促甲状腺激素型垂体腺瘤的临床诊疗特点

目的 研究促甲状腺激素(TSH)型垂体腺瘤的临床诊断和治疗特点.方法 回顾性分析2001年1月至2008年12月收治的19例TSH型垂体腺瘤患者的临床资料.男性14例,女性5例;年龄20～70岁,平均40.5岁;病程1～228个月,平均55个月.15例患者因甲状腺功能亢进(甲亢)症状就诊,其中12例被误诊为原发性甲亢并口服抗甲亢药物治疗,另3例入院后很快确诊.4例患者因头痛和视力视野障碍等肿瘤占位效应就诊.在12例误诊患者中,2例行131I放射性核素治疗,1例行甲状腺大部分切除.所有患者均行经蝶垂体腺瘤切除术.结果 病理均为垂体腺瘤,免疫组化TSH阳性17例,阴性2例,生长激素阳性2例,泌乳素阳性1例,促肾上腺皮质激素阳性1例.术后MRI显示肿瘤全切除15例,肿瘤残留4例.随访时间6个月～7年,平均3.6年.术后3个月内甲状腺激素水平各项均正常13例,其中2例3个月后复查TSH再次升高,但MRI未见肿瘤复发,行垂体放疗后甲状腺各项激素均正常.手术治愈率11/19,手术加放疗治愈率13/19.结论 对合并TSH升高的甲亢患者的筛查是提高TSH型垂体腺瘤的早期诊断的关键.治疗采用以手术治疗为主,垂体放疗和生长抑素为辅的治疗方法.

Abstract：

Objective To study the clinical characteristics, diagnosis and surgical effects of thyroid-stimulating hormone pituitary adenomas (TSH-omas). Methods The clinical data of 19 patients (14 female and 5 male) with TSH-omas were analyzed retrospectively in this study from January 2001 to December 2008. The patients ranged from 20 to 70 years old ( average 40. 5 years old) and had disease histories from 1 to 228 months (average 55 months). Among these patients, 15 of them complained of thyrotoxicosis symptoms, while the other 4 patients' symptoms were associated with headache and/or visual disturbance caused by the tumor mass effect. Initially, 12 of the 15 patients with thyrotoxicosis symptoms were misdiagnosed with Grave's disease. As a result 2 of them received 131Iodine, and one received subtotal thyroidectomy. All of these patients underwent transsphenoidal microsurgery. Results Average follow-up period was 3. 6 years (6 months-7 years). Pathological analysis of the surgical specimen showed pituitary adenoma in all patients, immunohistostains were positive for TSH in 17 cases, negative for TSH in 2,positive for growth hormone in 2, positive for prolactin in 1, and positive for adrenocorticotrophic hormone in 1. Postoperative MRI revealed that the tumors in 15 patients were removed totally, though 4 patients still had residual tumors. The thyroid hormone level tests suggested that 13 patients could be considered normal 3 months after their tumors were removed, though 2 of patients with normal postoperative MRI and thyroid hormones showed increased levels of TSH. For these 2 patients, tumors did not recur and their thyroid hormone levels returned to normal after pituitary radiotherapy. The cure rate was 11/19 after surgery and 13/19 after surgery plus pituitary radiotherapy. Conclusions The screening test for hyperthyroidism patients with high TSH levels is a key point to improve the accuracy rate in early diagnoses of TSH-omas. The transsphenoidal microsurgery is first choice to treat TSH-omas, while pituitary radiotherapy and somatostatin analogs are beneficially adjunctive therapies.     

