垂体腺瘤不同手术入路的适应症及其术后效果研究
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摘要
研究背景
垂体腺瘤是发生于脑垂体的一种肿瘤，约占颅内肿瘤的5-10％。它起源于垂体前叶，通常情况下是良性的。垂体腺瘤多发生于30-40岁，男女发生率相等。本研究的主要目的是评价垂体腺瘤的3种手术入路与肿瘤类型、切除程度和肿瘤分级之间关系。我们选择了50例这样的病人，分别采用3种不同手术入路(经蝶、经额下、经翼点)进行手术。对病人的选择、手术技巧、内分泌的变化、术后并发症及这三种入路与术后辅助治疗之间相互关系进行研究。
方法
对50例分别采用经蝶、经额下、经翼点三种入路进行手术的垂体腺瘤病人进行回顾性研究。按视力情况、内分泌的变化及肿瘤类型进行分类。肿瘤的级别以肿瘤的侵袭程度来分(Hardy分级法)。所有的病例均行MRI检查，并经病理学检查证实。本组病例男性29人(58％)，女性21人(42％)，年龄16—74岁，平均45岁。垂体腺瘤可分为功能性垂体腺瘤和无功能性垂体腺瘤，本组中两种分别为58％(29例)和42％(21例)。在29例功能性垂体腺瘤中44.8％(13例)为GH腺瘤，31.0％(9例)为PRL腺瘤，6.8％(2例)为ACTH腺瘤，17.2％(5例)为既分泌GH又分泌PRL的混合性腺瘤。所有结果采用SPSS 12.0软件包进行卡方检验分析，取P＜0.05作为差异有显著性的标准。
结果
经蝶入路肉眼下全切肿瘤21例，次全切3例，部分切除5例。16例行额下入路的病例中4例获的全切，7例次全切，5例部分切除。5例经翼点入路的病例中次全切的1例，部分切除的4例。对三种手术入路和肿瘤类型进行卡方检验，P＞0.05 x~2=12.091，说明三种手术入路和肿痛类型无明显相关性。但是，经蝶入路适用于各种垂体瘤，而额下入路更适用于无功能性垂体腺瘤。经检验三种手术入路和肿瘤的切除率有明显的相关性(P＜0.05 x~2=20.043)。完全的肿瘤切除多见于经蝶入路，而翼点入路少见。更有统计学意义的是三种手术和肿瘤的级别(P＜0.05 x~2=27.077)。经蝶入路更适用于A级、B级的垂体微腺瘤，而对C级、D级的大腺瘤则适用经翼点入路。术后出现暂时尿崩的病例中经蝶入路9例，额下入路8例，翼点入路1例。1例经蝶入路的病例出现长期尿崩。1例经额下入路的病例出现切口感染。经翼点入路的病例中1例视力恶化，1例出现脑脊液漏。1例经额下入路的病例由于术后出现肝功能衰竭并发症而死亡。术前所有的病例均有视力下降，视野缺损，术后除1例视力恶化外，其余视力均得到明显改善。术后40％的病例行Y—刀辅助治疗。
Background and objective: Pituitary adenoma is a tumor of the pituitary gland which contributes 5-10% of the intracranial tumors. They arise from the anterior portion of the gland and usually benign. They are most common in 3rd and 4th decade of life and affect both sexes equally. The main aim of this study is to evaluate the feasibility and therapeutic effectiveness of 3 different surgical approaches on different types of pituitary adenoma and to study the relation between 3 different approaches and types, amount of tumor resection and grading in suprasellar extension of the pituitary adenoma. We described 3 different surgical approaches (transphenoidal surgery, sub-frontal craniotomy and pterional craniotomy), presented and reviewed of 50 cases undergoing these procedures with emphasis on patient selection, surgical technique, endocrinological study, post operative complications and post operative adjunctive therapy.
