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溴隐亭治疗侵袭性巨大泌乳素腺瘤的综合治疗

2012-05-10 17:39 来源:澳门新葡新京

张宏伟 于春江 孙炜 杨军 闫长祥 寸恩浩

【摘要】 目的 观察溴隐亭治疗侵袭性巨大泌乳素腺瘤综合治疗的远期疗效。方法 符合侵袭性巨大泌乳素腺瘤(IGPs)诊断标准的患者34例,均溴隐亭进行治疗,其中11例同时配合放疗。服药期间根据肿瘤缩小后的残留部位、有无继续显著缩小、有无耐药等情况决定是否行手术,立体定向放射外科治疗或二者联合应用。术后继续以小剂量溴隐亭维持治疗。结果 平均随访33.6个月,33例患者的临床症状显著改善,1例放疗后视力改善不明显。肿瘤体积平均缩小91.4%,泌乳素平均下降约97.1%,睾酮下降、皮质醇功能低下分别由治疗前的17例、10例恢复至6例、6例。溴隐亭治疗期间出现脑脊液漏2例,1例自行缓解,1例行经蝶、开颅联合入路切除肿瘤、修补瘘口;4例出现不同程度的耐药现象。结论 侵袭性巨大泌乳素腺瘤应药物治疗,部分患者仅通过药物治疗即达到影像学上肿瘤消失的目的,大部分患者需辅助经蝶手术、立体定向放射外科治疗,可以明显缩短治疗时间、减少药物的用量甚至停药,但要慎行放疗。

【关键词】 巨大泌乳素腺瘤;侵袭性;药物治疗;放射治疗

Bromocriptine treatment of invasive giant prolactinomas prior to comprehensive treatments: results of a long-term follow up

ZHANG Hong-wei, YU Chun-jiang, SUN Wei, YANG Jun, YAN Chang-xiang, CUN En-hao .Department of neurosurgery, Beijing Sanbo Fuxing Brain Hospital& Fuxing Hospital, Affiliated to the Capital University of Medical Science, Beijing 100038, China

Corresponding author: YU Chun-jiang, Email:Cjyu1955@sina.com

【Abstract】 Objective To observe long-term outcomes of patients with invasive giant prolactinomas (IGPs) treated with bromocriptine followed by comprehensive treatments. Methods Thirty-four patients met the criteria of IGPs were treated with bromocriptine initially. Among of them, 11 had radiotherapy at the same time. During the treatments, transsphenoidal surgery or/and Gamma knife were considered to apply to the patients according to the location, shrinkage of residual tumors and resistance of bromocriptine. Small dosage of bromocriptine was kept after operation. Results The average follow-up duration is 33.6 months. Thirty-three patients obtained significant improvement, but one failed recovery of vision due to side-injury by radiotherapy. Tumor volume on magnetic resonance imaging (MRI) was decreased on average by 91.4%, PRL by 97.1%. The number of patients with low testosterone level restored from 17 to 6 and hypoadrenalism from 10 to 6 after combined treatment with priority of medical therapy. Rhinorrhea occurred in 2 cases, 1 restored in two weeks, 1 had transsphenoidal combined with transcranial surgery to remove the tumor and repair the fistula. 4 had resistance to bromocriptine to some extend. Conclusions Dopamine agonist medications are effective as a first-line therapy for IGPs. In some patients treated by bromocriptine only, the tumor may disappear on MRI. Combined with surgery and Gamma Knife, the duration of treatment could be shortened and the dosage may be minimized, but using radiotherapy should be cautions.

【Key Words】 Giant prolactinomas; invasiveness; medical therapy; radiotherapy

垂体腺瘤直径在4cm以上,侵袭邻近结构,泌乳素(Prolactin, PRL)水平大于200ng/ml,并有相应的高泌乳素血症的表现和占位效应者称之为侵袭性巨大泌乳素腺瘤(Invasive Giant Prolactinomas,IGPs),约占所有垂体腺瘤的0.5%-2%[1,2],因肿瘤巨大、侵袭性生长,单一手术、药物、放疗效果均不理想,低,始终是神经外科医生的治疗难题。对于IGPs的治疗,国内外文献大宗病案报道很少,治疗意见亦不统一,由于手术本身仅能使0-5%的IGPs患者PRL水平正常化,因此术后仍需配合药物治疗和(或)放疗,手术所带来的高并发症亦不符合微创治疗的理念,故多数学者认为应以多巴胺受体激动剂治疗(药物治疗)为主。本组报告了34例IGPs患者,采取溴隐亭进行治疗,必要时辅以手术和(或)伽玛刀治疗的综合性治疗措施,并进行了长期的随访观察,是迄今为止例数多的一组报道。

资料与方法

1.一般资料:自1999年12月至2006年4月期间收治了溴隐亭进行治疗的IGPs患者34例,其中男性25例,女性9例,年龄17-70岁,平均36岁。病程1个月-10年,平均3.3年。患者表现为视力下降和(或)视野改变28例(82.4%);头痛22例(64.7%);性功能障碍18例(52.5%),包括性欲下降、阳痿和射精不能;停经9例(100%);泌乳4例(44.4%)。全部病例严格按照IGPs的诊断标准入选[3],其中4例分别为外院经蝶术后复发,1例为一期经鼻腔切除了蝶窦及鼻腔内的肿瘤,拟二期开颅切除颅内部分,2例分别为外院开颅术后复发,此7例患者亦符合IGPs诊断标准,溴隐亭进行治疗。

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