促甲状腺激素型垂体腺瘤的临床诊疗特点

目的 研究促甲状腺激素(TSH)型垂体腺瘤的临床诊断和治疗特点.方法 回顾性分析2001年1月至2008年12月收治的19例TSH型垂体腺瘤患者的临床资料.男性14例,女性5例;年龄20～70岁,平均40.5岁;病程1～228个月,平均55个月.15例患者因甲状腺功能亢进(甲亢)症状就诊,其中12例被误诊为原发性甲亢并口服抗甲亢药物治疗,另3例入院后很快确诊.4例患者因头痛和视力视野障碍等肿瘤占位效应就诊.在12例误诊患者中,2例行131I放射性核素治疗,1例行甲状腺大部分切除.所有患者均行经蝶垂体腺瘤切除术.结果 病理均为垂体腺瘤,免疫组化TSH阳性17例,阴性2例,生长激素阳性2例,泌乳素阳性1例,促肾上腺皮质激素阳性1例.术后MRI显示肿瘤全切除15例,肿瘤残留4例.随访时间6个月～7年,平均3.6年.术后3个月内甲状腺激素水平各项均正常13例,其中2例3个月后复查TSH再次升高,但MRI未见肿瘤复发,行垂体放疗后甲状腺各项激素均正常.手术治愈率11/19,手术加放疗治愈率13/19.结论 对合并TSH升高的甲亢患者的筛查是提高TSH型垂体腺瘤的早期诊断的关键.治疗采用以手术治疗为主,垂体放疗和生长抑素为辅的治疗方法.     

促甲状腺激素型垂体腺瘤的临床诊疗特点

目的 研究促甲状腺激素(TSH)型垂体腺瘤的临床诊断和治疗特点.方法 回顾性分析2001年1月至2008年12月收治的19例TSH型垂体腺瘤患者的临床资料.男性14例,女性5例;年龄20～70岁,平均40.5岁;病程1～228个月,平均55个月.15例患者因甲状腺功能亢进(甲亢)症状就诊,其中12例被误诊为原发性甲亢并口服抗甲亢药物治疗,另3例入院后很快确诊.4例患者因头痛和视力视野障碍等肿瘤占位效应就诊.在12例误诊患者中,2例行131I放射性核素治疗,1例行甲状腺大部分切除.所有患者均行经蝶垂体腺瘤切除术.结果 病理均为垂体腺瘤,免疫组化TSH阳性17例,阴性2例,生长激素阳性2例,泌乳素阳性1例,促肾上腺皮质激素阳性1例.术后MRI显示肿瘤全切除15例,肿瘤残留4例.随访时间6个月～7年,平均3.6年.术后3个月内甲状腺激素水平各项均正常13例,其中2例3个月后复查TSH再次升高,但MRI未见肿瘤复发,行垂体放疗后甲状腺各项激素均正常.手术治愈率11/19,手术加放疗治愈率13/19.结论 对合并TSH升高的甲亢患者的筛查是提高TSH型垂体腺瘤的早期诊断的关键.治疗采用以手术治疗为主,垂体放疗和生长抑素为辅的治疗方法.     

垂体功能性促性腺激素腺瘤临床病例分析

目的研究分析垂体功能性促性腺激素腺瘤女性患者的临床特征,以期达到早期诊断及治疗的目的。方法回顾性分析我院收治的5例垂体功能性促性腺激素腺瘤女性患者的临床特点及诊治经过。结果 5例患者均为生育年龄女性,平均年龄38.8岁,临床表现为月经紊乱、溢乳、头痛和视野缺损。盆腔超声发现双侧卵巢增大,内见多房囊性无回声。性激素检查雌激素4 377.65～12 973.45pmol/L,均值7 800.66pmol/L,而FSH和/或LH并未被异常升高的雌激素负反馈抑制,泌乳素(PRL)升高至1 268.18～2 794.16nmol/L,均值1 726.95nmol/L。垂体磁共振(MRI)检查发现垂体大腺瘤样改变。5例患者均接受垂体腺瘤切除术,病理切片免疫组化检查提示FSH/LH阳性,术后随访至今(3～5年)无肿瘤复发迹象。结论当绝经前女性出现月经紊乱、溢乳、头痛、视野缺损、反复发生的卵巢多房囊肿、雌激素异常升高的同时促性腺激素未被负反馈抑制时,应行垂体核磁共振检查,如发现垂体肿瘤,应考虑垂体功能性促性腺激素腺瘤的诊断。垂体瘤切除手术是首选治疗。     

