Brain Tumor Center & Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA.
J Neurosurg. 2013 Mar;118(3):613-20. doi: 10.3171/2012.11.JNS112020. Epub 2012 Dec 14.
Endoscopy as a visual aid (endoscope assisted) or as the sole visual method (fully endoscopic) is increasingly used in pituitary adenoma surgery. Authors of this study assessed the value of endoscopic visualization for finding and removing residual adenoma after initial microscopic removal.
Consecutive patients who underwent endoscope-assisted microsurgical removal of pituitary adenoma were included in this study. The utility of the endoscope in finding and removing residual adenoma not visualized by the microscope was noted intraoperatively. After maximal tumor removal under microscopic visualization, surgeries were categorized as to whether additional tumor was removed via endoscopy. Tumor removal and remission rates were also noted. Patients undergoing fully endoscopic tumor removal during this same period were excluded from the study.
Over 3 years, 140 patients (41% women, mean age 50 years) underwent endoscope-assisted adenoma removal of 30 endocrine-active microadenomas and 110 macroadenomas (39 endocrine-active, 71 endocrine-inactive); 16% (23/140) of patients had prior surgery. After initial microscopic removal, endoscopy revealed residual tumor in 40% (56/140) of cases and the additional tumor was removed in 36% (50 cases) of these cases. Endoscopy facilitated additional tumor removal in 54% (36/67) of the adenomas measuring ≥ 2 cm in diameter and in 19% (14/73) of the adenomas smaller than 2 cm in diameter (p < 0.0001); additional tumor removal was achieved in 20% (6/30) of the microadenomas. Residual tumor was typically removed from the suprasellar extension and folds of the collapsed diaphragma sellae or along or within the medial cavernous sinus. Overall, 91% of endocrine-inactive tumors were gross-totally or near-totally removed, and 70% of endocrine-active adenomas had early remission.
After microscope-based tumor removal, endoscopic visualization led to additional adenoma removal in over one-third of patients. The panoramic visualization of the endoscope appears to facilitate more complete tumor removal than is possible with the microscope alone. These findings further emphasize the utility of endoscopic visualization in pituitary adenoma surgery. Longer follow-ups and additional case series are needed to determine if endoscopic adenomectomy translates into higher long-term remission rates.
内镜作为一种视觉辅助手段（内镜辅助）或作为唯一的视觉方法（全内镜），在垂体腺瘤手术中越来越多地被应用。本研究的作者评估了内镜可视化在发现和切除显微镜初次切除后残留腺瘤方面的价值。
本研究纳入了连续接受内镜辅助显微镜下垂体腺瘤切除术的患者。术中记录了内镜在发现和切除显微镜未观察到的残留腺瘤方面的作用。在显微镜下最大程度地切除肿瘤后，根据是否通过内镜切除额外肿瘤对手术进行分类。还记录了肿瘤的切除率和缓解率。在此期间，接受全内镜肿瘤切除术的患者被排除在研究之外。
在 3 年期间，140 例患者（41%为女性，平均年龄 50 岁）接受了内镜辅助腺瘤切除术，其中 30 例为内分泌活性微腺瘤，110 例为大腺瘤（39 例内分泌活性，71 例内分泌无活性）；16%（23/140）的患者曾接受过手术。在初次显微镜切除后，内镜检查发现 40%（56/140）的病例存在残留肿瘤，其中 36%（50 例）的病例切除了额外肿瘤。内镜辅助切除了 54%（36/67）直径≥2cm的腺瘤和 19%（14/73）直径<2cm的腺瘤中的额外肿瘤（p<0.0001）；在 30 例微腺瘤中有 20%（6 例）切除了额外肿瘤。残留肿瘤通常位于鞍上延伸部位、鞍隔塌陷的褶皱处，或沿着或位于海绵窦内侧。总的来说，91%的无内分泌活性肿瘤完全或接近完全切除，70%的内分泌活性腺瘤有早期缓解。
在显微镜下肿瘤切除后，内镜可视化使超过三分之一的患者获得了额外的肿瘤切除。与单独使用显微镜相比，内镜的全景可视化似乎更有利于更完全地切除肿瘤。这些发现进一步强调了内镜可视化在垂体腺瘤手术中的应用价值。需要更长时间的随访和更多的病例系列来确定内镜腺瘤切除术是否能转化为更高的长期缓解率。
