Department of Neurosurgery, Monash Health, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.
Department of Neurosurgery, St Vincent's Health, Melbourne, VIC, Australia.
Neurosurg Rev. 2022 Feb;45(1):843-853. doi: 10.1007/s10143-021-01617-y. Epub 2021 Aug 9.
Surgery for pituitary adenoma is indicated for relief of mass effect and control of endocrinopathy. Setting benchmarks for visual and hormonal outcomes is important for monitoring performance of surgical centres, while understanding the preoperative factors that predict endocrine cure and visual improvement facilitates tailored counselling for patients prior to surgery. A prospective, consecutive cohort of surgically managed (endoscopic transsphenoidal) pituitary adenoma (n = 304) were analysed. Preoperative and postoperative endocrine and visual field assessments were performed and compared to demographic, imaging and pathological data. Larger adenomas tended to have preoperative endocrine deficiency (p < 0.001) and visual field defects (p < 0.001). The largest tumours did not experience normalisation of their endocrinopathy or visual fields with surgery. Of the adenomas with normal preoperative endocrine function, 92.0% (126/137) maintained this postoperatively; only 2 of the 11 patients with new hypopituitarism required long-term hormone replacement. Functional tumour cure was achieved in 65.2% (86/116) after surgery; 74.4% (32/43) of acromegalics and 70.0 (35/50) of Cushing's disease patients achieved hormonal control. All patients with isolated hyperprolactinaemia from stalk effect normalised with surgery, while only 15.9% (7/44) with hypopituitarism recovered normal endocrine function. New hypopituitarism was predicted by younger age and functional adenoma, particularly Cushing's disease. Resolution of endocrinopathy was less likely with reoperative cases and those with cavernous sinus invasion (Knosp grade > 2) or preoperative ophthalmoplegia. One-third of the cohort (102/304, 33.6%) had a preoperative field cut, most commonly an incomplete (51.0%) or complete (31.4%) bitemporal hemianopsia. Only two patients (2/304, 0.7%) had visual field worsening after surgery, while 71.6% (73/102) experienced partial or complete resolution of their field cut after surgery. Complete resolution of visual field defect was predicted by younger age and incomplete bitemporal hemianopsia. Surgery is a safe and effective therapy for pituitary adenomas. Nearly all patients experience improvement in visual fields, especially the young and those with incomplete bitemporal defects. Reoperative cases and those with cavernous sinus involvement (high Knosp grade/ophthalmoplegia) are less likely to have resolution of endocrinopathy. Visual worsening, new ophthalmoplegia or endocrinopathy were rare complications of surgery.
手术治疗垂体腺瘤的目的是缓解占位效应和控制内分泌紊乱。为了监测手术中心的表现，设定视觉和激素结果的基准很重要，而了解预测内分泌治愈和视觉改善的术前因素则有助于在手术前为患者提供个性化咨询。对 304 例接受内镜经蝶窦手术治疗的垂体腺瘤患者进行了前瞻性、连续队列研究。对术前和术后的内分泌和视野评估与人口统计学、影像学和病理学数据进行了比较。较大的腺瘤往往存在术前内分泌功能减退（p<0.001）和视野缺损（p<0.001）。最大的肿瘤在手术后并没有恢复正常的内分泌功能或视野。在术前内分泌功能正常的腺瘤中，92.0%（126/137）术后保持正常；仅有 11 例新发垂体功能减退的患者需要长期激素替代治疗。手术后功能性肿瘤治愈率为 65.2%（86/116）；74.4%（32/43）的肢端肥大症患者和 70.0%（35/50）的库欣病患者实现了激素控制。所有因 stalk 效应导致孤立性高催乳素血症的患者经手术均可恢复正常，而仅有 15.9%（7/44）的垂体功能减退患者恢复了正常的内分泌功能。新的垂体功能减退与年龄较小和功能性腺瘤有关，尤其是库欣病。对于复发性病例和海绵窦侵袭（Knosp 分级>2）或术前眼肌麻痹的患者，内分泌功能的恢复不太可能。该队列的三分之一（102/304，33.6%）术前存在视野缺损，最常见的是不完全（51.0%）或完全（31.4%）双颞侧偏盲。术后仅有 2 例（2/304，0.7%）出现视野恶化，而术后 71.6%（73/102）的患者视野缺损部分或完全缓解。年轻和不完全性双颞侧偏盲的患者更有可能完全缓解视野缺损。手术是治疗垂体腺瘤的一种安全有效的方法。几乎所有患者的视野均得到改善，尤其是年轻患者和存在不完全性双颞侧视野缺损的患者。复发性病例和存在海绵窦受累（高 Knosp 分级/眼肌麻痹）的患者内分泌功能恢复的可能性较小。手术的罕见并发症包括视觉恶化、新发眼肌麻痹或内分泌功能减退。
