海绵窦海绵状血管瘤的诊断和治疗
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摘要
背景和目的：放射外科可以有效地控制较小海绵窦海绵状血管瘤的生长,对较大者,采用分次射波刀治疗也取得较好的近期效果。放射治疗计划的制定需要较明确的影像学诊断,本文拟量化CSHs的影像学特征,为进一步治疗提供依据。
方法：回顾性分析2006年1月-2009年12月133例海绵窦病变的影像学特征。根据病理结果分为CSHs组(24例)和非CSHs组(109例),后者又分为脑膜瘤(33例)、神经鞘瘤(37例)和其他(39例)三类。针对12项影像学特征,分别进行单因素卡方分析,p<0.01被认为有统计学意义。
结果：T2加权的超高信号,信号均一,哑铃样外形和鞍区浸润在鉴别CSHs和非CSHs时被认为具有统计学意义。当四者同时作为CSHs的诊断标准时,敏感度为87.5%,特异度96.3,精确度为94.7%。
结论：MR-T2加权见海绵窦内均匀的超高信号病灶,呈哑铃样或者尖嘴样浸润鞍区,注射造影剂后均匀强化,则海绵窦海绵状血管瘤的可能性极大,较小者可据此直接行放射外科治疗而不必取病理活检。
目的：探讨海绵窦海绵状血管瘤合理治疗方案
方法：回顾性分析1996年1月至2010年6月复旦大学附属华山医院收治的所有75例海绵窦海绵状血管瘤的诊疗经过。病例分为前期组(1996年1月至2002年12月,29例)和后期组(2003年1月至2010年6月,46例),前期组以手术治疗为主,后期组24例患者首选手术,22例首选放射治疗。收集所有患者症状、体征、肿瘤大小和范围、治疗经过等资料,并进行临床和影像学随访,对结果采用SPSS16.0软件进行统计分析。
结果：男性22例,女性53例,发病年龄11-74岁,平均51.0岁。首发症状包括头痛头胀35例,面部麻木15例,眼睑下垂18例,复视18例,停经6例。术后随访68例(90.7%),随访时间0.5～14年,平均6.0年。
前期组29例,其中28例首选手术治疗,1例伽玛刀治疗3个月后手术。肿瘤全切17例(58.6%),不全切除12例(41.4%)。手术经中颅底硬膜外入路16例,肿瘤平均径为41.4cm,全切15例,次全切除1例。次全切除者术后辅以伽玛刀治疗,已失访,其余15例(93.8%)患者平均随访11.3年,其中视力较术前改善6例(40.0%),与术前相似5例(33.3%),较术前下降4例(26.7%)。眼球活动改善7例(46.7%),相似2例(13.3%),加重6例(40.0%)。面部麻木改善9例(60%),相似2例(13.3%),加重4例(26.7%)。影像学随访无残留或复发。
前期组经硬膜下入路手术13例,肿瘤平均径为45.8cm,其中肿瘤全切2例,次全切除5例,部分切除6例。部分切除者中,1例并发脑梗塞于术后第11天死亡,1例采用伽玛刀放疗。术后失访2例,术后两年非疾病相关死亡1例,均为肿瘤部分切除者。其余9例(88.9%)患者平均随访10.7年,其中视力较手术前改善2例(22.2%),与术前相似4例(44.4%),较术前下降3例(33.3%)；眼球活动改善1例(11.1%),相似2例(22.2%),加重6例(66.7%)；面部麻木与手术前相似6例(66.7%),加重3例(33.3%)。术后MRI随访,2例(22.2%)全切者无复发,3例残余肿瘤无明显改变,4例残余肿瘤较手术后增大。
后期组46例,24例首选手术,均采用中颅底硬膜外入路,肿瘤平均径为38.7cm。其中肿瘤全切19例,次全切除2例,部分切除3例,1例部分切除患者术后行常规放疗。术后失访2例,包括全切患者及部分切除患者各1例。其余22例(91.7%)平均随访4.2年,其中视力较手术前改善4例(18.2%),相似18例(81.8%)；眼球活动改善7例(31.8%),相似8例(36.4%),加重7例(31.8%)；面部麻木改善4例(18.2%),相似16例(72.7%),加重2例(9.1%)。术后采用MRI随访,18例全切者无复发,2例残瘤较术后缩小,1例无明显改变,1例复发。
后期组22例首选放射外科治疗,其中伽玛刀治疗6例,射波刀分次放疗16例,肿瘤平均径为25.9cm。伽玛刀治疗平均周边剂量13.3Gy,等剂量曲线50%。平均随访4.5年,无失访。其中视力较手术前改善2例(33.3%),相似2例(33.3%),加重2例(33.3%)。眼球活动较手术前改善2例(33.3%),相似4例(66.7%)。面部麻木较手术前改善3例(50.0%),相似3例(50.0%)。影像学随访全部部分缓解。射波刀分三次放疗,每次7Gy(共21Gy),等剂量曲线66%。平均随访1.3年,无失访。其中视力较术前改善10例(62.5%),相似6例(37.5%)。眼球活动较术前改善11例(68.8%),相似5例(31.2%)。面部麻木较术前改善12例(75.0%),相似4例(25.0%)。采用MRI随访,14例部分缓解,2例无明显改变。
结论：手术切除是治疗海绵窦海绵状血管瘤有效方法,中颅底硬膜外入路在肿瘤全切率和神经功能保护方面均优于硬膜下入路。对较小的海绵窦海绵状血管瘤,放射外科可以有效地控制肿瘤生长,术后的神经功能恢复亦优于手术。对较大的病灶,分次射波刀治疗近期效果良好,远期效果尚有待观察。
BACKGROUND AND PURPOSE:Surgical management of cavernous sinus hemangiomas (CSHs) is extremely challenging because of the low rates of total removal and the high rates of neurological morbidity after surgery. However, fractionated radiotherapy is currently being considered for the primary management of patients with CSHs, thus, a relatively clear diagnosis may be the most important aspect of therapeutic modification for this condition.
