Ipofisectomia transfenoidale nel cane

Sara Del Magno, Med Vet

Ipofisectomia transfenoidale nel cane

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L’ipofisectomia transfenoidale rappresenta una terapia efficace per il trattamento degli adenomi ipofisari; tuttavia pochi centri veterinari propongono questa opzione terapeutica.

La tecnica chirurgica prevede un approccio transorale, transfenoidale con rimozione completa della ghiandola ipofisaria. In caso di macroadenomi il chirurgo mira ad asportare quanto più tessuto neoplastico possibile per migliorare e prolungare la vita del paziente.

La diagnostica per immagini avanzata è necessaria per ottenere una localizzazione precisa della fossa ipofisaria e informazioni dettagliate sulla forma, dimensioni ed estensione della neoplasia.

Nonostante le difficoltà gestionali del paziente, la percentuale di mortalità perioperatoria riportata risulta contenuta (da 8-16%) così come la percentuale di recidive. Quest’ultima aumenta in caso di macroadenomi.

Lo scopo di questa review è di analizzare la tecnica chirurgica e la gestione del paziente nel periodo perioperatorio, evidenziando la necessità di una curva di apprendimento per l’esecuzione della chirurgia e la gestione perioperatoria da parte di più specialisti.

Dipartimento di Scienze Mediche Veterinarie, Alma Mater Studiorum, Ozzano dell’Emilia (BO)

Via Tolara di Sopra, 50, 40060 Ozzano dell’Emilia (BO)

* Corresponding Author (luciano.pisoni@unibo.it)

Ricevuto: 23/01/2015 - Accettato: 13/04/2015 Luciano Pisoni*,

Med Vet, PhD

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Nel cane è necessario asportare completamente la ghiandola per ridurre le probabilità di lasciare porzioni di tessuto tumorale in situ.

Figura 1 - Cranio di cane sezionato longitudinalmente, la freccia rossa indica l’osso sfenoide che forma la fossa hypophysialis. La freccia azzurra indica un processo amulare, utilizzato dal chirur- go per localizzare la posizione dell’ipofisi (Done SH, Goody PC, Evans SA, Stickland NC, Color Atlas of Veterinary Anatomy. The dog and cat, modificato).

Figura 2 - Veduta dorsale della base del cranio in seguito ad asportazione dell’encefalo (è rimasta parte dei lobi olfattori). No- tare i nervi ottici recisi (frecce bianche), uno dei due nervi oculo- motore reciso (freccia nera), il seno cavernoso (triangolo nero) e la fossa in cui è alloggiata l’ipofisi (fossa hypophysialis).

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L’ipofisi è posta ventralmente al diencefalo, all’interno di una “culla” definita fossa hypophisialis. La posizione dell’ipofisi rispetto alle prominenze ossee del cranio è variabile a seconda della morfologia del cane.

Figura 3 - Immagine di tomografia computerizzata in sezione tra- sversa del cranio di un cane, maschio, bassotto di 6 anni con sin- drome di Cushing, dopo somministrazione di mezzo di contrasto.

È evidente un adenoma ipofisario. I triangoli gialli indicano i pro- cessi amulari, poco pronunciati perché in questa posizione sono quasi terminati; la freccia rossa indica la superficie dello sfenoide che si presenta piatta in questo caso. Questi ultimi sono i punti di repere che il chirurgo utilizza per localizzare la posizione dell’ipo- fisi. (Per gentile concessione della Dott.ssa Federica Rossi)

Figura 4 - Risonanza magnetica del cranio di un cane, maschio, meticcio di 8 anni con sintomatologia neurologica. Sezione tra- sversa pesata in T1 dopo somministrazione di mezzo di contra- sto, è evidente un macroadenoma ipofisario asimmetrico verso destra.

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La via di accesso chirurgica, secondo la tecnica descritta da Meij nel 1997, è trans-orale, trans- sfenoidale.

Video 1 - http://cms.scivac.it/it/v/11327/1 Cane, Coton de Tulear, maschio di anni 9 affetto da ipercortisolismo ipofisi dipen- dente. Si noti l’andatura compulsiva del soggetto e la rarefazione del pelo caratteri- stica della Sindrome di Cushing. La tomo- grafia computerizzata ha messo in eviden- za un macroadenoma ipofisario di notevoli dimensioni in grado di spiegare la sintomatologia compulsiva.

Protocollo diagnostico pre-operatorio Esame emocromocitometrico, biochimico, coagulativo completo

Esame chimico-fisico delle urine ed esame batteriologi- co delle urine

Esame radiografico del torace Ecografia addominale

Esame elettrocardiografico ed ecocardiografico in caso di sospette alterazioni cardiache

Misurazione della pressione arteriosa non invasiva Prelievo per misurazione di ACTH endogeno prima della chirurgia

Tomografia computerizzata o risonanza magnetica nucleare

Tabella 1 Protocollo utilizzato prima della chirurgia per valutare i pazienti da sottoporre ad ipofisectomia.

