颅底脊索瘤的影像学诊断及治疗研究（附26例报告）

目的：探讨颅底脊索瘤的CT、MRI表现及治疗措施。方法：回顾性分析经病理证实的26例脊索瘤患者的临床资料。肿瘤位于鞍区及鼻咽部者9例,位于中颅窝者5例,位于后颅窝者8例,混合型4例。手术入路：额颞入路一翼点开颅9例,鼻内镜下经蝶入路5例,颞下、颞枕及扩大中颅窝入路8例,4例未手术行放射治疗。结果：肿瘤全切8例,大部及次全切14例,围手术期未见死亡病例。25例患者获得随访;3例于术后1年内复发,其中2例死亡,余者颅神经损伤及肢体症状均有改善。结论：脊索瘤无典型临床表现,现多可通过术前影像学检查得以诊断,少数位于特殊位置者需与垂体瘤,颅咽管瘤,三叉神经鞘瘤等鉴别;肿瘤全切较为困难,根据需要选择相应的手术入路可明显提高手术效果;放疗可作为术后辅助治疗。     

额底纵裂入路手术对鞍上第三脑室底垂体瘤的疗效分析

目的：分析经额底纵裂入路治疗鞍上第三脑室底垂体瘤的疗效,探讨其临床适用性。方法：选择从2011年1月~2013年1月与我院行额底纵裂入路手术治疗的30例鞍上第三脑室底垂体瘤的患者,术中行单侧额或双侧额弧形切口,根据术中所见肿瘤位置,由终板、视神经一颈内动脉等存在的生理间隙处切除肿瘤,观察所有患者的手术疗效。结果：所有患者术中可见肿瘤位于鞍内鞍上,部分或全部突入第三脑室底,其中有6例患者伴有脑积水。术中肿瘤全切23例,次全切5例,大部切除2例,无手术死亡病例。术前25例患者视力减退,术后23例患者视力均获得不同程度改善,仅1例暂无明显变化。术后19例出现电解质紊乱,患者经治疗后均已纠正;12例出现不同程度的尿崩症,给予患者药物治疗后,病情得到缓解。术后随访6个月,23例肿瘤全切患者病灶无复发,另外4例次全切者病灶也无明显变化,仅1例次全切和2例大部切除患者于术后行伽马刀再次治疗。结论：经额底纵裂入路治疗鞍上第三脑室底垂体瘤可以达到视野清晰,直观下进行肿瘤切除,手术效果好,并发症较少,适合临床长期推广应用。     

显微手术治疗囊性听神经瘤的临床研究

目的:探讨显微外科开颅治疗囊性听神经鞘瘤的肿瘤全切情况及面、听神经的保留情况。方法:回顾性分析2006年8月至2013年9月我院收治的42例经枕下乙状窦后入路开颅囊性听神经鞘瘤手术患者的临床资料,同时对37例患者进行术后随访,并对结果进行统计学分析。结果:囊性听神经鞘瘤(42例)手术全切率simpson(Ⅰ-Ⅱ级)为64.28%(27例),次全切除率(simpsonⅢ级)为26.19%(11例),部分切除率为(simpsonⅣ级)为9.53%(4例),面神经解剖保留率为71.43%(30例),面神经功能保留率为14.29%(6例),听神经解剖保留率为7.1%,听神经功能保留3例,较实质性听神经瘤的手术效果差。结论:囊性听神经瘤的面、听神经解剖与功能保护尚有难度,需要进一步提高。     

鞍区HRCT扫描在单鼻孔蝶窦入路切除垂体腺瘤中的作用

目的:探讨术前鞍区HRCT扫描在单鼻孔蝶窦入路切除垂体腺瘤中的作用.方法:回顾性分析42例经单鼻孔蝶窦入路垂体腺瘤切除病人鞍区薄层HRCT检查的结果和经验.结果:蝶窦呈鞍彤35例,鞍前形7例,鞍底骨质破坏19例.术后鞍底骨窗均小于1.5 cm × 1.5cm.肿瘤全切除28例,次全切除10例,部分切除4例.术后视力及视野改善者31例,内分泌指标恢复正常者35例.术后脑脊液鼻漏5例.本组无死亡病例,没有出现因骨窗咬除而出现的视神经损伤、海绵窦出血等并发症.结论:鞍区薄层HRCT检查有利于指导手术入路的设计和术中手术方位的判断.     

