本文選題：內(nèi)分泌紊亂 + 腎上腺占位��； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：目的:分析、總結(jié)腎上腺占位的臨床特點(diǎn),探討腎上腺占位的臨床診斷和治療措施,以期提高其診治水平,改善臨床預(yù)后。對(duì)象和方法:以2006年1月-2015年12月山東大學(xué)附屬省立醫(yī)院內(nèi)分泌科就診發(fā)現(xiàn)的腎上腺占位作為研究對(duì)象。納入標(biāo)準(zhǔn)為以?xún)?nèi)分泌科為首診,并最終確定診斷為腎上腺占位的病人。根據(jù)納入標(biāo)準(zhǔn),共66例患者被納入該項(xiàng)研究。采用回顧性分析方法,查閱患者的臨床病例資料,如其基本資料、臨床表現(xiàn)、影像學(xué)檢查結(jié)果、內(nèi)分泌學(xué)檢查結(jié)果、占位特征等;對(duì)患者進(jìn)行回訪調(diào)查,并比較手術(shù)治療組與保守治療組患者預(yù)后的差別。結(jié)果:1.一般資料:共有66例病例符合篩選標(biāo)準(zhǔn)而納入本研究,其中男性28例,占42.4%,女性38例,占57.6%,男:女=1:1.36。病例年齡范圍22-85歲,平均年齡為47.68± 13.80歲。按治療方式大致分為兩組,手術(shù)治療組20例(30.3%),保守治療組46例(69.7%)�；颊咦≡簳r(shí)間3-30天(9.09±5.58),住院費(fèi)用 1799-27294 元(7466.62±5429.85)。2.疾病譜:此研究中,臨床診斷為單純腺瘤者25例,占37.9%;庫(kù)興綜合征者14例,占21.2%;原發(fā)性醛固酮增多癥者12例,占18.2%;未明確性質(zhì)者5例,占7.6%;皮質(zhì)結(jié)節(jié)狀增生5例,占7.6%;兒茶酚胺增多癥(嗜鉻細(xì)胞瘤)2例,占3.0%;腎上腺皮質(zhì)癌2例,占3.0%;節(jié)細(xì)胞神經(jīng)瘤1例,占1.5%。3.性別差異:患者的臨床類(lèi)型在不同性別間分布不同,庫(kù)興綜合征中明顯女性患者多于男性患者(χ2 =12.54,P=0.006)。且男性更容易發(fā)生電解質(zhì)紊亂,差別有統(tǒng)計(jì)學(xué)意義(χ2=10.93,P=0.027)。4.各年齡組差異:各年齡組中性別分布有差異,青年、中年組中女性居多,老年組中男性居多,差別有統(tǒng)計(jì)學(xué)意義(χ2 =6.45,P=0.04)。不同年齡分組間患者的高血壓病史差異無(wú)統(tǒng)計(jì)學(xué)意義,說(shuō)明腎上腺占位患者的高血壓病史與年齡無(wú)關(guān)。5.臨床表現(xiàn):患者臨床表現(xiàn)復(fù)雜,具有多樣化特點(diǎn)。以高血壓作為主要臨床表現(xiàn)者最常見(jiàn),共24例,占36.4%。出現(xiàn)電解質(zhì)紊亂者共29例,占43.9%,其中低鉀血癥26例,占39.4%,其余為低鈉血癥、低鈣血癥。即高血壓是最常見(jiàn)的就診原因,且常伴有低血鉀。6.實(shí)驗(yàn)室檢查:(1)所有病例均進(jìn)行血游離皮質(zhì)醇及晝夜節(jié)律測(cè)定,對(duì)庫(kù)興綜合征患者,其靈敏度(真陽(yáng)性人數(shù)/(真陽(yáng)性人數(shù)+假陰性人數(shù))*100%)為92.86%,特異度(即真陰性人數(shù)/(真陰性人數(shù)+假陽(yáng)性人數(shù))*100%)為71.15%。(2)所有病例均進(jìn)行腎素-血管緊張素-醛固酮測(cè)定,對(duì)原發(fā)性醛固酮增多癥患者,其靈敏度為58.33%,特異度為79.63%。(3)所有病例均進(jìn)行醛固酮/腎素比值測(cè)定。對(duì)原發(fā)性醛固酮增多癥患者,其靈敏度為66.67%,特異度為92.59%。(4)共3例病人進(jìn)行了尿香草苦杏仁酸測(cè)定,占總病例數(shù)4.55%。3例病人結(jié)果均在正常范圍內(nèi),后分別確診為庫(kù)興綜合征、嗜鉻細(xì)胞瘤、原發(fā)性醛固酮增多癥。(5)共3例病人進(jìn)行了血漿及尿兒茶酚胺類(lèi)物質(zhì)測(cè)定,該項(xiàng)檢查對(duì)嗜鉻細(xì)胞瘤患者檢出率為50.00%。(6)共14例患者進(jìn)行了小劑量地塞米松抑制試驗(yàn),占總病例數(shù)21.21%。對(duì)庫(kù)興綜合征患者,其靈敏度100%,特異度66.67%。(7)共12例患者進(jìn)行了大劑量地塞米松抑制試驗(yàn),占總病例數(shù)18.20%。在所有11例進(jìn)行此項(xiàng)試驗(yàn)的庫(kù)興綜合征患者中,此項(xiàng)試驗(yàn)結(jié)果均為陽(yáng)性。(8)共6例病人進(jìn)行了卡托普利試驗(yàn),占總病例數(shù)9.10%,對(duì)原發(fā)性醛固酮增多癥,其陽(yáng)性率50%。7.影像學(xué)檢查:(1)9例患者進(jìn)行了超聲檢查,占病例總數(shù)13.6%,檢查對(duì)占位成功診斷率為77.8%。(2)57例患者進(jìn)行了 CT檢查,占病例總數(shù)86.4%,對(duì)占位的成功診斷率為94.7%。CT顯示的占位直徑與實(shí)際直徑差異無(wú)統(tǒng)計(jì)學(xué)意義(Z=-4.32,P=0.67)。(3)8例患者進(jìn)行了核磁共振成像掃描(MRI),占病例總數(shù)12.1%,對(duì)占位的成功診斷率為100%。8.占位特點(diǎn):腎上腺占位位于左側(cè)者39例,占病例總數(shù)59.1%,位于右側(cè)者21例(31.8%),位于雙側(cè)者6例(9.1%)。占位為單發(fā)者59例(89.4%),多發(fā)者7例(10.6%)。占位性質(zhì)大多數(shù)為腺瘤,共46例,占總數(shù)69.7%,其中經(jīng)手術(shù)病理明確診斷的皮質(zhì)腺瘤10例,占總病例數(shù)15.2%。9.手術(shù)情況:20例患者經(jīng)手術(shù)治療,所行手術(shù)類(lèi)型皆為腹腔鏡手術(shù);17例行患側(cè)腎上腺切除術(shù),3例行患側(cè)腎上腺腫瘤切除術(shù)。手術(shù)時(shí)間30-300分鐘,手術(shù)期間出血量5-500 ml。術(shù)后引流時(shí)間3-9天(5.70±1.56)。手術(shù)組患者住院天數(shù) 5-30 天(11.70 ±7.88),住院費(fèi)用 1799-29274 元(7905.35 ±6594.76)。10.手術(shù)組與保守治療組對(duì)比:性別、占位位置、初發(fā)癥狀、臨床類(lèi)型分布等因素在兩組間差異均無(wú)統(tǒng)計(jì)學(xué)意義。