肾上腺占位66例临床研究

发布时间：2018-07-04 12:03

本文选题：内分泌紊乱 + 肾上腺占位　；参考：《山东大学》2017年硕士论文

【摘要】：目的:分析、总结肾上腺占位的临床特点,探讨肾上腺占位的临床诊断和治疗措施,以期提高其诊治水平,改善临床预后。对象和方法:以2006年1月-2015年12月山东大学附属省立医院内分泌科就诊发现的肾上腺占位作为研究对象。纳入标准为以内分泌科为首诊,并最终确定诊断为肾上腺占位的病人。根据纳入标准,共66例患者被纳入该项研究。采用回顾性分析方法,查阅患者的临床病例资料,如其基本资料、临床表现、影像学检查结果、内分泌学检查结果、占位特征等;对患者进行回访调查,并比较手术治疗组与保守治疗组患者预后的差别。结果:1.一般资料:共有66例病例符合筛选标准而纳入本研究,其中男性28例,占42.4%,女性38例,占57.6%,男:女=1:1.36。病例年龄范围22-85岁,平均年龄为47.68± 13.80岁。按治疗方式大致分为两组,手术治疗组20例(30.3%),保守治疗组46例(69.7%)。患者住院时间3-30天(9.09±5.58),住院费用 1799-27294 元(7466.62±5429.85)。2.疾病谱:此研究中,临床诊断为单纯腺瘤者25例,占37.9%;库兴综合征者14例,占21.2%;原发性醛固酮增多症者12例,占18.2%;未明确性质者5例,占7.6%;皮质结节状增生5例,占7.6%;儿茶酚胺增多症(嗜铬细胞瘤)2例,占3.0%;肾上腺皮质癌2例,占3.0%;节细胞神经瘤1例,占1.5%。3.性别差异:患者的临床类型在不同性别间分布不同,库兴综合征中明显女性患者多于男性患者(χ2 =12.54,P=0.006)。且男性更容易发生电解质紊乱,差别有统计学意义(χ2=10.93,P=0.027)。4.各年龄组差异:各年龄组中性别分布有差异,青年、中年组中女性居多,老年组中男性居多,差别有统计学意义(χ2 =6.45,P=0.04)。不同年龄分组间患者的高血压病史差异无统计学意义,说明肾上腺占位患者的高血压病史与年龄无关。5.临床表现:患者临床表现复杂,具有多样化特点。以高血压作为主要临床表现者最常见,共24例,占36.4%。出现电解质紊乱者共29例,占43.9%,其中低钾血症26例,占39.4%,其余为低钠血症、低钙血症。即高血压是最常见的就诊原因,且常伴有低血钾。6.实验室检查:(1)所有病例均进行血游离皮质醇及昼夜节律测定,对库兴综合征患者,其灵敏度(真阳性人数/(真阳性人数+假阴性人数)*100%)为92.86%,特异度(即真阴性人数/(真阴性人数+假阳性人数)*100%)为71.15%。(2)所有病例均进行肾素-血管紧张素-醛固酮测定,对原发性醛固酮增多症患者,其灵敏度为58.33%,特异度为79.63%。(3)所有病例均进行醛固酮/肾素比值测定。对原发性醛固酮增多症患者,其灵敏度为66.67%,特异度为92.59%。(4)共3例病人进行了尿香草苦杏仁酸测定,占总病例数4.55%。3例病人结果均在正常范围内,后分别确诊为库兴综合征、嗜铬细胞瘤、原发性醛固酮增多症。(5)共3例病人进行了血浆及尿儿茶酚胺类物质测定,该项检查对嗜铬细胞瘤患者检出率为50.00%。(6)共14例患者进行了小剂量地塞米松抑制试验,占总病例数21.21%。对库兴综合征患者,其灵敏度100%,特异度66.67%。(7)共12例患者进行了大剂量地塞米松抑制试验,占总病例数18.20%。在所有11例进行此项试验的库兴综合征患者中,此项试验结果均为阳性。(8)共6例病人进行了卡托普利试验,占总病例数9.10%,对原发性醛固酮增多症,其阳性率50%。7.影像学检查:(1)9例患者进行了超声检查,占病例总数13.6%,检查对占位成功诊断率为77.8%。(2)57例患者进行了 CT检查,占病例总数86.4%,对占位的成功诊断率为94.7%。CT显示的占位直径与实际直径差异无统计学意义(Z=-4.32,P=0.67)。(3)8例患者进行了核磁共振成像扫描(MRI),占病例总数12.1%,对占位的成功诊断率为100%。8.占位特点:肾上腺占位位于左侧者39例,占病例总数59.1%,位于右侧者21例(31.8%),位于双侧者6例(9.1%)。占位为单发者59例(89.4%),多发者7例(10.6%)。占位性质大多数为腺瘤,共46例,占总数69.7%,其中经手术病理明确诊断的皮质腺瘤10例,占总病例数15.2%。9.手术情况:20例患者经手术治疗,所行手术类型皆为腹腔镜手术;17例行患侧肾上腺切除术,3例行患侧肾上腺肿瘤切除术。手术时间30-300分钟,手术期间出血量5-500 ml。术后引流时间3-9天(5.70±1.56)。手术组患者住院天数 5-30 天(11.70 ±7.88),住院费用 1799-29274 元(7905.35 ±6594.76)。10.手术组与保守治疗组对比:性别、占位位置、初发症状、临床类型分布等因素在两组间差异均无统计学意义。两组间占位直径差异亦无统计学意义(Z=-1.43,P=0.152)。11.病理结果:患者获明确病理诊断者共20人,占总体比例30.3%,而与临床诊断一致者共19人,占明确诊断者95.0%。仅一例病例行免疫组化检查,结果显示 a-inhibin(+)syn(+)cga(-)s-100(-)ki-67 3%。12.回访结果:本研究纳入的66例患者中成功回访57例,失访率为13.6%。患者经治疗后主要临床表现显著改善者32人,占回访病例总数56.1%,症状略有改善者22人,占回访病例总数38.6%,症状无改善者3例,占回访病例总数5.3%;出院后定期进行内分泌学检查者26例,其中检查结果正常者18例,结果有异常者8例。根据保守治疗组与手术治疗组患者的回访结果分析,手术组患者的主要症状改善状况优于保守治疗组。结论:1.肾上腺占位患者中,以高血压、低血钾为主要表现的患者占最大比例;单纯腺瘤、库兴综合征、原醛、儿茶酚胺增多症均是肾上腺占位重要的表现形式。2.定位诊断的影像学检查当中,CT应用最广,MRI则在诊断的灵敏度上表现突出。3.术后病理结果以肾上腺皮质腺瘤所占比例最大,多分布于单侧,为单发性。4.腹腔镜手术是治疗良性肾上腺肿瘤的主要方法,长期预后优于保守治疗组,但对部分症状不明显或因其他原因不适合手术的患者,保守治疗并长期随访也不失为一种好的方法。
[Abstract]:Objective: to analyze and summarize the clinical characteristics of adrenal space occupying position and to explore the clinical diagnosis and treatment of adrenal space occupying position in order to improve the level of diagnosis and treatment and improve the clinical prognosis. The adrenal occupying sites in Department of Endocrinology, affiliated to the Provincial Hospital Affiliated to Shandong University, January 2006, in December -2015, were studied as the research object. According to the inclusion criteria, a total of 66 patients were included in the study. A retrospective analysis was used to refer to the patient's clinical data, such as basic data, clinical manifestations, imaging findings, endocrinological findings, occupying features, and so on. The difference of prognosis between the surgical treatment group and the conservative treatment group was compared. Results: 1. general data: a total of 66 cases were included in this