Sarkar Sauradeep, Rajaratnam Simon, Chacko Geeta, Mani Sunithi, Hesargatta Asha S, Chacko Ari George
Sections of Neurosurgery Department of Neurological Sciences, Christian Medical College, Vellore, India.
Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, India.
Acta Neurochir (Wien). 2016 Jan;158(1):77-86; discussion 86. doi: 10.1007/s00701-015-2638-7. Epub 2015 Nov 17.
This study was performed to examine patient outcomes following pure endoscopic transsphenoidal surgery (ETS) for Cushing's disease (CD).
We studied 64 consecutive patients who underwent 69 endoscopic transsphenoidal procedures. Radiological evaluation comprised detailed examination of preoperative magnetic resonance images (MRI), including positron emission tomography (PET) for select cases. Inferior petrosal sinus sampling (IPSS) was not performed for any patient. Remission was defined by the presence of hypocortisolemia with requirement for steroid replacement therapy or eucortisolemia with suppression to <1.8 μg/dl after 1 mg dexamethasone on evaluation at least 3 months after surgery.
Preoperative MRI was abnormal in 87.5 % of cases and included 11 macroadenomas (17.2 %). PET was used to localize the adenoma in four cases. For microadenomas, operative procedures executed were as follows: selective adenomectomy (n = 15), enlarged adenomectomy (n = 21) and subtotal/hemihypophysectomy (n = 17). Overall, pathological confirmation of an adenoma was possible in 58 patients (90.6 %). Forty-nine patients (76.6 %) developed hypocortisolemia (<5 μg/dl) in the early postoperative period. Mean follow-up was 20 months (range 6-18 months). Remission was confirmed in 79.7 % of the 59 cases followed up for >3 months and was superior for microadenomas (86.4 %) versus macroadenomas (55.6 %) and equivocal MRI adenomas (66.7 %). Postoperative CSF rhinorrhea occurred in five patients, and new endocrine deficits were noted in 17.1 % patients. A nadir postoperative cortisol <2 μg/dl in the 1st week after surgery was highly predictive of remission (p = 0.001).
ETS allows for enhanced intrasellar identification of adenomatous tissue, providing remission rates that are comparable to traditional microsurgery for CD. The best predictor of remission remains induction of profound hypocortisolemia in the early postoperative period.
本研究旨在探讨库欣病（CD）患者接受单纯内镜经蝶窦手术（ETS）后的治疗效果。
我们研究了连续64例接受69次内镜经蝶窦手术的患者。影像学评估包括对术前磁共振成像（MRI）进行详细检查，部分病例还包括正电子发射断层扫描（PET）。所有患者均未进行岩下窦取样（IPSS）。缓解的定义为术后至少3个月评估时出现皮质醇减少症且需要类固醇替代治疗，或皮质醇正常且1毫克地塞米松后皮质醇抑制至<1.8μg/dl。
87.5%的病例术前MRI异常，其中包括11例大腺瘤（17.2%）。4例患者使用PET定位腺瘤。对于微腺瘤，实施的手术操作如下：选择性腺瘤切除术（n = 15）、扩大腺瘤切除术（n = 21）和次全/半垂体切除术（n = 17）。总体而言，58例患者（90.6%）能够进行腺瘤的病理确诊。49例患者（76.6%）术后早期出现皮质醇减少症（<5μg/dl）。平均随访时间为20个月（范围6 - 18个月）。在随访超过3个月的59例患者中，79.7%确认缓解，微腺瘤的缓解率（86.4%）高于大腺瘤（55.6%）和MRI表现不明确的腺瘤（66.7%）。5例患者术后出现脑脊液鼻漏，17.1%的患者出现新的内分泌功能减退。术后第1周皮质醇最低点<2μg/dl高度预测缓解（p = 0.001）。
ETS能够增强鞍内腺瘤组织的识别，其缓解率与CD的传统显微手术相当。缓解的最佳预测指标仍然是术后早期出现严重的皮质醇减少症。
