醛固酮瘤的诊断和治疗
摘要
目的提高醛固瘤的临床诊断和治疗水平。
资料和方法回顾性分析41例醛固酮瘤病例的临床资料,包括临床诊断、术前准备及手术方式等。
结果以头晕、头痛为首发症状者33例,占80.5%,以肌无力为首发症状表现6例(14.6%)。具有头痛、头晕症状者35例(85.4%),肌无力20例(48.9%);同时具有头痛、头晕、肌无力三症状的典型临床表现者16例(39.0%)。37例(90.2%)有高血压症状,血压波动范围140～220/90～140mmHg,平均180/120 mmHg。低血钾(血钾浓度<3.5mmol/L)22例(53.6%),血钾水平1.86～3.01(2.52±0.86)mmol/L。41例血浆醛固酮均升高。38例患者行体位激发试验, 23例(60.5%)患者直立位时醛固酮水平较卧位时降低、不变或升高幅度小于30%, 15例(39.5%)醛固酮升高幅度大于30%。所有病例均有影像学检查并都有影像学阳性发现,其中B超、CT、MRI检查肿瘤阳性发现率分别为85.4%, 94.1%与90.9%。41例患者均为单侧单发肾上腺肿瘤,其中左侧肾上腺腺瘤25例(61.0%),右侧16例(39.0%)。41例均采用手术治疗,麻醉均采用全麻。术前所有高血压病例采用口服安体舒通控制血压,血压控制欠佳者加用其他类降压药,低血钾病例以口服或静脉给药方式补充氯化钾,待血钾升至3. 5 mmol/L以上时,行手术治疗。其中21例行开放性手术,20例行后腹腔镜手术。病灶处理方式为患侧肾上腺部分切除或肿瘤切除。全部患者均经手术成功切除肿瘤,无手术死亡病例,所有患者均安全渡过围手术期,未发现严重术后并发症。术后病理报告均符合肾上腺皮质腺瘤。在37例术前高血压病例中,术后血压恢复正常34例(91.9%) ,其中在术后1个月内血压恢复正常26例,在术后2～3个月内血压恢复正常4例。另外7例术后血压仍高于正常,但较术前水平下降,应用降压药物疗效满意。所有术前低血钾及肌无力病例术后未再发生低血钾及肌无力。所有病例术后复查B超皆未发现患侧肿瘤复发。术后仍高血压病例亦未发现对侧肾上腺肿瘤。
结论临床表现、生化检查、影像学检查及病理检查结果是醛固瘤的诊断主要依据。手术切除肿瘤是一有效的治疗措施,充分的术前准备是手术成功的保证。
Purpose: To study and improve the clinical diagnosis and treatment level of aldosteronoma.
Materials and Methods 41 cases of aldosteronoma (or aldosterone-producing adenoma, APA) were analyzed retrospectively. Parameters examined included clinical diagnosis, preoperative preparation and operative access.