颈静脉孔区肿瘤各手术入路的选择及对比分析

颈静脉孔区肿瘤位置深,结构复杂,周围有重要的神经血管走形,此区域肿瘤类型较多,常见的有颈静脉球瘤,其次为神经鞘瘤和脑膜瘤。由于此区域位置深,结构复杂,手术显露困难,切除此区域肿瘤难度较大,选择合适的手术入路以及术中正确的处理是该区域肿瘤手术成功的关键。此区域的手术入路可分为三种:后方入路、侧方入路、前方入路;各自又有新型的改良术式。手术入路的选择取决于病变性质、生长范围、受累结构、患者的功能状态及术者的个人经验。术中保护重要的神经血管是此手术的关键。尽管如此,术后出现的并发症在所难免,其主要的并发症有:脑神经损伤后功能障碍、脑脊液漏和脑膜炎等。     

经鼻蝶入路显微侵袭切除垂体腺瘤的临床疗效

目的:对比观察经鼻蝶显微技术下入路与经鼻蝶神经内窥镜下入路手术切除垂体腺瘤的疗效,探讨切除垂体瘤的良好辅助方法。方法:78例患者分别采用经鼻蝶显微技术下入路和经鼻蝶神经内窥镜下入路手术切除垂体腺瘤。结果:与经鼻蝶显微技术下入路比较,经鼻蝶神经内窥镜下入路手术者住院时间短、肿瘤全切除率高、鼻出血率低、术后并发症发生率低(P<0.05),但是经鼻蝶神经内窥镜下手术切除肿瘤时术中出血需显微镜下止血。结论:经鼻蝶神经内窥镜下手术入路是垂体腺瘤切除的良好手术切除垂体瘤的入路,如有条件也可将二者联合应用取长补短。     

颞叶内侧胶质瘤的显微手术治疗体会

目的:探讨颞叶内侧胶质瘤的显微手术疗效并总结经验。方法:回顾性分析23例行显微手术治疗的颞叶内侧胶质瘤患者的临床资料及手术并发症的发生情况。结果:23例患者中,20例全切除,3例次全切除术,术后术区残血1例,无手术死亡病例。术前癫痫发作18例,术后缓解16例;术前有失语8例,后缓解3例;术前8例偏盲,术后改善2例;术前偏瘫2例,术后改善1例;术后新增失语2例,术后新增偏盲3例,术后新增偏瘫1例,1年随访复发3例。结论:经侧裂入路切除颞叶内侧胶质瘤的手术疗效良好,可以最大程度切除术肿瘤,并发症较少。     

外科治疗囊性听神经瘤14 例临床观察

目的:探讨囊性听神经瘤的临床特点及手术经验。方法:回顾分析2006年1月-2010年12月我院收治的14例囊性听经瘤的临床资料。结果:肿瘤全切除12例,不全切除2例,无死亡病例,术后4例病人面瘫加重,1例病人听力丧失。结论:与实质性听神经瘤相比,囊性听神经瘤体积较大,病程短,始发症状不典型,颅神经常被累及,可不发生内听道扩大,脑积水发生率低,手术效果差。     

