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Fan Y, Guo S, Tao C, Fang H, Mou A, Feng M, Wu Z. Noninvasive radiomics approach predicts dopamine agonists treatment response in patients with prolactinoma: a multicenter study. Acad Radiol 2024:S1076-6332(24)00672-X. [PMID: 39332989 DOI: 10.1016/j.acra.2024.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 09/05/2024] [Accepted: 09/06/2024] [Indexed: 09/29/2024]
Abstract
RATIONALE AND OBJECTIVES The first-line treatment for prolactinoma is drug therapy with dopamine agonists (DAs). However, some patients with resistance to DA treatment should prioritize surgical treatment. Therefore, it is crucial to accurately identify the drug treatment response of prolactinoma before treatment. The present study was performed to determine the DA treatment response of prolactinoma using a clinical radiomic model that incorporated radiomic and clinical features before treatment. MATERIALS AND METHODS In total, 255 patients diagnosed with prolactinoma were retrospectively divided to training and validation sets. An elastic net algorithm was used to screen the radiomic features, and a fusion radiomic model was established. A clinical radiomic model was then constructed to integrate the fusion radiomic model and the most important clinical features through multivariate logistic regression analysis for individual prediction. The calibration, discrimination, and clinical applicability of the established models were evaluated. 60 patients with prolactinoma from other centers were used to validate the performance of the constructed model. RESULTS The fusion radiomic model was constructed from three significant radiomic features, and the area under the curve in the training set and validation set was 0.930 and 0.910, respectively. The clinical radiomic model was constructed using the radiomic model and three clinical features. The model exhibited good recognition and calibration abilities as evidenced by its area under the curve of 0.96, 0.92, and 0.92 in the training, validation, and external multicenter validation set, respectively. Analysis of the decision curve showed that the fusion radiomic model and clinical radiomic model had good clinical application value for DA treatment response prediction in patients with prolactinoma. CONCLUSION Our clinical radiomic model demonstrated high sensitivity and excellent performance in predicting DA treatment response in prolactinoma. This model holds promise for the noninvasive development of individualized diagnosis and treatment strategies for patients with prolactinoma.
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Affiliation(s)
- Yanghua Fan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing, China
| | - Shuaiwei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuming Tao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hua Fang
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Anna Mou
- Department of Radiology, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdu, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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2
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Tsai YH, Li CR, Wang YT, Chen SY. Feasibility of Early Surgical Treatment for Adolescent Patients with Prolactinoma: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1345. [PMID: 39202626 PMCID: PMC11356365 DOI: 10.3390/medicina60081345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/10/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024]
Abstract
Background and Objectives: Prolactinomas are the most common pituitary adenomas, comprising 30-50% of such tumors. These adenomas cause hyperprolactinemia, leading to decreased fertility, reduced energy and libido, and galactorrhea. Diagnosing and treating prolactinomas in adolescents present unique challenges, as symptoms may be confused with age-related developmental variations. This case report explores the outcomes of early surgical intervention in an adolescent with a prolactinoma. Materials and Methods: A 14-year-old female presented delayed menarche and absent pubertal development. Initial evaluation revealed hyperprolactinemia (228.37 ng/mL) with normal estradiol levels. Initial management through observation was adopted, but persistent amenorrhea and severe headaches prompted further investigation. Magnetic resonance imaging revealed a cystic pituitary mass with apoplexy. Due to concerns regarding delayed puberty and the need for rapid normalization of prolactin levels, the patient underwent transsphenoidal surgery. Results: After operation, prolactin levels normalized, menarche occurred within three months, and secondary sexual characteristics developed within eight months. Pathology confirmed a pituitary adenoma with a high Ki-67 index (15%). Conclusions: Early surgical intervention for prolactinomas in adolescents can achieve successful biochemical remission and resolution of endocrine symptoms. Adolescents, particularly those with a high Ki-67 index and potential resistance to dopamine agonists, may benefit from prompt surgical management, resulting in improved clinical outcomes and complete tumor resection.
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Affiliation(s)
- Yu-Hung Tsai
- Department of Neurosurgery, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
| | - Chi-Ruei Li
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yu-Ting Wang
- Department of Anatomical Pathology, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
- School of Medicine, College of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Se-Yi Chen
- Department of Neurosurgery, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
- School of Medicine, College of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
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3
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Findlay MC, Sabahi M, Azab M, Drexler R, Rotermund R, Ricklefs FL, Flitsch J, Smith TR, Kilgallon JL, Honegger J, Nasi-Kordhishti I, Gardner PA, Gersey ZC, Abdallah HM, Jane JA, Knappe UJ, Uksul N, Schroder HWS, Eördögh M, Losa M, Mortini P, Gerlach R, Antunes ACM, Couldwell WT, Budohoski KP, Rennert RC, Karsy M. The role of surgical management for prolactin-secreting tumors in the era of dopaminergic agonists: An international multicenter report. Clin Neurol Neurosurg 2024; 236:108079. [PMID: 38091700 DOI: 10.1016/j.clineuro.2023.108079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE First-line prolactin-secreting tumor (PST) management typically involves treatment with dopamine agonists and the role of surgery remains to be further explored. We examined the international experience of 12 neurosurgical centers to assess the patient characteristics, safety profile, and effectiveness of surgery for PST management. METHODS Patients surgically treated for PST from January 2017 through December 2020 were evaluated for surgical characteristics, outcomes, and safety. RESULTS Among 272 patients identified (65.1% female), the mean age was 38.0 ± 14.3 years. Overall, 54.4% of PST were macroadenomas. Minor complications were seen in 39.3% of patients and major complications were in 4.4%. The most common major complications were epistaxis and worsened vision. Most minor complications involved electrolyte/sodium dysregulation. At 3-6 months, local control on imaging was achieved in 94.8% of cases and residual/recurrent tumor was seen in 19.3%. Reoperations were required for 2.9% of cases. On multivariate analysis, previous surgery was significantly predictive of intraoperative complications (6.14 OR, p < 0.01) and major complications (14.12 OR, p < 0.01). Previous pharmacotherapy (0.27 OR, p = 0.02) and cavernous sinus invasion (0.19 OR, p = 0.03) were significantly protective against early endocrinological cure. Knosp classification was highly predictive of residual tumor or PST recurrence on 6-month follow-up imaging (4.60 OR, p < 0.01). There was noted institutional variation in clinical factors and outcomes. CONCLUSION Our results evaluate a modern, multicenter, global series of PST. These data can serve as a benchmark to compare with DA therapy and other surgical series. Further study and longer term outcomes could provide insight into how patients benefit from surgical treatment.
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Affiliation(s)
- Matthew C Findlay
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA; School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Mohammadmahdi Sabahi
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mohammed Azab
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA; Boise State University, Boise, ID, USA
| | - Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John L Kilgallon
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Isabella Nasi-Kordhishti
- Department of Neurosurgery, University Hospital Tübingen, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Paul A Gardner
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zachary C Gersey
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussein M Abdallah
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Nesrin Uksul
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Henry W S Schroder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Márton Eördögh
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Rüdiger Gerlach
- Department of Neurosurgery, Helios Kliniken, Erfurt, Germany
| | - Apio C M Antunes
- Department of Neurosurgery Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Michael Karsy
- Global Neurosciences Institute, Philadelphia, PA, USA; Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, PA, USA.
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Kalyvas A, Almeida JP, Nassiri F, Lau R, O'Halloran PJ, Mohan N, Wälchli T, Ye VC, Tang DM, Soni P, Potter T, Ezzat S, Kshettry VR, Zadeh G, Recinos PF, Gentili F. Endoscopic endonasal surgery for prolactinomas: prognostic factors for disease control and management of persistent disease. Neurosurg Rev 2023; 46:295. [PMID: 37940745 DOI: 10.1007/s10143-023-02199-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/19/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023]
Abstract
Only a limited number of studies have focused on the results of the Endoscopic Endonasal Approach (EEA) for treatment of prolactinomas. We sought to assess the effectiveness of EEA for prolactinoma surgery, identify factors for disease remission, and present our approach for the management of persistent disease. Forty-seven prolactinomas operated over 10 years, with a mean follow-up of 59.9 months, were included. The primary endpoints were early disease remission and remission at last follow-up. Resistance/intolerance to DA were surgical indications in 76.7%. Disease remission was achieved in 80% of microprolactinomas and 100% of microprolactinomas enclosed by the pituitary. Early disease remission was correlated with female gender (p=0.03), lower preoperative PRL levels (p=0.014), microadenoma (p=0.001), lack of radiological hemorrhage (p=0.001), absence of cavernous sinus (CS) invasion (p<0.001), and extent of resection (EOR) (p<0.001). Persistent disease was reported in 48.9% of patients, with 47% of them achieving remission at last follow-up with DA therapy alone. Repeat EEA and/or radiotherapy were utilized in 6 patients, with 66.7% achieving remission. Last follow-up remission was achieved in 76.6%, with symptomatic improvement in 95.8%. Factors predicting last follow-up remission were no previous operation (p=0.001), absence of CS invasion (p=0.01), and EOR (p<0.001). Surgery is effective for disease control in microprolactinomas. In giant and invasive tumors, it may significantly reduce the tumor volume. A multidisciplinary approach may lead to long-term disease control in three-quarters of patients, with symptomatic improvement in an even greater proportion.
