经蝶入路显微手术治疗垂体腺瘤22例

目的探讨经蝶入路显微手术治疗垂体腺瘤的价值. 方法回顾性分析我院1990年1月～2001年12月22例经蝶入路显微手术治疗垂体腺瘤的临床资料. 结果肿瘤全切率68.2%(15/22).17例随访1～13年,视力视野障碍均有不同程度改善12例,5例失明均不能恢复. 结论经蝶入路显微手术治疗垂体腺瘤是微创、安全和有效的方法.     

内镜手术治疗泌乳素腺瘤52例分析

目的分析在神经内镜下经鼻蝶手术治疗泌乳素瘤的临床效果。方法神经内镜下经鼻蝶手术治疗的不同民族的泌乳素腺瘤病人52例,对52例病人术后疗效及肿瘤的大小、侵袭性、病人民族、术前服用溴隐亭、术前血清泌乳素(PRL)水平等相关影响因素进行分析。结果 52例病人术后临床症状及泌乳素水平均得到改善,总全切率为61. 5%(32/52),巨大腺瘤的全切率为35. 7%,微腺瘤和大腺瘤的全切率分别为100. 0%和68. 6%,差异有统计学意义(P 0. 05)。侵袭性与非侵袭性泌乳素腺瘤的全切率分别为29. 2%和89. 3%,两者比较差异有统计学意义(P 0. 05)。总的术后缓解率为65. 4%(34/52),其中术前PRL三组(依据术前PRL水平分为A组26例,PRL 100 ng/ml,B组16例,100 ng/ml≤PRL≤200 ng/ml,C组10例,PRL 200 ng/ml)之间的术后缓解率分别为76. 9%、62. 5%和40. 0%,无明显差异(P 0. 05)。不同民族之间的术后缓解率无明显差异(P 0. 05)。术前服用溴隐亭对其手术效果影响不大(P 0. 05)。术后无脑脊液鼻漏及视野缺损等并发症的发生,无病人死亡。结论手术疗效与肿瘤大小和侵袭性密切相关,术前服用或未服用溴隐亭对手术效果影响不大,不同民族之间的术后疗效无明显差异,全切率及术后PRL下降程度与肿瘤复发相关。     

垂体大腺瘤经蝶显微手术84例

目的总结经蝶入路治疗垂体大腺瘤的手术经验. 方法 1999年1月～2003年12月采用经蝶窦入路显微手术治疗垂体大腺瘤84例,其中经右侧鼻腔-鼻中隔-蝶窦入路74例,经唇下-鼻中隔-蝶窦入路10例. 结果手术无死亡.术后MRI复查显示,近全切除(>95%)56例(66.7%),次全切除(>85%)18例(21.4%),部分切除(<50%)10例(11.9%).4例部分切除,术后1周再次行经额或经翼点入路手术切除肿瘤.65例随访6～48个月,平均24个月,除3例复发接受放射治疗外,余62例均恢复良好. 结论经蝶显微手术治疗垂体大腺瘤是一种安全、有效的手术技术,术后放疗可以控制肿瘤复发.     

内镜辅助经鼻蝶入路至斜坡区的显微手术

目的 探讨内镜辅助经鼻蝶入路至斜坡区的显微手术方法和疗效.方法 根据经鼻蝶入路至鞍区斜坡区显微解剖学研究结果,采用内镜辅助经鼻蝶显微手术治疗该区肿瘤12例(侵袭性垂体腺瘤8例,脊索瘤3例,软骨瘤1例).所有病例均在3个月至6年内获得随访.结果 手术全切8例,次全切除3例,部分切除1例.术后发生短暂性尿崩症6例,脑脊液鼻漏2例,无死亡及颅内感染.随访3个月至6年,除1例脊索瘤残瘤继续生长外,其余患者未见肿瘤复发.结论 采用经蝶入路显微手术切除沿中线生长的鞍区斜坡区肿瘤,入路简便快捷,创伤小,手术显露良好,疗效满意.内镜辅助使得经蝶入路更为安全、有效.     