Method: A retrospective review was performed of patients who had undergone transphenoidal surgery (TSS), sub-frontal craniotomy and pterional craniotomy approach
垂体腺瘤是发生于脑垂体的一种肿瘤，约占颅内肿瘤的5-10％。它起源于垂体前叶，通常情况下是良性的。垂体腺瘤多发生于30-40岁，男女发生率相等。本研究的主要目的是评价垂体腺瘤的3种手术入路与肿瘤类型、切除程度和肿瘤分级之间关系。我们选择了50例这样的病人，分别采用3种不同手术入路(经蝶、经额下、经翼点)进行手术。对病人的选择、手术技巧、内分泌的变化、术后并发症及这三种入路与术后辅助治疗之间相互关系进行研究。
方法
对50例分别采用经蝶、经额下、经翼点三种入路进行手术的垂体腺瘤病人进行回顾性研究。按视力情况、内分泌的变化及肿瘤类型进行分类。肿瘤的级别以肿瘤的侵袭程度来分(Hardy分级法)。所有的病例均行MRI检查，并经病理学检查证实。本组病例男性29人(58％)，女性21人(42％)，年龄16—74岁，平均45岁。垂体腺瘤可分为功能性垂体腺瘤和无功能性垂体腺瘤，本组中两种分别为58％(29例)和42％(21例)。在29例功能性垂体腺瘤中44.8％(13例)为GH腺瘤，31.0％(9例)为PRL腺瘤，6.8％(2例)为ACTH腺瘤，17.2％(5例)为既分泌GH又分泌PRL的混合性腺瘤。所有结果采用SPSS 12.0软件包进行卡方检验分析，取P＜0.05作为差异有显著性的标准。
结果
经蝶入路肉眼下全切肿瘤21例，次全切3例，部分切除5例。16例行额下入路的病例中4例获的全切，7例次全切，5例部分切除。5例经翼点入路的病例中次全切的1例，部分切除的4例。对三种手术入路和肿瘤类型进行卡方检验，P＞0.05 x~2=12.091，说明三种手术入路和肿痛类型无明显相关性。但是，经蝶入路适用于各种垂体瘤，而额下入路更适用于无功能性垂体腺瘤。经检验三种手术入路和肿瘤的切除率有明显的相关性(P＜0.05 x~2=20.043)。完全的肿瘤切除多见于经蝶入路，而翼点入路少见。更有统计学意义的是三种手术和肿瘤的级别(P＜0.05 x~2=27.077)。经蝶入路更适用于A级、B级的垂体微腺瘤，而对C级、D级的大腺瘤则适用经翼点入路。术后出现暂时尿崩的病例中经蝶入路9例，额下入路8例，翼点入路1例。1例经蝶入路的病例出现长期尿崩。1例经额下入路的病例出现切口感染。经翼点入路的病例中1例视力恶化，1例出现脑脊液漏。1例经额下入路的病例由于术后出现肝功能衰竭并发症而死亡。术前所有的病例均有视力下降，视野缺损，术后除1例视力恶化外，其余视力均得到明显改善。术后40％的病例行Y—刀辅助治疗。
Background and objective: Pituitary adenoma is a tumor of the pituitary gland which contributes 5-10% of the intracranial tumors. They arise from the anterior portion of the gland and usually benign. They are most common in 3rd and 4th decade of life and affect both sexes equally. The main aim of this study is to evaluate the feasibility and therapeutic effectiveness of 3 different surgical approaches on different types of pituitary adenoma and to study the relation between 3 different approaches and types, amount of tumor resection and grading in suprasellar extension of the pituitary adenoma. We described 3 different surgical approaches (transphenoidal surgery, sub-frontal craniotomy and pterional craniotomy), presented and reviewed of 50 cases undergoing these procedures with emphasis on patient selection, surgical technique, endocrinological study, post operative complications and post operative adjunctive therapy.