鼻内镜技术用于鼻腔鼻窦良恶性肿瘤的治疗

目的:评估鼻内镜手术对于鼻腔鼻窦良恶性肿瘤的治疗效果及应用价值.方法:收集我科采用鼻内镜或鼻内镜辅助手术治疗的鼻腔鼻窦良恶性肿瘤共109例,并进行回顾性分析.结果:经随访12-60个月,本组109例患者中,应用单纯鼻内镜下治疗的4例鼻腔鼻窦肿瘤患者术后出现复发,1例失访,复发率为5％;鼻内镜联合柯陆氏入路手术的16例患者中未出现术后复发;2例鼻内镜辅助鼻侧切开手术治疗的恶变内翻乳头状瘤患者术后1年出现局部复发及广泛脑膜侵犯死亡;鼻内镜辅助鼻侧切开手术中的2例恶性黑色素瘤其中1例术前已出现颊部及颈部淋巴结转移,于术后8个月-1.5年中出现远处转移后死亡.结论:鼻内镜手术已经逐渐成为多种鼻腔鼻窦良性肿瘤以及部分恶性肿瘤的首选治疗方式.     

两种手术方式治疗Krouse分级T2、T3上颌窦内翻性乳头状瘤的疗效及对炎性应激指标的影响

目的:对比鼻内镜下经泪前隐窝入路、鼻内镜下中下鼻窦道开窗术两种手术方式治疗Krouse分级T2、T3的上颌窦内翻性乳头状瘤的疗效及对炎性应激指标的影响。方法:回顾性分析50例上颌窦内翻性乳头状瘤患者的临床资料。根据手术方式分成A组(n=26,鼻内镜下中下鼻窦道开窗术)和B组(n=24,鼻内镜下经泪前隐窝入路)。考察两组围术期指标、炎性应激指标[白介素-8(IL-8)、白介素-10(IL-10)、降钙素原(PCT)]、并发症、复发率。结果:与A组相比,B组的术中出血量更少,手术时间、术后鼻腔内创面愈合时间、住院时间更短,术后疼痛程度更轻,组间对比差异有统计学意义(P<0.05)。两组术前、术后1 d、术后10 d的IL-8、PCT水平呈先升高后降低趋势,IL-10呈先降低后升高趋势(P<0.025),B组术后1 d的IL-8、PCT水平低于A组,IL-10水平高于A组(P<0.05)。两组并发症发生率、术后复发率组间对比均无统计学意义(P>0.05)。结论:以鼻内镜下经泪前隐窝入路治疗Krouse分级为T2、T3的上颌窦内翻性乳头状瘤患者,创伤小,术后恢复快,可减轻患者炎性应激,术后并发症少,是治疗上颌窦内翻性乳头状瘤疗效较好的手术方式之一。     

显微镜下锁孔手术的临床应用研究

目的：探讨显微镜下锁孔手术的临床应用。方法：回顾性分析近10年来收治的锁孔手术459例的手术经验,总结锁孔手术临床应用。经眉弓锁孔入路治疗颅内病变的手术270例。经翼点锁孔入路治疗颅内病变的手术52例。经后颅窝锁孔入路的手术137例。结果：外伤及高血压引起脑内血肿23例,经翼点锁孔入路治疗效果良好。颅内肿瘤全切除266例（74．7％）,次全切除90例（25．3％）。术后并发症发生率为3．8％,无与手术入路相关并发症。结论：显微镜下锁孔手术是一种安全、有效的微创手术,值得进行深入研究和广泛应用。     

The role of radiotherapy in the prevention of recurrence and central nervous system metastases in childhood medulloblastoma

PURPOSE: To present the postoperative radiotherapy technique in children with medulloblastoma, and analyse the effectiveness of radiotherapy and the survival data. MATERIALS AND METHODS: 66 consecutive children (45 male and 21 female) received postoperative chemotherapy and radiotherapy between 1986 and 1998. The mean age was 8.3 years. The radiotherapy was performed with linear accelerator 9MV X-ray irradiation. The high risk patients received 36 Gy craniospinal irradiation, the low risk patients recived 30 Gy. The boost irradiation to the posterior fossa was 20 Gy in both patient groups. The patients received multi-drug chemotherapy immediately after the tumor resection. The radiotherapy started 6-8 weeks after the operation. RESULTS: All 66 patients were evaluated. The mean follow-up time was 45.4 months. The chance of cure is higher at age 8 or more, and less favorable under age 8. After 60 months 68.6% of children under age 8 and 75.9% older than 8 are alive. 20 children (64.5%) are alive after radical tumorectomy and 11 died. The 5 year overall survival was 71%. Recurrence was observed in 23/66 cases, it was the most frequent cause of death. Local failure was in posterior fossa in 15 patients (68.2%). CONCLUSION: The radicality of operation had no significant influence to the overall survival. The tumor stage, age of patients, risk group and metastases are important prognostic factors.     