脑肿瘤

颅内高度恶性非生殖细胞瘤性生殖细胞肿瘤；应用替莫唑胺对照司莫司丁治疗恶性脑胶质瘤的疗效观察；胚胎发育不良性神经上皮肿瘤临床及病理分析；三脑室脑膜瘤；脑胶质瘤特异性6HRE-GFAP-Bax α基因治疗系统的构建；垂体泌乳素腺瘤术后复发相关因素分析；神经节细胞胶质瘤（附28例分析）；影响垂体生长激素腺瘤经蝶手术疗效的因素分析     

亚临床垂体腺瘤卒中的临床诊治

目的探讨亚临床垂体腺瘤卒中的临床特点、诊断和治疗。方法回顾性分析经手术治疗的130例亚临床垂体腺瘤卒中患者的临床资料。所有患者术前、术后均行内分泌激素及头颅CT和(或)MRI检查。结果经蝶入路手术89例,开颅手术41例,无手术死亡。泌乳素(PRL)腺瘤最多见(56．2％)。绝大多数为大或巨大垂体腺瘤(97％)。可能的诱发因素为高血压(6％)和糖尿病(4％)。术后随访时间平均为3．2年,肿瘤复发8例。术后12例放疗(4例残留,8例复发)。术后需要长期应用甲状腺激素、皮质类固醇激素及抗利尿激素进行替代治疗者分别为25％、20％和1％。结论亚临床垂体腺瘤卒中发生率较高。PRL腺瘤在亚临床垂体腺瘤卒中中最多见。MRI是亚临床垂体腺瘤卒中首选的检查方法。经蝶入路手术是治疗亚临床垂体腺瘤卒中安全有效的方法。亚临床垂体腺瘤卒中内分泌激素替代治疗率低,预后较好,术后放疗仅适用于肿瘤残留或复发者。     

经蝶显微手术治疗泌乳素腺瘤301例

目的 探讨经蝶显微手术治疗泌乳素腺瘤的临床疗效。 方法 分析2000年1月至2009年12月经蝶显微手术治疗301例泌乳素腺瘤的随访结果。手术采用经唇下或单鼻孔蝶窦入路,显微镜下切除肿瘤,瘤床填塞凝胶海绵或肌肉浆。 结果 术后3d内复查MR,鞍内生长微腺瘤、鞍外生长微腺瘤、鞍内生长大腺瘤、鞍外生长大腺瘤及巨大腺瘤的全切除率分别为97.7％(43/44例)、50.0％（1/2例）、94.4％(67/71例)、64.4％（96/149例）及22.9％(8/35例);随访1年,高泌乳素血症的缓解率分别为81.8％（36/44例）、0％（0/2例）、66.2％（47/71例）、3.4％（5/149例）及0％(0/35例)。高泌乳素血症缓解率与肿瘤全切除、生长方式及大小有关。术后并发脑脊液漏11例、短暂性尿崩9例、垂体功能低下25例、嗅觉丧失3例。 结论 经蝶显微手术能安全有效的切除泌乳素腺瘤及缓解高泌乳素血症,可作为局限于鞍内泌乳素微腺瘤、大腺瘤的首选治疗。     

神经内镜下手术治疗巨大垂体泌乳素腺瘤疗效分析

目的分析神经内镜下手术治疗巨大垂体泌乳素腺瘤的疗效、并发症及其相关因素。方法选取郑州大学第一附属医院2015-11—2017-01间神经内镜下手术治疗43例巨大垂体泌乳素腺瘤患者的临床及随访资料,分析手术效果及并发症相关因素。结果肿瘤全切除或近全切除23例,次全切除9例,部分切除11例。肿瘤切除程度与肿瘤质地和Knosp分级相关(P0.05)。治疗有效32例,无效11例,疗效与术前泌乳素水平和肿瘤切除程度相关(P0.05)。术中出现脊液漏10例,其发生与肿瘤质地和肿瘤Hardy-Wilson分级相关(P0.05)。术后一过性尿崩9例,其发生与肿瘤Hardy-Wilson分级相关(P0.05)。术后鞍区脓肿1例。结论神经内镜下手术治疗是巨大垂体泌乳素腺瘤的有效疗法,其疗效受多种因素影响。     

