颅咽管瘤手术中关于垂体柄合理处理的临床研究

发布时间：2018-06-20 09:10

本文选题：颅咽管瘤 + 垂体柄　；参考：《中南大学》2014年博士论文

【摘要】：目的：本文拟通过回顾性分析203例接受颅咽管瘤手术患者的资料,同时通过长期的随访,观察垂体柄保留和切除的患者复发率和内分泌功能上的差异,探讨术中对垂体柄切除和保留的标准,总结颅咽管瘤手术中对垂体柄的处理原则。方法：我们回顾性分析了过去20年由同一教授连续主刀完成的203例颅咽管瘤患者,对患者的肿瘤起源进行了记录,对术中垂体柄的保留与切除情况进行了记录。其中,从2010年开始,将术中认为被肿瘤侵犯的垂体柄进行电镜检测,观察是否存在肿瘤细胞。同时对患者进行了长期随访,记录肿瘤是否复发,术后患者内分泌情况、视力视野情况以及患者生存质量情况。对垂体柄切除和保留的患者进行复发率和内分泌功能的比较。结果： 203例颅咽管瘤患者,175人获得全切除(175/203,86.2%),2828人获得次全切除(28/203,13.8%).在所有203例病人中,25例病人失访,不纳入分析,四例围手术期死亡病人(4/203,1.97%),其余174名患者接受随访。全切除组的157名患者复发14名(14/157,8.9%),次全切除组的21名患者肿瘤再生长7名(7/21,33.3%),两者在肿瘤进展上有显著性差异。本组患者5年PFS为84.2%。203例患者中,165例起源于垂体柄,36例起源于鞍内,2例异位起源。垂体柄保留的患者34例(34/203,16.7%)。选取全切的且接受随访的157例患者进行分析,垂体柄保留的患者复发率(4/34,11.8%)与垂体柄切除(10/123,8.1%)的患者复发率无差异。考虑到起源的影响,选取这157例患者中起源于垂体柄的128例患者进行研究,垂体柄保留的患者复发率(1/19,5.3%)与垂体柄切除(6/109,5.5%)的患者复发率同样无差异。在有内分泌资料的91人中,垂体柄保留组的内分泌功能正常、较好、较差的人数分别是(5,18,0),而垂体柄切除组的内分泌功能正常、较好、较差的人数分别是(1,60,7),有统计学差异。在尿崩发生率上,垂体柄保留组的发生率为(5/31,16.1%),垂体柄切除组的发生率为(44/118,37.3%),两者有差异性。术中切除的垂体柄15例,进行电镜超微观察,15例均发现肿瘤细胞和垂体柄特有结构。结论： 1.行手术全切除肿瘤是治疗颅咽管瘤的有效手段。 2.颅咽管瘤手术应尽可能全切除肿瘤,获得全切除的患者生存时间长于未全切除患者,且肿瘤进展风险小于未全切患者,再次手术的患者肿瘤复发进展的风险高于原发肿瘤的患者。 3.颅咽管瘤手术中对于垂体柄的处理应遵循一定的标准,本文提出的基本标准有效,但仍需更多验证。 4.对于起源于垂体柄的颅咽管瘤,严格把握垂体柄切除的标准,保留没有被肿瘤侵犯的垂体柄并不增加患者复发的风险,且对于患者垂体前叶的功能保留和术后的内分泌功能有重要的意义。
[Abstract]:Objective: to retrospectively analyze the data of 203 patients undergoing craniopharyngioma surgery, and to observe the difference of recurrence rate and endocrine function in patients with pituitary stalk preservation and resection through long-term follow-up. To discuss the standard of resection and preservation of pituitary stalk during operation, and summarize the principle of management of pituitary stalk in craniopharyngioma. Methods: we retrospectively analyzed 203 patients with craniopharyngioma who had been performed by the same professor for the past 20 years. The origin of the tumor was recorded and the preservation and excision of the pituitary stalk during the operation were recorded. From 2010 onwards, the pituitary stalk which was believed to have been invaded by tumor was examined by electron microscope to observe whether there were tumor cells. At the same time, the patients were followed up for a long time to record the recurrence, endocrine status, visual field and quality of life. The recurrence rate and endocrine function of patients with pituitary stalk resection and preservation were compared. Results: of the 203 patients with craniopharyngioma, 175 received total resection. Out of 203 cases, 25 cases were not included in the analysis. Four patients died during perioperative period and 4 / 203 / 1.97%. The remaining 174 patients were followed up. There was a significant difference in tumor progression between 157 patients in the total resection group and 21 patients in the subtotal resection group. There was a significant difference in tumor progression between 14 / 157 patients (14 / 157 / 8.9) and 7 patients (7 / 21 / 33. 33.3) in the subtotal resection group. In this group, the PFS in 5 years was 84.2% and 203 cases. 165 cases originated from pituitary stalk in 36 cases from 2 cases of heterotopic origin. There were 34 patients with pituitary stalk preservation. According to the analysis of 157 patients who were followed up, the recurrence rate of patients with pituitary stalk preservation was 4 / 34 / 11.8) and the recurrence rate of pituitary stalk resected by 10 / 123 / 8 ~ (1) was not different from that of 10 / 12 / 123 / 8 ~ (1) of pituitary stalk resection. Considering the influence of the origin, 128 of the 157 patients with pituitary stalk were studied. The recurrence rate of the patients with pituitary stalk was 1 / 19 / 5. 3) and that of the patients with pituitary stalk resection was 6 / 10 9 / 5. 5) there was no significant difference in the recurrence rate between the patients with pituitary stalk reservation and those with pituitary stalk resection (10 / 10 9 / 5. 5). In 91 people with endocrine data, the endocrine function of pituitary stalk retention group was normal, better, and the inferior group was 50.180%, while the endocrine function of pituitary stalk resected group was normal, better, and the worse group was 607m (P < 0.05). In the incidence of urinary avalanche, the incidence of pituitary stalk retention group was 5 / 31 / 16.1%, and that of pituitary stalk resection group was 44% 1180.37. 3%, there was a difference between the two groups. 15 cases of pituitary stalk were resected during operation, 15 cases were observed by electron microscope and 15 cases were found to have special structure of tumor cell and pituitary stalk. Conclusion: 1. Total resection of tumors is an effective treatment for craniopharyngioma. 2. In craniopharyngioma surgery, the tumor should be removed as completely as possible. The survival time of the patients with total resection is longer than that of the patients without total resection, and the risk of tumor progression is lower than that of the patients without total resection. The risk of tumor recurrence and progression in patients undergoing reoperation was higher than that in patients with primary tumors. The treatment of pituitary stalk in craniopharyngioma operation should follow certain standard. The basic standard proposed in this paper is effective, but it still needs more verification. 4. In the case of craniopharyngioma originating from the pituitary stalk, the criteria for resection of the pituitary stalk are strictly adhered to, and the preservation of the pituitary stalk that is not invaded by the tumor does not increase the risk of recurrence. It is of great significance for the preservation of anterior pituitary function and the endocrine function after operation.
【学位授予单位】：中南大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R739.41

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