study, including 28 men, 42.4%, 38 women, 57.6%, male: the age range of female =1:1.36. cases was 22-85 years, the average age was 47.68 + 13.80 years old. According to the method of treatment, the method was roughly the way of treatment. There were two groups, 20 (30.3%) in the operation group and 46 in the conservative treatment group (69.7%). The hospitalization time was 3-30 days (9.09 + 5.58) and the hospitalization cost was 1799-27294 yuan (7466.62 + 5429.85).2. disease spectrum. In this study, the clinical diagnosis was 25 cases of simple adenoma, accounting for 37.9%; %, 5 cases, 7.6%, 5 cases of cortical nodular hyperplasia, 7.6%, 2 cases of catecholamines (pheochromocytoma), 3%, 2 adrenocortical cancer, 3%, and 1 cases of ganglion neuroma, which accounted for 1.5%.3. sex differences: the clinical types of the patients were different from the same sex, and the female patients in the Cushing syndrome were more than the male patients. People (x 2 =12.54, P=0.006). And men were more likely to have electrolyte disorders, the difference was statistically significant (x 2=10.93, P=0.027).4. in all age groups: there were differences in gender distribution in all age groups, young, middle age group, and older group, with statistical significance (x 2 =6.45, P=0.04). Higher levels of patients in different age groups. There was no statistical difference in the history of blood pressure, indicating that the history of hypertension in the adrenal space occupying patients was not related to the age of.5.. The clinical manifestations of the patients were complex and diversified. Hypertension was the most common clinical manifestation, 24 cases, accounting for 29 cases of electrolyte turbulence, accounting for 43.9%, of which 26 cases of hypokalemia, accounting for 39., were 39.. 4%, the rest of hyponatremia and hypocalcemia, which is the most common cause of hypertension, and often accompanied by a low blood potassium.6. laboratory examination: (1) all cases were measured in blood free cortisol and circadian rhythm, and the sensitivity (true positive / (true positive + false negative) *100%) was 92.86% for patients with Cushing syndrome (that is, 92.86%). The true negative number / (true negative number + false positive) *100%) the renin angiotensin aldosterone determination for all cases of 71.15%. (2), the sensitivity of the patients with primary aldosteronism was 58.33%, and the specificity was 79.63%. (3) for all cases of aldosterone / renin ratio determination. For patients with primary aldosteronism, the patients were all cases of aldosteronism. The sensitivity was 66.67% and the specificity was 92.59%. (4). A total of 3 patients were measured in the urine vanilla bitter almond acid. The total number of cases in the total number of cases was in the normal range, and the results were confirmed as Cushing's syndrome, pheochromocytoma, primary aldosteronism. (5) a total of 3 patients were measured in plasma and urine catecholamines. The detection rate of pheochromocytoma was 50.00%. (6) in a total of 14 patients with a small dose of dexamethasone inhibition test. The total number of cases was 21.21%. to Cushing's syndrome. The sensitivity was 100% and the specificity of 66.67%. (7) in 12 patients with a large dose of dexamethasone inhibition test, accounting for the total number of cases of 18.20%. in all 11 cases. In the test, the results of the test were all positive. (8) a total of 6 patients were tested by Kato Pury, accounting for 9.10% of the total cases. The positive rate of the primary aldosteronism was 50%.7. imaging examination: (1) 9 cases were examined by ultrasound, accounting for 13.6% of the total cases, and