医学精品课件：垂体瘤.ppt

1、垂体腺瘤垂体腺瘤 Pituitary adenomaAdenom der Hypophyse华中科技大学同济医学院华中科技大学同济医学院附属同济医院神经外科附属同济医院神经外科 陈旭陈旭 Case 1 Patient,female,31y Amenorrhea,galactorrhea and infertility for 5 years P.E:(-)Ultrasound:uterus and appendix(-)Hormone:PRL 134.2 ng/ml Treatment:bromocriptine 2.5mg p.o b.i.dWhats the possible diagno

2、sis?Case 2 Patient,male,34y Sight decreased for 5 months P.E:Vision L 0.2、R 0.3.Double temporal visual field were lost.Eyeground(-).Whats the possible diagnosis?Case 3 Patient,male,61y Sudden heavy headache,with sharply sight decreased for one day P.E:Vision L light perception、R 0.1.Left visual fiel

3、d was lost.Eyeground(-).Head CT:asymmetrical density in saddle area Whats the possible diagnosis?Diagnosis?Diagnosis?诊断思路诊断思路B超（超（-）定位定位子宫子宫卵巢卵巢垂体垂体下丘脑下丘脑Case 1 Case 2 Case 3 定位定位定位定位眼科检查眼科检查眼部眼部头部头部MRIMRI头部头部MRI垂垂体体腺腺瘤瘤 1、Overview 垂体腺瘤垂体腺瘤主要起源垂体前叶垂体前叶(腺垂体腺垂体)，是一种常见的颅内肿瘤。人群发病率一般为1/10万。约占颅内肿瘤的10%，尸检中

4、发现率为2030%，发病率仅次于胶质瘤和脑膜瘤，近年来有增多的趋势。2、Anatomy 位置位置 Location 分部分部 Division 起源起源 Origin 毗邻毗邻 Adjacent垂体瘤起源于腺垂体垂体瘤起源于腺垂体Sphenoidal sinus向上向上 垂体柄垂体柄Pituitary stalkLeft optic n.向下向下 蝶窦蝶窦两侧两侧 海绵窦海绵窦 毗邻：向下-蝶窦 向上-垂体柄、鞍膈、三脑室底、视交叉 两侧-颈内A、海绵窦、颅神经（3,4,5,6）血液供应：颈内动脉分支垂体上A、垂体下A 2、Anatomy PRL GH TSH FSH/LH ACTH ADH

5、Oxytocin 3、Secretion of pituitary 4、Clinical manifestation 一般症状一般症状 General symptom 功能性垂体腺瘤的表现功能性垂体腺瘤的表现 Functional tumor 垂体瘤卒中垂体瘤卒中 Apoplexy 头痛头痛 Headache 视力下降、视野缺失视力下降、视野缺失 Sight descent and field lost 其他神经功能损害其他神经功能损害Damage of cranial nerve or brain tissue 4、Clinical manifestation 一般症状一般症状 Genera

6、l symptom 功能性垂体腺瘤的表现功能性垂体腺瘤的表现 Functional tumor 垂体瘤卒中垂体瘤卒中 ApoplexyDecrease or accentuation of pituitary and target glandPRL腺瘤腺瘤 Female：Amenorrhea(闭经闭经)galactorrhea(溢乳溢乳)infertility(不孕不孕)MaleFeminization(女性化)pool sexual function(性功能差)ACTH腺瘤腺瘤皮质醇增多症（皮质醇增多症（Cushings Disease）buffalo hump(水牛背水牛背)moon-sh

7、aped face(满月脸满月脸)centripetal obesity(向心性肥胖向心性肥胖)purple striae(紫纹紫纹)Decrease or accentuation of pituitary and target glandGH腺瘤腺瘤 Acromegaly(肢端肥大症肢端肥大症)Gigantism(巨人症巨人症)Decrease or accentuation of pituitary and target gland 4、Clinical manifestation 一般症状一般症状 General symptom 功能性垂体腺瘤的表现功能性垂体腺瘤的表现 Functio

