下垂体腫瘍に対する手術適応 機能性腺腫とincidentaloma
下垂体腫瘍, 特に機能性下垂体腺腫およびincidentalomaに対する手術適応について述べる. 下垂体腺腫に対する治療法には手術療法, 薬物療法, 放射線療法があるが, 特に機能性下垂体腺腫では手術療法と薬物療法の選択が重要である. 機能性腺腫のうち成長ホルモン産生腺腫, adrenocorticotropin stimulating hormone (ACTH) 産生腺腫, thyrotropin stimulating hormone (TSH) 産生腺腫では, 薬物療法による根治的治療法がないため手術を中心とした治療計画を立てる. 一方, プロラクチノーマでは根治可能な薬物療法があり...
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| Published in | 脳神経外科ジャーナル Vol. 25; no. 8; pp. 637 - 645 |
|---|---|
| Main Authors | , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
日本脳神経外科コングレス
2016
|
| Subjects | |
| Online Access | Get full text |
| ISSN | 0917-950X 2187-3100 |
| DOI | 10.7887/jcns.25.637 |
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| Abstract | 下垂体腫瘍, 特に機能性下垂体腺腫およびincidentalomaに対する手術適応について述べる. 下垂体腺腫に対する治療法には手術療法, 薬物療法, 放射線療法があるが, 特に機能性下垂体腺腫では手術療法と薬物療法の選択が重要である. 機能性腺腫のうち成長ホルモン産生腺腫, adrenocorticotropin stimulating hormone (ACTH) 産生腺腫, thyrotropin stimulating hormone (TSH) 産生腺腫では, 薬物療法による根治的治療法がないため手術を中心とした治療計画を立てる. 一方, プロラクチノーマでは根治可能な薬物療法があり, 手術適応は限られる. 成長ホルモン産生腺腫では手術が第1選択ではあるが, 術前のsomatostatin analogによる薬物療法が有用な症例がある. 術直後はinsulin growth factor-Ⅰ (IGF-Ⅰ) が高値であっても, GH値が正常であれば徐々にIGF-Ⅰ低下が望めるため, すぐに再手術や後療法に移る必要はない. 残存腫瘍に対する再手術は腫瘍がトルコ鞍内に限られるものには有用である. プロラクチノーマは薬物療法が第1選択となるが, 薬物療法も根治のためには長期服用が必要である. 長期服用困難な例, 薬剤抵抗性の腫瘍の場合は手術も考慮する. ACTH産生腺腫の場合には, 腫瘍局在を確認することが手術適応を決めるうえで最も重要である. Incidentalomaとして発見される下垂体腫瘍はほとんどが非機能性下垂体腺腫とラトケ囊胞であるが, それぞれの腫瘍で手術の適応は異なる. 非機能性腺腫は緩徐ではあるが増大するため, 特に鞍上部進展を認める例では早晩視機能障害をきたすことが多く, 手術を検討してよい. また, 前頭蓋底や海綿静脈洞に進展している例では治療が困難になることも多く, 早期の治療が望ましい. ラトケ囊胞では囊胞の自然縮小が生じることも認められ, 手術後の再発率の高さから考えても下垂体機能障害がなければ経過観察でよい. 下垂体機能障害は高度になると不可逆的であるため, 下垂体機能障害が軽度でも存在する場合は手術を考慮してよい. |
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| AbstractList | 下垂体腫瘍, 特に機能性下垂体腺腫およびincidentalomaに対する手術適応について述べる. 下垂体腺腫に対する治療法には手術療法, 薬物療法, 放射線療法があるが, 特に機能性下垂体腺腫では手術療法と薬物療法の選択が重要である. 機能性腺腫のうち成長ホルモン産生腺腫, adrenocorticotropin stimulating hormone (ACTH) 産生腺腫, thyrotropin stimulating hormone (TSH) 産生腺腫では, 薬物療法による根治的治療法がないため手術を中心とした治療計画を立てる. 一方, プロラクチノーマでは根治可能な薬物療法があり, 手術適応は限られる. 成長ホルモン産生腺腫では手術が第1選択ではあるが, 術前のsomatostatin analogによる薬物療法が有用な症例がある. 術直後はinsulin growth factor-Ⅰ (IGF-Ⅰ) が高値であっても, GH値が正常であれば徐々にIGF-Ⅰ低下が望めるため, すぐに再手術や後療法に移る必要はない. 残存腫瘍に対する再手術は腫瘍がトルコ鞍内に限られるものには有用である. プロラクチノーマは薬物療法が第1選択となるが, 薬物療法も根治のためには長期服用が必要である. 長期服用困難な例, 薬剤抵抗性の腫瘍の場合は手術も考慮する. ACTH産生腺腫の場合には, 腫瘍局在を確認することが手術適応を決めるうえで最も重要である. Incidentalomaとして発見される下垂体腫瘍はほとんどが非機能性下垂体腺腫とラトケ囊胞であるが, それぞれの腫瘍で手術の適応は異なる. 非機能性腺腫は緩徐ではあるが増大するため, 特に鞍上部進展を認める例では早晩視機能障害をきたすことが多く, 手術を検討してよい. また, 前頭蓋底や海綿静脈洞に進展している例では治療が困難になることも多く, 早期の治療が望ましい. ラトケ囊胞では囊胞の自然縮小が生じることも認められ, 手術後の再発率の高さから考えても下垂体機能障害がなければ経過観察でよい. 下垂体機能障害は高度になると不可逆的であるため, 下垂体機能障害が軽度でも存在する場合は手術を考慮してよい. |
| Author | 富永, 篤 木下, 康之 栗栖, 薫 |
