复发性垂体神经内分泌肿瘤：全切术的解剖学预测因素及拟议的垂体可切除性评分

文献信息

中文摘要

目的： 由于解剖结构改变和瘢痕形成，针对复发性垂体神经内分泌肿瘤（PitNET）的再次内镜下经鼻蝶窦手术（EETA）具有挑战性。我们前瞻性评估了切除范围、临床结局及可切除性的解剖学预测因素，并评估了拟议的垂体可切除性评分（PRS）。
方法： 32例复发性或残留性PitNET患者于2023年1月至2025年6月期间接受了EETA。切除范围（EOR）分为全切、近全切、次全切或部分切除，并使用Fisher精确检验与解剖学特征进行相关性分析。术前基于MRI分配的PRS（海绵窦侵犯、大小、形态、鞍外扩展）与结局进行了评估。
结果： 平均年龄为44±10岁；66%为男性。44%的患者实现了全切（GTR），与PRS分级相关（I级91%，II级57%，III-IV级0%）。解剖学预测因素——形态、海绵窦侵犯、大小和鞍外扩展——与EOR显著相关（所有p<0.001）。术中脑脊液漏发生率为22%（3.1%需要再次手术），短暂性尿崩症为13%，鼻窦炎为19%，第六神经麻痹为3.1%，无死亡病例。76%的术前有视力缺陷的患者视力改善。在中位18个月的随访中，所有接受辅助放射外科或分期颅脑手术的患者均维持稳定的肿瘤控制。
结论： 在复发性PitNET中，决定可切除性的是解剖复杂性，而非复发状态。肿瘤形态、海绵窦侵犯、大小和鞍外扩展是GTR的主要限制因素。拟议的PRS是一种可在床旁计算、基于MRI的框架，用于构建对手术目标的术前预期。在这组治疗异质性队列中，多模式管理实现了稳定的控制。在采用之前仍需外部验证。

英文摘要

OBJECTIVE: Revision endoscopic endonasal transsphenoidal surgery (EETA) for recurrent pituitary neuroendocrine tumors (PitNET) is challenging due to altered anatomy and scarring. We prospectively evaluated extent of resection, clinical outcomes, and anatomical predictors of resectability, and assessed a proposed Pituitary Resectability Score (PRS).
METHODS: Thirty-two patients with recurrent or residual PitNET underwent EETA between January 2023 and June 2025. Extent of resection (EOR) was classified as gross-total, near-total, subtotal, or partial and correlated with anatomical characteristics using Fisher's exact test. A preoperatively assigned MRI-based PRS (cavernous sinus invasion, size, morphology, extrasellar extension) was evaluated against outcomes.
RESULTS: Mean age was 44±10 years; 66% were male. GTR was achieved in 44%, correlating with PRS class (91% Class I, 57% Class II, 0% Classes III-IV). Anatomical predictors - morphology, cavernous sinus invasion, size, and extrasellar extension - were significantly associated with EOR (all p<0.001). Intraoperative CSF leak occurred in 22% (3.1% requiring reoperation), transient diabetes insipidus in 13%, sinusitis in 19%, and sixth-nerve palsy in 3.1%, with no mortality. Visual improvement occurred in 76% of patients with preoperative deficits. At median 18-month follow-up, all patients receiving adjuvant radiosurgery or staged cranial surgery maintained stable tumor control.
CONCLUSION: Anatomical complexity, not recurrence status, determines resectability in recurrent PitNET. Tumor morphology, cavernous sinus invasion, size, and extrasellar extension were the principal limitations to GTR. The proposed PRS is a bedside-computable, MRI-based framework for structuring preoperative expectations about surgical goals. Multimodal management achieved stable control in this heterogeneously treated cohort. External validation remains necessary before adoption.