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Figura 5 - Cane, maschio, Labrador, con sintomatologia endocri- na conseguente a panipopituitarismo. Posizionamento del cane in decubito sternale con la testa sollevata e la bocca aperta. La mascella viene ancorata su una barra tramite i canini, la mandibola viene posizionata mediante l’utilizzo di bende orlate. Il cranio è as- sicurato mediante cerotto ai supporti laterali montati sul tavolo per garantire l’immobilità della testa dell’animale. Il collo è supportato da un cuscino morbido. Il tavolo è inclinato di circa 30 gradi.

Figura 6 - Cane maschio, meticcio, di 9 anni con sintomatolo- gia neurologica, immagine intraoperatoria. Dopo l’incisione a tutto spessore del palato molle, questo viene divaricato con un divari- catore di Gelpi, si accede così al naso faringe e risulta evidente il mucoperiosto che ricopre l’osso sfenoide. Ai lati sono ben visibili i processi amulari (frecce bianche).

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Figura 7 - Cane, boxer, maschio, 6 anni, con sindrome di Cushing.

Immagine intraoperatoria, notare il palato molle che è stato inciso in posizione mediana, viene tenuto retratto da un divaricatore di Gelpi.

Il beccuccio metallico dell’aspiratore è in direzione del foro eseguito nell’osso sfenoide in corrispondenza della ghiandola ipofisaria, che è il tessuto rosato che protrude dal foro.

Figura 8 - Cane, femmina, 8 anni, galgo spagnolo, visione intrao- peratoria dopo la chiusura dello sfenoide con cera per ossa.

Figura 9 - Cane, femmina, 8 anni, galgo spagnolo, visione intrao- peratoria dopo la ricostruzione del palato molle.

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Terapia immediato periodo post-operatorio ANTIBIOTICO

Ampicillina e sulbactam 20 mg/kg q8h per 15 giorni ANALGESIA

Metadone Buprenorfina Tramadolo

0.1-0.2 mg/kg q4h per 1-2 giorni

15 µg/kg q6 h per 2 giorni 2 mg/kg q8 h per 7 giorni FLUIDOTERAPIA

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Durante chirurgia 10 ml/kg/h Poi velocità di infusione viene modificata in base all’output urinario SUPPLEMENTAZIONE

ORMONALE Idrocortisone Poi cortisone acetato Desmopressina Tiroxina

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A scalare fino 0.25 mg/kg q12 h

1 goccia (circa 5 µg) nel sacco congiuntivale q8h 15 µg/kg q12 h

TERAPIA

ANTICOAGULANTE Eparina calcica

150 UI/kg q8h

Tabella 2 Terapie necessarie nel primo periodo post-operatorio.

Terapia di mantenimento

SUPPLEMANTAZIONE ORMONALE

Cortisone acetato Levotiroxina Desmopressina

1 mg/kg q12h, a scalare in 4 settimane 0.25-0.5 mg/kg q12h a vita.

15 µg/kg q12h a vita.

1 goccia (circa 5 µg) nel sac- co congiuntivale q8h per 2-3 settimane, in alcuni soggetti a vita.

ANTIBIOTICO Amoxicillina e acido clavulanico

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ANALGESIA Buprenorfina Tramadolo

15 µg/kg q6-8 h per 2-3 giorni

2 mg/kg q8h per 5-7 giorni

FLUIDOTERAPIA

Il tipo varia a seconda delle alterazioni elettrolitiche

La quantità di fluidi varia in base all’output urinario del paziente, del peso del paziente e a quanta acqua assume il paziente per via orale

Tabella 3 Terapie di mantenimento e da continuare a vita dopo l’intervento d’ipofisectomia.

Video 2 - http://cms.scivac.it/it/v/11327/2 Primo giorno post-operatorio: cane, La- brador, maschio di 4 anni affetto da iper- cortisolismo ipofisi dipendente e ipovisio- ne. Il cane presentava un macroadenoma di grandi dimensioni (P/B value 0,9). Si noti la difficoltà nella deambulazione e il blefarospasmo.

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Una buona opzione potrebbe essere l’esecuzione dell’ipofisectomia associata a protocolli radioterapici.

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Video 3 - http://cms.scivac.it/it/v/11327/3 Primo giorno post-operatorio: cane, Bas- sotto, maschio di 7 anni affetto da ipercorti- solismo ipofisi dipendente. Il cane presenta- va un macroadenoma (P/B value 0,48), che non causava sintomatologia neurologica. Si noti la normale andatura del cane, che non mostrava alterazioni neurologiche.