions that did not adhere to adjacent tissues were removed completely. Histopathological examination confirmed the tumors to be adamantinomatous craniopharyngioma. The post-operative course was uneventful for all patients uneventful and no tumor recurrences were detected at the last follow-up. Primary CPA craniopharyngioma can be completely removed surgically, provided it does not densely adhere to vital structures.     

Infrasellar craniopharyngioma

Object

Infrasellar craniopharyngioma (IC) is a rare tumor. This study aimed to investigate the clinical manifestations, treatment methods, and prognosis of IC, which invades the cranial base, nasal sinuses, nasopharynx and clivus.

Methods

Eleven consecutive cases of IC who received treatment in People's Liberation Army Navy General Hospital from 1988 to 2007 were retrospectively analyzed, and the clinical manifestations of IC were summarized. At the same time, literature pertinent to IC was reviewed. These patients consisted of six males and five females with an average age of 28.5 years (range 7–52 years old). Among them, nine cases were identified as simple IC and two cases as suprasellar and IC. Clinical manifestations included headache (seven cases), nasal obstruction (four cases), polydipsia and polyuria (four cases), visual disorder (five cases), delayed sex organ development (three cases), menstrual disorder (one case) and no symptoms (one case). Tumor invasion regions included sellar bottom, ethmoidal sinus, maxillary sinus, sphenoidal sinus, infrasellar region, clivus, nasopharynx and nasal cavity. Solid craniopharyngioma was observed in three cases, cystic craniopharyngioma in seven cases, and mixed cystic and solid type in one case. Four cases underwent craniotomy for tumor resection (three cases also received adjuvant external beam radiation therapy), two cases underwent transnasal approach tumor resection under endoscope guidance (one case simultaneously received adjuvant interstitial brachytherapy) and four cases underwent stereotactic interstitial radiation (radioisotope ³²P brachytherapy).

Results

All cases were followed up for an average of 22.5 years (range 9–98 months). Imaging results showed that tumors disappeared in one case, were clearly reduced in eight cases and were stable in two cases. Clinical symptoms disappeared in three cases, and improved in seven cases. No symptoms appeared in the case presenting with no symptoms. All patients were able to resume work, study and daily tasks.

Conclusions

IC is rare (the present cases account for 0.23% of all retrieved cases). Its chief clinical manifestations include headache, nasal obstruction, polydipsia and polyuria, and visual disorder. Lesions include solid, cystic, and mixed cystic and solid types. It is very difficult to resect the whole diseased region because this disease invades the cranial base, nasal sinuses and nasopharynx. Individualized treatments should be used according to lesion characteristics and invasion range, for example, stereotaxic interstitial brachytherapy. Radical resection or partial resection plus external beam radiation therapy produces better prognosis in IC than intracranial craniopharyngioma.     

Intracystic chemotherapy with bleomycin in the treatment of craniopharyngiomas

OBJECT: Since bleomycin has not yet been used very frequently in the treatment of patients with craniopharyngioma, it seemed important to document the course of a series of such patients treated with this preparation. METHODS AND RESULTS: Local chemotherapy with bleomycin was performed in 24 patients (20 children and 4 adults), 16 of whom presented with cystic or mixed (solid/cystic) craniopharyngioma and 8, with recurrent cystic craniopharyngioma. The drug was administered through an Ommaya reservoir, which was placed either by using a direct surgical approach (6 patients) or a stereotactic approach (16 patients), or with endoscopic assistance in patients with hydrocephaly (2 patients). Injection of bleomycin was always preceded by a water-tightness test. Each patient received a 3-mg dose of bleomycin every other day. The total dose of bleomycin injected ranged from 28 mg to 150 mg. Most patients (17, or 70%) were treated only with intracystic chemotherapy. Chemotherapy was followed by surgery in 7 patients. Five were operated on at the beginning of our study, and 2 required surgery because chemotherapy yielded poor results. A toxic dose was injected in 1 patient only: a severe complication, i.e. blindness, was observed. The follow-up period ranged from 2 years to 10 years. CONCLUSION: Our results show that bleomycin can be an alternative in the treatment of cystic craniopharyngiomas or cystic recurrences, as it reduces surgical morbidity and improves clinical results.     