Method: A retrospective review was performed of patients who had undergone transphenoidal surgery (TSS), sub-frontal craniotomy and pterional craniotomy approach
引文
1) Mark S. Greenberg, Tumor, Pituitary adenoma in Handbook of Neurosurgery Thieme 5~(th) edition: 2001 pp 419-436
2) W. Jeffrey Elias & Edward R. Law Jr.: Transphenoidal approach to lesion of sellar. In operative surgical technique, Schimidek H H & Sweet W H(eds) WB. Saunders, Philadelphia 4~(th) ed., 2000, vol l: pp 373: 374
3) Alleyne CHJr, Barrow DL, Oyesiku NM. Combined transphenoidal and pterional craniotomy approach to giant pituitary tumors: Surg. Neurol 2002; 57: 380-90
4) Laws Er Jr: Transphenoidal microsurgery in management of Craniopharyngioma. J. Neurosurg,1980, 52: 661-666
5) Ciric I, Ragin A, Baumgartner C, et al: Complication of TSS: results of a national survey, review of the literature & the personal experience: Neurosurgery,1997 40: 225-237
6) Kelly DF, Laws ER Jr, Fossett D: Delayed hyponatremia after TSS for Pituitary adenoma. Report of nine cases J.Neurosurg,1995, 83: 363-367
7) Goel A, Nadkami T. Surgical management of giant pituitary tumors: review of 30 cases. Acta Neurochirugia: 1996; 138: 1042-8
8) Symon L, Jakubowski J, Kendall B, Surgical treatment of giant pituitary adenomas. J.Neurol Neurosurg Psychiatry 1979; 42: 973-82
9) Hattori K, Kunwayama A, current technical aspect in TSS pituitary adenomectomy: Nippon Rinsho 1993; 51: 2742-7
10) Pamela F, Sharon W, Karmen D, Long term endocrinology follow-up evaluation in 115 patient who underwent TSS for acromegaly: J. Neurosurg,1998,89: 353-358
11) Fahlbuch R. Honeggar J, Buchfelder M: Surgical management of acromegaly: Endocrinol Metabchin North AM; 1992, 21: 669-692
12) Yousef AS, Agazzi S, Van Loveren H.R: Transcranial surgery for pituitary adenomas: J Neurosurgery: 57 July 2005, 168-175
13) Hardy J: Transphenoidal microsurgical removal of pituitary adenoma: Prog Neurosurg1975, 6: 200-216
14) Nelson PB, Goodman M, Maroon JC, et al: Factors in predicting outcome from operation in patients with prolactin-secreting pituitary adenoma. Neurosurgery, 1983, 13: 634-641
15) Schelate J, Sherman B, Halmi N, et al: Prolactin-secreting pituitary tumors in amenorrheic women: a comprehensive study. Endocr Rev,1980 1: 295-301
16) Seri O, Rasio E, Bearuregard H, et al: Recurrence of hyperprolactinemia after selective transphenoidal adenomectomy in women with prolactinoma. N Engl J, 1983,Med 309: 280-283
17) Johnson DG, Prescott RW, Kendall-Taylor P, et al: Hyperprolactinemia. Longterm effects of bromocriptine. Am J Med,1983, 75: 868-874
18) Mohr G, Hardy J, Comtois R, et al: Surgical management of giant pituitary adenomas. Can J Neurol Sci, 1990, 17: 62-66
19) Tyrrell JB, Lamborn KR, Hannegan LT, et al: Transphenoidal microsurgical therapy of prolactinoma: initial outcomes and long-term results: Neurosurgery 1999, 44: 254-263
20) Arguello C, Blevins LS: Prolactinomas: diagnosis and management. Contemp, 1995,Neurosurg 17: 1-6
21) Motlitch ME, Elton RL, Blackwell RE, et al: Bromocriptin as primary therapy for prolactin-secreting macroadenomas: results of a prospective multicenter study. J Clin Endocrinol Metab, 1985, 60: 698-705