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Affiliation(s)
- Aristotelis Kalyvas
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
| | | | - Farshad Nassiri
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ruth Lau
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Philip J O'Halloran
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nilesh Mohan
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Thomas Wälchli
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vincent C Ye
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Dennis M Tang
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Pranay Soni
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tamia Potter
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Shereen Ezzat
- Endocrine Oncology Site, Princess Margaret Cancer Center, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Varun R Kshettry
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Pablo F Recinos
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fred Gentili
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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5
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Kwancharoen R, Deerochanawong C, Peerapatdit T, Salvatori R. Pituitary adenomas registry in Thailand. J Clin Neurosci 2023; 115:138-147. [PMID: 37572520 DOI: 10.1016/j.jocn.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/25/2023] [Accepted: 07/29/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE Pituitary adenomas are the most common sellar tumors, and may cause adverse outcomes in terms of morbidity and mortality if left untreated or if diagnosis is delayed. No data exists on the prevalence, characteristics, and prognosis of pituitary adenomas in Thailand. The systematic registration of clinical characteristics may improve patient care and prognosis for this disease in Thailand. METHODS This was a retrospective study conducted in 11 academic referral centers. All patients diagnosed with pituitary adenomas during the 2011---2014 period were enrolled in the study. The information was correlated with two national databases. RESULTS A total of 1,283 pituitary adenoma patients were identified. The adenomas were: non-functioning 50.1%, prolactinoma 29.4%, acromegaly 14.7%, Cushing disease 3.8%, gonadotropin-producing tumor 1.0%, TSH-secreting tumor 0.6%. The mean age was 49.2±15.2 years. Sixty-three percent of patients were female. Most common complaint was visual impairment (27.7%). The average size of the tumor was 22.2±16.1 mm. Fifty-nine percent of patients underwent surgery. Median follow-up was 27.4 months (0-24 years). After treatment, 72.4% improved, and 10.4% were cured. Overall results of treatment in non-functioning adenoma, prolactinoma (medically treated), acromegaly, Cushing, TSH, gonadotropin producing adenoma were: improved/cured in 81/5.5, 86/5.7, 55.9/30, 54.2/31.2, 85.7/14.3, 69.2/15.4% respectively. CONCLUSION Pituitary adenomas in academic centers in Thailand were found predominantly in female in the 4th decade of life. After treatment 72.4% of patients improved and 10% had full recovery. A health promotion system aimed to improve patient and physician recognition and physician expertise may improve the prognosis of these diseases.
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Affiliation(s)
- Ratchaneewan Kwancharoen
- Division of Endocrinology and Metabolism, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand.
| | - Chaicharn Deerochanawong
- Division of Endocrinology and Metabolism, Rajavithi Hospital, College of Medicine, Rangsit University, Thailand
| | - Thawatchai Peerapatdit
- Division of Endocrinology and Metabolism, Faculty of Medicine Siriraj Hospital, Thailand
| | - Roberto Salvatori
- Division of Endocrinology and Metabolism Department of Medicine, Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Irfan H, Shafiq W, Siddiqi AI, Ashfaq S, Attaullah S, Munir Alvi A, Khan SA, Abu Bakar M, Azmat U. Prolactinoma: Clinical Characteristics, Management and Outcome. Cureus 2022; 14:e29822. [PMID: 36337795 PMCID: PMC9626374 DOI: 10.7759/cureus.29822] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2022] [Indexed: 12/31/2022] Open
Abstract
Aim Prolactinoma, a prolactin (PRL) secreting functioning pituitary tumor, is the most common of all pituitary adenomas (PA) accounting for 40-60% and dopamine agonists (DA) are the cornerstone of treatment. The aim of this study was to review the clinical presentation, treatment modalities and therapeutic outcomes of patients with prolactinomas in the South Asia region. Methods This retrospective study was conducted in the Endocrinology Department of Shaukat Khanum Memorial Cancer Hospital and Research Centre from December 2011 till December 2019. Medical records were used to retrieve for patient's demographics, clinical features at diagnosis, PRL levels and size of prolactinoma on MRI at diagnosis and after start of dopamine agonists and outcome of medical management. Results A total of 107 patients were included in this study. Mean age at diagnosis was 35 (22-54) years for men and 32 (18-50) years for women and 66.4% (71) of the patients were females. Our study included 38 (35.5%) microadenoma, 50 (46.7%) macroadenoma and 19 (17.8%) giant adenomas. At presentation, the most common symptom among females was menstrual irregularity/amenorrhea seen in 73.2% of females and among males was visual disturbance (80.6%). A significant reduction in PRL levels was seen within six to 12 months of treatment. Mean PRL levels decreased from 3162.8 ng/ml to 1.52 ng/ml. A notable decrease in tumor size was seen with medical management, mean adenoma size decreased from 2.18 cm to 1.04 cm. With cabergoline (CAB) 83.3% biochemical cure was seen compared to bromocriptine (BRC) which has 60.4%. The radiological response rate in CAB and BRC groups was 65.45% and 60%, respectively. Complete resolution of adenoma was seen in 13 patients (nine were microadenoma, two macro and two giant adenomas). The prolactin level at diagnosis was positively correlated with maximum tumor diameter (r = 0.469, P = 0.001). Two patients developed cerebrospinal fluid (CSF) rhinorrhea and the defect was repaired in both patients. Median follow-up duration was 40 (12-288) months. Conclusion Clinical presentation and demographics of prolactinoma are the same in our region when compared to the rest of the world. Cabergoline is superior to bromocriptine in prolactin normalization and tumor shrinkage but still bromocriptine is being used in a significant number of patients in low-income countries as first-line due to its low cost.
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Affiliation(s)
- Hira Irfan
- Endocrinology and Diabetes, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Waqas Shafiq
- Endocrinology and Diabetes, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Ahmed Imran Siddiqi
- Endocrinology and Diabetes, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Sara Ashfaq
- Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Sadaf Attaullah
- Endocrinology and Diabetes, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Asim Munir Alvi
- Endocrinology and Diabetes, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Sardar Ali Khan
- Endocrinology and Diabetes, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Muhammad Abu Bakar
- Biostatistics and Epidemiology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Umal Azmat
- Endocrinology and Diabetes, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
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7
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Iuliano SL, Bi WL, Laws ER. Changes in the Options for Management of Prolactin Secreting Pituitary Adenomas. Skull Base Surg 2022; 83:e49-e53. [DOI: 10.1055/s-0040-1722665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives Initial therapy for the management of prolactinomas has long been maintained to be medical, consisting of a dopamine agonist. These therapies may have troublesome side effects, and some prolactinomas are resistant to medical therapy regarding lowering prolactin levels or shrinking the tumor. These issues have revived interest in surgery for prolactin-secreting adenomas as an early therapeutic option. We report our analysis of surgery for prolactin microadenomas in women, using the transsphenoidal endoscopic approach.
Design We reviewed a contemporary series of 33 women (mean age = 31.8 years) with microprolactinomas who underwent early surgical intervention, which was a three-dimensional transnasal transsphenoidal endoscopic operation.
Setting The study was conducted at a tertiary academic referral center for pituitary tumors.
Main Outcome Measures Preoperative and postoperative prolactin.
Results Overall, 28 patients had received preoperative dopamine agonists, 24 of these experienced a variety of drug-related side effects, and 4 had tumors that were resistant to lowering prolactin or tumor shrinkage. Preoperative prolactin levels averaged 90.3 ng/mL (range = 30.7–175.8 ng/mL). We observed a 94% normalization rate in postoperative prolactin (mean = 10.08 ng/mL, range = 0.3–63.1 ng/mL). During the follow-up (mean = 33.9 months), five patients had elevated prolactin; four required reinitiation of medical therapy, two had surgical reexploration, and none received radiation therapy. Complications included syndrome of inappropriate antidiuretic hormone secretion (n = 3), transient diabetes insipidus (n = 1), postoperative epistaxis (n = 1), and fat graft site infection (n = 1).
Conclusion This review supports the consideration of transsphenoidal surgery as an early intervention for some women with prolactin-secreting microadenoma. Indications include significant side effects of medical therapy and tumors that do not respond to standard medical management.
