Dehdashti Amir R, Gentili Fred
Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Ontario, Canada.
Neurosurg Focus. 2007;23(3):E9. doi: 10.3171/foc.2007.23.3.11.
Transsphenoidal pituitary surgery is the primary therapy for Cushing disease because of its potential to produce lasting remission without the need for long-term drug or hormone replacement therapy. The authors evaluated the current role of pure endoscopic endonasal pituitary surgery in the treatment of Cushing disease.
Twenty-five patients underwent pure endoscopic surgery for confirmed Cushing disease. Thirteen patients had microadenomas and seven had macroadenomas; magnetic resonance images obtained in five patients were only suspicious or nondiagnostic, and thus they underwent inferior petrosal sinus sampling. Two patients had evidence of cavernous sinus involvement. Final histological results were consistent with adrenocorticotropin hormone (ACTH)-secreting adenoma in 20 patients.
Twenty patients (80%) had clinical remission and laboratory confirmation of hypocortisolemia (serum cortisol < 100 nmol/L requiring substitution therapy), suppression to low-dose dexamethasone, and normal 24-hour urinary free cortisol. The median follow-up period was 17 months (range 3-32 months). There was no recurrence at the time of the last follow-up. Three patients presented with new anterior pituitary deficiency, but no one had permanent diabetes insipidus. In one patient a cerebrospinal fluid leak developed but later resolved following lumbar drainage. Treatment failure was attributable to involvement of the cavernous sinus in two patients, incomplete tumor removal in one, negative exploration in one, and nodular corticotroph hyperplasia of the pituitary gland in one.
Early results indicated that endoscopic endonasal surgery is a safe and effective treatment for ACTH-producing adenomas. The rate of remission in this study is comparable to those in previous series, and the rate of major postoperative complications is extremely low. Further studies with a larger number of patients and longer follow-ups are required to determine whether this more minimally invasive pure endoscopic approach should become the standard of care for the surgical treatment of Cushing disease.
经蝶窦垂体手术是库欣病的主要治疗方法，因为它有可能实现持久缓解，而无需长期药物或激素替代治疗。作者评估了单纯内镜下经鼻垂体手术在库欣病治疗中的当前作用。
25例确诊为库欣病的患者接受了单纯内镜手术。13例患者为微腺瘤，7例为大腺瘤；5例患者的磁共振成像仅显示可疑或无法确诊，因此他们接受了岩下窦取样。2例患者有海绵窦受累的证据。最终组织学结果显示20例患者符合促肾上腺皮质激素（ACTH）分泌性腺瘤。
20例患者（80%）实现临床缓解，实验室检查证实存在皮质醇减退（血清皮质醇<100 nmol/L，需要替代治疗），对小剂量地塞米松有抑制反应，24小时尿游离皮质醇正常。中位随访期为17个月（范围3 - 32个月）。最后一次随访时无复发。3例患者出现新的垂体前叶功能减退，但无人发生永久性尿崩症。1例患者发生脑脊液漏，但经腰大池引流后后来好转。治疗失败的原因包括2例患者海绵窦受累、1例肿瘤切除不完全、1例探查阴性以及1例垂体结节性促肾上腺皮质激素细胞增生。
早期结果表明，内镜下经鼻手术是治疗ACTH分泌性腺瘤的一种安全有效的方法。本研究中的缓解率与先前系列研究相当，术后主要并发症发生率极低。需要进行更多患者和更长随访时间的进一步研究，以确定这种创伤更小的单纯内镜方法是否应成为库欣病手术治疗的标准方法。