内窥镜下直接经蝶入路切除垂体腺瘤

目的 探讨内窥镜控制下直接经蝶入路切除垂体腺瘤的方法。方法 22例垂体腺瘤患者,在内窥镜控制下,经单鼻孔进入,术中不切除鼻中隔,直接自蝶窦开口打开蝶突前壁,进一步经鞍底切除垂体腺瘤。结果 22例患者中,15例肿瘤全部切除,7例肿瘤次全切除。术后随访1－12个月,17例患者内分泌功能恢复正常。4例术后发生暂时性尿崩症。结论 内窥镜控制下直接经蝶切除垂体腺瘤入路与目前常规经蝶显微手术比较,入路途径较短,且安全简捷、损伤小,手术显露良好,术后反应小,值得进一步推广。     

CT仿真内镜在垂体微腺瘤经蝶显微手术的应用

目的 探讨CT仿真内镜(CT virtual endoscopy,CTVE)在垂体微腺瘤经蝶显微手术中的应用价值. 方法 在18例垂体微腺瘤经蝶手术中,对常规术前垂体CT检查数据进行CTVE重建,并用于指导术前计划、术中定位.对CTVE显示的鞍底三维图像与术中显微镜所见图像进行比较. 结果 CTVE能以三维图像形式显示鞍底解剖结构,对表面结构:蝶窦内隔、鞍底、颈内动脉隆起、视神经管隆起、视神经管-颈内动脉隐窝的显示率分别为344.4%、100%、41.7%、36.1%、58.3%.显示范围较较术中显微镜大.通过透视功能或调高观察阈值,CTVE能显示鞍底深面的颈内动脉、垂体组织、部分视神经管,通过二维图像,能准确的标出肿瘤在CTVE图像上的位置.CTVE能反复模拟手术入路及部分经蝶手术过程. 结论 CTVE能显示蝶窦及鞍底的表面解剖标志同深面结构的三维解剖关系.在垂体微腺瘤经蝶手术中,CTVE能指导术前计划形成及术中定位.     

Bromocriptine treatment of invasive giant prolactinomas involving the cavernous sinus: results of a long-term follow up

OBJECT: The aim of this study was to observe long-term clinical outcomes in a group of patients treated with bromocriptine for invasive giant prolactinomas involving the cavernous sinus. METHODS: Data from 20 patients with invasive giant prolactinomas at the authors' institutions between July 1997 and June 2004 were retrospectively reviewed. The criteria to qualify for study participation included: (1) tumor diameter greater than 4 cm, invading the cavernous sinus to an extent corresponding to Grade III or IV in the classification scheme of Knosp and colleagues; (2) serum prolactin (PRL) level greater than 200 ng/ml; and (3) clinical signs of hyperprolactinemia and mass effect. Among the 20 patients who met the criteria, six had undergone unsuccessful transcranial or transsphenoidal microsurgery prior to bromocriptine treatment and 14 patients received bromocriptine as the primary treatment. Eleven of the 20 patients underwent adjuvant radiotherapy. After a mean follow-up period of 37.3 months, the clinical symptoms in all patients improved by different degrees. Tumor volume on magnetic resonance images was decreased by a mean of 93.3%. In 11 patients, the tumor had almost completely disappeared; in the other nine patients, residual tumor invaded the cavernous sinus. Visual symptoms improved in 13 of the patients who had presented with visual loss. Eight patients had normal PRL levels. The postoperative PRL level was more than 200 ng/ml in seven patients. During the course of drug administration, cerebrospinal fluid leakage occurred in one patient, who subsequently underwent transsphenoidal surgery. No case of apoplexy occurred during bromocriptine treatment. CONCLUSIONS: Dopamine agonist medications are effective as a first-line therapy for invasive giant prolactinomas, because they can significantly shrink tumor volume and control the PRL level. Tumor mass vanishes in some patients after bromocriptine treatment; in other patients with localized residual tumor, stereotactic radiosurgery is a viable option so that unnecessary surgery can be avoided. The application of radiotherapy does not reliably shrink tumor volume.     