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Affiliation(s)
- Sherry L. Iuliano
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Edward R. Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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8
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Cai X, Zhu J, Yang J, Tang C, Cong Z, Ma C. Are dopamine agonists still the first-choice treatment for prolactinoma in the era of endoscopy? A systematic review and meta-analysis. Chin Neurosurg J 2022; 8:9. [PMID: 35395837 PMCID: PMC8994364 DOI: 10.1186/s41016-022-00277-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background For prolactinoma patients, dopamine agonists (DAs) are indicated as the first-line treatment and surgery is an adjunctive choice. However, with the development of surgical technique and equipment, the effect of surgery has improved. The aim of this study was to assess the efficacy and safety of surgery versus DAs in patients with different types of prolactinomas. Methods A systematic search of literature using Web of Science, PubMed, Cochrane Library, and Clinical Trial databases was conducted until July 12, 2019. Prolactinoma patients treated with DAs (bromocriptine or cabergoline) or surgery (microscopic or endoscopic surgery) were included. Outcomes included the biochemical cure rate, recurrence rate, prolactin level, improvement rates of symptoms, and incidence rates of complications. A random-effects model was used to pool the extracted data. Qualitative comparisons were conducted instead of quantitative comparison. Results DAs were better than surgery in terms of the biochemical cure rate (0.78 versus 0.66), but surgery had a much lower recurrence rate (0.19 versus 0.57). Full advantages were not demonstrated in improvement rates of symptoms and incidence rates of complications with both treatment options. In microprolactinoma patients, the biochemical cure rate of endoscopic surgery was equal to the average cure rate of DAs (0.86 versus 0.86) and it surpassed the biochemical cure rate of bromocriptine (0.86 versus 0.76). In macroprolactinoma patients, endoscopic surgery was slightly higher than bromocriptine (0.66 versus 0.64) in terms of the biochemical cure rate. Conclusion For patients with clear indications or contraindications for surgery, choosing surgery or DAs accordingly is unequivocal. However, for patients with clinical equipoise, such as surgery, especially endoscopic surgery, in microprolactinoma and macroprolactinoma patients, we suggest that neurosurgeons and endocrinologists conduct high-quality clinical trials to address the clinical equipoise quantitatively. Supplementary Information The online version contains supplementary material available at 10.1186/s41016-022-00277-1.
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Affiliation(s)
- Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Chiyuan Ma
- School of Medicine, Southeast University, Nanjing, China. .,School of Medicine, Nanjing Medical University, Nanjing, China. .,Department of Neurosurgery, Jinling Hospital, Nanjing, China. .,School of Medicine, Nanjing University, Nanjing, China.
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9
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Tavakol S, Catalino MP, Cote DJ, Boles X, Laws ER, Bi WL. Cyst Type Differentiates Rathke Cleft Cysts From Cystic Pituitary Adenomas. Front Oncol 2021; 11:778824. [PMID: 34956896 PMCID: PMC8702518 DOI: 10.3389/fonc.2021.778824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/19/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose A classification system for cystic sellar lesions does not exist. We propose a novel classification scheme for these lesions based on the heterogeneity of the cyst wall/contents and the presence of a solid component on imaging. Methods We retrospectively reviewed 205 patients’ medical records (2008–2020) who underwent primary surgery for a cystic sellar lesion. Cysts were classified a priori into 1 of 4 cyst types based on the heterogeneity of the cyst wall/contents and the presence of a solid component imaging. There was high interrater reliability. Univariable and multivariable models were used to estimate the ability of cyst type to predict the two most common diagnoses: Rathke cleft cyst (RCC) and cystic pituitary adenoma. Results The frequencies of RCC and cystic pituitary adenoma in our cohort were 45.4% and 36.4%, respectively. Non-neoplastic lesions (e.g., arachnoid cysts and RCC) were more likely to be Type 1 or 2, whereas cystic neoplasms (e.g., pituitary adenomas and craniopharyngiomas) were more likely to be Type 3 or 4 (p<0.0001). Higher cyst types, compared to Type 1, had higher odds of being cystic pituitary adenomas compared to RCCs (OR: 23.7, p=0.033, and 342.6, p <0.0001, for Types 2 and 4, respectively). Lesions with a fluid-fluid level on preoperative MRI also had higher odds of being pituitary adenomas (OR: 12.7; p=0.023). Cystic pituitary adenomas were more common in patients with obesity (OR: 5.0, p=0.003) or symptomatic hyperprolactinemia (OR: 11.5; p<0.001, respectively). The multivariable model had a positive predictive value of 82.2% and negative predictive value of 86.4%. Conclusion When applied to the diagnosis of RCC versus cystic pituitary adenoma, higher cystic lesion types (Type 2 & 4), presence of fluid-fluid level, symptomatic hyperprolactinemia, and obesity were predictors of cystic pituitary adenoma. Further validation is needed, but this classification scheme may prove to be a useful tool for the management of patients with common sellar pathology.
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Affiliation(s)
- Sherwin Tavakol
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Michael P. Catalino
- Department of Neurosurgery, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - David J. Cote
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Xian Boles
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Edward R. Laws
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: Edward R. Laws Jr, ; Wenya Linda Bi,
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: Edward R. Laws Jr, ; Wenya Linda Bi,
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10
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Lasolle H, Teulade M, Lapras V, Vasiljevic A, Borson-Chazot F, Jouanneau E, Raverot G. Postoperative remission of non-invasive lactotroph pituitary tumor: a single-center experience. ANNALES D'ENDOCRINOLOGIE 2021; 83:1-8. [PMID: 34871604 DOI: 10.1016/j.ando.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Dopaminergic agonists (DA) are the first-line treatment in lactotroph pituitary tumor but treatment usually needs to be life-long. After surgical transphenoid resection, remission rates range from 60% to 90%, with low morbidity. OBJECTIVE The objective was to evaluate outcome of surgical treatment of selected non-invasive prolactinoma, and to identify factors associated with long-term remission. METHOD Early postoperative (3 months) and last follow-up data for non-invasive lactotroph tumors operated on in intention-to-cure in our center, between 2008 and 2017 were retrospectively reviewed: prolactin (PRL) level, DA treatment, pituitary function, and MRI data. Remission was defined as PRL plasma level below the upper limit of normal without DA treatment. RESULTS Fifty-three of the 60 patients (32 of the 33 microadenomas) were in remission at 3 months and 46 (28/33 microadenomas) at last follow-up 22.7 months (range, 1.1-126.5 months) after surgery. Five-year recurrence-free survival was 77.5% [65.8-91.2]. Male gender, larger tumor size at diagnosis and before surgery and higher plasma PRL level at diagnosis were all significantly associated with lower remission rates on univariate analysis. Transient diabetes insipidus and hyponatremia occurred in 2 and 5 patients respectively. One case of isolated thyrotroph insufficiency was observed. During follow-up, 13 women became pregnant (12 spontaneously). CONCLUSION This cohort confirmed the high remission rate of lactotroph tumors after surgery in a selected population, with limited morbidity, and conserved pituitary function in almost all cases.
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Affiliation(s)
- Hélène Lasolle
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires (HYPO) Hospices Civils de Lyon, Groupement Hospitalier Est, Bron, France; Université Lyon 1, Lyon, France; INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon, F-69372 Lyon, France
| | - Marie Teulade
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires (HYPO) Hospices Civils de Lyon, Groupement Hospitalier Est, Bron, France; Université Lyon 1, Lyon, France; INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon, F-69372 Lyon, France
| | - Véronique Lapras
- Service d'imagerie médicale et interventionnelle, Hôpital Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Alexandre Vasiljevic
- Université Lyon 1, Lyon, France; INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon, F-69372 Lyon, France; Centre de Pathologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires (HYPO) Hospices Civils de Lyon, Groupement Hospitalier Est, Bron, France; Université Lyon 1, Lyon, France
| | - Emmanuel Jouanneau
- Université Lyon 1, Lyon, France; INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon, F-69372 Lyon, France; Service de Neurochirurgie, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires (HYPO) Hospices Civils de Lyon, Groupement Hospitalier Est, Bron, France; Université Lyon 1, Lyon, France; INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon, F-69372 Lyon, France.
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11
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Wei L, Wei X. Outcomes of transsphenoidal surgery in dopamine agonist-resistant prolactinomas: a retrospective study. Hormones (Athens) 2021; 20:745-752. [PMID: 34275094 DOI: 10.1007/s42000-021-00309-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Dopamine agonists (DA) comprise first-line treatment for prolactinomas. However, some patients show no response to DA and are considered resistant. In this study, we retrospectively analyzed the outcomes of DA-resistant prolactinoma patients after transsphenoidal surgery (TSS). METHODS A total of 94 consecutive patients with DA-resistant prolactinomas who underwent TSS were retrospectively enrolled in the present study. Early postoperative remission rate, prolactin (PRL) levels, and recurrence rate were analyzed. RESULTS Of 94 DA-resistant patients, 47 (50%) achieved early remission 1 week post-surgery, including 41.18% of macroprolactinoma patients and 73.08% of microprolactinoma patients. PRL levels on the first postoperative day were significantly lower than preoperative PRL levels (p < 0.001). Total resection rate in macro- and microprolactinomas were, respectively, 75 and 96.15%. A recurrence of hyperprolactinemia and tumor was, respectively, found in 31.91 and 19.15% of patients with a follow-up of 39.53 ± 2.172 months (range 3-86). A higher hyperprolactinemia recurrence was observed in patients with invasive prolactinomas (p = 0.021) or preoperative PRL levels ≥ 200 ng/ml (p = 0.029). Univariate logistic regression indicated that larger maximum tumor diameter (p = 0.045), invasive prolactinomas (p = 0.002), and absence of early postoperative remission (p = 0.004) were significant predictors of tumor recurrence. However, using multivariate stepwise logistic regression, only invasiveness and early postoperative remission remained significant. CONCLUSION Tumor invasiveness and preoperative PRL levels were significant predictors of hyperprolactinemia recurrence after TSS. For tumor recurrence, invasiveness and early postoperative remission were independent predictors.