METHODS:This cohort study included133histologically proven space-occupying lesions in the cavernous sinus of133patients of age ranging from3-80years, in the past three years. The lesions were detected using clinical symptoms, computerized tomography and magnetic resonance imaging (MRI). Using univariate and multivariate analyses the diagnostic values of several MRI features were compared.
RESULTS:The sensitivity of the parameters is near or higher than90%in univariate analysis, however the specificity is not ideal. In multivariate analysis, the best model for predicting CSHs is a combination of shape, the sellar invasion and the signal on T2WI. These parameters generated the most accurate diagnosis of CSHs, with sensitivity, specificity and accuracy87.5%,94.7%and96.3%respectively.
CONCLUSION:The MRI characteristics including super-hyperintensity lesion on T2WI with a dumbbell-like or acutilingual appearance infiltration from the parasellar to the sellar regions with marked homogeneous or trend-homogeneous enhancement provides great confidence in diagnosing cavernous sinus hemangiomas.
PURPOSE:To evaluate the possible treatment strategies of CSHs focusing on the better surgical results and post treatment life quality.
Methods:A retrospective study of all patients admitted to Huashan Hospital with CSHs diagnosed by pathology or imaging from Jan.1996to Jun.2010.75patients were enrolled, Patients were divided into two groups:the earlier and later groups. x2test were used by SPSS16.0statistics software to analyze the prognosis of CSHs.
Results:There were22men and53women. Their mean age was51.0years (range,11-74yrs). Of these patients,35presented with headache or retroorbital pain,15with facial numbness,18with blepharoptosis,18with diplopia, six with abnormal menstruation.
In the earlier group,29patients received open surgery as primary therapy. Total tumor removal was achieved in17cases and additional gamma knife radiosurgery (GKR) was performed in2cases. During a meanly11.0years' follow-up (from8.0to14.0years,(24/27)88.9%cases followed), tumor recurrence occurred in4(14.3%) patients who had partial or subtotal tumor removal and did not receive any kind of radiotherapy. Patients treated with an extra-dural transcavernous approach had more extent of tumor removal and better neurological rehabilitation than those with intra-dural approach.
In the latter group, tumor removal via the extra-dural approach was performed in24cases as primary therapy, while direct radiosurgery, GKR or fractionated Cyberknife radiosurgery (CKR), was used in the remaining22cases. In the operated cases, total tumor removal was achieved in19cases (79.2%), subtotal in2cases and partial in3. Adjuvant GKR or CKR for tumor remnant was applied in1case. In all the primarily radiosurgically treated patients, direct GKR was performed in6cases and CKR in16cases. GKR with a mean dose of13.3Gy (from10to16Gy) applied to the50%isodose line was administrated. CKR was delivered in three sessions and a cumulative average marginal dose of21.0Gy.
In the latter group, patients were meanly followed up for3.5years (from1.0to7.0years,22/24,91.6%cases followed). During the follow-up, enlargement of the tumor remnant occurred in1cases (4.5%), one underwent a second operation while the other received GKR. In the primarily GKR or CKR treated patients, the tumor volume shrinked over50%in20cases and there was no enlargement during the follow-up. Preoperative symptom disappeared or relieved in all of the patients and there was no additional neurological dysfunction except for2who developed hypopsia.
CONCLUSION:Our experience has reinforced the attitude that the epidural approach is superior to the intradural approach in ways of tumor removal and neurovascular protection. Direct radiosurgery can be more often used as first choice to treat the CSHs. Fractioned Cyber knife therapy has shown its potential to treat CSHs of large volume. Surgical resection via epidural transcavernous approach with adjuvant radiosurgery for the remnant is optimal for patients with extremely large CSHs.
