2017年 · 第97卷第15期

Pituitary thyroid stimulating hormone (TSH) adenoma was developed by Jailer et al.^[1]It was first reported in 1960 that the clinical manifestation was hyperthyroidism (hereinafter referred to as hyperthyroidism). The first diagnosis was Graves' disease with pituitary lesions, and the symptoms of hyperthyroidism were significantly relieved after receiving radiotherapy for pituitary lesions. Therefore, it is considered that the primary lesion is located in the pituitary gland, and it is the hyperthyroidism caused by excessive secretion of TSH by the pituitary TSH adenoma. Pituitary TSH adenomas account for about 0.5% ~3.0% of pituitary adenomas^[2]The incidence is less than 1 million people^－1· Years^－1[3]It is a rare disease, common in 30-60 years old, and there is no significant difference in incidence between men and women. Although pituitary TSH adenoma is not common in patients with central hyperthyroidism, its treatment is completely different from that of primary hyperthyroidism. Using commonly used treatment measures for primary hyperthyroidism not only fails to control central hyperthyroidism, but will aggravate the risk of pituitary adenoma. Therefore, correct diagnosis is the prerequisite for appropriate treatment^[4]。 The diagnosis of pituitary TSH adenoma is difficult, and requires high level of laboratory examination, imaging diagnosis and clinician diagnosis and treatment. Due to the uneven level of hospitals in various regions of China, the phenomenon of misdiagnosis and mistreatment emerges one after another, which brings unnecessary harm to patients. Based on this situation, the diagnosis and treatment of TSH should be paid attention to and standardized.

On the occasion of the publication of the Expert Consensus on the Diagnosis and Treatment of Pituitary Thyroid Stimulating Hormone Adenoma in China (2017) (hereinafter referred to as this consensus), this article is written at the invitation of Professor Wang Renzhi, leader of China Pituitary Tumor Collaboration Group. On the one hand, I would like to congratulate the publication of this consensus. On the other hand, I would like to introduce the purpose of writing this consensus, the writing process and the problems that need to be solved in the future from the perspective of the main participants and writers, so that doctors in hospitals in various regions and levels can understand this consensus more comprehensively in clinical practice and use it more appropriately, so that it can play a greater value in clinical diagnosis and treatment, and finally achieve the purpose of improving the diagnosis and treatment level of pituitary thyroid stimulating hormone (TSH) adenoma in China.

In the first half of the 20th century, the legal professional thinking mode was advocated, and it was indestructible^[1]。 By the second half of the 20th century, the number of medical lawsuits in many countries exploded, the medical contradiction intensified day by day, and both doctors and patients fell into "litigation burden"^[2]。 Facing the challenges of the society, the legal profession and the legal circles began to change their ideas and explore to promote the judicial reform. Non-litigation and harmony have become a value orientation that human society pursues together, and the value of mutual respect and tolerance has been paid full attention to. China is no exception. In recent years, with the improvement of people's knowledge level and the enhancement of the concept of rule of law, medical disputes are also increasing constantly. How to alleviate these contradictions is also a specific problem faced by hospitals at all levels. Now on the medical dispute in our country the people's mediation and litigation mechanism of the related issues are expounded as follows.

Pituitary thyroid stimulating hormone (TSH) adenoma is a type of functional pituitary adenoma, which is the main cause of central hyperthyroidism (hereinafter referred to as hyperthyroidism). The clinical features were increased serum free thyroid hormone (FT4, FT3) levels, uninhibited serum TSH levels, accompanied by different degrees of thyrotoxicosis and goiter. TSH adenomas are rare, with an incidence of less than 1 million people^－1· Years^－1[1]0.5% to 3.0% of pituitary adenomas^[2]At present, there are few reports in domestic and foreign literatures^[3,4,5,6]。 In recent years, with the increasing sensitivity of TSH detection technology and the widespread use of imaging techniques such as magnetic resonance (MRI), the detection and diagnosis rate of TSH adenoma has increased obviously^[7]。 TSH adenomas are often misdiagnosed as primary hyperthyroidism, especially as toxic diffuse goiter (Graves disease), and are mistreated with subtotal thyroidectomy or radioiodine therapy, which instead promotes the enlargement of TSH adenomas. Therefore, it is necessary to guide and standardize the diagnosis and treatment of TSH adenoma.

Permanent intertissue implantation of radioactive particles (abbreviated as seed implantation) has become a standard treatment for early prostate cancer. The guidelines of American Cancer Society, Urology Society, Clinical Oncology Society, Radiation Oncology Society, Close Society and NCCN have been popularized and popularized as standards^[1,2,3]。 Because prostate cancer seed implantation treatment is guided by transrectal ultrasound, combined with perineal template technology, the accurate three-dimensional distribution of particles in the prostate is realized, and the dose is highly conformal, so as to increase the dose and achieve the purpose of radical cure of tumors. Because the tumors in the head and neck, chest, abdomen and pelvic cavity are affected by bone structure, gas and organ movement, it is difficult to achieve intraoperative image acquisition, three-dimensional reconstruction and guided seed implantation by ultrasound technology. In 2002, Chinese scholars creatively introduced CT guidance technology into the field of seed implantation therapy for the first time in the world. Combining 4D-CT scanning technology, punching technology and fixed needle technology to overcome the influence of gas, bone structure and organ movement, established the standard of CT guidance seed implantation therapy, greatly improved the accuracy of seed implantation therapy, broadened the application scope of seed implantation therapy, enriched and developed seed implantation brachytherapy, and published a series of research results^{[4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31]}。 However, there is no systematic research and report on the technical specifications and standards of CT guidance at present. This consensus mainly discusses the technical process of CT guidance particle implantation, and the efficacy and research results will be reported one after another with clinical research.

