内镜下扩大经鼻蝶入路鞍上垂体柄占位性病变活检术临床价值初探
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摘要
研究背景垂体柄占位性病变病因广泛,诊断相对困难,鞍上垂体柄占位性病变活检术的临床意义至今仍存争议。目的探讨内镜下扩大经鼻蝶入路行垂体柄占位性病变活检术的临床价值及安全性。方法与结果采用内镜下扩大经鼻蝶入路采集2011-2017年共16例鞍上垂体柄占位性病变患者病灶组织标本,以脂肪"浴缸塞"式联合带蒂鼻中隔黏膜瓣进行鞍底重建。术后病理学证实生殖细胞瘤10例、朗格汉斯细胞组织细胞增生症3例、淋巴细胞性垂体炎2例和颅咽管瘤1例。术后除2例发生中枢神经系统感染,无一例出现新发腺垂体功能减退、视力视野损害、脑脊液鼻漏、非计划再次手术或死亡等严重并发症。结论内镜下扩大经鼻蝶入路行鞍上垂体柄占位性病变活检术安全可靠,对明确诊断、制定下一步治疗方案具有重要指导意义,值得广泛推广。
Background Pituitary stalk occupation can result from various lesions, therefore the diagnosis is difficult to a certain extent. The clinical significance of the biopsy to pituitary stalk occupying lesions on suprasellar region remains controversal. Objective To analyze the value and safety of pituitary stalk biopsy by endoscopic extended transsphenoidal approach in the diagnosis of pituitary stalk occupying lesions. Methods and Results There were 16 patients who received pituitary stalk biopsy by endoscopic extended transsphenoidal approach from 2011 to 2017, and reconstruction of sellar floor was done by bathplug technique and pedicled nasoseptal flap. Postoperative pathological examination identified germinoma in 10 cases, Langerhans' cell histiocytosis(LCH) in 3 cases, lymphocytic hypophysitis in 2 cases and craniopharyngioma in one case. After operation, 2 patients had central nervous system(CNS) rhinorrhea,while no patient had new hypopituitarism, damage of visual field and eyesight, cerebrospinal fluid(CSF)rhinorrhea, unplanned secondary surgery, death or other serious complications. Conclusions Pituitary stalk biopsy by endoscopic extended transsphenoidal approach is a safe and reliable surgical method which is instructive for patient's diagnosis and treatment plan. It is worth popularizing widely.
Background Pituitary stalk occupation can result from various lesions, therefore the diagnosis is difficult to a certain extent. The clinical significance of the biopsy to pituitary stalk occupying lesions on suprasellar region remains controversal. Objective To analyze the value and safety of pituitary stalk biopsy by endoscopic extended transsphenoidal approach in the diagnosis of pituitary stalk occupying lesions. Methods and Results There were 16 patients who received pituitary stalk biopsy by endoscopic extended transsphenoidal approach from 2011 to 2017, and reconstruction of sellar floor was done by bathplug technique and pedicled nasoseptal flap. Postoperative pathological examination identified germinoma in 10 cases, Langerhans' cell histiocytosis(LCH) in 3 cases, lymphocytic hypophysitis in 2 cases and craniopharyngioma in one case. After operation, 2 patients had central nervous system(CNS) rhinorrhea,while no patient had new hypopituitarism, damage of visual field and eyesight, cerebrospinal fluid(CSF)rhinorrhea, unplanned secondary surgery, death or other serious complications. Conclusions Pituitary stalk biopsy by endoscopic extended transsphenoidal approach is a safe and reliable surgical method which is instructive for patient's diagnosis and treatment plan. It is worth popularizing widely.
引文
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[10]Bellastella G,Maiorino MI,Bizzarro A,Giugliano D,Esposito K,Bellastella A,De Bellis A.Revisitation of autoimmune hypophysitis:knowledge and uncertainties on pathophysiological and clinical aspects[J].Pituitary,2016,19:625-642.
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[12]Nishiki M,Murakami Y,Ozawa Y,Kato Y.Serum antibodies to human pituitary membrane antigens in patients with autoimmune lymphocytic hypophysitis and infundibuloneurohypophysitis[J].Clin Endocrinol(Oxf),2001,54:327-333.
[13]Weiss HL.Transnasal transsphenoidal approach[M]//Apuzzo MJ.Surgery of the third ventricle.Baltimore:Williams&Wilkins,1987:476-494.
[14]Jinguji S,Nishiyama K,Yoshimura J,Yoneoka Y,Harada A,Sano M,Fujii Y.Endoscopic biopsies of lesions associated with a thickened pituitary stalk[J].Acta Neurochir(Wien),2013,155:119-124.