22) Shimon I, Melmed S: Management of pituitary tumors. Ann Intern Med, 1998 129: 472-483
23) Dolenc VV: Transcranial epidural approach to pituitary tumors extending beyond sella. Neurosurg,1997, 41: 542-552
24) Hashimoto N, Handa H, Yamashita J, et al: Long-term follow up of large or invasive pituitary adenomas. Surg Neurol,1986, 25: 49-54
25) King WA, Rodts GE Jr, Becker DP, et al: Microsurgical management of giant pituitary tumors: Skull base surgery, 1996, 6: 17-26
26) Shrivastava RK, Arginteu MS, King WA, Post KD: Giant prolactinomas:clinical management and long term follow up: J Neurosurgery,2002,97: 299-306
27) Miura M, Matsukado Y, Koduma T, Treatment of large pituitary adenoma: Neurologia Medico-Chirugica, Volume 25, issue12, 1985, pp 1019-1028
28) Backlund EO: Stereiotactic Radiosurgery for Pituitary adenomas and Craniopharyngiomas. In Operative Surgical Technique., Schimedek HH & Sweet HH(eds) WB Saunders, Philadelphia 9~(th) ed.,2000 pp 467-472
29) Ganz JC: Gamma knife treatment of pituitary adenomas: stereotact Funct Neurosurg,1995, 64(Suppl 1): 3-10
30) Motti ED, Lossa M, Pieralli S, et al: Sterieotactic radiosurgery of pituitary adenoma, Metabolism, 1996, 45(8 suppl 1): 111-114
31) Yoon SC, Suh TS, Jang HS, et al: Clinical results of 24 pituitary macroadenoma with linac-based stereotactic radiosurgery. Int J Raiat Oncol Biol Phys,1998 41: 849-853
32) Jonas., Mary V., Johan S., Dilantha E., and Edward L; Radiosurgery for Cushing's disease after failed TSS: J Neurosurgery, 2000, 93: 738-742
33) Backlund EO, Ganz JC: Pituitary adenomas: Gamma knife, in Alexandra E, Loeffer JS, Lunsford LD(eds): Stereotactic Radiosurgery, Newyork: McGraw-Hill 1993, pp 167-17
34) Thapar K, Kovacs K, Scheithauer BW, Lloyd RY, eds. Diagnosis and Management of Pituitary Tumors. Totawa, NJ: Humana Press Inc, 2000 pp 199-110
35) Mehzarin M: Cushing disease, transphenoidal surgical results of 11 cases: Arch Iranian Med(1), 2004: 53-56
36) Jane JA, ER Laws: Surgical management of Pituitary adenoma: Singapore Med J: 2002 vol 43(6): 318-323
1) BD Chaurasia, Cranial Cavity: Human Anatomy 4~(th) edition vol 3-2004: pp98-100
2) William F Ganong, Pituitary tumor in Review of Medical Physiology, Lange 21~(st) edition 2003,pp319-414
3) Snell R., Head & Neck: Clinical anatomy for medical students.6~(th) eds,2000,pp700-701
4) Guyton CA, Hall JE; Pituitary hormones & their control by the hypothalamus: Text book of medical physiology 10~(th) eds,2000, pp 846-853
5) Thorner MO, Vance ML, Laws ER Jr, et al. The anterior pituitary. In: Wilson JD, Foster DW, Kronenberg HM, Larsen PR, eds. Williams Textbook of Endocrinology, 9th ed. Philadelphia: WB Saunders, 1998: 249-340
6) Thapar K, Kovacs K, Scheithauer BW, Lloyd RY, eds. Diagnosis and Management of Pituitary Tumors. Totawa, NJ: Humana Press Inc, 2000,pp 199-110
7) Mark S. Greenberg, Tumor, Pituitary adenoma in Handbook of Neurosurgery, Thieme 5~(th) edition: 2001 pp 419-436
8) Molitch ME Medical treatment of prolactinomas. Endocrinol Metab Clin North Am: 1999, 28: 143-169