神经导航在经蝶垂体腺瘤手术中的应用

目的 总结神经导航下经蝶手术治疗垂体腺瘤的经验,并讨论其适应证.方法 对2006年1月至2010年12月138例神经导航下经蝶垂体腺瘤手术病例进行回顾性分析.手术适应证包括:既往经蝶手术后复发性垂体腺瘤36例,侵袭型垂体腺瘤45例,位于垂体侧方或深部的微腺瘤45例,蝶窦气化不良4例,颅底异常增厚3例,双侧颈内动脉间距狭窄4例,鼻中隔偏曲1例.结果 复发性垂体腺瘤全切除12例,次全切除9例,术后出现瘤腔血肿2例,脑脊液漏4例,其中3例合并颅内感染,2例合并交通性脑积水,永久性动眼神经麻痹1例,垂体功能低下者3例;治愈9例,缓解8例.侵袭型垂体腺瘤全切除5例,次全切除27例,术后出现脑脊液漏并颅内感染1例,瘤腔血肿1例;治愈2例,缓解22例;侵袭型激素分泌型垂体腺瘤30例均未治愈缓解.微腺瘤45例均为激素分泌型,均全部切除,治愈38例.颈动脉间距狭窄4例和鼻中隔偏曲1例均全切除和治愈.蝶窦气化不良肿瘤全切除2例,次全切除2例,治愈1例.颅底异常增厚肿瘤全切除2例,次全切除1例,治愈1例.结论 神经导航可以使部分经蝶垂体腺瘤切除手术更加准确、安全、有效,在一定程度上扩大了经蝶手术的适应证.

Abstract：

Objectives To summarize the experiences in clinical application of neuronavigation in transsphenoidal microsurgery of specific pituitary adenomas, and to discuss its indications. Methods From January 2006 to December 2010,138 cases of transsphenoidal microsurgery for specific pituitary adenomas under neuronavigation were reviewed. The indications for neuronavigation in transsphenoidal microsurgery includes: recurrent or regrowth of residual pituitary adenomas after former transsphenoidal surgery in 36 cases, invasive pituitary adenomas in 45 cases, extremely laterally or deeply situated microadenomas in 45 cases, poor pneumatization of the sphenoid in 4 cases, skull base anomalies due to osteodysplasia fibrosa in 3 cases, narrow space between bilateral internal carotid arteries in 4 cases, distortion of nasal septum in 1 case. Results In the recurrence group, 12 were totally removed, 9 subtotally removed;postoperative complications included hematoma within the tumor cavity in 2 cases, cerebrospinal fluid (CSF) leakage in 4 cases among which 3 developed intracranial infection and 2 communicating hydrocephalus, oculomotor paralysis in 1 case and hypopituitarysm in 3 cases;9 were cured and 8 remission. In the invasive group, 5 were totally removed, 27 subtotally removed;postoperative complications included hematoma within the tumor cavity in 1 case, CSF leakage and intracranial infection in 1 case;2 were cured and 22 remission. None of the 30 invasive hormone-secreting adenomas were cured or remission. The 45 cases of hormone-secreting microadenomas were all totally removed, among which 38 were cured. Among the poor sphenoid pneumatization group, total and subtotal tumor removal were achieved in 2 cases respectively with only one cured. In the skull base anomaly group, 2 were totally removed and 1 subtotally removed, with only one cured. For the cases with narrow space between bilateral internal carotid arteries and distortion of nasal septum, all were totally removed and cured. Conclusions Transsphenoidal microsurgery under neuronavigation can be applied for pituitary adenomas in above specific indications. It is an accurate, safe and effective approach for specific pituitary adenomas, which can not only expand the indication of transsphenoidal microsurgery for pituitary adenomas, but also reduce the harmful exposure of X-rays for the operating staff.     