8、nal tumor 垂体瘤卒中垂体瘤卒中 Apoplexy Reason:Hemorrhage and necrosis in tumor Clinical:Sudden headache Sight decease sharply Severity -Lethargy and coma 5、Classification1、形态学：微腺瘤 (D1.0cm)巨大腺瘤 (D3.0cm)大腺瘤大腺瘤巨大腺瘤巨大腺瘤微腺瘤微腺瘤 5、Classification2、内分泌功能分类：泌乳素细胞腺瘤（PRL瘤）常见常见 生长激素细胞腺瘤（GH瘤）常见常见 促肾上腺皮质激素细胞腺瘤（ACTH瘤）常见常见 促

9、甲状腺素细胞腺瘤（TSH瘤）促性腺激素腺瘤（FSH/LH瘤）多分泌功能细胞腺瘤 无内分泌功能细胞腺瘤 6、Examination 1、Imageology Head X-ray Head CT Pituitary MRI+C 2、Lab examination Hormone test T3，T4，TSH Estrogen、Progestogen、Testosterone、FSH、LH、PRL ACTH、Hydrocortisone（8Am,4Pm）GH 6、Examination Clinical manifestation+Imageology +Lab Examination 7、Dia

10、gnosisDiagnosisPathology!1、Other tumors located in sella turcica Craniopharyngioma(颅咽管瘤)Meningioma of tuberculum sellae(鞍结节脑膜瘤）2、other disease Hypophysitis(垂体炎)Abscess of pituitary(垂体脓肿)Pituitary hyperplasia(垂体增生)Anterior communicating aneurysms（前交通动脉瘤）Differential diagnisis MRI垂体柄受压移位垂体柄受压移位CT肿瘤明显钙

11、化肿瘤明显钙化 (Calcification)Craniopharyngioma 颅咽管瘤颅咽管瘤炎症：垂体脓肿炎症：垂体脓肿术前术前MRIMRI增强增强(sagittal)(sagittal)术前术前MRIMRI增强增强(coronal)(coronal)术中所见术中所见继发于甲减的垂体增生继发于甲减的垂体增生服药前服药前服药服药3M后后1)、Surgery2)、Radiotherapy 3)、Medicine 8、Treatment经蝶手术经蝶手术开颅手术开颅手术VSGH腺瘤腺瘤Hormone substitution treatmentPRL腺瘤腺瘤-BromocriptineGH腺瘤腺

12、瘤Octreotide 垂体瘤手术演进史垂体瘤手术演进史经额入路经额入路经口鼻蝶入路经口鼻蝶入路经鼻蝶入路经鼻蝶入路经翼点入路经翼点入路早期垂体瘤手术体位现在的手术体位 Shorten surgery time,without apparent cut Decease the damage to optic nervous and adjacent arteries.Decease the damage to the pituitary function Lower complication and mortality Improve the resection of all tumor Sh

13、orten the time in hospital例一 术 前/后例二 术 前/后例三 术前/后经鼻蝶手术演示单鼻孔前庭弧形切口，沿软骨分离至骨性钝性剥离经鼻前庭-鼻中隔-蝶窦入路经鼻前庭-鼻中隔-蝶窦入路斜坡鞍底经鼻前庭-鼻中隔-蝶窦入路经鼻前庭-鼻中隔-蝶窦入路围手术期的治疗 术前术前：对于较大的腺瘤，术前晚经静脉给予地塞米10mg 术后术后：1、静脉用甲基强的松龙40mg qd。一般 情况较好的病人，3天后改为强的松口 服5mg tid，注意减量。2、注意电解质平衡，尤其是低钠和高钠 （术中对垂体柄刺激引起）3、控制尿量，处理“尿崩症”（垂体后叶素、弥凝片、长效尿崩停）垂体瘤手术效果良好率在60%90%，复发率约735%。术后需要定期随访，监测血激素水平，并复查垂体动态增强MRI。术后辅助化疗或药物治疗等方法。8、Outcome经鼻蝶手术演示经鼻蝶手术演示Any Question?Thanks for your attention!Thanks for your attention!