9) Freda PU, Wardlaw SL: Diagnosis and treatment of pituitary tumors. J Clin Endocrinol Metab: 1999, 84: 3859-3866
10) Serri O, Rasio E, Beauregard H, Hardy J, Somma M: Recurrence of hyperprolactinaemia after selective adenomectomy in women with prolactinomas. N Engl J Med: 1983, 309: 280-283
11) Liuzzi A, Oppizzi G:Microprolactinomas: why requiem for surgery J Endocrinol Invest: 1996, 19: 196-198
12) Turner HE, Adams CBT, Wass AH:Trans-sphenoidal surgery for microprolactinoma: an acceptable alternative to dopamine agonists Eur J Endocrinol: 1999, 140: 43-47
13) Molitch ME, Thorner MO, Wilson C:Therapeutic controversy: management of prolactinomas. J Clin Endocrinol Metab1997, 82: 996- 1000
14) Bates A, Van Hoff W, Jone J, Clayton R: An audit on the outcome of acromegaly: QJ Med: 1993, 86: 293-299
15) Rajasoorya C, Holdaway IM, Wrightson P, Scott DJ, Ibbertson HK: Determinants of clinical outcome and survival in acromegaly: Clin Endocrinol (Oxf): 1994, 41: 95-102
16) Cushing H: Partial hypophysectomy for acromegaly: with remarks on function of hypophysis. Ann Surg: 1909, 50: 1002-1017
17) Schelate J, Sherman B, Halmi N, et al: Prolactin-secreting pituitary tumor in amenrrheic women: comprehensive study: Endocr Rev: 1980, 1: 295-301
18) Seri O, Rasio E, Bearuregard H, et al: Recurrence of hyperprolactinemia after selective transphenoidal adenomectomy in women with prolactinoma. N Engl J Med: 1983, 309: 280-283
19) Johnson DG, Prescott RW, Kendall-Taylor P, et al: Hyperprolactinemia. Long-term effects of bromocriptine. Am J Med 75: 868-874,1983 Pamela F, Sharon W, Karmen D, Long term endocrinology follow-up evaluation in 115 patient who underwent TSS for acromegaly: J. Neurosurg: 1998, 89: 353-358
20) Fahlbuch R. Honeggar J, Buchfelder M: Surgical management of acromegaly: Endocrinol Metabchin North AM; 1992, 21: 669-692
21) Pamela F, Sharon W, Karmen D, Long term endocrinology follow-up evaluation in 115 patient who underwent TSS for acromegaly: J. Neurosurg: 1998, 89: 353-358
22) Backlund EO, Ganz JC: Pituitary adenomas: Gamma knife, in Alexandra E, Loeffer JS, Lunsford LD(eds): Stereotactic Radiosurgery, Newyork: McGraw-Hill 1993, pp 167-17
23) Hardy J: Transphenoidal microsurgical removal of pituitary adenoma: Prog Neurosurg: 1975, 6: 200-216
24) W. Jeffrey Elias & Edward R. Law Jr.: Transphenoidal approach to lesion of sellar. In operative surgical technique, Schimidek H H & Sweet W H(eds) WB. Saunders, Philadelphia 4~(th) ed.,2000, vol 1:pp 373: 374
25) Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic pituitary surgery: an early experience. Surg Neurol 1997; 47: 213-23
26) Yousef AS, Agazzi S, Van Loveren H.R: Transcranial surgery for pituitary adenomas: J Neurosurgery: 57 July 2005 168-175
27) Couldwell W:Transsphenoidal and transcranial surgery for pituitary adenomas; J Neurooncol. 2004 Aug-Sep; 69(1-3): 237-56
28) Czepko R, Danilewicz B, Anilewicz M, Uhl H:Early results of treating pituitary adenomas by means of transcranial and transsphenoidal approach;Prezl Lek: 1999; 56(10): 638-43