神经内镜辅助经蝶显微手术切除侵犯中下斜坡的垂体腺瘤

目的 探讨神经内镜辅助经蝶切除侵犯中下斜坡垂体腺瘤的手术技巧和临床效果。方法 采用经口鼻蝶窦入路切除向中下斜坡发展的垂体腺瘤16例，术中配合神经内镜观察，术后复查影像学资料、内分泌水平等评估手术效果。结果 手术近全切除肿瘤13例，次全切除3例。术后8例功能性腺瘤内分泌恢复正常者3例，激素水平下降超过80％者4例、未达80％者l例。结论 神经内镜辅助经口鼻蝶窦入路显微手术可切除侵犯中下斜坡的垂体腺瘤，手术效果比较满意。     

Transsphenoidal microsurgery for pituitary tumors associated with hyperprolactinemia.

The results of transsphenoidal microsurgery in treating 37 patients (30 women and seven men) with pituitary tumors associated with hyperprolactinemia are presented. Immediate (10-day) postoperative fasting prolactin levels were normal (less than 25 ng/ml) in 19 of 26 patients whose preoperative prolactin level was less than 200 ng/ml, and in only three of 11 patients in whom preoperative prolactin was greater than 200 ng/ml. Twelve of 13 patients with normal preoperative pituitary-target organ function maintained normal axes postoperatively. Thirteen other patients had preoperative deficiencies in one or more pituitary-target organ axes. Postoperatively, in these latter 13 patients, a pituitary-target organ axis that was deficient preoperatively returned to normal in six cases; there was no change in five, and there was impairment in another axis in four instances. Although gross total tumor removal was believed to be complete in 35 of 37 patients, serial postoperative prolactin determinations in four of these 35 patients indicate tumor regrowth. The authors conclude that transsphenoidal microsurgery is currently the operative procedure of choice for the majority of pituitary tumors associated with hyperprolactinemia.     

Gamma Knife radiosurgery for functioning pituitary microadenoma

Transsphenoidal microsurgery remains the treatment of choice for pituitary microadenomas One hundred and six patients were treated with Gamma Knife radiosurgery (GKRS) for pituitary adenomas, and of these, 23 patients (1 male, 22 female) had microadenomas. Twenty-two of these patients were followed up and endocrinological tests were available for 15 of these 22. Thirteen of these 15 had prolactinomas, while the remaining 2 had acromegaly. The follow-up period was from 3 to 26 months (median 12 months). The mean age was 33.6 years (range 21 to 60 years). The mean maximum tumor dose was 35.7 Gy and the mean margin dose was 22 Gy. Serum prolactin (PRL) was normalized in three patients, decreased in eight and unchanged in two. The growth hormone (GH) secretion in the acromegalic patients has remained unchanged through the follow-up period. Thus, GKRS is a valuable adjuvant to transsphenoidal microsurgery for patients with pituitary microadenomas.     