Oncogenic osteomalacia associated with mesenchymal tumor in the middle cranial fossa: a case report

ABSTRACT: INTRODUCTION: Tumor-induced osteomalacia is a paraneoplastic syndrome of hypophosphatemia. Osteomalacia causes multiple bone fractures and severe pain. CASE PRESENTATION: We report the case of a 57-year-old Japanese man with tumor-induced osteomalacia associated with a middle cranial fossa bone tumor. The tumor was successfully resected by using a middle fossa epidural approach. His phosphate level recovered to a normal range immediately after the surgery. CONCLUSIONS: It is rare that tumor-induced osteomalacia originates from the middle skull base. This report suggests that, if patients have a clinical and biochemical picture suggestive of tumor-induced osteomalacia, it is crucial to perform a meticulous examination to detect the tumor or the lesion responsible for the tumor. The serum level of fibroblast growth factor 23 is the most reliable marker for evaluating the treatment outcome of tumor-induced osteomalacia.     

神经导航下经胼胝体-穹窿间入路切除丘脑胶质瘤的临床应用价值分析

目的:探讨神经导航系统辅助下经胼胝体-穹窿间入路手术切除丘脑胶质瘤的临床应用价值。方法:选择2016年2月至2018年9月我院收治的丘脑胶质瘤患者60例为研究对象,以其中采用神经导航系统辅助下的经胼胝体-穹隆间入路显微切除丘脑胶质瘤的30例患者作为实验组,另外30例采用常规手术切除的患者作为对照组。分析和比较两组手术情况、治疗效果及并发症的发生情况。结果:治疗后,实验组手术时间、住院时间均比对照组明显缩短,术中出血量及术中引流量显著少于对照组(均P0.05);实验组肿瘤全切除率高于对照组,次全切除率及部分切除率均低于对照组(P0.05);实验组并发症发生率(20.0%)显著低于对照组(53.3%)(P0.05)。结论:与常规手术相比,神经导航系统辅助下经胼胝体-穹窿间入路切除丘脑胶质瘤能显著缩短手术时间,减少术中出血量及术后引流量,显著提高丘脑肿瘤全切除率,并降低术后并发症的发生率。     

Lymphocyte-Related Inflammation and Immune-Based Scores Predict Prognosis of Chordoma Patients After Radical Resection

The inflammatory microenvironment plays a critical role in the development and progression of malignancies. In the present study, we aimed to evaluate the prognostic value of lymphocyte-related inflammation and immune-based prognostic scores in patients with chordoma after radical resection, including the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), and systemic immune-inflammation index (SII). A total of 172 consecutive patients with chordoma who underwent radical resection were reviewed. R software was used to randomly select 86 chordoma patients as a training set and 86 chordoma patients as a validation set. Potential prognostic factors were also identified, including age, sex, tumor localization, KPS, Enneking stage, tumor size, and tumor metastasis. Overall survival (OS) was calculated using the Kaplan–Meier method and multivariate Cox regression analyses. NLR, PLR, SII, Enneking stage, tumor differentiation and tumor metastasis were identified as significant factors from the univariate analysis in both the training and validation sets and were subjected to multivariate Cox proportional hazards analysis. The univariate analysis showed that NLR ≥1.65, PLR ≥121, and SII ≥370×10⁹/L were significantly associated with poor OS. In the multivariate Cox proportional hazard analysis, SII, Enneking stage and tumor metastasis were significantly associated with OS. As noninvasive, low-cost, reproducible prognostic biomarkers, NLR, PLR and SII could help predict poor prognosis in patients with chordoma after radical resection. This finding may contribute to the development of more effective tailored therapy according to the characteristics of individual tumors.     