Craniopharyngiomas in children: recurrence,reoperation and outcome

Introduction Craniopharyngioma bears a high rate of recurrence and morbidity in childhood. Although the outcome after recurrence and reoperation is an important parameter for the long-term evaluation of craniopharyngioma, it is poorly documented in literature. Materials and methods We studied children reoperated for recurrent craniopharyngioma in our institution since the advent of computed tomography (CT) scanner. Reoperation for tumor resection was decided whenever the recurrence was solid, with the aim total resection if possible and reasonable. Stereotactic techniques were used in case of cystic recurrence, and external irradiation was used only in case of recurrent tumor not amenable to surgery. Results From September 1981 to January 2007, we performed one or more reoperations in 20 children presenting with recurrent craniopharyngiomas. The total number of reoperations was 29: resection was total in 12 cases, near-total in 8 cases, partial in 8 cases, and undocumented in 1. In addition, stereotactic procedures were performed in 11 cases, and 5 patients underwent external irradiation. Discussion No patient died after surgery or because of tumor progression; one patient died abruptly of an undiagnosed cause during external irradiation. The event-free survival after reoperation was 49.9% at 5years and 40.0% at 10years. At last control, after a mean follow-up of 70.4months after the last surgery, nine patients were tumor-free and ten had stable disease. Conclusion Reoperation for recurrent craniopharyngioma is an efficient method for tumor control and should be proposed whenever the recurrent tumor is solid. Morbidity results above all from tumor aggressiveness, rather than from surgical damage.     

Rathke囊肿并垂体腺瘤2例报告并文献复习

目的总结垂体腺瘤伴Rathke囊肿的临床特征与治疗方法。方法回顾性分析2例经手术病理证实伴有Rathke囊肿的垂体腺瘤病例资料。结合临床特征、影像学表现、手术治疗以及相关文献进行分析。结果 2例病人均经翼点入路行开颅手术,术后病理结果为垂体腺瘤合并Rathke囊肿。1例术后随访13个月复查MRI示未见肿瘤及囊肿复发,1例术后视力较术前好转。结论伴有Rathke囊肿的垂体腺瘤临床罕见,鞍区MRI提示垂体腺瘤旁存在囊性信号应考虑合并Rathke囊肿。临床明确诊断依赖于组织病理学观察及免疫组化标记。对于压迫症状明显且伴有Rathke囊肿的垂体腺瘤可手术治疗。     

Metastatic craniopharyngioma: case report and literature review

Background  Distant spread of craniopharyngioma is a rare but important complication. Most cases are a result of spread along the surgical path. We describe a rare case of metastatic leptomeningeal craniopharyngioma as a result of dissemination along CSF pathways in a child. A review of previously described cases is provided. Case presentation  A 14-year-old male was diagnosed with metastatic craniopharyngioma on routine follow-up imaging after multiple surgeries and radiation for locally recurrent craniopharyngioma. The lesion was erosive through the right parietal bone, but had remained clinically silent. The lesion was distant from previous surgical paths. The patient underwent right parietal craniotomy and resection of the lesion. Duraplasty and cranioplasty were necessary for closure. Histopathology confirmed adamantinomatous craniopharyngioma. One-year follow-up demonstrated no recurrence. Discussion  A review of reported cases suggests that leptomeningeal implantation may be an important step in metastases of craniopharyngioma, although the mechanism is poorly understood. Attention to tumor spillage at the time of surgery may be important in preventing distant recurrences.     

经眶额颞-终板入路显微手术切除视交叉后部病变

目的报告23例视交叉后部病变的手术治疗经验，探讨视交叉后部病变的手术入路和显微手术技巧。方法采用眶额颞-终板入路显微切除视交叉后占位性病变23例，其中颅咽管瘤13例，垂体腺瘤4例，术前诊断未明者6例。结果16例病灶全切除，5例次全切，2例部分切除。15例术中解剖保留垂体柄。术后并发一过性尿崩17例，永久性尿崩1例，视力障碍加重2例。术后15例随访16—48个月，8例随访3-12个月，其中2例复发。结论经眶额颞-终板入路对于视交叉后部病变可提供足够的操作空间，术中显微解剖鞍区各脑池，妥善保护好颅底前循环及其重要穿通支、视通路、垂体柄和下丘脑等，术后可取得良好的临床疗效。