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| References | 13) Higgins DM, Van Gompel JJ, Nippoldt TB, Meyer FB : Symptomatic Rathke cleft cysts : extent of resection and surgical complications. Neurosurg Focus 31 : E2, 2011. 17) Messerer M, Dubourg J, Raverot G, Bervini D, Berhouma M, George I, Chacko AG, Perrin G, Levivier M, Daniel RT, Trouillas J, Jouanneau E : Non-functioning pituitary macro-incidentalomas benefit from early surgery before becoming symptomatic. Clin Neurol Neurosurg 115 : 2514-2520, 2013. 5) Carlsen SM, Svartberg J, Schreiner T, Aanderud S, Johannesen O, Skeie S, Lund-Johansen M, Fougner SL, Bollerslev J ; POTA study group : Six-month preoperative octreotide treatment in unselected, de novo patients with acromegaly : effect on biochemistry, tumour volume, and postoperative cure. Clin Endocrinol (Oxf) 74 : 736-743, 2011. 6) Caron PJ, Bevan JS, Petersenn S, Flanagan D, Tabarin A, Prévost G, Maisonobe P, Clermont A ; PRIMARYS Investigators : Tumor shrinkage with lanreotide Autogel 120 mg as primary therapy in acromegaly : results of a prospective multicenter clinical trial. J Clin Endocrinol Metab 99 : 1282-1290, 2014. 14) Jahangiri A, Molinaro AM, Tarapore PE, Blevins L Jr, Auguste KI, Gupta N, Kunwar S, Aghi MK : Rathke cleft cysts in pediatric patients : presentation, surgical management, and postoperative outcomes. Neurosurg Focus 31 : E3, 2011. 19) Nomikos P, Buchfelder M, Fahlbusch R : The outcome of surgery in 668 patients with acromegaly using current criteria of biochemical ‘cure’. Eur J Endocrinol 152 : 379-387, 2005. 16) Kinoshita Y, Tominaga A, Usui S, Arita K, Sakoguchi T, Sugiyama K, Kurisu K : The long-term recurrence of Rathke’s cleft cysts as predicted by histology but not by surgical procedure. J Neurosurg 15 : 1-6, 2016. [Epub ahead of print] 4) Arita K, Tominaga A, Sugiyama K, Eguchi K, Iida K, Sumida M, Migita K, Kurisu K : Natural course of incidentally found nonfunctioning pituitary adenoma, with special reference to pituitary apoplexy during follow-up examination. J Neurosurg 104 : 884-891, 2006. 15) Kinoshita Y, Tominaga A, Usui S, Arita K, Sakoguchi T, Sugiyama K, Kurisu K : Clinical features and natural course of acromegaly in patients with discordance in the nadir GH level on the oral glucose test and the IGF-1 value at 3 months after adenomectomy. Neurosurg Rev 39 : 313-319, 2016. 26) Zhong W, You C, Jiang S, Huang S, Chen H, Liu J, Zhou P, Liu Y, Cai B : Symptomatic Rathke cleft cyst. J Clin Neurosci 19 : 501-508, 2012. 9) Fernández-Balsells MM, Murad MH, Barwise A, Gallegos-Orozco JF, Paul A, Lane MA, Lampropulos JF, Natividad I, Perestelo-Pérez L, Ponce de León-Lovatón PG, Erwin PJ, Carey J, Montori VM : Naural history of nonfunctioning pituitary adenomas and incidentalomas : a systematic review and metaanalysis. J Clin Endocrinol Metab 96 : 905-912, 2011. 18) Nishioka H, Haraoka J, Izawa H, Ikeda Y : Headaches associated with Rathke’s cleft cyst. Headache 46 : 1580-1586, 2006. 22) Trifanescu R, Stavrinides V, Plaha P, Cudlip S, Byrne JV, Ansorge O, Wass JA, Karavitaki N : Outcome in surgically treated Rathke’s cleft cysts : long-term monitoring needed. Eur J Endocrinol 165 : 33-37, 2011. 