Intraoperative bilateral cavernous sinus sampling for ACTH measurements during transsphenoidal pituitary surgery in patients with Cushing's disease

Intraoperative bilateral cavernous sinus sampling combined with rapid ACTH measurement was performed in a pilot study in seven patients with Cushing's disease during transsphenoidal pituitary surgery before and immediately after removal of the ACTH-producing pituitary microadenoma. Before tumor removal a gradient in ACTH concentrations greater than 1.5:1 toward the side of the tumor was found in six patients whereas ACTH concentrations in the right and left cavernous sinuses were similar in one patient with a midline tumor. Immediately after tumor removal, six of seven patients showed variable decreases in ACTH levels in the ipsilateral and/or contralateral side, whereas in one patient the ACTH levels in cavernous sinuses failed to reflect successful tumor removal. These results indicate that intraoperative bilateral cavernous sinus sampling combined with rapid ACTH measurement may be useful to confirm and lateralize ACTH-producing pituitary microadenomas during surgery, but ACTH levels measured immediately after tumor removal do not always predict surgical cure.     

Management of Cushing's disease using cavernous sinus sampling: effectiveness in tumor lateralization

OBJECTIVE: The aim of this study was to determine the accuracy of bilateral cavernous sinus sampling (CSS) in preoperative tumor lateralization (right/left) within the pituitary in patients with Cushing's disease (CD). PATIENTS AND METHODS: The study consisted of 26 consecutive patients who had undergone CSS followed by transsphenoidal surgery (TS) for CD between 2000 and 2006 at our institution. The magnetic resonance imaging (MRI) of the selected patients either revealed a normal pituitary or a lesion 相似文献   

垂体ACTH腺瘤的诊断和治疗(附29例报告)

目的 分析和探讨垂体ACTH腺瘤的诊断和治疗。方法 对我科收治的29例垂体ACTH腺瘤患者的临床特点和治疗效果进行了回顾性分析。结果 垂体ACTH微腺瘤的诊断较为困难，有库欣氏综合征表现的患者，辅以血清ACTH、地塞米松抑制试验等并结合影像学资料方可确诊，经蝶手术切除肿瘤复发率仅为6．9％。结论 垂体ACTH腺瘤的诊断须依靠临床表现、实验室检查和影像学检查等。经蝶手术切除肿瘤是治疗垂体ACTH腺瘤的首选方法。     

经蝶窦显微外科手术治疗541例库欣病

目的 探讨经蝶窦入路显微外科手术治疗库欣病的疗效。方法 总结北京协和医院神经外科1981年至2007年收治的541例库欣病的临床资料。结果CT和（或）MRI显示微腺瘤、大腺瘤、巨大腺瘤和未见异常的比例分别为66.2％( 358/541)、14.0％( 76/541)、0.6％( 3/541)和19.2％(104/541)。病理为垂体ACTH腺瘤、增生和既未见肿瘤又未见增生的比例分别为75.4％(408/541)、8.3％ (45/541)和16.3％ (88/541)。病理明确腺瘤、增生以及病理阴性者术后近期（半年内）治愈率分别是85.0％( 347/408)、24.4％ (11/45)和45.5％(40/88)。随访0.5 -25.0年（平均3.1年）,复发率13.3％(53/398),复发时间0.5 -16.5年（平均3.4年）。结论 经蝶窦选择性垂体腺瘤切除加瘤周垂体组织大部分切除是治疗库欣病安全有效的首选方法。对首次手术无效或复发性库欣病,可以再次经蝶窦手术或垂体放疗。     

神经导航辅助下甲介型蝶窦垂体微腺瘤的经蝶入路手术

目的：介绍神经导航辅助下甲介型蝶窦垂体微腺瘤经蝶手术。方法：应用StealthStation神经导航系统指导经碟手术入路，使用高速磨钻靡除蝶窦内骨质。结果：10例甲介型蝶窦垂体微腺瘤达到全切除，无手术并发症。10例平均坐标误差1．14－3．91mm(平均2．30mm)，术前准备时间为9－15min(平均10．3min)，手术时间为90－140min(平均120min)，结论：神经导航提供实时三维定位，指导甲介型蝶窦垂体微腺瘤的经蝶手术，疗效满意。     

Growth hormone secreting adenoma with unusual extension: coexisting pituitary cyst and its clinical significance.

