Neurological Surgery 脳神経外科37巻8号

2009年08月発行

解剖を中心とした脳神経手術手技

脳下垂体腺腫の被膜外摘出

著者： 堀智勝¹ 川俣貴一¹ 天野耕作¹

所属機関： ¹東京女子医科大学脳神経外科

ページ範囲：P.743 - P.754

Ⅰ．はじめに

　脳下垂体腺腫は原発性脳腫瘍の約18％を占める良性の疾患である．しかしその外科的治療に関しては患者の視機能をはじめ，間脳下垂体機能に重大な影響を及ぼすので脳神経外科医にとって非常に重要な分野である^{1,7-16,18,28)}．筆者らは1998年6月以来2008年末まで，東京女子医科大学脳神経外科において，一側鼻孔より経蝶形骨アプローチにて腺腫摘出術を行い，704例に達した．筆者の1人堀は鳥取大学で1996年以来，すべての経蝶形骨洞手術を一側経鼻で現在まで連続して行っており，鳥取大学の経鼻症例数38例を加えると，現在約750例の連続一側経鼻経蝶形骨洞手術例を経験したことになる（関連病院での手術は除く）．この10年間を，Ⅰ期1998～2001年，Ⅱ期2002～2005年，Ⅲ期2006～2008年，の3つの時期に分けて成長ホルモン産生腺腫の手術成績を治癒判定規準（コルチナコンセンサス）による治癒基準（75g oral glucose tolerance test（OGTT）でgrowth hormone（GH）＜1ng/mlに抑制・IGF-1正常域sex-age matched）で比較する¹⁸⁾と，段階的に治療成績の向上がみられ，Knosp grade 0～1ではⅢ期治癒率100％を達成した．一方，術後のホルモン検査ではこのⅢ期において，ホルモン障害を含めた合併症には差がなかった．

　なぜこのような治療成績の向上がこの10年間でみられたのかを考察したところ，特に被膜外摘出法^{6,14,24,26,27)}が有効であったと考えられた．そこで本稿では，解剖に基づいた被膜外摘出法について，特に摘出組織の組織学的所見に関連して説明し，われわれの手術法について詳述する．

参考文献

1）Abe T, Ludecke DK：Recent primary transnasal surgical outcomes associated with intraoperative growth hormone measurement in acromegaly. Clin Endocrinol (Oxf) 50：27-35, 1999

2）Bergland R：Pathological considerations in pituitary tumors. Prog Neurol Surg 6：62-94, 1975

3）Chacko AG, Chacko G, Seshadri MS, Chandy MJ：The “capsule” of pituitary macroadenomas represents normal pituitary gland：a histolopathological study. Br J Neurosurg 17：213-218, 2003

4）Ciric I：On the origin and nature of the pituitary gland capsule. J Neurosurg 46：596-600, 1977

5）Farnoud MR, Kujas M, Derome P, Racadot J, Peillon F, Li JY：Interactions between normal and tumoral tissues at the boundary of human anterior pitiuitary adenomas. An immunohistochemical study. Virchows Arch 424：75-82, 1994

6）Hashimoto N, Handa H, Yamagami T：Transsphenoidal extracapsular approach to pituitary adenomas. J Neurosurg 64：16-20, 1986

7）堀　智勝：下垂体腺腫の外科治療─経蝶形骨洞腺腫除去術─．日本医事新報3254：16-20, 1986

8）Jacoby JAK Jr, Hedley-White ET, Pulsaki K, Seizinger Br, Martuza RL：Clonal origin of pituitary adenomas. J Neurosurg 73：731-735, 1990

9）Jho HD, Carrau RL：Endoscopic endonasal transsphenoidal surgery：experience with 50 patients. J Neurosurg 87：44-51, 1997

10）Kawamata T, Kamikawa S, Iseki H, Hori T：Flexible endoscope-assisted endonasal transsphenoidal surgery for pituitary tumors. Min Inv Neurosurg 45：208-210, 2002