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Affiliation(s)
- Liguang Wei
- Neurosurgery Unit, The Second People's Hospital of Qinzhou, Qinzhou, China
| | - Xialin Wei
- Oncology Unit, The First People's Hospital of Qinzhou, Qinzhou, China.
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12
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Kim HK, Hong JW, Moon JH, Ahn SS, Kim EH, Lee SK, Lee EJ, Park YW, Ku CR. Efficacy and Cerebrospinal Fluid Rhinorrhea after Cabergoline Treatment in Patients with Bioactive Macroprolactinoma. Cancers (Basel) 2021; 13:cancers13215374. [PMID: 34771538 PMCID: PMC8582509 DOI: 10.3390/cancers13215374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/23/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
Predicting dopamine agonist resistance in patients with macroprolactinoma is essential for clinicians to prevent treatment failure and subsequent complications such as medication-induced cerebrospinal fluid (CSF) rhinorrhea. We evaluated the features of patients with cabergoline resistance and CSF rhinorrhea in patients with prolactinomas with prolactin levels ≥1000 ng/mL. A total of 140 patients who were newly diagnosed with prolactinoma secreting only prolactin ≥1000 ng/mL and treated with cabergoline for the first time were included in this study. Based on the hormonal and radiologic response of the prolactinoma, the patients were divided into responders and non-responders. Non-responders (36/140, 25.8%) included a higher number of patients receiving hormone replacement than responders (responders, n (%) = 12(11.5) vs. non-responders = 13(36.1), p = 0.001). In propensity score matching analysis, patients who developed CSF rhinorrhea presented more frequent hormone deficiency than responders regardless of initial cabergoline dose. Hormone deficiency was associated with a greater odds ratio for the risk of non-responders (adjusted odds ratio = 5.13, 95% CI 1.96-13.46, p = 0.001). Cabergoline was effective in bioactive macroprolactinoma. Furthermore, initial cabergoline dose was not significantly associated with long-term responsiveness and development of CSF rhinorrhea but the hypopituitarism was independently associated with an increased risk of cabergoline resistance and CSF rhinorrhea.
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Affiliation(s)
- Hae-Kyung Kim
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul 03722, Korea; (H.-K.K.); (E.-J.L.)
- Pituitary Tumor Center, Severance Hospital, Seoul 03722, Korea; (J.-H.M.); (S.-S.A.); (E.-H.K.); (S.-K.L.)
| | - Jae-Won Hong
- Department of Internal Medicine, Division of Endocrinology, Ilsan-Paik Hospital, Inje University College of Medicine, 170 Juhawro, Ilsanseo-gu, Goyang 10380, Korea;
| | - Ju-Hyung Moon
- Pituitary Tumor Center, Severance Hospital, Seoul 03722, Korea; (J.-H.M.); (S.-S.A.); (E.-H.K.); (S.-K.L.)
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Sung-Soo Ahn
- Pituitary Tumor Center, Severance Hospital, Seoul 03722, Korea; (J.-H.M.); (S.-S.A.); (E.-H.K.); (S.-K.L.)
- Center for Clinical Imaging Data Science, Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Eui-Hyun Kim
- Pituitary Tumor Center, Severance Hospital, Seoul 03722, Korea; (J.-H.M.); (S.-S.A.); (E.-H.K.); (S.-K.L.)
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Seung-Koo Lee
- Pituitary Tumor Center, Severance Hospital, Seoul 03722, Korea; (J.-H.M.); (S.-S.A.); (E.-H.K.); (S.-K.L.)
- Center for Clinical Imaging Data Science, Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Eun-Jig Lee
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul 03722, Korea; (H.-K.K.); (E.-J.L.)
- Pituitary Tumor Center, Severance Hospital, Seoul 03722, Korea; (J.-H.M.); (S.-S.A.); (E.-H.K.); (S.-K.L.)
| | - Yae-Won Park
- Pituitary Tumor Center, Severance Hospital, Seoul 03722, Korea; (J.-H.M.); (S.-S.A.); (E.-H.K.); (S.-K.L.)
- Center for Clinical Imaging Data Science, Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: (Y.-W.P.); (C.-R.K.); Tel.: +82-2-2228-7400 (Y.-W.P.); +82-2-2228-0833 (C.R.K.); Fax: +82-2-393-3035 (Y.-W.P.); +82-2-312-0578 (C.-R.K.)
| | - Cheol-Ryong Ku
- Department of Internal Medicine, Institute of Endocrine Research, Yonsei University College of Medicine, Seoul 03722, Korea; (H.-K.K.); (E.-J.L.)
- Pituitary Tumor Center, Severance Hospital, Seoul 03722, Korea; (J.-H.M.); (S.-S.A.); (E.-H.K.); (S.-K.L.)
- Correspondence: (Y.-W.P.); (C.-R.K.); Tel.: +82-2-2228-7400 (Y.-W.P.); +82-2-2228-0833 (C.R.K.); Fax: +82-2-393-3035 (Y.-W.P.); +82-2-312-0578 (C.-R.K.)
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13
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Penn MC, Cardinal T, Zhang Y, Abt B, Bonney PA, Lorenzo P, Lin M, Rosner J, Weiss M, Zada G, Carmichael JD. Cure and Hormonal Control After Prolactinoma Resection: Case Series and Systematic Review. J Endocr Soc 2021; 5:bvab074. [PMID: 34466765 PMCID: PMC8402931 DOI: 10.1210/jendso/bvab074] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Indexed: 11/19/2022] Open
Abstract
Context Surgical management of prolactinomas is an important treatment for patients intolerant of dopamine agonist therapy. However, predictors of postoperative outcomes remain unclear. Object While transsphenoidal surgical resection (TSSR) is important second-line therapy in prolactinoma patients, predictors of surgical cure and biochemical remission following TSSR remain sparse. Methods A retrospective review of prolactinoma patients undergoing TSSR at the USC Pituitary Center from 1995 to 2020 was conducted. Participants were categorized as surgical cure (normalization of serum prolactin without medical treatment), surgical noncure, biochemical control (prolactin normalization with or without adjuvant therapy), and nonbiochemical control. A systematic review of the outcomes of surgically managed prolactinomas was performed. Results The 40 female and 16 male participants had an average age of 35.6 years. Prior treatment included transsphenoidal resection (6, 11%) and dopamine agonist treatment (47, 84%). The 40 macroadenomas and 15 microadenomas exhibited suprasellar extension (24, 43%) and parasellar invasion (20, 36%). Fifteen (27%) were purely intrasellar. Gross total resection was achieved in 25 patients (45%) and subtotal in 26 (46%). Surgical cure was achieved in 25 patients (46%) and biochemical control in 35 (64%). Surgical cure was more likely in smaller, noninvasive tumors, those that were fully resected, and patients with lower preoperative (< 1000 ng/mL) and immediately postoperative (< 7.6 ng/mL) prolactin levels. Ten of 26 patients (38%) undergoing adjuvant therapy achieved biochemical control, which was less likely in men and those with higher preoperative prolactin or invasive tumors. Conclusion Surgical resection of prolactinomas is a safe procedure that, when offered judiciously, can achieve symptom and/or biochemical control in a majority of patients. A variety of predictors may be useful in advising patients on likelihood of postoperative remission.
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Affiliation(s)
- Marisa C Penn
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Yanchen Zhang
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Brittany Abt
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Patricia Lorenzo
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Michelle Lin
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Jack Rosner
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Martin Weiss
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA.,USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - John D Carmichael
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California 90033, USA.,USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, California 90033, USA
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14
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Determinants of Surgical Remission in Prolactinomas: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 154:e349-e369. [PMID: 34325023 DOI: 10.1016/j.wneu.2021.07.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Prolactin-secreting tumors respond well to medical management, with a few patients requiring surgery. We conducted a systematic review and meta-analysis to study the determinants of surgical remission in these tumors. METHODS We searched PubMed to identify eligible studies reporting postoperative remission in patients treated with transsphenoidal surgery for prolactinoma. Primary outcomes included postoperative remission, follow-up remission, and recurrence. Postoperative and follow-up remission were defined as normoprolactinemia at <1 year and >1 year after operation, respectively. Recurrence was defined as hyperprolactinemia after initial normalization of prolactin levels. Odds ratios (ORs) were calculated, stratified by radiologic size, tumor extension, and tumor invasion, and analyzed using a random-effects model meta-analysis. RESULTS Thirty-five studies were included. Macroadenomas were associated with lower rates of postoperative remission (OR, 0.20; 95% confidence interval [CI], 0.16-0.24) and lower rates of remission at follow-up (OR, 0.11; 95% CI, 0.053-0.22). Postoperative remission was less likely in tumors with extrasellar or suprasellar extension (OR, 0.16; 95% CI, 0.06-0.43) and tumors with cavernous sinus invasion (OR, 0.03; 95% CI, 0.01-0.13). Female gender and absence of preoperative dopamine agonist treatment were also associated with higher remission rates. Across the included studies, there was considerable heterogeneity in each primary outcome (postoperative remission, I2 = 94%; follow-up remission, I2 = 86%; recurrence, I2 = 68%). CONCLUSIONS Transsphenoidal surgery for prolactinomas may be particularly effective in small, noninvasive, treatment-naive tumors and may provide a viable first-line alternative to dopamine agonist therapy in such patients.