方法：回顾性分析2006年1月-2009年12月133例海绵窦病变的影像学特征。根据病理结果分为CSHs组(24例)和非CSHs组(109例),后者又分为脑膜瘤(33例)、神经鞘瘤(37例)和其他(39例)三类。针对12项影像学特征,分别进行单因素卡方分析,p<0.01被认为有统计学意义。
结果：T2加权的超高信号,信号均一,哑铃样外形和鞍区浸润在鉴别CSHs和非CSHs时被认为具有统计学意义。当四者同时作为CSHs的诊断标准时,敏感度为87.5%,特异度96.3,精确度为94.7%。
结论：MR-T2加权见海绵窦内均匀的超高信号病灶,呈哑铃样或者尖嘴样浸润鞍区,注射造影剂后均匀强化,则海绵窦海绵状血管瘤的可能性极大,较小者可据此直接行放射外科治疗而不必取病理活检。
目的：探讨海绵窦海绵状血管瘤合理治疗方案
方法：回顾性分析1996年1月至2010年6月复旦大学附属华山医院收治的所有75例海绵窦海绵状血管瘤的诊疗经过。病例分为前期组(1996年1月至2002年12月,29例)和后期组(2003年1月至2010年6月,46例),前期组以手术治疗为主,后期组24例患者首选手术,22例首选放射治疗。收集所有患者症状、体征、肿瘤大小和范围、治疗经过等资料,并进行临床和影像学随访,对结果采用SPSS16.0软件进行统计分析。
结果：男性22例,女性53例,发病年龄11-74岁,平均51.0岁。首发症状包括头痛头胀35例,面部麻木15例,眼睑下垂18例,复视18例,停经6例。术后随访68例(90.7%),随访时间0.5～14年,平均6.0年。
前期组29例,其中28例首选手术治疗,1例伽玛刀治疗3个月后手术。肿瘤全切17例(58.6%),不全切除12例(41.4%)。手术经中颅底硬膜外入路16例,肿瘤平均径为41.4cm,全切15例,次全切除1例。次全切除者术后辅以伽玛刀治疗,已失访,其余15例(93.8%)患者平均随访11.3年,其中视力较术前改善6例(40.0%),与术前相似5例(33.3%),较术前下降4例(26.7%)。眼球活动改善7例(46.7%),相似2例(13.3%),加重6例(40.0%)。面部麻木改善9例(60%),相似2例(13.3%),加重4例(26.7%)。影像学随访无残留或复发。
前期组经硬膜下入路手术13例,肿瘤平均径为45.8cm,其中肿瘤全切2例,次全切除5例,部分切除6例。部分切除者中,1例并发脑梗塞于术后第11天死亡,1例采用伽玛刀放疗。术后失访2例,术后两年非疾病相关死亡1例,均为肿瘤部分切除者。其余9例(88.9%)患者平均随访10.7年,其中视力较手术前改善2例(22.2%),与术前相似4例(44.4%),较术前下降3例(33.3%)；眼球活动改善1例(11.1%),相似2例(22.2%),加重6例(66.7%)；面部麻木与手术前相似6例(66.7%),加重3例(33.3%)。术后MRI随访,2例(22.2%)全切者无复发,3例残余肿瘤无明显改变,4例残余肿瘤较手术后增大。
后期组46例,24例首选手术,均采用中颅底硬膜外入路,肿瘤平均径为38.7cm。其中肿瘤全切19例,次全切除2例,部分切除3例,1例部分切除患者术后行常规放疗。术后失访2例,包括全切患者及部分切除患者各1例。其余22例(91.7%)平均随访4.2年,其中视力较手术前改善4例(18.2%),相似18例(81.8%)；眼球活动改善7例(31.8%),相似8例(36.4%),加重7例(31.8%)；面部麻木改善4例(18.2%),相似16例(72.7%),加重2例(9.1%)。术后采用MRI随访,18例全切者无复发,2例残瘤较术后缩小,1例无明显改变,1例复发。
后期组22例首选放射外科治疗,其中伽玛刀治疗6例,射波刀分次放疗16例,肿瘤平均径为25.9cm。伽玛刀治疗平均周边剂量13.3Gy,等剂量曲线50%。平均随访4.5年,无失访。其中视力较手术前改善2例(33.3%),相似2例(33.3%),加重2例(33.3%)。眼球活动较手术前改善2例(33.3%),相似4例(66.7%)。面部麻木较手术前改善3例(50.0%),相似3例(50.0%)。影像学随访全部部分缓解。射波刀分三次放疗,每次7Gy(共21Gy),等剂量曲线66%。平均随访1.3年,无失访。其中视力较术前改善10例(62.5%),相似6例(37.5%)。眼球活动较术前改善11例(68.8%),相似5例(31.2%)。面部麻木较术前改善12例(75.0%),相似4例(25.0%)。采用MRI随访,14例部分缓解,2例无明显改变。
结论：手术切除是治疗海绵窦海绵状血管瘤有效方法,中颅底硬膜外入路在肿瘤全切率和神经功能保护方面均优于硬膜下入路。对较小的海绵窦海绵状血管瘤,放射外科可以有效地控制肿瘤生长,术后的神经功能恢复亦优于手术。对较大的病灶,分次射波刀治疗近期效果良好,远期效果尚有待观察。
BACKGROUND AND PURPOSE:Surgical management of cavernous sinus hemangiomas (CSHs) is extremely challenging because of the low rates of total removal and the high rates of neurological morbidity after surgery. However, fractionated radiotherapy is currently being considered for the primary management of patients with CSHs, thus, a relatively clear diagnosis may be the most important aspect of therapeutic modification for this condition.