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。     

大型垂体腺瘤经蝶显微外科治疗技术要点

报道经蝶显微手术治疗大型垂体腺瘤145例,均经CT扫描或MRI确诊,肿瘤向鞍上扩展直径>10mm。在手术显微镜下经唇下—鼻中隔—蝶窦入路或经鼻前庭—鼻中隔—蝶窦入路两种方式行肿瘤切除术。术中于腰蛛网膜下腔予置一导管,用于注射生理盐水,增加颅内压力,使鞍上瘤块进入手术野,以利切除。102例(70.4％)肿瘤获全切除;35例(24.1％)达次全切除;余8例(5.5％)系哑铃型或纤维性腺瘤,行部分切除。术后无死亡。132例平均随访观察3.5年,其中93例(70.5％)恢复良好,39例(29.5％)肿瘤复发,需再次手术,或采用药物、放疗或放射外科治疗。文中对本型肿瘤经蝶显微外科处理的方法与技术要点进行了讨论。     

经单鼻孔蝶窦入路显微手术切除垂体腺瘤

目的探讨经单鼻孔蝶窦入路显微手术切除垂体腺瘤的手术方法。方法回顾性分析46例垂体腺瘤患者的临床资料,均采用经单鼻孔蝶窦入路显微手术切除肿瘤。术前行高分辨率CT鞍区薄层扫描及MRI检查,充分了解蝶窦的气化程度、蝶窦分隔和鞍底隆突的解剖学特点。结果44例术中依靠蝶窦相关解剖标志,准确定位蝶窦及鞍底,2例出现偏差。肿瘤全切33例,大部分切除9例,部分切除3例,1例因海绵间窦出血终止手术,无手术死亡。术后一过性尿崩症12例,予药物治疗3～7d后好转 脑脊液漏4例,2例保守治疗治愈,1例予腰大池置管引流后治愈,1例再次经蝶入路修补鞍底后治愈。46例平均随访8个月（3个月～2年）,3例复发。结论单鼻孔蝶窦入路显微手术切除垂体腺瘤是一种安全有效的微侵袭手术方法 熟悉相关解剖标志,准确定位是手术成功的关键。     

垂体微腺瘤的诊断和治疗探讨

目的 探讨垂体微腺瘤（直径≤５ｍｍ）的诊断和治疗方法。方法 总结经ＣＴ垂体薄层扫描加矢,冠状重建诊断的垂体微腺瘤（直径≤５ｍｍ）２８例,全部采用经口鼻蝶窦入路显微手术切除。随访临床资料和内分泌改变,定期复查ＣＴ。结果 ２８例中病理证实２６例为垂体腺瘤,１例为炎症、１例为增生,诊断率达到９２．８％。汪变的术中定位成ＣＴ立体定位所见的位置完全符合。术后全部病例病情痊愈或好转,无手术死亡和并发症。２２例     

Thyroid-stimulating hormone pituitary adenomas

OBJECT: Thyroid-stimulating hormone (TSH)-secreting pituitary adenomas are rare, representing < 2% of all pituitary adenomas. METHODS: The authors conducted a retrospective analysis of patients with TSH-secreting or clinically silent TSH-immunostaining pituitary tumors among all pituitary adenomas followed at their institution between 1987 and 2003. Patient records, including clinical, imaging, and pathological and surgical characteristics were reviewed. Twenty-one patients (6 women and 15 men; mean age 46 years, range 26-73 years) were identified. Of these, 10 patients had a history of clinical hyperthyroidism, of whom 7 had undergone ablative thyroid procedures (thyroid surgery/(131)I ablation) prior to the diagnosis of pituitary adenoma. Ten patients had elevated TSH preoperatively. Seven patients presented with headache, and 8 presented with visual field defects. All patients underwent imaging, of which 19 were available for imaging review. Sixteen patients had macroadenomas. RESULTS: Of the 21 patients, 18 underwent transsphenoidal surgery at the authors' institution, 2 patients underwent transsphenoidal surgery at another facility, and 1 was treated medically. Patients with TSH-secreting tumors were defined as in remission after surgery if they had no residual adenoma on imaging and had biochemical evidence of hypo-or euthyroidism. Patients with TSH-immunostaining tumors were considered in remission if they had no residual tumor. Of these 18 patients, 9 (50%) were in remission following surgery. Seven patients had residual tumor; 2 of these patients underwent further transsphenoidal resection, 1 underwent a craniotomy, and 4 underwent postoperative radiation therapy (2 conventional radiation therapy, 1 Gamma Knife surgery, and 1 had both types of radiation treatment). Two patients had persistently elevated TSH levels despite the lack of evidence of residual tumor. On pathological analysis and immunostaining of the surgical specimen, 17 patients had samples that stained positively for TSH, 8 for alpha-subunit, 10 for growth hormone, 7 for prolactin, 2 for adrenocorticotrophic hormone, and 1 for follicle-stimulating hormone/luteinizing hormone. Eleven patients (61%) ultimately required thyroid hormone replacement therapy, and 5 (24%) required additional pituitary hormone replacement. Of these, 2 patients required treatment for new anterior pituitary dysfunction as a complication of surgery, and 2 patients with preoperative partial anterior pituitary dysfunction developed complete panhypopituitarism. One patient had transient diabetes insipidus. The remainder had no change in pituitary function from their preoperative state. CONCLUSIONS: Thyroid-stimulating hormone-secreting pituitary lesions are often delayed in diagnosis, are frequently macroadenomas and plurihormonal in terms of their pathological characteristics, have a heterogeneous clinical picture, and are difficult to treat. An experienced team approach will optimize results in the management of these uncommon lesions.     