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15
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Mattogno PP, D’Alessandris QG, Chiloiro S, Bianchi A, Giampietro A, Pontecorvi A, De Marinis L, Olivi A, Anile C, Lauretti L. Reappraising the Role of Trans-Sphenoidal Surgery in Prolactin-Secreting Pituitary Tumors. Cancers (Basel) 2021; 13:cancers13133252. [PMID: 34209686 PMCID: PMC8269319 DOI: 10.3390/cancers13133252] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/13/2021] [Accepted: 06/24/2021] [Indexed: 01/04/2023] Open
Abstract
Simple Summary Prolactinomas constitute a subgroup of pituitary adenomas for which there are several treatment options. Dopamine agonists (DA), since their introduction, have shown a strong efficacy both in the control of hyperprolactinemia and of the significant volumetric reduction of prolactinomas, leading, in some cases, to a definitive cure. Trans-sphenoidal surgery (TSS) has been traditionally confined to a failure of medical therapy, pituitary apoplexy with neurological worsening, and prolactinomas with wide cystic components. Moreover, the recent technical innovations introduced in TSS and increasing experience of surgeons have allowed to achieve better results, such as complete tumor resection with lower complication rates. On these grounds, the authors reviewed the extensive institutional Prolactinomas case series over the last 25 years to analyze the role of TSS in the management of Prolactinomas, particularly in terms of the cure rate. Abstract Background: Prolactinomas represent a unique challenge for endocrinologists and neurosurgeons. Considering recent innovations in surgical practice, the authors aimed to investigate the best management for prolactinomas. Methods: A retrospective, cross-sectional and monocentric study was designed. Consecutive patients affected by prolactinomas were enrolled if treated with a first-line treatment with a dopamine agonist (DA) or trans-sphenoidal surgery (TSS). Patients carried giant prolactinomas, and those with a follow-up <12 months were excluded. Results: Two hundred and fifty-nine patients were enrolled. The first treatment was DA for 140 patients and TS for 119 cases. One hundred and forty-six of 249 patients (58.6%) needed a second therapy. The mean follow-up was 102.2 months (12–438 months). Surgery highly impacted on the cure rate—in particular, in females (p = 0.0021) and in microprolactinomas (p = 0.0020). Considering the multivariate analysis, the female gender and surgical treatment in the course of the clinical history were the only independent positive predictors of a cure at the end of 5 years follow-up (p = 0.0016, p = 0.0005). The evaluation of serum prolactin (24 hours after TSS) revealed that 86.4% of patients with postoperative prolactin (PRL) ≤10 ng/mL were cured at the end of the follow-up (p < 0.0001). Conclusions: According to our experience, surgery allows a high cure rate of prolactinomas, particularly in females with microadenoma, with a good safety profile. TSS for prolactinomas should be considered as a concrete option, during the multidisciplinary evaluation, in centers of reference for pituitary diseases.
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Affiliation(s)
- Pier Paolo Mattogno
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (Q.G.D.); (A.O.); (C.A.); (L.L.)
- Correspondence:
| | - Quintino Giorgio D’Alessandris
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (Q.G.D.); (A.O.); (C.A.); (L.L.)
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Gemelli IRCCS-Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (S.C.); (A.B.); (A.G.); (A.P.); (L.D.M.)
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Gemelli IRCCS-Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (S.C.); (A.B.); (A.G.); (A.P.); (L.D.M.)
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Gemelli IRCCS-Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (S.C.); (A.B.); (A.G.); (A.P.); (L.D.M.)
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Gemelli IRCCS-Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (S.C.); (A.B.); (A.G.); (A.P.); (L.D.M.)
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Gemelli IRCCS-Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (S.C.); (A.B.); (A.G.); (A.P.); (L.D.M.)
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (Q.G.D.); (A.O.); (C.A.); (L.L.)
| | - Carmelo Anile
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (Q.G.D.); (A.O.); (C.A.); (L.L.)
| | - Liverana Lauretti
- Institute of Neurosurgery, Fondazione Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore-Roma, Largo A. Gemelli 8, 00168 Rome, Italy; (Q.G.D.); (A.O.); (C.A.); (L.L.)
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16
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Ouyang T, Zhang N, Xie S, Tang B, Li J, Xiao L, Zhang F, Wu B, Zhou D, Li M, Hong T. Outcomes and Complications of Aggressive Resection Strategy for Pituitary Adenomas in Knosp Grade 4 With Transsphenoidal Endoscopy. Front Oncol 2021; 11:693063. [PMID: 34235083 PMCID: PMC8255811 DOI: 10.3389/fonc.2021.693063] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/20/2021] [Indexed: 11/30/2022] Open
Abstract
Surgery for pituitary adenomas (PAs) with cavernous sinus (CS) invasion in Knosp grade 4 is a great challenge and whether to adopt a conservative or aggressive surgical strategy is controversial. The aim of this study is to provide the outcomes and complications of an aggressive resection strategy for Knosp grade 4 PAs with transsphenoidal endoscopic surgery. Outcomes and complications were retrospectively analyzed in 102 patients with Knosp grade 4 PAs. Among them, primary PAs were seen in 60 patients and recurrent PAs were seen in 42 cases. Gross total resection (GTR) of the entire tumor was achieved in 72 cases (70.6%), subtotal tumor resection (STR) in 18 cases (17.6%), and partial tumor resection (PTR) in 12 cases (11.8%). Additionally, GTR of the tumor within the CS was achieved in 82 patients (80.4%), STR in 17 patients (16.7%), and PTR in 3 patients (2.9%). Statistical analyses showed that both recurrent tumors and firm consistency tumors were adverse factors for complete resection (P<0.05). Patients with GTR of the entire tumor were more likely to have favorable endocrine and visual outcomes than those with incomplete resection (P<0.05). Overall, the most common surgical complication was new cranial nerve palsy (n=7, 6.8%). The incidence of internal carotid artery (ICA) injury and postoperative cerebrospinal fluid (CSF) leakage was 2.0% (n=2) and 5.9% (n=6), respectively. Six patients (5.9%) experienced tumor recurrence postoperatively. For experienced neuroendoscopists, an aggressive tumor resection strategy via transsphenoidal endoscopic surgery may be an effective and safe option for Knosp grade 4 PAs.
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Affiliation(s)
- Taohui Ouyang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Na Zhang
- Department of Neurology, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shenhao Xie
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Junjun Li
- Department of Neurosurgery, Wuhan Union Hospital, Wuhan, China
| | - Limin Xiao
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fabao Zhang
- Department of Radiology, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bowen Wu
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Dongwei Zhou
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Meihua Li
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Hong
- Department of Neurosurgery, the First Affiliated Hospital of Nanchang University, Nanchang, China
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Van Gerven L, Qian Z, Starovoyt A, Jorissen M, Meulemans J, van Loon J, De Vleeschouwer S, Lambert J, Bex M, Vander Poorten V. Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients. Front Oncol 2021; 11:643550. [PMID: 34026618 PMCID: PMC8138557 DOI: 10.3389/fonc.2021.643550] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/06/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve. MATERIAL AND METHODS All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records. RESULTS Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015). CONCLUSION The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.