3) Annamalai AK, Webb A, Kandasamy N, Elkhawad M, Moir S, Khan F, Maki-Petaja K, Gayton EL, Strey CH, O’Toole S, Ariyaratnam S, Halsall DJ, Chaudhry AN, Berman L, Scoffings DJ, Antoun NM, Dutka DP, Wilkinson IB, Shneerson JM, Pickard JD, Simpson HL, Gurnell M : A comprehensive study of clinical, biochemical, radiological, vascular, cardiac, and sleep parameters in an unselected cohort of patients with acromegaly undergoing presurgical somatostatin receptor ligand therapy. J Clin Endocrinol Metab 98 : 1040-1050, 2013. 8) Dogansen SC, Selcukbiricik OS, Tanrikulu S, Yarman S : Withdrawal of dopamine agonist therapy in prolactinomas : In which patients and when? Pituitary 19 : 303-310, 2016. 24) Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF : A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. Cabergoline Comparative Study Group. N Engl J Med 331 : 904-909, 1994. 11) Fougner SL, Bollerslev J, Svartberg J, Øksnes M, Cooper J, Carlsen SM : Preoperative octreotide treatment of acromegaly : long-term results of a randomised controlled trial. Eur J Endocrinol 171 : 229-235, 2014. 12) Freda PU, Beckers AM, Katznelson L, Molitch ME, Montori VM, Post KD, Vance ML ; Endocrine Society : Pituitary incidentaloma : an endocrine society clinical practice guideline. J Clin Endocrinol Metab 96 : 894-904, 2011. 2) Aho CJ, Liu C, Zelman V, Couldwell WT, Weiss MH : Surgical outcomes in 118 patients with Rathke cleft cysts. J Neurosurg 102 : 189-193, 2005. 21) Shin MS, Yu JH, Choi JH, Jung CH, Hwang JY, Cho YH, Kim CJ, Kim MS : Long-term changes in serum IGF-1 levels after successful surgical treatment of growth hormone-secreting pituitary adenoma. Neurosurgery 73 : 473-479, 2013. 20) Potts MB, Jahangiri A, Lamborn KR, Blevins LS, Kunwar S, Aghi MK : Suprasellar Rathke cleft cysts : clinical presentation and treatment outcomes. Neurosurgery 69 : 1058-1068, 2011. 23) Wait SD, Garrett MP, Little AS, Killory BD, White WL : Endocrinopathy, vision, headache, and recurrence after transsphenoidal surgery for Rathke cleft cysts. Neurosurgery 67 : 837-843, 2010. 1) Abe T, Lüdecke DK : Recent results of secondary transnasal surgery for residual or recurring acromegaly. Neurosurgery 42 : 1013-1022, 1998. 7) Colao A, Di Sarno A, Guerra E, Pivonello R, Cappabianca P, Caranci F, Elefante A, Cavallo LM, Briganti F, Cirillo S, Lombardi G : Predictors of remission of hyperprolactinaemia after long-term withdrawal of cabergoline therapy. Clin Endocrinol (Oxf) 67 : 426-433, 2007. 10) Ferrari CI, Abs R, Bevan JS, Brabant G, Ciccarelli E, Motta T, Mucci M, Muratori M, Musatti L, Verbessem G, Scanlon MF : Treatment of macroprolactinoma with cabergoline : a study of 85 patients. Clin Endocrinol (Oxf) 46 : 409-413, 1997. 25) Yamada S, Fukuhara N, Oyama K, Takeshita A, Takeuchi Y : Repeat transsphenoidal surgery for the treatment of remaining or recurring pituitary tumors in acromegaly. Neurosurgery 67 : 949-956, 2010. |