兩組間占位直徑差異亦無(wú)統(tǒng)計(jì)學(xué)意義(Z=-1.43,P=0.152)。11.病理結(jié)果:患者獲明確病理診斷者共20人,占總體比例30.3%,而與臨床診斷一致者共19人,占明確診斷者95.0%。僅一例病例行免疫組化檢查,結(jié)果顯示 a-inhibin(+)syn(+)cga(-)s-100(-)ki-67 3%。12.回訪結(jié)果:本研究納入的66例患者中成功回訪57例,失訪率為13.6%�；颊呓�(jīng)治療后主要臨床表現(xiàn)顯著改善者32人,占回訪病例總數(shù)56.1%,癥狀略有改善者22人,占回訪病例總數(shù)38.6%,癥狀無(wú)改善者3例,占回訪病例總數(shù)5.3%;出院后定期進(jìn)行內(nèi)分泌學(xué)檢查者26例,其中檢查結(jié)果正常者18例,結(jié)果有異常者8例。根據(jù)保守治療組與手術(shù)治療組患者的回訪結(jié)果分析,手術(shù)組患者的主要癥狀改善狀況優(yōu)于保守治療組。結(jié)論:1.腎上腺占位患者中,以高血壓、低血鉀為主要表現(xiàn)的患者占最大比例;單純腺瘤、庫(kù)興綜合征、原醛、兒茶酚胺增多癥均是腎上腺占位重要的表現(xiàn)形式。2.定位診斷的影像學(xué)檢查當(dāng)中,CT應(yīng)用最廣,MRI則在診斷的靈敏度上表現(xiàn)突出。3.術(shù)后病理結(jié)果以腎上腺皮質(zhì)腺瘤所占比例最大,多分布于單側(cè),為單發(fā)性。4.腹腔鏡手術(shù)是治療良性腎上腺腫瘤的主要方法,長(zhǎng)期預(yù)后優(yōu)于保守治療組,但對(duì)部分癥狀不明顯或因其他原因不適合手術(shù)的患者,保守治療并長(zhǎng)期隨訪也不失為一種好的方法。
[Abstract]:Objective: to analyze and summarize the clinical characteristics of adrenal space occupying position and to explore the clinical diagnosis and treatment of adrenal space occupying position in order to improve the level of diagnosis and treatment and improve the clinical prognosis. The adrenal occupying sites in Department of Endocrinology, affiliated to the Provincial Hospital Affiliated to Shandong University, January 2006, in December -2015, were studied as the research object. According to the inclusion criteria, a total of 66 patients were included in the study. A retrospective analysis was used to refer to the patient's clinical data, such as basic data, clinical manifestations, imaging findings, endocrinological findings, occupying features, and so on. The difference of prognosis between the surgical treatment group and the conservative treatment group was compared. Results: 1. general data: a total of 66 cases were included in this study, including 28 men, 42.4%, 38 women, 57.6%, male: the age range of female =1:1.36. cases was 22-85 years, the average age was 47.68 + 13.80 years old. According to the method of treatment, the method was roughly the way of treatment. There were two groups, 20 (30.3%) in the operation group and 46 in the conservative treatment group (69.7%). The hospitalization time was 3-30 days (9.09 + 5.58) and the hospitalization cost was 1799-27294 yuan (7466.62 + 5429.85).2. disease spectrum. In this study, the clinical diagnosis was 25 cases of simple adenoma, accounting for 37.9%; %, 5 cases, 7.6%, 5 cases of cortical nodular hyperplasia, 7.6%, 2 cases of catecholamines (pheochromocytoma), 3%, 2 adrenocortical cancer, 3%, and 1 cases of ganglion neuroma, which accounted for 1.5%.3. sex differences: the clinical types of the patients were different from the same sex, and the female patients in the Cushing syndrome were more than the male patients. People (x 2 =12.54, P=0.006). And men were more likely to have electrolyte disorders, the difference was statistically significant (x 2=10.93, P=0.027).4. in all age groups: there were differences in gender distribution in all age groups, young, middle age group, and older group, with statistical significance (x 2 =6.45, P=0.04). Higher levels of patients in different age groups. There was no statistical difference in the history of blood pressure, indicating that the history of hypertension in the adrenal space occupying patients was not related to the age of.5.. The clinical manifestations of the patients were complex and diversified. Hypertension was the most common clinical manifestation, 24 cases, accounting for 29 cases of electrolyte turbulence, accounting for 43.9%, of which 26 cases of hypokalemia, accounting for 39., were 39.. 4%, the rest of hyponatremia and hypocalcemia, which is the most common cause of hypertension, and often accompanied by a low blood potassium.6. laboratory examination: (1) all cases were measured in blood free cortisol and circadian rhythm, and the sensitivity (true positive / (true positive + false negative) *100%) was 92.86% for patients with Cushing syndrome (that is, 92.86%). The true negative number / (true negative number + false positive) *100%) the renin angiotensin aldosterone determination for all cases of 71.15%. (2), the sensitivity of the patients with primary aldosteronism was 58.33%, and the specificity was 79.63%. (3) for all cases of aldosterone / renin ratio determination. For patients with primary aldosteronism, the patients were all cases of aldosteronism. The sensitivity was 66.67% and the specificity was 92.59%. (4). A total of 3 patients were measured in the urine vanilla bitter almond acid. The total number of cases in the total number of cases was in the normal range, and the results were confirmed as Cushing's syndrome, pheochromocytoma, primary aldosteronism. (5) a total of 3 patients were measured in plasma and urine catecholamines. The detection rate of pheochromocytoma was 50.00%. (6) in a total of 14 patients with a small dose of dexamethasone inhibition test. The total number of cases was 21.21%. to Cushing's syndrome. The sensitivity was 100% and the specificity of 66.67%. (7) in 12 patients with a large dose of dexamethasone inhibition test, accounting for the total number of cases of 18.20%. in all 11 cases. In the test, the results of the test were all positive. (8) a total of 6 patients were tested by Kato Pury, accounting for 9.10% of the total cases. The positive rate of the primary aldosteronism was 50%.7. imaging examination: (1) 9 cases were examined by ultrasound, accounting for 13.6% of the total cases, and the examination of the successful rate of 77.8%. (2) in 57 cases. The patients were examined by CT, accounting for 86.4% of the total cases. There was no statistically significant difference between the occupying diameter and the actual diameter (Z=-4.32, P=0.67). (3) 8 patients underwent magnetic resonance imaging (MRI), accounting for 12.1% of the total cases, and the successful diagnosis rate of the occupying position was 100%.8. occupying position: adrenal space occupying position. There were 39 cases in the left side, the total number of cases was 59.1%, 21 cases (31.8%) in the right side, 6 cases (9.1%) in bilateral, 