保乳手术联合放射治疗84例乳腺癌患者临床疗效观察

目的:观察保乳手术联合放射治疗乳腺癌患者临床疗效。方法:选取我院收治的乳腺癌患者84例,均采取保乳手术联合放射治疗,观察临床疗效。结果:所有患者手术均获得成功,84例乳腺癌患者均在出院后进行随访,平均随访时间(2.1±0.4)年,各项检查未发现复发迹象。在放疗的期间内,乳房出现刺痛、发痒的不适患者20例,皮肤色素沉着、红斑的患者37例,在治疗后发生湿性脱皮患者10例,放射性食管炎患者8例;在放疗结束1个月,出现反射性肺炎患者2例。手术及放疗后,患者乳房的美容效果中优秀患者49例,良好患者29例,较差患者6例;行肿瘤扩大切除术患者优秀率高于行象限切除术患者,差异有统计学意义(P0.05)。结论:保乳手术联合放疗可保证治疗效果,同时降低并发症的发生,有利于美观,是一种优秀的乳腺癌治疗方法。     

腹腔镜下头侧中间入路治疗直肠癌患者的近期疗效及对第253组淋巴结的清扫效果分析

摘要 目的：分析头侧中间入路对腹腔镜直肠癌患者的近期疗效及第253组淋巴结的清扫效果。方法：2017年6月到2020年6月选择在江苏省中医院诊治的80例直肠癌作为研究对象,根据手术入路方式的不同分为中间组42例与外侧组38例。所有患者都给予腹腔镜直肠癌根治术治疗,中间组采用头侧中间入路,外侧组给予外侧入路,记录与随访近期疗效及第253组淋巴结的清扫效果。结果：所有患者手术过程顺利,吻合后系膜、肠管均无张力;中间组的第253组淋巴结清扫时间少于外侧组(P<0.05),两组的第253组淋巴结清扫数量对比差异无统计学意义(P>0.05)。两组的手术时间、术中出血量对比差异无统计学意义(P>0.05),中间组的术后肛门首次排气时间、术后拔除引流管时间、术后住院时间显著少于外侧组(P<0.05)。中间组术后9个月的肠梗阻、吻合口漏、吻合口出血、切口感染等并发症发生率为4.8 %,显著低于外侧组23.7 %(P<0.05)。所有患者术后随访9个月,中间组的复发率为2.4 %,显著低于外侧组的15.8 %(P<0.05)。结论：头侧中间入路在腹腔镜直肠癌患者中的应用能提高第253组淋巴结的清扫效率,促进患者康复,减少术后并发症的发生,降低近期复发率。     

Skull base tumors: a comprehensive review of transfacial swing osteotomy approaches

Numerous techniques have been proposed for the resection of skull base tumors, each one unique with regard to the region exposed and degree of technical complexity. This study describes the use of transfacial swing osteotomies in accessing lesions located at various levels of the cranial base. Eight patients who underwent transfacial swings for exposure and resection of cranial base lesions between 1996 and 2002 were studied. The mandible was the choice when wide exposure of nasopharyngeal and midline skull base tumors was necessary, especially when they involved the infratemporal fossa. The midfacial swing osteotomy was an option when access to the entire clivus was necessary. An orbital swing approach was used to access large orbital tumors lying inferior to the optic nerve and posterior to the globe, a region that is often difficult to visualize. Gross total tumor excision was possible in all patients. Six patients achieved disease control and two had recurrences. The complications of cerebrospinal fluid leak, infection, hematoma, or cranial nerve damage did not occur. After surgery, some patients experienced temporary symptoms caused by local swelling. The aesthetic result was considered good. Transfacial swing osteotomies provide a wide exposure to tumors that occur in the central skull base area. Excellent knowledge of the detailed anatomy of this region is paramount to the success of this surgery. The team concept is essential; it is built around the craniofacial surgeon and an experienced skull base neurosurgeon.