[15]Yoneoka Y,Watanabe N,Okada M,Fujii Y.Observation of the neurohypophysis,pituitary stalk,and adenohypophysis during endoscopic pituitary surgery:demonstrative findings as clues to pituitary-conserving surgery[J].Acta Neurochir(Wien),2013,155:1049-1055.
[16]Ivan ME,Iorgulescu JB,El-Sayed I,McDermott MW,Parsa AT,Pletcher SD,Jahangiri A,Wagner J,Aghi MK.Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery[J].J Clin Neurosci,2015,22:48-54.
[2]Beni-Adani L,Sainte-Rose C,Zerah M,Brunelle F,Constantini S,Renier D,Lellouch-Tubiana A,Leger J,Pierre-Kahn A.Surgical implications of the thickened pituitary stalk accompanied by central diabetes insipidus[J].J Neurosurg,2005,103(2 Suppl):142-147.
[3]Guzzo MF,Bueno CB,Amancio TT,Rosemberg S,Bueno C,Arioli EL,Glezer A,Bronstein MD.An intrasellar germinoma with normal tumor markerconcentrations mimicking primary lymphocytic hypophysitis[J].Arq Bras Endocrinol Metabol,2013,57:566-570.
[4]Turcu AF,Erickson BJ,Lin E,Guadalix S,Schwartz K,Scheithauer BW,Atkinson JL,Young WF Jr.Pituitary stalk lesions:the Mayo Clinic experience[J].J Clin Endocrinol Metab,2013,98:1812-1818.
[5]Jian F,Bian L,Sun S,Yang J,Chen X,Chen Y,Ma Q,Miao F,Wang W,Ning G,Sun Q.Surgical biopsies in patients with central diabetes insipidus and thickened pituitary stalks[J].Endocrine,2014,47:325-335.
[6]Czernichow P,Garel C,Léger J.Thickened pituitary stalk on magnetic resonance imaging in children with central diabetes insipidus[J].Horm Res,2000,53 Suppl 3:61-64.
[7]Zhang Y,Zhu H,Deng K,Ma W,Wang Y,Sun J,Lian X,Pan H,Wang R,Yao Y.Results of biopsy-proven sellar germ cell tumors:nine years'experience in a single center[J].World Neurosurg,2018,112:E229-239.
[8]Zhou LF.Modern neurosurgery[M].2nd ed.Shanghai:Fudan University Press,2001:705.[周良辅.现代神经外科学[M].2版.上海:复旦大学出版社,2001:705.]
[9]Xu JL,Feng F,You H,Li ML.MRI manifestation of 48 cases of pituitary stalk thickening[J].Zhongguo Yi Xue Ying Xiang Xue Za Zhi,2017,25:98-100.[徐加利,冯逢,有慧,李明利.48例垂体柄增粗MRI表现[J].中国医学影像学杂志,2017,25:1098-100.]
[10]Bellastella G,Maiorino MI,Bizzarro A,Giugliano D,Esposito K,Bellastella A,De Bellis A.Revisitation of autoimmune hypophysitis:knowledge and uncertainties on pathophysiological and clinical aspects[J].Pituitary,2016,19:625-642.
[11]Howlett TA,Levy MJ,Robertson IJ.How reliably can autoimmune hypophysitis be diagnosed without pituitary biopsy[J].Clin Endocrinol(Oxf),2010,73:18-21.
[12]Nishiki M,Murakami Y,Ozawa Y,Kato Y.Serum antibodies to human pituitary membrane antigens in patients with autoimmune lymphocytic hypophysitis and infundibuloneurohypophysitis[J].Clin Endocrinol(Oxf),2001,54:327-333.
[13]Weiss HL.Transnasal transsphenoidal approach[M]//Apuzzo MJ.Surgery of the third ventricle.Baltimore:Williams&Wilkins,1987:476-494.
[14]Jinguji S,Nishiyama K,Yoshimura J,Yoneoka Y,Harada A,Sano M,Fujii Y.Endoscopic biopsies of lesions associated with a thickened pituitary stalk[J].Acta Neurochir(Wien),2013,155:119-124.
[15]Yoneoka Y,Watanabe N,Okada M,Fujii Y.Observation of the neurohypophysis,pituitary stalk,and adenohypophysis during endoscopic pituitary surgery:demonstrative findings as clues to pituitary-conserving surgery[J].Acta Neurochir(Wien),2013,155:1049-1055.
[16]Ivan ME,Iorgulescu JB,El-Sayed I,McDermott MW,Parsa AT,Pletcher SD,Jahangiri A,Wagner J,Aghi MK.Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery[J].J Clin Neurosci,2015,22:48-54.