Results 33 cases (80.5%)had dizziness and headache as the first clinical manifestation, and 6 cases had amyosthenia as the first clinical manifestation. 35 cases (85.4%) had dizziness and headache , and 20 cases(48.8%) had amyosthenia.16 cases (39.0%) simultaneously had symptom of dizziness , headache and myasthenia. By biochemistry test of blood, 22 patients , accounting for 53.6%, were found hypokalemia (potassium concentration< 3.5mmol/L), with a range between 1.86～3.01(2.52±0.86)mmol/L. Of all the 41 cases, 37cases (90.2%) had hypertension. All cases were with aldosterone excess. In 38 patients who underwent posture– test, decrease of the plasma aldosterone after posture– test was found in 23 patients(60.5%), and increase in 15 patients(39.5%). Each case underwent at least one kind of medical imaging investigations and all had positive discovery of tumour .The positive rate of tumor discovery by B-ultrasonography, CT and MRI was 85.4%, 94.1% and 90.9% respectively. Only one tumour was found in each case.25 cases(61.0%) was found a tumour in the left adrenal gland and 16 in the right. All cases underwent an operation with general anesthesia. In cases of hypertension, spironolactone was administrated preoperatively as the main drug to control blood pressure, and other kind of antihypertensive drugs were needed if the blood pressure could not be controlled under an ideal level. Potassium chloride was prescribed to patients with hypokalemia to increase the blood potassium concentration above 3.5mmol/L befove operation. 21 patients underwent open surgery and 20 patients underwent laparoscopic adrenalectomy. Resection of adenoma or partial excision of adrenal gland were successfully performed in all the cases, and no one died. No severe postoperative complications were ot observed. All tumours resected were pathologically diagnosed as adrenocortical adenoma. Of all the 37 cases with hypertension, 34 patients(91.9%) resume normal blood pressure level after operation. Among them, 26 patients recovered the blood pressure to normal during the first month after operation and 4 patients during 2 or 3 months after operation. In other cases with preoperative hypertension, the postoperative blood pressure was still higher than normal level, but lower than the preoperation level, and could be dominated under an ideal level with antihypertensive drugs. No patient with hypokalemia and amyosthenia preoperatively resumed hypokalemia and amyosthenia after operation. No recurrence of tumour was found by B-ultrasonography postoperatively. And in cases with hypertension postoperatively no tumour was discovered in the contralateral adrenal gland.
Conclusions Diagnosing aldosteronoma was mainly based on clinical manifestations, biochemical test of blood , medical imaging investigation and pathological diagnosis. Surgical management was the only effective way to cure and only sufficient preoperative preparation can ensure the success of the operation.
资料和方法回顾性分析41例醛固酮瘤病例的临床资料,包括临床诊断、术前准备及手术方式等。
结果以头晕、头痛为首发症状者33例,占80.5%,以肌无力为首发症状表现6例(14.6%)。具有头痛、头晕症状者35例(85.4%),肌无力20例(48.9%);同时具有头痛、头晕、肌无力三症状的典型临床表现者16例(39.0%)。37例(90.2%)有高血压症状,血压波动范围140～220/90～140mmHg,平均180/120 mmHg。低血钾(血钾浓度<3.5mmol/L)22例(53.6%),血钾水平1.86～3.01(2.52±0.86)mmol/L。41例血浆醛固酮均升高。38例患者行体位激发试验, 23例(60.5%)患者直立位时醛固酮水平较卧位时降低、不变或升高幅度小于30%, 15例(39.5%)醛固酮升高幅度大于30%。所有病例均有影像学检查并都有影像学阳性发现,其中B超、CT、MRI检查肿瘤阳性发现率分别为85.4%, 94.1%与90.9%。41例患者均为单侧单发肾上腺肿瘤,其中左侧肾上腺腺瘤25例(61.0%),右侧16例(39.0%)。41例均采用手术治疗,麻醉均采用全麻。术前所有高血压病例采用口服安体舒通控制血压,血压控制欠佳者加用其他类降压药,低血钾病例以口服或静脉给药方式补充氯化钾,待血钾升至3. 5 mmol/L以上时,行手术治疗。其中21例行开放性手术,20例行后腹腔镜手术。病灶处理方式为患侧肾上腺部分切除或肿瘤切除。全部患者均经手术成功切除肿瘤,无手术死亡病例,所有患者均安全渡过围手术期,未发现严重术后并发症。术后病理报告均符合肾上腺皮质腺瘤。在37例术前高血压病例中,术后血压恢复正常34例(91.9%) ,其中在术后1个月内血压恢复正常26例,在术后2～3个月内血压恢复正常4例。另外7例术后血压仍高于正常,但较术前水平下降,应用降压药物疗效满意。所有术前低血钾及肌无力病例术后未再发生低血钾及肌无力。所有病例术后复查B超皆未发现患侧肿瘤复发。术后仍高血压病例亦未发现对侧肾上腺肿瘤。
结论临床表现、生化检查、影像学检查及病理检查结果是醛固瘤的诊断主要依据。手术切除肿瘤是一有效的治疗措施,充分的术前准备是手术成功的保证。
Purpose: To study and improve the clinical diagnosis and treatment level of aldosteronoma.
