Watson J C, Shawker T H, Nieman L K, DeVroom H L, Doppman J L, Oldfield E H
Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland 20892-1414, USA.
J Neurosurg. 1998 Dec;89(6):927-32. doi: 10.3171/jns.1998.89.6.0927.
Pituitary surgery has been reported to produce remission of Cushing's disease with preservation of pituitary function in only 60 to 70% of patients. The inability to identify an adenoma accounts for most failed sellar explorations. Most negative surgical explorations occur in patients in whom magnetic resonance (MR) imaging of the pituitary demonstrates normal findings, which happens in at least 35 to 45% of patients with Cushing's disease.
To examine the usefulness of intraoperative ultrasonography (IOUS) for identifying an adenoma in patients with no demonstrable tumor (negative findings) on pituitary MR imaging. we prospectively assessed the results of IOUS in 68 patients with a negative (59 patients) or equivocal (nine patients) MR image from a consecutive series of 107 patients with Cushing's disease (64%). We compared surgical findings and outcomes in these 68 patients with a group of 68 patients with Cushing's disease and negative findings on MR imaging in whom IOUS was not available. Intraoperative ultrasonography localized a tumor in 47 (69%) of 68 patients with negative findings on MR imaging. Surprisingly, the size of the adenomas that were detected with IOUS compared with the size of those not detected did not differ (6.8+/-3.4 mm compared with 6.1+/-2.8 mm [mean+/-standard deviation], respectively [p=0.51). In four patients, no adenoma was found at surgery or in the pathological specimen ("true negative"). In eight patients, nine abnormalities detected by IOUS that were suspected adenomas were negative on exploration ("false positive"). Thus, IOUS has a sensitivity of 73% and a positive predictive value of 84% for detecting pituitary adenomas in patients with Cushing's disease and negative findings on MR imaging. Compared with the 68 patients who did not undergo IOUS. remission after surgery was improved (61 patients [90%] compared with 57 patients [84%]), the number of tumors found on exploration was increased (61 tumors compared with 51 tumors, p=0.02), and the number of hemihypophysectomies was decreased (five compared with 15; p=0.02) with IOUS. When the groups were compared after excluding patients with prior pituitary surgery, tumors were found in 91% versus 72% (p=0.008), and remission occurred in 95% versus 87% of patients, respectively, in the groups that had or did not have IOUS.
The IOUS is a sensitive imaging modality when used in patients with Cushing's disease in whom findings on pituitary MR imaging are negative. The improved ability to detect and localize these tumors by using IOUS positively affects surgical outcome.
据报道，垂体手术可使库欣病缓解，且仅60%至70%的患者垂体功能得以保留。无法识别腺瘤是大多数蝶鞍探查失败的原因。大多数手术探查阴性发生在垂体磁共振（MR）成像显示正常结果的患者中，这种情况在至少35%至45%的库欣病患者中出现。
为了研究术中超声检查（IOUS）在垂体MR成像未显示肿瘤（阴性结果）的患者中识别腺瘤的效用，我们前瞻性评估了连续107例库欣病患者（占64%）中68例MR图像为阴性（59例）或不明确（9例）患者的IOUS结果。我们将这68例患者的手术结果与另一组68例库欣病且MR成像为阴性但未进行IOUS检查的患者进行比较。术中超声检查在68例MR成像为阴性的患者中定位出47例（69%）肿瘤。令人惊讶的是，经IOUS检测出的腺瘤大小与未检测出的腺瘤大小并无差异（分别为6.8±3.4毫米和6.1±2.8毫米[平均值±标准差]，p = 0.51）。4例患者在手术或病理标本中未发现腺瘤（“真阴性”）。8例患者中，IOUS检测出的9处疑似腺瘤异常在探查时为阴性（“假阳性”）。因此，IOUS在库欣病且MR成像为阴性的患者中检测垂体腺瘤的敏感性为73%，阳性预测值为84%。与未进行IOUS检查的68例患者相比，IOUS组术后缓解情况有所改善（61例[90%]对比57例[84%]），探查发现的肿瘤数量增加（61个对比51个，p = 0.02），半垂体切除术的数量减少（5例对比15例；p = 0.02）。在排除既往有垂体手术史的患者后比较两组，有IOUS组和无IOUS组分别有91%和72%的患者发现肿瘤（p = 0.008），缓解率分别为95%和87%。
当用于垂体MR成像结果为阴性的库欣病患者时，IOUS是一种敏感的成像方式。通过使用IOUS提高检测和定位这些肿瘤的能力对手术结果有积极影响。