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Affiliation(s)
- Laura Van Gerven
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and transplantation, Allergy and Clinical Immunology Research Unit, KU Leuven, Leuven, Belgium
| | - Zhen Qian
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Anastasiya Starovoyt
- Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
| | - Mark Jorissen
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Meulemans
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Johannes van Loon
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Steven De Vleeschouwer
- Neurosciences, Research Group Experimental Neurosurgery and Neuroanatomy and Leuven Brain Institute, Leuven, Belgium
| | - Julie Lambert
- Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marie Bex
- Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Vincent Vander Poorten
- Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
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18
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Akkus G, Karagun B, Yaldız HN, Evran M, Sert M, Tetiker T. Outcomes of surgical and/or medical treatment in patients with prolactinomas during long-term follow-up: a retrospective single-centre study. Horm Mol Biol Clin Investig 2020; 42:153-157. [PMID: 34332519 DOI: 10.1515/hmbci-2020-0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/03/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Prolactinoma is the most common cause of pituitary tumours. Current medical guidelines recommend dopamine agonists (cabergoline or bromocriptine) as the initial therapy for prolactinoma. However, surgical removal can also be considered in selected cases, such as patients with macroadenomas with local complications (bleeding or optic chiasm pressure) or those not responding to medical treatment. METHODS The present retrospective study included patients with prolactinomas (n=43; female, 24; male, 19) who were primarily managed with medical (n=32) or surgical (n=11) treatment. RESULTS Macroadenoma (n=29.67%) was commonly detected in both genders (female, 54%; male, 84%). Moreover, the mean pre-treatment prolactin levels were similar in both genders (female, 683.3 ± 1347 ng/mL; male, 685.4 ± 805 ng/mL; p=0.226). Surgically treated patients had a greater reduction in tumour size (27.7 ± 17.9 mm pre-treatment vs. 8.72 ± 14.2 mm post-treatment) than non-surgically treated ones (12.5 ± 7.5 mm pre-treatment vs. 4.1 ± 4.2 mm post-treatment; p=0.00). However, the decrease in prolactin levels was similar between the two patient groups (p=0.108). During the follow-up period (10.6 ± 7.0 years), the average cabergoline dose of the patients was 1.42 ± 1.47 mcg/week. CONCLUSIONS Although a surgical approach was considered for selected cases of prolactinoma, the average dose used for medical treatment was highly inadequate for the patients in the present study.
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Affiliation(s)
- Gamze Akkus
- Division of Endocrinology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Barış Karagun
- Division of Endocrinology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Hilal Nur Yaldız
- Division of Internal Medicine, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Mehtap Evran
- Division of Endocrinology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Murat Sert
- Division of Endocrinology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Tamer Tetiker
- Division of Endocrinology, Faculty of Medicine, Cukurova University, Adana, Turkey
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Vermeulen E, D'Haens J, Stadnik T, Unuane D, Barbe K, Van Velthoven V, Gläsker S. Predictors of dopamine agonist resistance in prolactinoma patients. BMC Endocr Disord 2020; 20:68. [PMID: 32429916 PMCID: PMC7236128 DOI: 10.1186/s12902-020-0543-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical resection of prolactinomas resistant to dopamine agonists is frequently incomplete due to fibrotic changes of the tumour under pharmacological therapy. In order to identify a subgroup of patients who may benefit from early surgery, we thought to investigate possible predictive factors of pharmacological resistance of prolactinomas to dopamine agonists. METHODS We retrospectively analyzed a database of a Belgian tertiary reference center for patients with pituitary tumours from 2014 to 2016. The groups of interest were patients with dopamine agonist responsive and resistant prolactinomas. The possible predictive factors, including MRI findings, endocrinological parameters, response of tumour and patient factors for dopamine agonist resistance were investigated. RESULTS We included 69 patients of whom 52 were women (75,4%) and 17 were men (24,6%). Rate of dopamine agonist resistance was 15.9%. We identified four significant predictors of dopamine agonist resistance: male gender, a large tumour volume, prolonged time to prolactin normalization and presence of a cystic, hemorrhagic and/or necrotic component. In addition, symptoms due to mass effect, high baseline prolactin level and a high contrast capture on MRI are factors that can be taken into consideration. CONCLUSION We identified predictive factors for pharmacological resistance and developed a scoring system for patient specific prediction of resistance to dopamine agonists. This scoring system may have impact on the timing and decision of surgery in prolactinoma patients after further prospective evaluation.
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Affiliation(s)
- Elle Vermeulen
- Department of Neurosurgery, VUB University Hospital of Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Jean D'Haens
- Department of Neurosurgery, VUB University Hospital of Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Tadeusz Stadnik
- Department of Radiology, VUB University Hospital of Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - David Unuane
- Department of Endocrinology, VUB University Hospital of Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Kurt Barbe
- Department of Statistics, VUB University Hospital of Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Vera Van Velthoven
- Department of Neurosurgery, VUB University Hospital of Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Sven Gläsker
- Department of Neurosurgery, VUB University Hospital of Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium.
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20
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Phenotype and resistance patterns of 10 resistant prolactinomas. ENDOCRINOL DIAB NUTR 2020; 67:194-204. [DOI: 10.1016/j.endinu.2019.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022]
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21
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Abstract
PURPOSE Aggressive prolactinomas are defined as radiologically invasive tumors which cannot be cured by surgery, and that have an unusually rapid rate of tumor growth despite dopamine agonist treatment and surgery. In some cases, metastasis occurs, defining prolactin carcinoma which is the second most frequent pituitary carcinoma. METHODS A literature search was performed to review the available data on the treatment of aggressive pituitary prolactinomas or carcinomas. RESULTS When optimal standard therapies (high dose cabergoline, surgery and radiotherapy) failed, temozolomide, an alkylating drug, is currently the best option, allowing to control tumor growth in about 50% of treated prolactinomas and improving overall survival of these patients. However, long-term complete response occurs in a limited subgroup of tumors. Alternative drugs could be discussed in a subset of aggressive prolactinomas either before temozolomide (pasireotide, peptide receptor radionuclide therapy…) or after temozolomide failure. CONCLUSION Despite the significant improvement obtained with the use of temozolomide, a need for alternative drugs persists since a majority of these tumors are resistant or will recur during the follow-up. Patients suffering from such a rare condition should have access to clinical trials available for other types of rare cancers, such as tyrosine kinase inhibitors or immunotherapy.
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Affiliation(s)
- Hélène Lasolle
- INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon, 69008, Lyon, Auvergne-Rhône-Alpes, France
- Lyon 1 University, 69100, Villeurbanne, Auvergne-Rhône-Alpes, France
- Endocrinology Department, Reference Center for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est" Hospices Civils de Lyon, Auvergne-Rhône-Alpes, 69677, Bron, France
| | - Mirela Diana Ilie
- Endocrinology Department, "C.I.Parhon" National Institute of Endocrinology, 011863, Bucharest, Bucharest-Ilfov, Romania
| | - Gérald Raverot
- INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon, 69008, Lyon, Auvergne-Rhône-Alpes, France.
- Lyon 1 University, 69100, Villeurbanne, Auvergne-Rhône-Alpes, France.
- Endocrinology Department, Reference Center for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est" Hospices Civils de Lyon, Auvergne-Rhône-Alpes, 69677, Bron, France.
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Abstract
Pituitary adenomas are a rare but important central nervous system tumor in children. Because of differences in growth and development, the manifestations of pituitary adenomas in children may differ from those seen in adults. Unlike adult patients, the pediatric population more often presents with clinically secretory adenomas. Although medical management is first-line treatment of prolactinomas, transsphenoidal surgery is appropriate for most children with Cushing disease and gigantism. Although some pediatric patients present surgical challenges because of small anatomic dimensions or an incompletely developed sphenoid sinus, transsphenoidal surgery can be safely and effectively undertaken in most children, with low complication rates.
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Affiliation(s)
- Alexandria C Marino
- Department of Neurological Surgery, University of Virginia Health Sciences Center, PO Box 800212, Charlottesville, VA 22908, USA
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia Health Sciences Center, PO Box 800212, Charlottesville, VA 22908, USA
| | - Bhargav Desai
- Department of Neurological Surgery, University of Virginia Health Sciences Center, PO Box 800212, Charlottesville, VA 22908, USA
| | - John A Jane
- Department of Neurological Surgery, University of Virginia Health Sciences Center, PO Box 800212, Charlottesville, VA 22908, USA.
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23
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Abstract
Prolactinomas are the most common functional pituitary adenoma. Many prolactinomas can be treated with medication, but all patients should be evaluated at a neuroendocrine center including experienced neurosurgeons trained in transsphenoidal surgery. Surgery for prolactinomas is feasible and can be performed with low morbidity. Patients never previously treated with dopamine agonists should be considered for surgery if they have neurologic deficits, pituitary apoplexy, an uncertain diagnosis, or a significantly cystic prolactinoma. Patients previously treated with dopamine agonists should be considered for surgery in cases of intolerance or resistance. Recurrent and aggressive prolactinomas often require multimodal therapy.