垂体腺瘤经蝶显微手术的疗效分析

目的 探讨经蝶显微手术治疗垂体腺瘤的临床综合疗效、手术技巧、新技术应用等。方法 对于1997～2001年经蝶显微手术治疗的1462例垂体腺瘤患者的临床资料、影像学、内分泌及病理检查结果、肿瘤切除率、术后并发症以及随访结果进行回顾性总结和分析。结果 Hardy Ⅰ级的肿瘤全切率已达97．0％、Ⅱ级95．2％、Ⅲ级90．5％、Ⅳ级47．4％;术后患者临床症状及内分泌功能有显著改善,肿瘤复发率低(0．3％)。结论 随着神经显微操作技术的日益娴熟及新技术的应用,经蝶入路手术指征不断扩大,内窥镜和(或)神经导航辅助显微外科经鼻-蝶窦入路手术,是垂体腺瘤的首选治疗方法;肿瘤全切除的患者术后不必行常规放疗。     

Neurosurgical management of acromegaly. Results in 82 patients treated between 1972 and 1977.

A consecutive series of 82 acromegalic patients who underwent transsphenoidal surgery during a 5-year period is presented. Preoperative and postoperative values for human growth hormone (HGH) were available in 80 cases. Microadenomas were present in 18 patients with a mean preoperative HGH value of 25.2 ng/ml, diffuse adenomas in 39 patients with mean of 53.8 ng/ml, and invasive adenomas in 25 with mean of 68.0 ng/ml. There was no operative mortality. The results reflected the classification of the tumors, with apparent cures accomplished in 87.5% of previously untreated patients with microadenoma, all of whom had anterior pituitary function preserved. The percentages of apparent cures in cases of diffuse adenoma (68%) and invasive adenoma (54%) were much less satisfactory. Transsphenoidal microsurgery is capable of achieving good results, particularly in patients with microadenoma.     

Prolactin-secreting adenomas: the preoperative response to bromocriptine treatment and surgical outcome

Controversy exists regarding the effects of bromocriptine on the success of transsphenoidal surgery for patients with prolactinomas. Various studies on this drug have reported adverse effects, improvement, and no effect upon the subsequent surgical outcome. The authors have retrospectively reviewed the case histories of 55 patients with immunocytochemically confirmed prolactin-secreting pituitary adenomas operated on by a transsphenoidal approach between 1981 and 1985. All patients had received bromocriptine in a variety of doses and for variable durations prior to surgery. Thirty-nine patients were women and 16 were men, with an age range of 8 to 72 years. Basal prolactin levels prior to bromocriptine treatment ranged from 38 to 100 ng/ml in 11 patients, from 101 to 200 ng/ml in 12, and greater than 200 ng/ml in 29. The "cure" rates were 54%, 58%, and 38%, respectively. Thirty-one patients had microadenomas, with a postoperative cure rate of 68%; 12 had diffuse expansive adenomas, with a 17% cure rate; and 12 had grossly invasive tumors, with a 17% cure rate. A response to preoperative bromocriptine therapy was defined as a return of the basal prolactin level to normal: 18 patients were responders and 29 were hyporesponders; in eight the data were not available. The postoperative cure rate was 50% for the responders and 31% for the hyporesponders. Taking into account the distribution of tumor type, there was no actual difference in outcome between the responder and the hyporesponder groups. The total bromocriptine dose received preoperatively was nearly identical for all groups. No significant differences in the frequency or extent of fibrosis, calcification, or prolactin immunoreactivity were observed in the 55 patients when compared with 26 control prolactinomas not treated with bromocriptine. It is concluded that short-term bromocriptine treatment does not adversely affect surgical outcome in any of the prolactin-secreting adenoma groups, nor does response or lack of response to bromocriptine predict surgical outcome.     