A 58 year old man showed acromegalic features. The serum growth hormone (GH) level was 7.3 ng/ml and SMC (somatomedin-C) 637 U/ml. Triple stimulation test showed abnormal response compatible with a GH secreting tumour. The conventional enhanced MRI revealed a less enhanced hemisphere-shaped lesion at the right corner of the sella turcica. In addition, dynamic MRI demonstrated an elongated lesion extending to the left beyond the midline. The patient underwent transsphenoidal surgery. Besides the soft and suckable tumour at the right corner, we entered into a small cavity loosely filled with the tumour, which was subsequently also removed. The operative finding corresponded to the lesion shown in dynamic MRI. Postoperative GH and SMC levels became 2.3 ng/ml and 326 U/ml respectively. Incidental pituitary cystic lesions in autopsied cases have been reported to be 6-33%. This case had a GH secreting adenoma with coexisting pituitary cyst. The coexisting pituitary cyst supposedly influenced the unusual shape and extension of the pituitary adenoma. Coexistence of such lesion should be kept in mind for microadenoma on neuroradiological evaluation and on intraoperative inspection surrounding the tumour.     

Invasive Crooke cell adenoma in a patient with diffuse large B-cell lymphoma

Crooke cell adenoma (CCA) is an aggressive corticotroph subtype of pituitary adenoma often with cyclically elevated blood adrenocorticotropic hormone (ACTH), which preoperative diagnosis is challenging especially in the context of a functionally silent invasive tumor and a history of high-stage malignancy such as diffuse large B-cell lymphoma (DLBCL). Here, we report the first case of invasive CCA in a patient with DLBCL. A 71 year-old previously healthy man was recently diagnosed with DLBCL that was treated with CHOP-R chemotherapy. Within one week of completing his first cycle of chemotherapy, he had a frontal headache that progressed to right-sided proptosis. Cranial MRI showed a heterogeneously enhancing mass with invasion into the sellar and suprasellar compartment, compression of the optic chiasm, as well as extension into the clivus, bilateral cavernous sinuses, and the prepontine cistern. He underwent a partial resection for the pituitary tumor debulking. Pathological examination revealed CCA with invasion into the adjacent tissue. The patient had no history of Cushing disease or syndrome, but his blood ACTH was found to be elevated on the operation day. Our present case and literature review suggest that comorbidity of CCA or ACTH-producing adenoma and B-cell lymphoma deserves awareness in our clinical practice, as these two diseases and/or their therapies may interact substantially. CAA should be considered in the major differential diagnosis for an invasive sellar tumor, even without blood ACTH elevation and/or with a history of malignant lymphoma.     

A case of non‐functioning pituitary adenoma with Cushing's syndrome upon recurrence

A 49‐year‐old woman presented with left visual disturbance. No signs of Cushing's disease were evident. Basal levels of serum cortisol and plasma adrenocorticotropic hormone (ACTH) were 16.8 μg/dL and 66.0 pg/mL, respectively. MRI demonstrated an irregularly shaped large pituitary tumor, and the patient then underwent transsphenoidal surgery. By light microscopy the tumor represented a chromophobic adenoma with a few of the adenoma cells showing immunoreactivity for ACTH. On the basis of clinical and light microscopic examinations, the diagnosis of silent corticotroph adenoma was made. Electron microscopy, however, demonstrated the honeycomb Golgi complex that has been reported as a typical finding of gonadotroph adenomas. MRI taken 7 months after the first operation revealed adenoma regrowth. Transcranial surgery was performed, and histology demonstrated a chromophobic pituitary adenoma with most cells immunopositive for ACTH. She was treated with gamma knife postoperatively. Three months later, MRI revealed remarkable shrinkage of the adenoma, but she developed typical signs and symptoms of Cushing's disease. Thus, the hormone immunostaining and biological activity of pituitary adenomas may change with time.     

Surgical Results of Growth Hormone-Secreting Pituitary Adenoma

Objective

We retrospectively analyzed the surgical outcomes of 42 patients with growth hormone (GH)-secreting pituitary adenoma to evaluate the clinical manifestations and to determine which preoperative factors that significantly influence the remission.