the examination of the successful rate of 77.8%. (2) in 57 cases. The patients were examined by CT, accounting for 86.4% of the total cases. There was no statistically significant difference between the occupying diameter and the actual diameter (Z=-4.32, P=0.67). (3) 8 patients underwent magnetic resonance imaging (MRI), accounting for 12.1% of the total cases, and the successful diagnosis rate of the occupying position was 100%.8. occupying position: adrenal space occupying position. There were 39 cases in the left side, the total number of cases was 59.1%, 21 cases (31.8%) in the right side, 6 cases (9.1%) in bilateral, 59 cases (89.4%), 7 cases (10.6%), and 7 (10.6%). The majority of the occupying sites were adenoma, altogether 46 cases, accounting for 69.7%, among which the surgical pathology clearly diagnosed the cortical adenoma in 10 cases, accounting for the total cases 15.2%.9. operation situation: 20 cases. The patients underwent laparoscopic surgery, 17 cases with lateral adrenalectomy and 3 cases of side adrenal tumor resection. The operation time was 30-300 minutes. The amount of bleeding was 5-500 ml. after operation for 3-9 days (5.70 + 1.56). The number of patients in the operation group was 5-30 days (11.70 + 7.88) and the hospitalization cost 1799-29274. Compared with the conservative treatment group, there were no significant differences in gender, position, primary symptoms and clinical type distribution between the two groups. There was no significant difference between the two groups in the two groups. The difference between the two groups was also not statistically significant (Z=-1.43, P=0.152).11. pathological results: the patients received a clear pathological diagnosis of 20 people, accounting for a total of 30 .3%, and a total of 19 patients with clinical diagnosis, accounting for only one case of 95.0%., the results showed that A-inhibin (+) syn (+) CGA (-) S-100 (-) Ki-67 3%.12. return visit results: 57 cases were successfully returned in the 66 cases of this study, and the loss rate was 32 in the major clinical manifestations of the patients after the treatment. The total number of cases returned to visit 56.1%, the symptoms slightly improved 22 people, accounting for 38.6% of the return cases, 3 cases without improvement, accounting for 5.3% of the total return visits, 26 cases of regular endocrinology examination after discharge, among which 18 cases were normal, and 8 cases were abnormal. According to the return visits of the conservative treatment group and the surgical treatment group, the results of the return visit were analyzed, The main symptoms of the patients in the operation group were better than those in the conservative treatment group. Conclusion: 1. of the patients with adrenal space occupying the largest proportion of the patients with hypertension and hypokalemia, the simple adenoma, Cushing syndrome, primary aldehyde, and catecholamine are all the imaging findings of the.2. location diagnosis of adrenal occupying weight. CT is the most widely used, and MRI shows the sensitivity of the diagnosis on the sensitivity of.3. with the largest proportion of the adrenocortical adenoma, which is most distributed on the unilateral. The single.4. laparoscopy is the main method for the treatment of benign adrenal tumors. The long-term prognosis is superior to the conservative treatment group, but it is not obvious to some symptoms or not for other reasons. Conservative treatment and long-term follow up are also a good method for patients undergoing surgery.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R736.6;R586

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