Primary culture of human functioning pituitary adenoma in monolayer and collagen gel culture

Human functioning pituitary adenomas (3 acromegalies, 3 prolactinomas) obtained at transsphenoidal hypophysectomy were dispersively embedded inside collagen gels and subjected to the conventional monolayer culture in Eagle's MEM medium containing fetal bovine serum. Basal secretion of growth hormone (GH) and prolactin (PRL) in the media of monolayer and collagen gel cultures were measured by radioimmunoassay (RIA) for 5 weeks. GH secretion in the culture media was initially high in all cases with acromegaly in both monolayer and collagen gel cultures. GH secretion in monolayer culture declined rapidly almost as a straight line on a semilogarithmic scale until 5 weeks, when GH level decreased around 10 ng/ml. GH secretion in collagen gel culture was preserved more than in monolayer culture, but declined slowly up to about 500 ng/ml within 5 weeks. PRL secretion in monolayer culture initially declined rapidly until 1 week, but after then remained constant or decreased slowly. In the other hand, PRL secretion in collagen gel culture remained almost constant for up to 5 weeks. It is concluded that this new culture method may provide suitable conditions for maintenance of the adenomas cells in vitro.     

Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas

BACKGROUND

Endonasal endoscopy is a promising minimally invasive surgery for the treatment of pituitary adenomas; it is also a good alternative to traditional sublabial microsurgery. In this study, we compared endoscopic surgery with microsurgery and evaluated both for their safety and effectiveness. We chose prolactinomas for study because their hormone and symptomatic changes facilitated the comparison.

METHODS

During the past five years, 44 randomized prolactinoma patients underwent pituitary adenomectomy. Group A (22 patients) underwent endonasal endoscopic surgery for prolactinomas. Group B (22 patients) underwent sublabial transsphenoidal microsurgery for prolactinomas.

RESULTS

In groups A and B, patients with prolactinoma exhibited significantly reduced postoperative prolactin levels, return of menstrual cycle, and relief of galactorrhea, (Wilcoxon signed rank test) (p < 0.001). But there were no statistically significant differences in the effectiveness of the procedures used in group A and group B. Visual improvement in cases of macroadenoma was satisfactory in both groups. Hospital stay in group A ranged from 2–5 days, with a mean of 3.2 days. Hospital stay in group B ranged from 4–8 days with a mean of 5.3 days. The hospital stay for group A patients was shorter (2.1 days) than for group B (Student t test, p < 0.05). The operative time was shorter by 1 hour in Group A (mean: 1.7 hours vs. mean: 2.7 hours, p < 0.05). There were fewer complications in group A (4.5%) than in group B (27%), p < 0.05.

CONCLUSIONS

The endoscopic era of pituitary surgery may be coming. Endonasal endoscopic surgery may have the same effectiveness as traditional microsurgery. However, endoscopic surgery may shorten hospital stay and operative time, and lead to fewer complications. It seems to be a good minimally invasive surgical technique for prolactinomas.     

Results of treatment for male prolactinomas

We evaluated the results of medical treatment for male prolactinomas. We encountered eight patients with male prolactinomas. The age was 25 to 54 years old (mean 43 years) and the chief clinical symptoms were visual acuity/field defect in three patients, pituitary apoplexy in one patient, disturbance of ejection in one patient, generalized convulsion in one patient, headache in one patient and general fatigue in one patient. The serum prolactin level was 279 to 7,360 ng/ml (mean 2,832 ng/ml). The tumors in all patients were large with a mean diameter of 34.9 mm (range, 21 to 43 mm). In only one patient, the operation was performed due to pituitary apoplexy. All the patients were treated by medication, with bromocriptine being used in seven patients and terguride in one. The follow-up period was 0.8 to 13 years (mean 5.9 years) and, in all patients, the medical treatment was continued. The tumor decreased in size in all patients and the serum prolactin level at the last follow-up observation was 0.5 to 70.5 ng/ml (mean 26.9 ng/ml). All the neurological symptoms disappeared in the early stage of treatment. As for the complications of medical treatment; in one patient, orthostatic hypotension occurred during the initial administration of bromocriptine and one patient suffered CSF leakage two months after the administration of bromocriptine, so the repair of the sella floor by transsphenoidal surgery was necessary. The medical treatment for male prolactinomas is effective for a long term and should be the primary treatment for the male prolactinomas. In conclusion, patients can maintain a good quality of life for a long time by using dopamine agonists.