Methods

Forty-two patients with GH-secreting pituitary adenoma underwent transsphenoidal surgery (TSS) between 1995 and 2007. The patient group included 23 women and 19 men, with a mean age of 40.2 (range 13-61) years, and a mean follow-up duration of 49.4 (range 3-178) months after the operation. For comparable radiological criteria, we classified parasellar growth into five grades according to the Knosp classification. We analyzed the surgical results of the patients according to the most recent stringent criteria for cure.

Results

The overall rate of endocrinological remission in the group of 42 patients after primary TSS was 64% (26 of 42). The remission rate was 67% (8 of 12) for microadenoma and 60% (18 of 30) for macroadenoma. The remission rate was 30% (3 of 10) for the group with cavernous sinus invasion and 72% (23 of 32) for the group with intact cavernous sinus. Cavernous sinus invasion in Knosp grade III and IV was significantly correlated with the remission rate. There was a significant relationship between preoperative mean GH concentration and early postoperative outcome, with most patients in remission having a lower preoperative GH concentration.

Conclusion

TSS is thought to be an effective primary treatment for GH-secreting pituitary adenomas according to the most recent criteria of cure. Because the remission rate in cases with cavernous sinus invasion is very low, early detection of the tumor before it extends into the cavernous sinus and a long-term endocrinological and radiological follow-up are necessary in order to improve the remission rate of acromegaly.     

经双鼻孔入路内镜下垂体腺瘤切除术

目的探讨经双鼻孔入路内镜下切除垂体腺瘤的方法、疗效、手术适应证和并发症。方法回顾性分析25例神经内镜下经双鼻孔入路垂体腺瘤切除术病人的手术经验。微腺瘤5例,大腺瘤20例,其中侵犯海绵窦5例。结果微腺瘤全切除5例;大腺瘤全切除13例,近全切除4例,大部切除3例;5例侵犯海绵窦的腺瘤中,近全切除3例,大部分切除2例。术后并发尿崩症6例,垂体前叶功能低下2例。结论经双鼻孔入路内镜下切除垂体腺瘤能够减少严重并发症,缩短手术时间,尤其适合治疗甲介型蝶窦、巨大和质地硬韧、鼻腔入路狭窄的垂体腺瘤及术中出血多的微腺瘤。     

Primary pituitary abscess: case report

Pituitary abscesses are potentially life-threatening lesions if not appropriately diagnosed and treated. The authors have operated on more than five hundred cases of pituitary tumors and only one represented a case of pituitary abscess. A 35-year-old woman was investigated for chronic frontal headache. CT scan showed a cystic sellar lesion with ring enhancement after contrast injection leading to an initial diagnosis of pituitary adenoma. She underwent a sublabial transsphenoidal approach to the pituitary gland. After dural opening, purulent material was obtained and no tumor or other associated lesion was detected. There was no evidence of current or previous septicemic illness, meningitis, cavernous sinus thrombosis or sinus infection. Cultures were negative. She was put on antibiotics and discharged after 4 weeks. Nowadays, 10 years after treatment, she is doing well, with no anterior pituitary hormone deficit. MRI shows a partially empty sella without residual lesion and the pituitary stalck is in the midline. The early diagnosis and adequate treatment of this life-threatening lesion may result in excellent prognosis.     

Transsphenoidal surgery assisted by a new guidance device: results of a series of 747 cases

Objective

The objective of this study is to report the efficacy and safety of microsurgical transsphenoidal surgery using a frame for sella guidance in a series of patients with untreated pituitary adenoma.

Methods

In this study, seven hundred and forty-seven patients undergoing transsphenoidal resection of a pituitary adenoma involving use of the frame were included. Follow-up of twelve to one hundred months was performed in all patients.

Results

During the procedures using the frame, pituitary adenomas were fully exposed, and no cavernous sinus haemorrhage due to anteroposterior displacement or internal carotid artery lesion due to right-and-left deviation occurred. The duration of the surgical procedure ranged from 28 min to 87 min with a mean of 44 min. The most frequent tumour type was prolactin-secreting adenoma (32.4%), followed by clinically non-functioning adenoma (NFPA) (28.5%), growth hormone-secreting adenoma (25.0%), and adrenocorticotropin-secreting adenoma (13.7%). Normalisation of visual defects occurred in 226 (42.2%) of the 535 patients with visual disturbances. Normalisation of hormone occurred in 458 of 551 patients with endocrine-active tumour in the follow-up period. Two patients died as a consequence of surgery.

