分期经蝶入路手术治疗向鞍上生长的垂体无功能巨腺瘤的临床价值

Stagedly Transsphenoidal Operations on Giant Nonfunctioning Pituitary Adenoma with Suprasellar Extension

目的探讨分次经蝶入路手术治疗向鞍上生长的垂体无功能巨腺瘤的临床价值。方法回顾性分析我科资料齐全的68例向鞍上生长的垂体无功能巨腺瘤患者的临床资料,重点分析肿瘤的手术处理,术后肿瘤的残余情况及相应的处理措施。结果 68例患者首次手术均采取经单鼻孔蝶窦入路手术。术后第1天MR I复查,一期手术鞍上扩展肿瘤全切者20例(20.6%),存在鞍上残余肿瘤者48例(79.4%)。术后3个月复查,残余肿瘤21例下降至鞍窝底,8例下降至鞍窝内,3例下降至垂体柄水平和鞍窝入口处(下降率为66.7%),均采用再次经蝶手术切除(下降后残余肿瘤的全切除率为96.9%);1例患者肿瘤虽然下降,但仍伴有鞍上扩展的残余肿瘤,采用开颅切除术。其余的16例有残余肿瘤的患者,由于术后MR I显示残余肿瘤小,采取持续临床观察,其中2例视力改善不明显者辅以伽马刀治疗。本组共32例接受了分期经蝶手术;无死亡病例;术后无脑脊液漏、脑膜炎、视力恶化发生;有2例术后常规CT检查中观察到鞍隔上少量出血,但不需手术处理。结论向鞍上生长的垂体无功能巨腺瘤宜采用分期经蝶手术切除治疗,疗效确切,并发症少;垂体无功能巨腺瘤向鞍上生长的方式应该是膨胀推挤性生长,而非侵袭破坏性生长;有关垂体腺瘤的生长方式问题尚需进一步研究。

Objective To explore the clinic value of stagedly transsphenoidal operations on giant nonfunctioning pituitary adenoma with suprasellar extension.Methods The clinical data of 68 cases suffering from giant nonfunctioning pituitary adenoma with suprasellar extension（SSE）admitted into our department were retrospectively analyzed,who underwent primary transsphenoidal surgery,mainly include data on intraoperative treatment methods,adenoma remainders′s turnover and treatment during following-up,and so on.Results All patients were treated transsphenoidally.20 SSE adenomas were totally removed（20.6%）,and in other 48 cases（79.4%）,SSE residues were shown in MRI recheck in the 1st day after operation.After 3 months,the 3rd MRI was performed only to find that 21 remainders descended to sellar floor,8 cases into intrasella,and 3 cases down to the level of stalk hypophysial and the entrance to the sella;all of resisdual tumors above got retranssphenoidal resection（the total removal rate of desending SSE residues amount to 96.9%）;there were 2 adenoma remainders with slight descend,obvious SSE adenoms could be visible,which were preformed by a transtranial approach;other 12 cases with small SSE tumor remnants were given consecutive clinical observation,of which,2 cases were aided by grammer knife because of unobvious visual promotion postoperatively.In the present goroup,there are 32 cases accepting stagedly transsphenoidal operations.The surgical mortality was 0%.The mortality of our series was zero,and there were no case of rhinorrhea,meningitis or visual deterioration.2 patients had supradiaphragmatic bleeding observed during routine postoperative CT that did not require operative revision.Conclusion Staged operations with two or multiple transsphenoidal resections of giant nonfunctioning pituitary adenoma with SSE have many advantages such as good therapeutic effects and few complications;At the same time,as the tumor grows larger,it should expand and shove the surrounding structures,not invade and destroy them;Further study need to be done in the growth pattern of pituitary adenoma.