鞍上中线脑膜瘤的起源部位和生长模式对肿瘤预后的影响

Influence of origin site and growth pattern in prognosis of midline suprasellar meningiomas tumors

目的探讨肿瘤生长方式及起源部位对鞍上中线脑膜瘤临床预后的影响。方法南方医科大学南方医院神经外科自2000年1月到2008年12月行手术治疗106例鞍上中线脑膜瘤患者，根据肿瘤的起源和生长方式，分为蝶骨平台脑膜瘤（PSM）组（n=22）、鞍结节脑膜瘤（TSM）组（n=27）和视交叉前置型鞍膈脑膜瘤（DSM）组（n=11）和视交叉后置型DSM组（n=46）。回顾性分析患者的临床资料，比较4组患者的临床症状，肿瘤直径，视神经通路、前交通动脉复合体和垂体柄受累情况，手术入路，视神经受累情况，全切率；多元线性回归分析患者术后视力恶化、视野缺损恶化、下丘脑．垂体轴损伤、肿瘤全切除、肿瘤复发的危险因素。结果视交叉后置型DSM组患者视力障碍、视野缺损、头痛的发生率最高（分别为97．8％、91.3％、76．1％）；视交叉前置型DSM组患者下丘脑-垂体轴功能障碍发生率最高（100％）；视交叉后置型DSM组患者视神经通路、前交通动脉复合体累及率最高（分别为97．8％、76．1％）；视交叉前置型DSM组患者垂体柄累及率最高（90．9％）。视交叉后置型DSM组患者视神经累及率最高（67％）。PSM组患者脑膜瘤全切除率最高（86％）。额颞入路是患者术后视力恶化的独立危险因素。TSM、视交叉前置型DSM、额颞入路是患者术后视野缺损症状恶化的独立危险因素。视交叉前置型DSM、手术入路是患者术后下丘脑．垂体轴损伤的独立危险因素。视交叉前置型DSM是影响肿瘤是否全切除的独立危险因素。次全切除是影响肿瘤是否复发的独立危险因素；随访期间肿瘤复发14例，PSM组、TSM组、视交叉前置型DSM组和视交叉后置型DSM组患者的平均无复发生存率和时间分别为95％和（103．9±3．91个月、93％和（107．1±4．6）个月、33％和（55．6±8．3）个月、89％和（105．3±4．51个月。结论肿瘤起源部位和生长方式是TSM手术切除及预后的重要影响因素，PSM手术全切除率高，无进展生存率高。TSM和视交叉后置型DSM侵犯视路结构，术后视神经功能损害发生率高，视交叉前置型DSM是次全切除、术后视力障碍以及下丘脑．垂体轴功能障碍的一个独立危险因素。次全切除是术后复发的独立危险因素。

Objective To elucidate the clinical and prognostic characteristics of the midline suprasellar meningiomas based on their origin site and growth pattern. Methods One hundred and six patients with midline suprasellar meningiomas, admitted to and underwent surgery in our hospital from January 2000 to December 2008, were chosen in our study; according to the origin and growth pattern of the tumors, they were divided into planum sphenoidal meningioma （PSM） group （n=22）, tuberculum sellae meningioma （TSM） group （n=27）, prefixed optic chiasm diaphragrna sellae meningioma （DSM） group （n=11） and postfixed optic chiasm DSM group （n=46）. A retrospective analysis of clinical symptoms, tumor diameters, optic pathways, anterior communicating artery complexes and pituitary stalk involvements, surgical approaches, optic nerve involvements and total resection rates was performed;multiple linear regression analysis of deterioration of visual acuity, visual field defect deteriorated hypothalamic-pituitary axis damage, tumor resection, risk factors of tumor recurrence was performed. Results Patients from postfixed optic chiasm DSM group had the highest rate of visual impairment （98%）, headache （76%）, optic pathway involvement （98%）, and anterior communicating artery complex involvement （76.1%）; patients from the DSM group had the highest rate of visual field defects （91%）; patients from prefixed optic chiasm DSM group had highest incidence of hypothalamic-pituitary axis dysfunction （100%） and pituitary stalk involvement （91%）. The most common optic nerve involvement appeared in patients from postfixed optic chiasm DSM group （67%）. Patients from the PSM group had the highest meningioma resection rate （86%）. Frontotemporal approach was considered as an independent risk factor for deterioration of visual acuity. TSM, prefixed optic chiasm DSM, DSM, and frontotemporal approach were independent risk Factors for postoperative visual feld defects. Prefixed optic chiasm DSM and surgical approach were independent risk factors for postoperative hypothalamic-pituitary axis injury. Prefixed optic chiasm DSM was an independent risk factor of tumor resection rate. Prefixed optic chiasm DSM and subtotal resection were independent risk factors for tumor relapse. Tumor recurrence was noted in 14 patients during the follow-up; the mean recurrence-flee survival rate was 95%, 93%, 33% and 89%, and the mean recurrence-free time was （103.9±3.9）, （107.1±4.6）, （55.6±8.3） and （105.3±4.5） months in the above groups, respectively. Conclusions Origin site and tumor growth pattern are important factors for surgery and prognosis of TSM; total resection rate and progression-free survival rate in PSM are high. High incidence of postoperative optic nerve damage is noted in patients with TSM and postfixed optic chiasm DSM; subtotal resection is an independent risk factor for recurrence.