Conclusion

The endonasal transsphenoidal technique is a safe, quick, and effective approach to pituitary adenomas. Our guidance frame allows the surgeon to open and close the wound rapidly, which avoids trajectory deviation and shortens the duration of the surgical procedure.     

Cavernous aneurysm and pituitary adenoma: management of dual intrasellar lesions.

A 53-year-old female with a functioning pituitary adenoma was found to also have an unruptured asymptomatic aneurysm in the cavernous sinus portion of the internal carotid artery on MRI. The adenoma had a suprasellar extension with optic chiasm compression and extended into the right cavernous sinus. An aneurysm-like flow-void adjacent to the left internal carotid artery in the sella and embedded in the adenoma was also found. The aneurysm was confirmed by conventional angiography. We used a right fronto-pterional approach to clip the aneurysm and to remove the pituitary tumor in a one-stage procedure. The outcome was good on long-term follow-up. It is important to thoroughly evaluate the anatomic relations around the sella turcica prior to procedures with limited exposure, including transsphenoidal surgery, to avoid unrecognized complications and morbidity.     

海绵窦内侧壁的显微解剖与扩大经蝶窦入路治疗侵袭海绵窦的垂体腺瘤（附103例分析）

目的研究海绵窦内侧壁结构的解剖特点，并探讨采用扩大经蝶窦入路治疗侵袭海绵窦垂体腺瘤的方法。方法在10具成人新鲜尸头上模拟扩大经蝶窦手术入路，观察海绵窦内侧壁结构的解剖特点。根据解剖学研究结果，指导临床采用扩大经蝶窦手术入路治疗侵袭海绵窦的垂体腺瘤103例。结果垂体侧方的海绵窦内侧壁薄弱，仅有一层疏松的纤维组织结构。颈内动脉是扩大经蝶窦入路海绵窦内所见的主要结构，可分为5段，有3个主要分支。颈内动脉海绵窦段主要的分支有脑膜垂体干、海绵窦下动脉和被囊动脉。向内侧走行的脑膜垂体干和被囊动脉是经蝶窦入路中较易损伤的血管。手术显微镜下全切除肿瘤62例（60．2％），次全切除38例（36．9％），大部切除3例（2．9％）；无手术死亡；手术并发症包括短暂性脑脊液鼻漏5例，暂时性脑神经功能损伤4例，垂体功能低下3例，颈内动脉损伤2例，永久性尿崩症1例。术后行放射治疗17例，γ刀治疗15例，药物治疗13例。随访3个月～8年，2例出现肿瘤复发而予以γ刀治疗。无再手术病例。结论扩大经蝶窦入路是切除侵袭海绵窦垂体腺瘤理想的入路；了解颈内动脉海绵窦段及其分支在解剖形态上的变化，对于减少术中出血，确保术中安全，具有重要意义。     

神经内镜下经鼻蝶治疗伴甲介型蝶窦垂体腺瘤

目的探讨伴甲介型蝶窦的垂体腺瘤手术治疗方法。方法回顾性分析12例甲介型蝶窦垂体腺瘤病人的临床资料。术前行CT多平面重建,术中应用神经内镜经鼻蝶入路结合磨钻暴露鞍底,切除垂体腺瘤。结果未使用定位设备的情况下,术中均能顺利暴露鞍底,切除肿瘤。术后MRJ复查示肿瘤全切除10例,次全切除2例,无严重并发症发生。随访6—12个月,病人恢复良好。结论经鼻蝶人路手术治疗甲介型蝶窦的垂体腺瘤,通过术前详细的影像学检查、术中神经内镜结合磨钻的使用,均能准确辨认及暴露鞍底、切除肿瘤,是一种创伤小、治疗效果良好的微侵袭神经外科手术方法。     

