内镜经鼻入路个体化切除侵袭海绵窦垂体腺瘤

Individual surgical treatment for pituitary adenoma invading cavernous sinus via endoscopic endonasal approach

摘要:

目的 初步探讨侵袭海绵窦垂体腺瘤的内镜手术策略，以提高手术安全性和肿瘤切除率。方法 回顾性分析连续收治的32例侵袭海绵窦垂体腺瘤患者的临床资料，结合患者手术前后影像学特点及术中情况，提出侵袭海绵窦垂体腺瘤的临床分型，并针对不同侵袭类型采取的手术策略及手术要点进行归纳总结。结果 32例患者术前均诊断为侵袭性垂体腺瘤，初发肿瘤21例、复发肿瘤11例，既往有放疗史6例；术前均行头颅MRI平扫+增强、导航序列、头颅三维脑窗+骨窗CT检查。根据肿瘤与颈内动脉(ICA)在海绵窦内走形的相对位置关系，将32例患者分为ICA外上型(10例)、ICA外下型(6例)和ICA外侧型(16例)3种类型。所有患者均行内镜经鼻入路手术治疗，其中全切5例(15.6%)，均为ICA外下型；近全切除23例(71.9%)；大部分切除4例(12.5%)，均为ICA外侧型。术中见肿瘤质软21例、质地中等9例、质韧2例；肿瘤内存在纤维分隔11例。术中发生脑脊液漏10例，术后均未发生脑脊液鼻漏。术后腰大池置管6例，颅内感染2例，无死亡病例。术前19例视力下降、视野缺损患者术后均有不同程度好转，术前1例眼睑下垂患者术后症状消失；术后新增复视及外展麻痹10例，1周至1个月逐渐恢复。结论 ICA外上型、ICA外下型和ICA外侧型是侵袭海绵窦的垂体腺肿瘤常见的3种侵袭类型，针对此3种类型的不同特点，由内而外、循“肿瘤通道”按需切开海绵窦壁及瘤内分隔，沿ICA走形切除肿瘤有利于提高手术安全性和肿瘤切除率。

关键词:鼻内镜;垂体腺瘤;海绵窦;侵袭性

Abstract:

Objective To explore the endoscopic surgical strategies for pituitary adenomas invading cavernous sinus, so as to improve surgical safety and tumor resection rate.Methods Clinical data of 32 cases with pituitary adenomas invading cavernous sinus surgically treated in our hospital were retrospectively analyzed. Based on preoperative and postoperative imaging characteristics and intraoperative findings, the clinical classification of pituitary adenomas invading cavernous sinus was proposed, and the surgical strategies and key points for different invasion types were summarized.Results All the 32 patients were diagnosed with invasive pituitary adenomas preoperatively, including 21 cases of primary tumor, 11 cases of recurrent tumor with a history of radiotherapy in 6. All patients had preoperative examinations including plain and enhanced skull magnetic resonance imaging with navigation sequence, and three-dimensional computed tomography of brain and bone window imagings. According to the relative positional relationship between the tumor and the internal carotid artery (ICA) in the cavernous sinus, all the 32 cases were classified into three types: ICA external superior type (10 cases), ICA external inferior type (6 cases), and ICA external lateral type (16 cases). All patients underwent endoscopic endonasal surgery. Total resection was achieved in 5 cases (15.6%) of the ICA external inferior type., near-total resection was performed in 23 cases (71.9%), and subtotal resection was performed in 4 cases (12.5%) of the ICA external lateral type. Intraoperative findings revealed soft tumor in 21 cases, moderate texture in 9 and tough in 2. Fibrous septa were observed in 11 cases. Intraoperative cerebrospinal fluid leakage occurred in 10 cases and postoperative cerebrospinal fluid leakage occurred in none. After surgery, lumbar drainage was placed in 6 cases, intracranial infection occurred in 2 and no deaths occurred. The visual acuity and visual field in 19 cases with preoperative visual impairment and visual field defects got improved to varying degrees after surgery, and blepharoptosis disappeared in one. Diplopia and abducent nerve paralysis occurred in 10 cases after surgery, but gradually recovered within one week to one month.Conclusions For pituitary adenomas invading the cavernous sinus, the ICA external superior type, ICA external inferior type, and ICA external lateral type are the three common types of invasion. Incision of the cavernous sinus wall and intratumor septum should follow the principles of from inside outside and along the “tumor channel” as needed for improving surgical safety and tumor resection rate.

Key words:Endoscope;Pituitary adenoma;Cavernous sinus;Invasiveness