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Affiliation(s)
- Daniel A Donoho
- Department of Neurosurgery, Brigham and Women's Hospital, BTM 4, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, BTM 4, 60 Fenwood Road, Boston, MA 02115, USA
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24
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Jian M, Du Q, Zhu D, Mao Z, Wang X, Feng Y, Xiao Z, Wang H, Zhu Y. Tumor suppressor miR-145-5p sensitizes prolactinoma to bromocriptine by downregulating TPT1. J Endocrinol Invest 2019; 42:639-652. [PMID: 30370446 DOI: 10.1007/s40618-018-0963-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 10/01/2018] [Indexed: 01/27/2023]
Abstract
PURPOSE Prolactinoma is the most commonly seen secretory tumor of pituitary glands, which accounts for approximately up to 40% of total pituitary adenomas. Due to its high drug resistance, dopamine agonist, such as bromocriptine, has limited effect on the treatment of patients with prolactinoma. Recent discoveries have revealed that multiple miRNAs were involved in regulating drug resistance. In this research, we explored the relationship between miR-145-5p expression as well as bromocriptine sensitivity both in vitro and in vivo. METHODS To study the role of miR-145-5p in drug resistance of prolactinoma, the expression levels of miR-145-5p in bromocriptine-resistant prolactinoma cell line MMQ/BRC and its parental cell line MMQ cells, 24 bromocriptine-resistant as well as eight sensitive clinical samples were measured by qRT-PCR. Moreover, CCK8, flow cytometry and immunofluorescence were performed to identify the biological characteristics of MMQ/BRC and MMQ. TPT1 was predicted as a direct target gene of miR-145-5p by bioinformatic methods. In addition, qRT-PCR, western blot and immunohistochemistry were used to detect the expression level of TPT1 in clinical specimens and cell lines. Xenograft mouse model was constructed to analyze whether miR-145-5p could reverse bromocriptine resistance in prolactinoma in vivo. RESULTS In our study, bromocriptine-resistant prolactinoma clinical samples and cell line had decreased miR-145-5p levels and expressed high levels of TPT1 compared with their sensitive counterparts. Bioinformatic methods and our preliminary dual luciferase reporter assay were utilized to elucidate that TPT1 was a direct target gene of miR-145-5p. Furthermore, introducing miR-145-5p mimic into MMQ cells led to a decrease of IC50 along with upregulation of TPT1; nevertheless, transfecting the corresponding inhibitor into MMQ cells resulted in an upregulation of IC50 as well as reduction of TPT1. CONCLUSIONS Collectively, our findings elucidated the role of miR-145-5p as an important regulator of drug resistance in prolactinoma by controlling TPT1, and implicated the potential application of miR-145-5p in cancer therapy as well.
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Affiliation(s)
- M Jian
- Department of Histology and Embryology, Medical School of Sun Yat-sen University, No. 74, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Q Du
- Department of Histology and Embryology, Medical School of Sun Yat-sen University, No. 74, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - D Zhu
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Z Mao
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - X Wang
- Department of Histology and Embryology, Medical School of Sun Yat-sen University, No. 74, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Y Feng
- Department of Histology and Embryology, Medical School of Sun Yat-sen University, No. 74, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Z Xiao
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - H Wang
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
| | - Y Zhu
- Department of Histology and Embryology, Medical School of Sun Yat-sen University, No. 74, Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
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Sahakian N, Castinetti F, Dufour H, Graillon T, Romanet P, Barlier A, Brue T, Cuny T. Clinical management of difficult to treat macroprolactinomas. Expert Rev Endocrinol Metab 2019; 14:179-192. [PMID: 30913932 DOI: 10.1080/17446651.2019.1596024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/13/2019] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Prolactinomas represent the most common pituitary adenomas encountered in the clinic. While a majority of these tumors will be successfully treated by dopamine agonist (DA) such as cabergoline, their management becomes problematic since a resistance to DA can occur and/or if the tumor displays features of aggressiveness, two conditions that are closely related. AREAS COVERED Epidemiology and medical treatment of prolactinomas; resistance to DA and molecular basis of DA-resistance; therapeutical alternatives in case of DA-resistant Prolactinomas and therapies in development; summarizing conclusions. EXPERT OPINION The management of DA-resistant prolactinomas requires a multidisciplinary approach by an expert team. Along with discussions about surgery with or without gamma knife radiosurgery, genetic screening for multiple endocrine neoplasia type 1 (MEN1) syndrome is actively discussed in a case-by-case approach. In case of surgery, a careful analysis of the tumor sample can provide information about its aggressivity potential according to recent criteria. Ultimately, temozolomide can be indicated if the tumor is rapidly growing and/or threatening for the patient.
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Affiliation(s)
- Nicolas Sahakian
- a Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Service d'Endocrinologie , Aix Marseille Univ, APHM , Marseille , France
| | - Frederic Castinetti
- a Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Service d'Endocrinologie , Aix Marseille Univ, APHM , Marseille , France
| | - Henry Dufour
- b Marseille Medical Genetics, Inserm U1251, Hôpital de la Timone, Service de Neurochirurgie , Aix Marseille Univ, APHM , Marseille , France
| | - Thomas Graillon
- b Marseille Medical Genetics, Inserm U1251, Hôpital de la Timone, Service de Neurochirurgie , Aix Marseille Univ, APHM , Marseille , France
| | - Pauline Romanet
- c Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Laboratoire de Biologie Moléculaire et Biochimie , Aix Marseille Univ, APHM , Marseille , France
| | - Anne Barlier
- c Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Laboratoire de Biologie Moléculaire et Biochimie , Aix Marseille Univ, APHM , Marseille , France
| | - Thierry Brue
- a Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Service d'Endocrinologie , Aix Marseille Univ, APHM , Marseille , France
| | - Thomas Cuny
- a Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Service d'Endocrinologie , Aix Marseille Univ, APHM , Marseille , France
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26
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Zhao Y, Jin D, Lian W, Xing B, Feng M, Liu X, Wang R. Clinical characteristics and surgical outcome of prolactinoma in patients under 14 years old. Medicine (Baltimore) 2019; 98:e14380. [PMID: 30732174 PMCID: PMC6380812 DOI: 10.1097/md.0000000000014380] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Prolactinoma is one of the most common pituitary tumors, but relatively uncommon in patients under 14 years old. Surgery is the second-line treatment for prolactinoma when patients show resistance or intolerance to medical therapy. There are only a few published series of children who underwent surgery treatment. This study is performed to investigate the clinical manifestation and surgical outcome of pituitary prolactinoma in patients under 14 years old who are resistant or intolerant to medical therapy of dopamine agonist.Thirty-six cases were included in a retrospective review of patients under 14 years old operated for prolactinoma between December 1987 and December 2015. Preoperative radiological and endocrinal evaluation was performed on every patient. All patients received operation with trans-sphenoidal approach.Based on enhanced pituitary magnetic resonance imaging (MRI) taken 2 months after the surgery, total resection was achieved in 16 patients (44.4%) and subtotal resection in 20 (55.6%). Thirty-four cases (94.4%) showed remarkable decrease of prolactin (PRL) level 7 days after surgery, and 16 (44.4%) returned to normal. All patients were followed up for 2 years. Tumor regrowth or recurrence occurred in 5 patients and secondary treatment was applied, including drug treatment in 2 patients, second surgery in 2, and radiotherapy in 1.Trans-sphenoidal pituitary surgery is an effective treatment for prolactinoma in patient under 14 years old. There is no significant difference between the patients under 14 years old and adults for prolactinoma in characteristics and treatment.
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Affiliation(s)
- Yi Zhao
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College
| | - Di Jin
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College
| | - Xiaohai Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College
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Vroonen L, Daly AF, Beckers A. Epidemiology and Management Challenges in Prolactinomas. Neuroendocrinology 2019; 109:20-27. [PMID: 30731464 DOI: 10.1159/000497746] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/06/2019] [Indexed: 11/19/2022]
Abstract
Clinically relevant pituitary adenomas are present in about 1 per 1,000 of the general population and prolactinomas are by far the most common clinical subtype of pituitary adenomas. Usually prolactinomas affect premenopausal women and present with typical symptoms of menstrual disturbance and/or galactorrhea. They are generally managed with dopamine agonists to restore fertility and to control symptoms and tumor size. In a subset of prolactinomas, however, management remains challenging. Studies in recent years have identified the factors related to dopamine agonist resistance, such as male sex, genetic features, and aggressive tumor behavior. Certain other patient groups represent particular challenges for management, such as pediatric patients and pregnant women. Treatment with dopamine agonists is usually safe and effective, and adverse effects such as clinically relevant cardiac valvular complications and impulse control disorders may occur in isolated instances. A number of important disease characteristics of prolactinomas remain to be explained, such as the difference in sex prevalence before and after menopause, the higher prevalence of macroadenomas in older males, and the biochemical mechanisms of resistance to dopaminergic agonists.
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Affiliation(s)
- Laurent Vroonen
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium
| | - Adrian F Daly
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium
| | - Albert Beckers
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium,
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Gao J, Liu Y, Han G, Deng K, Liu X, Bao X, Feng M, Yao Y, Lian W, Xing B, Lv X, Wang R. Metformin inhibits growth and prolactin secretion of pituitary prolactinoma cells and xenografts. J Cell Mol Med 2018; 22:6368-6379. [PMID: 30334324 PMCID: PMC6237574 DOI: 10.1111/jcmm.13963] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 09/02/2018] [Accepted: 09/20/2018] [Indexed: 12/31/2022] Open
Abstract
Metformin (MET) is a diabetes drug that activates AMP-activated protein kinase (AMPK), and is suggested to have anticancer efficacy. Here, we investigated the role of AMPK signalling in prolactinoma (PRLoma), with particular respect to MET and bromocriptine (BC) as a PRLoma treatment. We analysed AMPK phosphorylation, dopamine D2 receptor (D2R), and oestrogen receptor (ER) expression in both BC-sensitive and -resistant PRLoma samples; effects of the AMPK agonist MET (alone or with BC) on in vitro proliferation and apoptosis, xenograft growth and prolactin (PRL) secretion of BC-sensitive and -resistant cells, and ER expression in xenografts. Some BC-resistant PRLomas showed high D2R expression but extremely low AMPK activation. MET significantly inhibited proliferation of cultured PRLoma cells; MET + BC notably restrained their PRL secretion. MET + BC further decreased tumour growth and serum PRL levels in xenografts than BC treatment alone. ER was down-regulated after AMPK activation in both cultured cells and xenografts. Together, we propose that the AMPK signalling pathway down-regulates ERα and ERβ, and suppresses PRLoma growth as well as PRL secretion. Combined MET + BC is a potential treatment for PRLomas.