Thyroid-stimulating hormone pituitary adenomas and hyperthyroidism

Six cases of hyperthyroidism secondary to thyroid-stimulating hormone (TSH)-hypersecreting pituitary adenomas are presented (five females and one male). Hyperthyroidism presenting with diffuse goiter was associated with hyperprolactinemia in three cases. Elevation of triiodothyronine (T3) and thyroxine (T4) plasma levels was associated with TSH levels ranging between 2 and 2,000 microU/mL. Polytomography and computed tomography scanning with coronal views revealed four invasive and two enclosed tumors. Two patients underwent transfrontal operations, four underwent transsphenoidal operations, and one underwent both. Two cases of enclosed adenoma were cured primarily by a transsphenoidal approach without additional pituitary deficit. In four cases of invasive adenomas, operations and radiation therapy resulted in three failures and one cure. In cases presenting with hyperthyroidism and detectable TSH, early neuroradiological studies are indicated, as biological cure can be achieved by the transsphenoidal approach. Early treatment is also advocated because of the tendency for these tumors to become invasive (four out of six tumors).     

Developments in surgical treatment of pituitary adenomas

Summary Progress in pituitary surgery has arisen with the introduction of microsurgical technique, endocrinological functional tests and computerized tomography of the skull.Using such microsurgical procedures, the transsphenoidal approach to the sella with selective adenomectomy is rendered possible. Furthermore, this operative approach is recommended also for pituitary tumours growing symmetrically to the suprasellar region.Endocrinological functional tests permit exact measurement of pituitary insufficiency and hormonal excesses, including all hormones of the anterior pituitary; today, only 30% of the adenomas are regarded as hormonally inactive. The indication to operate, the approach and the extent of the operative procedures depend on these results. Further, the operative result can be controlled by endocrine tests; in this way treatment of acromegaly can be improved: in patients with intrasellar adenomas GH-excess can be normalized in 90% of the patients.Selective adenomectomy has also improved the treatment of Cushing's disease. In women with hyperprolactinemic amenorrhea, who wished to have children, ovarian cycles and pregnancy occurred. In the case of prolactinomas, for the first time medical treatment of pituitary adenomas has been successful. Computerized tomography of the skull is the most important examination in order to localize a tumour and to determine its extent whereby the operative procedure (transsphenoidal, transcranial) is decided. After operation, the radicality of the operation can thus be documented and in the case of tumour residuals a second operation may then be indicated.