29) Alleyne CH, Barrow DL, Oyesiku NM. Combined transphenoidal and pterional craniotomy approach to giant pituitary tumors: Surg. Neurol 2002; 57: 380-90
2) W. Jeffrey Elias & Edward R. Law Jr.: Transphenoidal approach to lesion of sellar. In operative surgical technique, Schimidek H H & Sweet W H(eds) WB. Saunders, Philadelphia 4~(th) ed., 2000, vol l: pp 373: 374
3) Alleyne CHJr, Barrow DL, Oyesiku NM. Combined transphenoidal and pterional craniotomy approach to giant pituitary tumors: Surg. Neurol 2002; 57: 380-90
4) Laws Er Jr: Transphenoidal microsurgery in management of Craniopharyngioma. J. Neurosurg,1980, 52: 661-666
5) Ciric I, Ragin A, Baumgartner C, et al: Complication of TSS: results of a national survey, review of the literature & the personal experience: Neurosurgery,1997 40: 225-237
6) Kelly DF, Laws ER Jr, Fossett D: Delayed hyponatremia after TSS for Pituitary adenoma. Report of nine cases J.Neurosurg,1995, 83: 363-367
7) Goel A, Nadkami T. Surgical management of giant pituitary tumors: review of 30 cases. Acta Neurochirugia: 1996; 138: 1042-8
8) Symon L, Jakubowski J, Kendall B, Surgical treatment of giant pituitary adenomas. J.Neurol Neurosurg Psychiatry 1979; 42: 973-82
9) Hattori K, Kunwayama A, current technical aspect in TSS pituitary adenomectomy: Nippon Rinsho 1993; 51: 2742-7
10) Pamela F, Sharon W, Karmen D, Long term endocrinology follow-up evaluation in 115 patient who underwent TSS for acromegaly: J. Neurosurg,1998,89: 353-358
11) Fahlbuch R. Honeggar J, Buchfelder M: Surgical management of acromegaly: Endocrinol Metabchin North AM; 1992, 21: 669-692
12) Yousef AS, Agazzi S, Van Loveren H.R: Transcranial surgery for pituitary adenomas: J Neurosurgery: 57 July 2005, 168-175
13) Hardy J: Transphenoidal microsurgical removal of pituitary adenoma: Prog Neurosurg1975, 6: 200-216
14) Nelson PB, Goodman M, Maroon JC, et al: Factors in predicting outcome from operation in patients with prolactin-secreting pituitary adenoma. Neurosurgery, 1983, 13: 634-641
15) Schelate J, Sherman B, Halmi N, et al: Prolactin-secreting pituitary tumors in amenorrheic women: a comprehensive study. Endocr Rev,1980 1: 295-301
16) Seri O, Rasio E, Bearuregard H, et al: Recurrence of hyperprolactinemia after selective transphenoidal adenomectomy in women with prolactinoma. N Engl J, 1983,Med 309: 280-283
17) Johnson DG, Prescott RW, Kendall-Taylor P, et al: Hyperprolactinemia. Longterm effects of bromocriptine. Am J Med,1983, 75: 868-874
18) Mohr G, Hardy J, Comtois R, et al: Surgical management of giant pituitary adenomas. Can J Neurol Sci, 1990, 17: 62-66
19) Tyrrell JB, Lamborn KR, Hannegan LT, et al: Transphenoidal microsurgical therapy of prolactinoma: initial outcomes and long-term results: Neurosurgery 1999, 44: 254-263
20) Arguello C, Blevins LS: Prolactinomas: diagnosis and management. Contemp, 1995,Neurosurg 17: 1-6
21) Motlitch ME, Elton RL, Blackwell RE, et al: Bromocriptin as primary therapy for prolactin-secreting macroadenomas: results of a prospective multicenter study. J Clin Endocrinol Metab, 1985, 60: 698-705
22) Shimon I, Melmed S: Management of pituitary tumors. Ann Intern Med, 1998 129: 472-483