| References_xml | – reference: 10) Ferrari CI, Abs R, Bevan JS, Brabant G, Ciccarelli E, Motta T, Mucci M, Muratori M, Musatti L, Verbessem G, Scanlon MF : Treatment of macroprolactinoma with cabergoline : a study of 85 patients. Clin Endocrinol (Oxf) 46 : 409-413, 1997. – reference: 7) Colao A, Di Sarno A, Guerra E, Pivonello R, Cappabianca P, Caranci F, Elefante A, Cavallo LM, Briganti F, Cirillo S, Lombardi G : Predictors of remission of hyperprolactinaemia after long-term withdrawal of cabergoline therapy. Clin Endocrinol (Oxf) 67 : 426-433, 2007. – reference: 25) Yamada S, Fukuhara N, Oyama K, Takeshita A, Takeuchi Y : Repeat transsphenoidal surgery for the treatment of remaining or recurring pituitary tumors in acromegaly. Neurosurgery 67 : 949-956, 2010. – reference: 13) Higgins DM, Van Gompel JJ, Nippoldt TB, Meyer FB : Symptomatic Rathke cleft cysts : extent of resection and surgical complications. Neurosurg Focus 31 : E2, 2011. – reference: 1) Abe T, Lüdecke DK : Recent results of secondary transnasal surgery for residual or recurring acromegaly. Neurosurgery 42 : 1013-1022, 1998. – reference: 4) Arita K, Tominaga A, Sugiyama K, Eguchi K, Iida K, Sumida M, Migita K, Kurisu K : Natural course of incidentally found nonfunctioning pituitary adenoma, with special reference to pituitary apoplexy during follow-up examination. J Neurosurg 104 : 884-891, 2006. – reference: 8) Dogansen SC, Selcukbiricik OS, Tanrikulu S, Yarman S : Withdrawal of dopamine agonist therapy in prolactinomas : In which patients and when? Pituitary 19 : 303-310, 2016. – reference: 21) Shin MS, Yu JH, Choi JH, Jung CH, Hwang JY, Cho YH, Kim CJ, Kim MS : Long-term changes in serum IGF-1 levels after successful surgical treatment of growth hormone-secreting pituitary adenoma. Neurosurgery 73 : 473-479, 2013. – reference: 17) Messerer M, Dubourg J, Raverot G, Bervini D, Berhouma M, George I, Chacko AG, Perrin G, Levivier M, Daniel RT, Trouillas J, Jouanneau E : Non-functioning pituitary macro-incidentalomas benefit from early surgery before becoming symptomatic. Clin Neurol Neurosurg 115 : 2514-2520, 2013. – reference: 26) Zhong W, You C, Jiang S, Huang S, Chen H, Liu J, Zhou P, Liu Y, Cai B : Symptomatic Rathke cleft cyst. J Clin Neurosci 19 : 501-508, 2012. – reference: 22) Trifanescu R, Stavrinides V, Plaha P, Cudlip S, Byrne JV, Ansorge O, Wass JA, Karavitaki N : Outcome in surgically treated Rathke’s cleft cysts : long-term monitoring needed. Eur J Endocrinol 165 : 33-37, 2011. – reference: 24) Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF : A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. Cabergoline Comparative Study Group. N Engl J Med 331 : 904-909, 1994. – reference: 2) Aho CJ, Liu C, Zelman V, Couldwell WT, Weiss MH : Surgical outcomes in 118 patients with Rathke cleft cysts. J Neurosurg 102 : 189-193, 2005. – reference: 18) Nishioka H, Haraoka J, Izawa H, Ikeda Y : Headaches associated with Rathke’s cleft cyst. Headache 46 : 1580-1586, 2006. – reference: 14) Jahangiri A, Molinaro AM, Tarapore PE, Blevins L Jr, Auguste KI, Gupta N, Kunwar S, Aghi MK : Rathke cleft cysts in pediatric patients : presentation, surgical management, and postoperative outcomes. Neurosurg Focus 31 : E3, 2011. – reference: 11) Fougner SL, Bollerslev J, Svartberg J, Øksnes M, Cooper J, Carlsen SM : Preoperative octreotide treatment of acromegaly : long-term results of a randomised controlled trial. Eur J Endocrinol 171 : 229-235, 2014. – reference: 9) Fernández-Balsells