经眉弓锁孔入路与单鼻孔蝶窦入路显微手术治疗垂体腺瘤的比较

目的 比较经眉弓锁孔入路和单鼻孔蝶窦入路显微手术治疗垂体腺瘤的临床效果和并发症. 方法 山东省聊城市脑科医院自2006年5月至2008年6月应用内镜辅助显微手术治疗直径≤3 cm的垂体腺瘤87例,其中经眉弓锁孔入路42例,经单鼻孔蝶窦入路45例,比较两种手术入路方式的临床效果和并发症的发生率. 结果 眉弓锁孔入路组向鞍上、鞍旁生长的肿瘤全切率(93.3%)高于单鼻孔蝶窦入路组(53.8%),微腺瘤和向蝶窦方向生长的肿瘤全切率低于单鼻孔蝶窦入路组,差异均有统计学意义(P<0.05);两组患者垂体内分泌功能及视力、视野改善率差异无统计学意义(P>0.05);眉弓锁孔入路组患者术后鼻衄和一侧嗅觉减退发生率(0,0)明显低于单鼻孔蝶窦入路组(11%,20%),差异有统计学意义(P<0.05).结论 眉弓锁孔入路手术无嗅觉减退、鼻衄、蝶窦炎等并发症的发生,适于向鞍上、鞍旁生长的垂体腺瘤,具有较大的临床推广价值.     

经鼻-蝶窦入路的内镜鞍周解剖学研究

目的 通过经鼻蝶窦入路的内窥镜解剖学研究，为临床内镜经蝶手术提供形态学基础。方法 在10具已经动脉灌注染料的成人尸头上模拟扩大经鼻蝶窦手术入路，同时测量海绵窦内重要结构与鞍底的距离。结果 根据蝶窦后壁的骨性结构特征将蝶窦腔分为中间腔、旁中间腔及外侧腔5部分。扩大经蝶手术入路可清晰显示鞍底的骨膜、硬脑膜外层、海绵窦内侧壁，海绵窦内的颈内动脉及其分支血管、动眼神经、滑车神经、外展神经及眼神经等结构；打开堞骨平台可显示视神经、视交叉、垂体柄、鞍隔及视丘下部等解剖结构。结论 内窥镜扩大经鼻蝶手术入路可清晰显露蝶鞍周围的解剖结构，可适用于鞍旁、鞍上病变的手术治疗。     

经蝶入路显微切除大和巨大型垂体腺瘤

目的 探讨大和巨大型垂体腺瘤较理想的手术治疗原则。方法 所有病例采用经唇下蝶窦入路显微镜下肿瘤切除术。结果 30例肿瘤手术全切除26例,4例肿瘤因侵袭入鞍膈上和/或海绵窦内而行大部分切除,其中1例经额术后再二期经鼻蝶入路显微切除鞍内和蝶窦内肿瘤。结论 多数大和巨大垂体腺瘤可选择经鼻蝶入路全切。     

Skull base surgery techniques in the treatment of pituitary adenomas

The giant pituitary adenoma surgery remains a real challenge to any neurosurgeon. Despite an extensive development of transsphenoidal techniques, open craniotomy procedures still are required in 5-10% of all cases with pituitary adenoma. The skull base surgery techniques not only allow to minimize the surgery-related trauma of the brain, but also improve the access to the operating field. In the years 1998-2001 the authors operated on the total of 395 pituitary adenoma patients, mostly using the transsphenoidal approach (320 cases), with skull base surgery techniques applied in 75 cases (i.e. in 19% of all patients)--in 67 patients the transbasal-subfrontal approach was applied, and in 2 cases--lateral rhinotomy. There were two indications to the transbasal-subfrontal approach: a large size of the tumor causing visual disturbances, and extension of the adenoma to adherent anatomical spaces. In this group of patients the total removal of the tumour was achieved in 88% of cases. In the remaining patients remnants of the tumor were left in the cavernous sinuses. The skull base surgery techniques are most useful in the treatment of selected patients with pituitary adenoma.     

岩下窦静脉取血在疑难ACTH依赖性库欣综合征诊断中的应用

目的 探讨岩下窦静脉取血(IPSS)在疑难库欣综合征诊断中的价值.方法 对20例疑难库欣综合征行岩下窦和外周静脉取血,测定血ACTH浓度比,评价其对库欣病诊断的敏感性和特异性.结果 18例患者的岩下窦与外周静脉血ACTH的比值＞2,其中13例行经蝶窦垂体术后病理为垂体ACTH腺瘤;1例行鞍区γ-刀治疗、4例行生长抑素治疗后病情缓解.2例岩下窦与外周静脉血ACTH的比值＜2,其中1例为右肺类癌,另1例为垂体ACTH腺瘤.本组IPSS诊断库欣病的敏感性和特异性分别为93%和100%.结论 IPSS操作安全,并发症少,可作为疑难库欣综合征的重要鉴别方法.