侵袭性垂体腺瘤的手术治疗策略

Microsurgical strategy of invasive pituitary adenomas

目的分析侵袭性垂体腺瘤不同手术方式的治疗效果，探讨合理的手术治疗策略。方法回顾性分析2012年7月至2015年6月首都医科大学附属北京天坛医院神经外科收治的441例侵袭性垂体腺瘤患者的临床资料，包括临床表现、影像学表现、手术入路、显微操作技巧以及预后情况。肿瘤向鞍上侵袭310例，向鞍旁侵袭293例，向鞍底侵袭187例。经蝶窦手术治疗318例；行开颅手术治疗123例，其中经冠切额下入路31例，经额外侧入路50例，经额颞入路22例，经终板入路11例，经胼胝体一穹窿间入路9例。采用单因素分析和多因素Logistics逐步回归分析探讨侵袭性垂体腺瘤手术治疗方式的影响因素。结果对于侵袭性垂体腺瘤，存在鞍上侵袭和肿瘤体积〉15cm^3均为选择开颅手术的主要相关因素（均P〈0．001），而存在鞍底侵袭为选择经蝶窦手术的主要因素（P〈0．001）。冠切额下入路、额外侧入路、额颞入路的选择与侵袭性垂体腺瘤的鞍旁侵袭（P〈0．001）、肿瘤宽度（P=0．001）相关。冠切额下入路、经终板入路、经胼胝体一穹窿间入路的选择与侵袭性垂体腺瘤的肿瘤高度相关（P〈0．001）。结论侵袭性垂体腺瘤的手术入路需结合影像学表现以及患者是否能耐受开颅手术决定。经蝶窦入路对于切除推挤海绵窦内侧壁的“假侵袭”肿瘤有独特优势。额外侧入路的手术视角兼顾冠切额下人路和额颞入路的优点，适用于侵袭鞍旁的肿瘤。经终板入路避免了经胼胝体一穹隆间入路术后失联合综合征的风险，亦可一期切除鞍内肿瘤，适用于向鞍上侵袭明显的病例。

Objective To analyze the efficacy of different surgical approach for invasive pituitary adenoma and to raise the rational mierosurgical strategy. Methods We retrospectively analyzed the clinical data of 441 patients with invasive pituitary adenomas at the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from July 2012 to June 2015. The clinical manifestation, imaging data, surgical methods, microsurgical skills and prognosis were reviewed. Suprasellar invasive was identified in 310 patients, parasellar invasion was in 293 patients and the sellar floor invasion was in 187 patient. 318 patients underwent transsphenoidal surgery, while 123 patients were treated by eraniotomy. In the cases of patients treated by craniotomy, the number of patients undergoing the subfrontal approach, the frontal lateral approach, the frontal temporal approach, the anterior interhemispheric approach and the callosal interforniceal approach was respectively 31, 50, 22, 11 and 9. Univariate analysis and Logistic regression analysis were used to evaluate the influencing factors of surgical approach for invasive pituitary adenoma. Results The suprasellar invasion （ P 〈 0. 001 ） , tumor volume 〉 15 em3 （ P 〈 0. 001 ） were the main factors to choose craniotomy, while the sellar floor invasion （ P 〈 0. 001 ） is the main factor to use transsphenoidal approach. The options of subfrontal approach, frontal lateral approach or frontal temporal approach were related to the parasellar invasion （P 〈 0. 001 ） and width of the tumor （P = 0. 001 ）. The height of the tumor （P 〈0.001 ） was associated with the selections of the subfrontal approach, the anterior interhemispherie approach or the callosal interforniceal approach. Conclusions The options of the surgical approaeh of invasive pituitary adenomas should be on the basis of preoperative patient status and imaging findings. Transsphenoidal surgery has unique advantages for excising the tumor which pushes the internal wall of the cavernous sinus -＂false tumor invasion＂. The frontal lateral approach takes a advantage of the subfrontal approach and the frontal temporal approach to remove the tumor in the cavernous sinus. The options of the anterior interhemispheric approach to remove tumor involving suprasellar space avoid the disconnection syndrome after the operation though the callosal interforniceal approach, and the gross-total resection rate is higher.