METHODS:This cohort study included133histologically proven space-occupying lesions in the cavernous sinus of133patients of age ranging from3-80years, in the past three years. The lesions were detected using clinical symptoms, computerized tomography and magnetic resonance imaging (MRI). Using univariate and multivariate analyses the diagnostic values of several MRI features were compared.
RESULTS:The sensitivity of the parameters is near or higher than90%in univariate analysis, however the specificity is not ideal. In multivariate analysis, the best model for predicting CSHs is a combination of shape, the sellar invasion and the signal on T2WI. These parameters generated the most accurate diagnosis of CSHs, with sensitivity, specificity and accuracy87.5%,94.7%and96.3%respectively.
CONCLUSION:The MRI characteristics including super-hyperintensity lesion on T2WI with a dumbbell-like or acutilingual appearance infiltration from the parasellar to the sellar regions with marked homogeneous or trend-homogeneous enhancement provides great confidence in diagnosing cavernous sinus hemangiomas.
PURPOSE:To evaluate the possible treatment strategies of CSHs focusing on the better surgical results and post treatment life quality.
Methods:A retrospective study of all patients admitted to Huashan Hospital with CSHs diagnosed by pathology or imaging from Jan.1996to Jun.2010.75patients were enrolled, Patients were divided into two groups:the earlier and later groups. x2test were used by SPSS16.0statistics software to analyze the prognosis of CSHs.
Results:There were22men and53women. Their mean age was51.0years (range,11-74yrs). Of these patients,35presented with headache or retroorbital pain,15with facial numbness,18with blepharoptosis,18with diplopia, six with abnormal menstruation.
In the earlier group,29patients received open surgery as primary therapy. Total tumor removal was achieved in17cases and additional gamma knife radiosurgery (GKR) was performed in2cases. During a meanly11.0years' follow-up (from8.0to14.0years,(24/27)88.9%cases followed), tumor recurrence occurred in4(14.3%) patients who had partial or subtotal tumor removal and did not receive any kind of radiotherapy. Patients treated with an extra-dural transcavernous approach had more extent of tumor removal and better neurological rehabilitation than those with intra-dural approach.
In the latter group, tumor removal via the extra-dural approach was performed in24cases as primary therapy, while direct radiosurgery, GKR or fractionated Cyberknife radiosurgery (CKR), was used in the remaining22cases. In the operated cases, total tumor removal was achieved in19cases (79.2%), subtotal in2cases and partial in3. Adjuvant GKR or CKR for tumor remnant was applied in1case. In all the primarily radiosurgically treated patients, direct GKR was performed in6cases and CKR in16cases. GKR with a mean dose of13.3Gy (from10to16Gy) applied to the50%isodose line was administrated. CKR was delivered in three sessions and a cumulative average marginal dose of21.0Gy.
In the latter group, patients were meanly followed up for3.5years (from1.0to7.0years,22/24,91.6%cases followed). During the follow-up, enlargement of the tumor remnant occurred in1cases (4.5%), one underwent a second operation while the other received GKR. In the primarily GKR or CKR treated patients, the tumor volume shrinked over50%in20cases and there was no enlargement during the follow-up. Preoperative symptom disappeared or relieved in all of the patients and there was no additional neurological dysfunction except for2who developed hypopsia.
CONCLUSION:Our experience has reinforced the attitude that the epidural approach is superior to the intradural approach in ways of tumor removal and neurovascular protection. Direct radiosurgery can be more often used as first choice to treat the CSHs. Fractioned Cyber knife therapy has shown its potential to treat CSHs of large volume. Surgical resection via epidural transcavernous approach with adjuvant radiosurgery for the remnant is optimal for patients with extremely large CSHs.
引文
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