MM, Murad MH, Barwise A, Gallegos-Orozco JF, Paul A, Lane MA, Lampropulos JF, Natividad I, Perestelo-Pérez L, Ponce de León-Lovatón PG, Erwin PJ, Carey J, Montori VM : Naural history of nonfunctioning pituitary adenomas and incidentalomas : a systematic review and metaanalysis. J Clin Endocrinol Metab 96 : 905-912, 2011. – reference: 19) Nomikos P, Buchfelder M, Fahlbusch R : The outcome of surgery in 668 patients with acromegaly using current criteria of biochemical ‘cure’. Eur J Endocrinol 152 : 379-387, 2005. – reference: 20) Potts MB, Jahangiri A, Lamborn KR, Blevins LS, Kunwar S, Aghi MK : Suprasellar Rathke cleft cysts : clinical presentation and treatment outcomes. Neurosurgery 69 : 1058-1068, 2011. – reference: 12) Freda PU, Beckers AM, Katznelson L, Molitch ME, Montori VM, Post KD, Vance ML ; Endocrine Society : Pituitary incidentaloma : an endocrine society clinical practice guideline. J Clin Endocrinol Metab 96 : 894-904, 2011. – reference: 5) Carlsen SM, Svartberg J, Schreiner T, Aanderud S, Johannesen O, Skeie S, Lund-Johansen M, Fougner SL, Bollerslev J ; POTA study group : Six-month preoperative octreotide treatment in unselected, de novo patients with acromegaly : effect on biochemistry, tumour volume, and postoperative cure. Clin Endocrinol (Oxf) 74 : 736-743, 2011. – reference: 16) Kinoshita Y, Tominaga A, Usui S, Arita K, Sakoguchi T, Sugiyama K, Kurisu K : The long-term recurrence of Rathke’s cleft cysts as predicted by histology but not by surgical procedure. J Neurosurg 15 : 1-6, 2016. [Epub ahead of print] – reference: 15) Kinoshita Y, Tominaga A, Usui S, Arita K, Sakoguchi T, Sugiyama K, Kurisu K : Clinical features and natural course of acromegaly in patients with discordance in the nadir GH level on the oral glucose test and the IGF-1 value at 3 months after adenomectomy. Neurosurg Rev 39 : 313-319, 2016. – reference: 6) Caron PJ, Bevan JS, Petersenn S, Flanagan D, Tabarin A, Prévost G, Maisonobe P, Clermont A ; PRIMARYS Investigators : Tumor shrinkage with lanreotide Autogel 120 mg as primary therapy in acromegaly : results of a prospective multicenter clinical trial. J Clin Endocrinol Metab 99 : 1282-1290, 2014. – reference: 23) Wait SD, Garrett MP, Little AS, Killory BD, White WL : Endocrinopathy, vision, headache, and recurrence after transsphenoidal surgery for Rathke cleft cysts. Neurosurgery 67 : 837-843, 2010. – reference: 3) Annamalai AK, Webb A, Kandasamy N, Elkhawad M, Moir S, Khan F, Maki-Petaja K, Gayton EL, Strey CH, O’Toole S, Ariyaratnam S, Halsall DJ, Chaudhry AN, Berman L, Scoffings DJ, Antoun NM, Dutka DP, Wilkinson IB, Shneerson JM, Pickard JD, Simpson HL, Gurnell M : A comprehensive study of clinical, biochemical, radiological, vascular, cardiac, and sleep parameters in an unselected cohort of patients with acromegaly undergoing presurgical somatostatin receptor ligand therapy. J Clin Endocrinol Metab 98 : 1040-1050, 2013. |
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| ispartofPNX | 脳神経外科ジャーナル, 2016, Vol.25(8), pp.637-645 |
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