Basis of persistent and recurrent Cushing disease: an analysis of findings at repeated pituitary surgery
Basis of persistent and recurrent Cushing disease: an analysis of findings at repeated pituitary surgery
复制标题
DOI：
10.3171/jns.2002.97.6.1343
复制
发表时间：
2002-12-01
影响因子：
4.1
通讯作者：
Oldfield, EH
中科院分区：
文献类型：
--
作者：
Dickerman, RD;Oldfield, EH
目的。本研究的目的是确定隐匿性硬脑膜侵犯（影像学检查中不明显且对外科医生来说不明显的硬脑膜或海绵窦侵犯）作为复发或持续性肿瘤和内分泌病基础的临床重要性。方法。作者回顾性地回顾了接受重复经蝶手术切除产生促肾上腺皮质激素（ACTH）的垂体腺瘤的患者的病例档案。患者选择需要获得初次和重复经蝶手术的手术和病理报告。因为如果在重复手术中无法定位肿瘤，则无法确定持续或复发性疾病的原因，因此还需要确认第二次手术中存在肿瘤的病理报告。68名患者符合这些标准。 43 名患者 (63%) 在初次手术时发现了产生 ACTH 的肿瘤，25 名患者 (37%) 没有发现肿瘤，3 名患者 (4%) 在手术时发现硬脑膜侵犯。 68 名患者中有 49 名 (72%) 的皮质醇增多症和复发性库欣病 (CD) 得到初步缓解，而 19 名患者 (28%) 在初次手术后仍存在持续性 CD。在初次手术时发现肿瘤的所有 43 名患者的重复手术中（初次手术后 44 +/- 35 个月），在同一部位或邻近同一部位发现了肿瘤。外科医生在最初的手术中仅发现 3 名患者出现硬脑膜侵犯，而在 68 名患者中，有 42 名 (62%) 在重复手术中发现了产生 ACTH 的肿瘤侵犯硬脑膜。此外，42 个侵袭性腺瘤中有 39 个（93%）位于侧面并累及海绵窦。在重复手术中，57 个微腺瘤中的 31 个（54%）和所有 11 个大腺瘤中发现腺瘤侵犯硬脑膜。通过磁共振 (MR) 成像研究的 59 名患者中，有 28 名未检测到肿瘤的存在，并且这 59 名患者中没有一位在 MR 图像上未发现明显的硬脑膜浸润。结论。复发性和持续性 CD 始终是由残留肿瘤引起的。在重复手术中，可以在最初发现肿瘤的部位处或紧邻最初发现肿瘤的部位发现残留肿瘤。未意识到的硬脑膜浸润伴海绵窦硬脑膜内残留肿瘤的生长，这种情况经常发生，而在 MR 图像上或手术过程中外科医生没有明显的残留肿瘤或硬脑膜浸润，这是许多 CD 患者手术失败的基础。肿瘤隐匿性的侧向硬脑膜侵犯也可能是其他类型垂体腺瘤复发的原因。
Object. The goal of this study was to establish the clinical importance of occult dural invasion-invasion of the dura mater or cavernous sinus that is not evident on imaging studies and is not obvious to the surgeon-as the basis of recurrent or persistent tumor and endocrinopathy.Methods. The authors retrospectively reviewed the case files of patients who underwent repeated transsphenoidal surgery for resection of an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma. Patient selection required the availability of operative and pathology reports from the initial and repeated transsphenoidal surgeries. Because no determination of the cause of persistent or recurrent disease could be made if the tumor could not be localized during the repeated surgery, a pathology report confirming the presence of tumor from the second surgery was also required.Sixty-eight patients met these criteria. In 43 patients (63%) an ACTH-producing tumor was identified at the initial surgery, in 25 patients (37%) no tumor was found, and in three patients (4%) dural invasion was noted at surgery. In 49 (72%) of the 68 patients there was initial resolution of hypercortisolism and recurrent Cushing disease (CD), whereas in 19 patients (28%) there was persistent CD after the initial surgery. At repeated surgery (44 +/- 35 months after the initial surgery) in all 43 patients in whom tumor had been identified at the initial surgery, the tumor was found at the same site or contiguous to the same site. Dural invasion was noted by the surgeon in only three patients at the original surgery, whereas dural invasion by an ACTH-producing tumor was identified during repeated surgery in 42 (62%) of the 68 patients. In addition, 39 (93%) of the 42 invasive adenomas were located laterally and involved the cavernous sinus. Adenomatous invasion of the dura mater was found in 31 (54%) of the 57 microadenomas and in all 11 macroadenomas at repeated surgery. The presence of tumor was not detected in 28 of the 59 patients studied with magnetic resonance (MR) imaging and in none of these 59 patients was dural invasion evident on MR images.Conclusions. Recurrent and persistent CD consistently results from residual tumor. At repeated surgery the residual tumor can be found at or immediately contiguous to the site at which the tumor was found originally. Unappreciated dural invasion with growth of residual tumor within the cavernous sinus dura, which frequently occurs without residual tumor or dural invasion being evident on MR images or to the surgeon during surgery, is the basis of surgical failure in many patients with CD. Occult lateral dural invasion by tumor may also underlie recurrences of other types of pituitary adenomas.