23) Dolenc VV: Transcranial epidural approach to pituitary tumors extending beyond sella. Neurosurg,1997, 41: 542-552
24) Hashimoto N, Handa H, Yamashita J, et al: Long-term follow up of large or invasive pituitary adenomas. Surg Neurol,1986, 25: 49-54
25) King WA, Rodts GE Jr, Becker DP, et al: Microsurgical management of giant pituitary tumors: Skull base surgery, 1996, 6: 17-26
26) Shrivastava RK, Arginteu MS, King WA, Post KD: Giant prolactinomas:clinical management and long term follow up: J Neurosurgery,2002,97: 299-306
27) Miura M, Matsukado Y, Koduma T, Treatment of large pituitary adenoma: Neurologia Medico-Chirugica, Volume 25, issue12, 1985, pp 1019-1028
28) Backlund EO: Stereiotactic Radiosurgery for Pituitary adenomas and Craniopharyngiomas. In Operative Surgical Technique., Schimedek HH & Sweet HH(eds) WB Saunders, Philadelphia 9~(th) ed.,2000 pp 467-472
29) Ganz JC: Gamma knife treatment of pituitary adenomas: stereotact Funct Neurosurg,1995, 64(Suppl 1): 3-10
30) Motti ED, Lossa M, Pieralli S, et al: Sterieotactic radiosurgery of pituitary adenoma, Metabolism, 1996, 45(8 suppl 1): 111-114
31) Yoon SC, Suh TS, Jang HS, et al: Clinical results of 24 pituitary macroadenoma with linac-based stereotactic radiosurgery. Int J Raiat Oncol Biol Phys,1998 41: 849-853
32) Jonas., Mary V., Johan S., Dilantha E., and Edward L; Radiosurgery for Cushing's disease after failed TSS: J Neurosurgery, 2000, 93: 738-742
33) Backlund EO, Ganz JC: Pituitary adenomas: Gamma knife, in Alexandra E, Loeffer JS, Lunsford LD(eds): Stereotactic Radiosurgery, Newyork: McGraw-Hill 1993, pp 167-17
34) Thapar K, Kovacs K, Scheithauer BW, Lloyd RY, eds. Diagnosis and Management of Pituitary Tumors. Totawa, NJ: Humana Press Inc, 2000 pp 199-110
35) Mehzarin M: Cushing disease, transphenoidal surgical results of 11 cases: Arch Iranian Med(1), 2004: 53-56
36) Jane JA, ER Laws: Surgical management of Pituitary adenoma: Singapore Med J: 2002 vol 43(6): 318-323
1) BD Chaurasia, Cranial Cavity: Human Anatomy 4~(th) edition vol 3-2004: pp98-100
2) William F Ganong, Pituitary tumor in Review of Medical Physiology, Lange 21~(st) edition 2003,pp319-414
3) Snell R., Head & Neck: Clinical anatomy for medical students.6~(th) eds,2000,pp700-701
4) Guyton CA, Hall JE; Pituitary hormones & their control by the hypothalamus: Text book of medical physiology 10~(th) eds,2000, pp 846-853
5) Thorner MO, Vance ML, Laws ER Jr, et al. The anterior pituitary. In: Wilson JD, Foster DW, Kronenberg HM, Larsen PR, eds. Williams Textbook of Endocrinology, 9th ed. Philadelphia: WB Saunders, 1998: 249-340
6) Thapar K, Kovacs K, Scheithauer BW, Lloyd RY, eds. Diagnosis and Management of Pituitary Tumors. Totawa, NJ: Humana Press Inc, 2000,pp 199-110
7) Mark S. Greenberg, Tumor, Pituitary adenoma in Handbook of Neurosurgery, Thieme 5~(th) edition: 2001 pp 419-436
8) Molitch ME Medical treatment of prolactinomas. Endocrinol Metab Clin North Am: 1999, 28: 143-169
9) Freda PU, Wardlaw SL: Diagnosis and treatment of pituitary tumors. J Clin Endocrinol Metab: 1999, 84: 3859-3866
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