---

Zusammenfassung Die Fortschritte in der Hypophysenchirurgie basieren auf der mikrochirurgischen Technik, der endokrinologischen Funktionsdiagnostik sowie der Computer-Tomographie.Das mikrochirurgische Vorgehen hat den transsphenoidalen Zugang mit selektiver Adenomektomie ermöglicht. Darüber hinaus empfiehlt sich dieser Operationsweg auch bei symmetrisch suprasellär aus der Sella herausgewachsenen Geschwülsten.Endokrinologisch lassen sich mit Hilfe der Funktionsdiagnostik Hypophysen-Insuffizienzen und Hormon-Exzesse, die alle Vorderlappenhormone betreffen können, exakt bestimmen; als inaktiv gelten heute nur noch etwa 30% der Adenome. Von diesen Ergebnissen hängt die Indikation zur Operation, die Art und das Ausmaß des operativen Eingriffs ab. Darüber hinaus läßt sich der Operationserfolg endokrinologisch kontrollieren; auf diese Weise ist z. B. in der Behandlung der Akromegalie eine Normalisierung des GH-Exzesses bei 90% der intrasellären Adenome erreicht worden.Die selektive Adenomektomie hat auch die Behandlung des hypothalamisch/hypophysären Cushing-Syndroms bereichert und bei Frauen mit hyperprolaktinämischer Amenorrhoe und Kinderwunsch die Wiedererlangung ovarieller Zyklen und Schwangerschaften ermöglicht. Für die Prolaktinome zeichnet sich erstmals eine erfolgversprechende medikamentöse Therapie der Hypophysenadenome ab.Zur Lokalisation und Bestimmung der Ausdehnung der Geschwülste ist die Computer-Tomographie die entscheidende Untersuchung, welche die Wahl des operativen Zugangs (transsphenoidal, transkranial) bestimmt und postoperativ die Radikalität des Eingriffs belegt und im Falle verbliebener Tumorreste zu einer zweiten Operation, u. U. auf dem anderen Operationsweg, Anlaß geben kann.

     

垂体腺瘤经蝶窦显微手术432例

目的 研究垂体瘤的临床特征及常规病理和超微结构改变。方法 回顾研究４３２例经蝶窦手术治疗垂体肿瘤的临床特点,其中１１９例术中鞍底膜活检,光镜检查４２４例,免疫组化检查２９例,电镜检查１０３例,临床结合病理进行分析研究。结果 发现鞍区非泌乳素（ＲＬ）垂体腺瘤同样可以产生高泌乳素血症 硬膜有瘤细胞浸及７８例（６５．５％）。结论 （１）高泌乳素血症并非泌乳素腺瘤所特有,在诊断中应注意鉴别;（２）鞍底硬膜     

Giant pituitary adenomas: clinical characteristics and surgical results

Although most pituitary neoplasms are benign, some grow rapidly, spreading to extrasellar tissues. Definition of these 'giant' pituitary adenomas (PAs) is not clear. In order to clarify this question, we studied all pituitary macroadenomas operated in our hospital during the last 20 years, differentiating those with diameter > or = 3 cm (n = 43) and attempting to identify their typical features and prognosis. The reason for consultation was local in 58.3% of giant PAs, hormonal in 22.9% and tumour recurrence in 16.7%. Surgery was performed via a trans-sphenoidal approach in 92.5% of cases and succeeded in completely removing the tumour in only 27% of cases. In conclusion, we found that giant PAs are not a special type but the extreme case in the gradient of invasiveness of tumours of adenohypophyseal origin. They are characterized by a higher frequency of neuro-ophthalmological symptoms and hormonal deficits, and poorer response to surgical treatment.     

Pituitary apoplexy: Endocrine,surgical and oncological emergency. Incidence,clinical course and treatment with reference to 799 cases of pituitary adenomas

Summary Authors analised retrospectively the incidence of pituitary apoplexy in a series of 799 pituitary adenomas with respect to the long term follow-up of the patients.Focal vascular abnormalities in histological specimens of tumours, regarded as morphological suggestion of past apoplexy (heamorrhage, ischaemic infarction or necrosis), were established in 113 out of 783 surgical cases (14.4%).Acute clinical onset, justifying the clinical diagnosis of pituitary apoplexy, occurred in 39 patients only (5% of the whole series), 19 of them were subjected to urgent surgical decompression due to severe neurological deficit. The haemorrhagic character of apoplexy was established in most cases requiring immediate surgery.The detailed clinical picture of this condition and its management are discussed with respect to the long term prognosis.On this basis the authors suggest the necessity of surgical treatment in every case of pituitary apoplexy, taking into account not only neurological recovery, but also endocrine and oncological aspects of the disease. The observation that pituitary apoplexy may be a marker of tumour invasiveness (even in small, enclosed adenomas) is highlighted.