59 cases (89.4%), 7 cases (10.6%), and 7 (10.6%). The majority of the occupying sites were adenoma, altogether 46 cases, accounting for 69.7%, among which the surgical pathology clearly diagnosed the cortical adenoma in 10 cases, accounting for the total cases 15.2%.9. operation situation: 20 cases. The patients underwent laparoscopic surgery, 17 cases with lateral adrenalectomy and 3 cases of side adrenal tumor resection. The operation time was 30-300 minutes. The amount of bleeding was 5-500 ml. after operation for 3-9 days (5.70 + 1.56). The number of patients in the operation group was 5-30 days (11.70 + 7.88) and the hospitalization cost 1799-29274. Compared with the conservative treatment group, there were no significant differences in gender, position, primary symptoms and clinical type distribution between the two groups. There was no significant difference between the two groups in the two groups. The difference between the two groups was also not statistically significant (Z=-1.43, P=0.152).11. pathological results: the patients received a clear pathological diagnosis of 20 people, accounting for a total of 30 .3%, and a total of 19 patients with clinical diagnosis, accounting for only one case of 95.0%., the results showed that A-inhibin (+) syn (+) CGA (-) S-100 (-) Ki-67 3%.12. return visit results: 57 cases were successfully returned in the 66 cases of this study, and the loss rate was 32 in the major clinical manifestations of the patients after the treatment. The total number of cases returned to visit 56.1%, the symptoms slightly improved 22 people, accounting for 38.6% of the return cases, 3 cases without improvement, accounting for 5.3% of the total return visits, 26 cases of regular endocrinology examination after discharge, among which 18 cases were normal, and 8 cases were abnormal. According to the return visits of the conservative treatment group and the surgical treatment group, the results of the return visit were analyzed, The main symptoms of the patients in the operation group were better than those in the conservative treatment group. Conclusion: 1. of the patients with adrenal space occupying the largest proportion of the patients with hypertension and hypokalemia, the simple adenoma, Cushing syndrome, primary aldehyde, and catecholamine are all the imaging findings of the.2. location diagnosis of adrenal occupying weight. CT is the most widely used, and MRI shows the sensitivity of the diagnosis on the sensitivity of.3. with the largest proportion of the adrenocortical adenoma, which is most distributed on the unilateral. The single.4. laparoscopy is the main method for the treatment of benign adrenal tumors. The long-term prognosis is superior to the conservative treatment group, but it is not obvious to some symptoms or not for other reasons. Conservative treatment and long-term follow up are also a good method for patients undergoing surgery.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R736.6;R586

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