11）Kawamata T, Iseki H, Shibasaki T, Hori T：Endoscopic augmented reality navigation system for endonasal transsphenoidal surgery to treat pituitarytumors：Technical note. Neurosurgery 50：1393-1397, 2002

12）Kawamata T, Iseki H, Ishizaki R, Hori T：Minimally invasive endoscope-assisted endonasal transsphenoidal microsurgery for pituitarytumors：Experience with 215 cases comparing with sublabial transsphenoidal approach. Neurol Res 24：259-265, 2002

13）Kawamata T, Kubo O, Hori T：Histological findings at the boundary of craniopharyngiomas. Brain Tumor Pathol 22：75-78, 2005

14）Kawamata T, Kubo O, Hori T：Surgical removal of growth hormone-secreting pituitary adenomas with intensive microsurgical pseudocapsule resection results in complete remission of acromegaly. Neurosurg Rev 28：201-208, 2005

15）Kawamata T, Inui A, Hosoda H, Kanagawa K, Hori T：Perioperative plasma active and total ghrelin levels in acromegaly are reduced compared to non-functioning pituitary tumors even after normalization of serum GH. Clin Endocrinol 67：140-144, 2007

16）Kawamata T, Amano K, Hori T：Novel flexible forceps for endoscopic transsphenoidal resection of pituitary tumors：Technical report. Neurosurg Rev 31：65-68, 2008

17）Knosp E, Steiner E, Kitz K, Matula C：Pituitary adenomas with invasion of the cavernous sinus space：a magnetic resonance imaging classification compared with surgical findings. Neurosurgery 33：1992-1998, 1993

18）Kreutzer J, Vance M, Lopes M, Laws EJ：Surgical management of GH-secreting pituitary adenomas：an outcome study using modern remission criteria. J Clin Endocrinol Metab 86：4072-4077, 2001

19）Kurosaki M, Hori T, Tanaka K, Kawakami H, Hirano H：Peanut agglutinin binding to human prolactin-producing pituitary adenomas. Acta Neuropathol 89：475-482, 1995

20）Kuwayama A：Surgery in endocrine disorders. 1. Pituitary tumors. Nippon Geka Gakkai Zasshi 85：1014-1018, 1984

21）Kuwayama A：Treatment and long-term results of Cushing disease. Folia Endocrinol Japn 79：17-19, 2003

22）Meiji B, LopesM, Ellegala D, Alden T, Laws EJ：The long-term significance of microscopic dural invasion in 354 patients with pituitary adenomas treated with transsphenoidal surgery. J Neurosurg 96：195-208, 2002

23）Oldfield EH, Chrousos GP, Schulte HM, Schaaf M, McKeever PE, Krudy AG, et al：Preoperative lateralization of ACTH-secreting pituitary adenomas by bilateral and simultaneous inferior or petrous venous sinus sampling. N Engl J Med 312：100-103, 1985

24）Oldfield EH, Vortmeyer AO：Development of a histological pseudocapsule and its use as a surgical capsule in the excision of pituitary tumors. J Neurosurg 104：7-19, 2006

25）Selman W, Laws EJ, Scheithauer B, Carpenter S：The occurrence of dural invasion in pituitary adenomas. J Neurosurg 64：402-407, 1986

26）Teramoto A, Sano K, Osamura R, Watanabe K：Immunohistochemical observations of the pituitary adenomas with the use of enzyme-labelled antibody method- on the residual pituitary gland and “capsule” of the adenoma. Neurol Med Chir (Tokyo) 19：895-902, 1979

27）Teramoto A, Takakura K, Fukushima T：The clinicopathological study on the boundary of pituitary adenomas. No To Shinkei 34：887-894, 1982

28）Zada G, Kelly D, Cohan P, Wang C, Swerdoff R：Endonasal transsphenoidal approach for pituitary denomas and other lesions：an assessment of efficacy, safety, and patient impressions. J Neorusurg 98：350-358, 2003