Case 1, male, 65 years old, was admitted to the Department of Neurology, Naval General Hospital on November 17, 2015 due to "episodic unconsciousness after eating for more than 2 months". The patient intermittently experienced dizziness after eating more than 2 months ago, followed by unconsciousness, and regained consciousness in the recumbent position for about several minutes. The self-measured blood pressure in the recumbent position was as low as 80/40 mmHg (1 mmHg =0.133 kPa), about 4 times/month. Follow-up medical history: The patient has left deviation since 2009, constipation in 2010, frequent urination and sexual dysfunction in 2012, and has not seen a doctor. Previous history of hypertension for 7 years, up to 180/110 mmHg in recumbent position, poor blood pressure control. Physical examination at admission: blood pressure 170/90 mmHg in the recumbent position, 90/60 mmHg in the standing position, and 80/50 mmHg in the recumbent position within 2 h after a meal. Forced laughter, positive palmopenial reflex, positive perioral reflex, normal muscle strength of limbs, increased muscle tone of limbs, active reflexes of bilateral biceps brachii, triceps brachii and Achilles tendon, positive bilateral Babinski sign and Chaddock sign, mutaxia and limb sensation were not abnormal. Auxiliary examination: MRI of the head showed atrophy of the pons and cerebellum, and the "cross" sign was seen in the pons (Figure 1，Figure 2)。 There were no abnormalities in blood routine, biochemistry and complete set of tumors. Video EEG examination after a full meal showed no abnormalities. Self-rated measures of anxiety and depression indicate mild depression and severe anxiety. Minimal Intelligence Status Scale (MMSE) 25 points. montreal cognitive assessment (MoCA) 18 points. Pancreatic CT showed no abnormalities. Anal sphincter electromyography (EAS-EMG) and urethral sphincter electromyography (US-EMG) showed a prolonged time limit of light contraction action potential and a simple phase of vigorous contraction recruitment potential (Table 1)。 Cutaneous sympathetic response (SSR): no waveform was elicited. Multiple system atrophy (MSA) was clinically confirmed. Treatment: Drinking water after meals, eating less carbohydrates, small meals and other changes in dietary patterns, and giving improved cocktail therapy on drugs, and the symptoms improved.

The patient Qiu, female, 50 years old, was admitted to the Department of Neurology, Suzhou Hospital affiliated to Nanjing Medical University on May 23, 2016 due to "headache for 10 years with blurred vision in the left eye for 5 h". The patient had a history of headache for more than ten years, mainly located in the left occipital region, and in severe cases, it involved pain in the forehead and around the orbit. It occurs 3 to 5 times a year, each time lasting from several days to half a month, and the headache lasts from 4 to 72 hours at the time of the attack. It is a left pulsatile headache, accompanied by photophobia and phonophobia. It is afraid to move during the attack, and there is no visual or sensory aura before the attack. This time, due to headache 1 d later, I felt blurred vision in my left eye and went to the ophthalmology department of our hospital. I found that my left eye pupil was dilated and my intraocular pressure was normal. The corresponding ophthalmic diseases were excluded and I was transferred to the neurology department for treatment. During the course of the disease, there were no nausea, vomiting, limb twitching, limb weakness, numbness, and loss of consciousness. Constipation for many years, no abnormalities in urination, sleep at night can. Deny history of other medical diseases, infectious diseases, drug allergies and blood transfusions. Physical examination: clear consciousness, normal cognitive function, physical examination cooperation, left pupil diameter 5.0 mm, right pupil diameter 2.0 mm, direct and indirect light reflection, no abnormality in all directions of eyeball movement, no nystagmus, other cranial nerve, muscle tone, muscle strength, mutaxia, reflex, sensation, meningeal irritation signs and other examinations were not abnormal. After admission, there were no obvious abnormalities in blood routine, biochemical complete set, coagulation series, immune series and thyroid function. Lumbar puncture CSF pressure 78 mmH₂O (1 mmH₂O =0.009 8 kPa), clear and transparent color, red blood cells 0×10⁶/L, white blood cells 2×10⁶/L, total protein 195 mg/L, albumin 137 mg/L, sugar quantity 4.10 mmol/L, chloride 129.3 mmol/L. Cryptococcus neoformans was not found by ink staining. MRI + TOF-MRA of the skull showed a few lacunar foci in the right basal ganglia area. Ophthalmologic consultation measurement of intraocular pressure, fundus and optical coherence tomography (OCT) examination showed no abnormalities. There were no abnormalities in EEG. After admission, the pupil gradually recovered after 3 days of intravenous infusion of normal saline 100 ml + dexamethasone 10 mg, and the pupil diameter returned to normal after 5 days of discharge. There was no recurrence of dilated pupils after 1 month and half-year follow-up.

AS a common type I allergic disease, allergic airway diseases are mainly mediated by immunoglobulin E (IgE), among which allergic rhinitis (AR) and allergic asthma (AS) are more common. In recent years, the incidence of airway allergic diseases has been increasing rapidly, and its harm to health and the burden on society and economy have become a problem that cannot be ignored^[1]。

The pituitary stalk is an important structure connecting the pituitary gland and the hypothalamus. The most common lesion is pituitary stalk thickness (PST). pituitary stalk thickness is an imaging diagnosis, which leads to a wide spectrum of diseases. The etiological diagnosis of thickened pituitary stem has always been full of challenges due to various etiologies, hidden lesions, atypical clinical manifestations and special locations, and it is still a difficult point in the clinical work of endocrinology and neurosurgery. This article intends to summarize the progress in etiology, imaging features, clinical features, biopsy indications and prognosis of pituitary stem thickening as follows.