Materials and Methods 41 cases of aldosteronoma (or aldosterone-producing adenoma, APA) were analyzed retrospectively. Parameters examined included clinical diagnosis, preoperative preparation and operative access.
Results 33 cases (80.5%)had dizziness and headache as the first clinical manifestation, and 6 cases had amyosthenia as the first clinical manifestation. 35 cases (85.4%) had dizziness and headache , and 20 cases(48.8%) had amyosthenia.16 cases (39.0%) simultaneously had symptom of dizziness , headache and myasthenia. By biochemistry test of blood, 22 patients , accounting for 53.6%, were found hypokalemia (potassium concentration< 3.5mmol/L), with a range between 1.86～3.01(2.52±0.86)mmol/L. Of all the 41 cases, 37cases (90.2%) had hypertension. All cases were with aldosterone excess. In 38 patients who underwent posture– test, decrease of the plasma aldosterone after posture– test was found in 23 patients(60.5%), and increase in 15 patients(39.5%). Each case underwent at least one kind of medical imaging investigations and all had positive discovery of tumour .The positive rate of tumor discovery by B-ultrasonography, CT and MRI was 85.4%, 94.1% and 90.9% respectively. Only one tumour was found in each case.25 cases(61.0%) was found a tumour in the left adrenal gland and 16 in the right. All cases underwent an operation with general anesthesia. In cases of hypertension, spironolactone was administrated preoperatively as the main drug to control blood pressure, and other kind of antihypertensive drugs were needed if the blood pressure could not be controlled under an ideal level. Potassium chloride was prescribed to patients with hypokalemia to increase the blood potassium concentration above 3.5mmol/L befove operation. 21 patients underwent open surgery and 20 patients underwent laparoscopic adrenalectomy. Resection of adenoma or partial excision of adrenal gland were successfully performed in all the cases, and no one died. No severe postoperative complications were ot observed. All tumours resected were pathologically diagnosed as adrenocortical adenoma. Of all the 37 cases with hypertension, 34 patients(91.9%) resume normal blood pressure level after operation. Among them, 26 patients recovered the blood pressure to normal during the first month after operation and 4 patients during 2 or 3 months after operation. In other cases with preoperative hypertension, the postoperative blood pressure was still higher than normal level, but lower than the preoperation level, and could be dominated under an ideal level with antihypertensive drugs. No patient with hypokalemia and amyosthenia preoperatively resumed hypokalemia and amyosthenia after operation. No recurrence of tumour was found by B-ultrasonography postoperatively. And in cases with hypertension postoperatively no tumour was discovered in the contralateral adrenal gland.
Conclusions Diagnosing aldosteronoma was mainly based on clinical manifestations, biochemical test of blood , medical imaging investigation and pathological diagnosis. Surgical management was the only effective way to cure and only sufficient preoperative preparation can ensure the success of the operation.
引文
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[44] 陈俊星,丘少鹏,陈祎,等. 后腹腔镜肾上腺手术经验体会附 186 例报告[J]. 中国内镜杂志,2004,10(7):50-52.
[45] W U ZP, XU DF. Laparoscope adrenalectomy tumors of retroperi- toneal[J].China Journal of Endoscopy,2004,10(2):86-88.
[46] 马潞林 ,那彦群.减少腹腔镜手术并发症 ,推动我国腹腔镜泌尿外科发展.中国微创外科杂志 ,2004 ,2:89 - 90.
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[49] Meria P, KempfBF, Hermieu JF, et al. Laparoscopic managementofprimary aldosteronism: clinical experience with 212 cases [J]. J Urol, 2003, 169 ( 1 ) : 32 – 35.
[50] 刘定益,张 宇,邵远,等. 影响肾上腺皮质醛固酮瘤术后血压恢复的相关因素分析[J]. 中华外科杂志,2004 .42 (10):587-589.
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