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Affiliation(s)
- Jun Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Yang Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China.,Head and Neck Surgery Department, National Cancer Center & Cancer hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Gaijing Han
- State Key Laboratory of Medical Molecular Biology, Department of Pathophysiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
| | - Xiang Lv
- State Key Laboratory of Medical Molecular Biology, Department of Pathophysiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing, China
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Vilar L, Abucham J, Albuquerque JL, Araujo LA, Azevedo MF, Boguszewski CL, Casulari LA, Cunha Neto MBC, Czepielewski MA, Duarte FHG, Faria MDS, Gadelha MR, Garmes HM, Glezer A, Gurgel MH, Jallad RS, Martins M, Miranda PAC, Montenegro RM, Musolino NRC, Naves LA, Ribeiro-Oliveira Júnior A, Silva CMS, Viecceli C, Bronstein MD. Controversial issues in the management of hyperprolactinemia and prolactinomas - An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:236-263. [PMID: 29768629 PMCID: PMC10118988 DOI: 10.20945/2359-3997000000032] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 08/09/2017] [Indexed: 11/23/2022]
Abstract
Prolactinomas are the most common pituitary adenomas (approximately 40% of cases), and they represent an important cause of hypogonadism and infertility in both sexes. The magnitude of prolactin (PRL) elevation can be useful in determining the etiology of hyperprolactinemia. Indeed, PRL levels > 250 ng/mL are highly suggestive of the presence of a prolactinoma. In contrast, most patients with stalk dysfunction, drug-induced hyperprolactinemia or systemic diseases present with PRL levels < 100 ng/mL. However, exceptions to these rules are not rare. On the other hand, among patients with macroprolactinomas (MACs), artificially low PRL levels may result from the so-called "hook effect". Patients harboring cystic MACs may also present with a mild PRL elevation. The screening for macroprolactin is mostly indicated for asymptomatic patients and those with apparent idiopathic hyperprolactinemia. Dopamine agonists (DAs) are the treatment of choice for prolactinomas, particularly cabergoline, which is more effective and better tolerated than bromocriptine. After 2 years of successful treatment, DA withdrawal should be considered in all cases of microprolactinomas and in selected cases of MACs. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) is to provide a review of the diagnosis and treatment of hyperprolactinemia and prolactinomas, emphasizing controversial issues regarding these topics. This review is based on data published in the literature and the authors' experience.
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Affiliation(s)
- Lucio Vilar
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Julio Abucham
- Unidade de Neuroendócrino, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp/EPM), São Paulo, SP, Brasil
| | - José Luciano Albuquerque
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Luiz Antônio Araujo
- Centro de Endocrinologia e Diabetes de Joinville (Endoville), Joinville, SC, Brasil
| | - Monalisa F Azevedo
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Cesar Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia, Hospital de Clínicas, Universidade Federal do Paraná (SEMPR), Curitiba, PR, Brasil
| | - Luiz Augusto Casulari
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Malebranche B C Cunha Neto
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Felipe H G Duarte
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manuel Dos S Faria
- Serviço de Endocrinologia, Hospital Universitário Presidente Dutra, Universidade Federal do Maranhão (UFMA), São Luís, MA, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brasil
| | - Heraldo M Garmes
- Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (FCM/Unicamp), Campinas, SP, Brasil
| | - Andrea Glezer
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Maria Helane Gurgel
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Raquel S Jallad
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manoel Martins
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Paulo A C Miranda
- Serviço de Endocrinologia e Metabologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
| | - Renan M Montenegro
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Nina R C Musolino
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | | | - Cíntia M S Silva
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil
| | - Camila Viecceli
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Marcello D Bronstein
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
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Zaidi HA, Wang AJ, Cote DJ, Smith TR, Prevedello D, Solari D, Cappabianca P, Quiroga M, Laws ER. Preoperative Stratification of Transsphenoidal Pituitary Surgery Patients Based on Surgical Urgency. Neurosurgery 2018; 81:659-664. [PMID: 28520927 DOI: 10.1093/neuros/nyx073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 01/31/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Currently, there is no prioritization scale available to distinguish those patients with pituitary tumors who require urgent surgical intervention from those who are candidates for elective treatment. OBJECTIVE To develop a classification system that can help primary care physicians, endocrinologists, neurosurgeons, ancillary support staff, and hospital administrators identify high-priority surgical candidates. METHODS An expert international panel of clinicians consisting of endocrinologists and neurosurgeons who are involved in the diagnosis and management of sellar disease was convened. The panel retrospectively reviewed individual experiences, including a cohort of patients operated upon for pituitary related disease at the Brigham and Women's Hospital from January 2008 to November 2015. A risk stratification schema was developed to streamline patient care pathways. RESULTS We identified 4 groups of surgical candidates with varying levels of risk, and then assigned treatment timelines and different differential diagnoses to each. The 4 groups were as follows: group A: urgent-immediate; group B: prompt-initiate treatment within 1 to 2 weeks; group C: soon-initiate treatment within 3 months; group D: elective-as soon as indicated. Among 472 patients treated at Brigham and Women's Hospital for pituitary adenomas, each was assigned to 1 of the 4 predetermined subgroups: group A, 6.8%; group B, 30.1%; group C, 31.1%; group D, 32.0%. CONCLUSIONS We developed a risk stratification schema that may serve as a platform to streamline care to the patients at highest risk. The expert opinions presented provide a basis for future studies regarding the risk prioritization of patients.
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Affiliation(s)
- Hasan A Zaidi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy J Wang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Cote
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Prevedello
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | | | | | - Monica Quiroga
- Department of Neurosurgery, Hospital Mexico, PINECOS, University of Costa Rica, San Jose, Costa Rica
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Liu X, Liu Y, Gao J, Feng M, Bao X, Deng K, Yao Y, Wang R. Combination Treatment with Bromocriptine and Metformin in Patients with Bromocriptine-Resistant Prolactinomas: Pilot Study. World Neurosurg 2018. [PMID: 29530699 DOI: 10.1016/j.wneu.2018.02.188] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prolactinomas are the most common functional pituitary adenomas and dopamine agonists are the primary therapy. However, some patients are resistant to dopamine agonists. Recently, metformin has been proposed as a cancer treatment. CASE DESCRIPTION This study is a retrospective review of 2 cases including 1 patient with prolactinoma who was resistant to bromocriptine, diagnosed with impaired glucose tolerance, and administered metformin. Surprisingly, combining the patient's treatment with metformin decreased prolactin (PRL) levels to 12 ng/mL and significantly decreased the size of the tumor after 1 year of combination therapy. As menstruation resumed and galactorrhea resolved, the patient became pregnant and stopped using metformin but continued taking bromocriptine. She gave birth to a healthy boy in August 2016. After delivery, she decided to breastfeed the baby and only took bromocriptine. After 14 months of using bromocriptine alone, her PRL level increased to 208 ng/mL and the tumor reappeared (7 mm × 8 mm × 9 mm). Interestingly, the patient's PRL level decreased from 208 ng/mL to 150 ng/mL 2 months after using combination treatment with bromocriptine and metformin. On the basis of these findings, a second bromocriptine-resistant patient was recruited. After 3 months of combined treatment with bromocriptine and metformin, the patient's PRL level decreased to 2.08 ng/mL, testosterone levels increased significantly, and the tumor size decreased. CONCLUSIONS Although more cases and investigations into the mechanisms underlying these effects are needed, these 2 cases support the hypothesis that the combination of metformin and bromocriptine might be a new treatment for resistant prolactinomas.
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Affiliation(s)
- Xiaohai Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China
| | - Yang Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China; Department of Head and Neck Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China
| | - Jun Gao
- Department of Neurosurgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China
| | - Ming Feng
- Department of Neurosurgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China
| | - Xinjie Bao
- Department of Neurosurgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China
| | - Kan Deng
- Department of Neurosurgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China
| | - Yong Yao
- Department of Neurosurgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China
| | - Renzhi Wang
- Department of Neurosurgery, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P. R. China.
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Rutkowski MJ, Aghi MK. Medical versus surgical treatment of prolactinomas: an analysis of treatment outcomes. Expert Rev Endocrinol Metab 2018; 13:25-33. [PMID: 30063440 DOI: 10.1080/17446651.2018.1411798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Prolactinomas are unique tumors that may go into both hormonal and radiographic remission with dopamine agonist therapy or transsphenoidal surgery. Regardless of modality, the goals of therapy remain the same: (1) biochemical remission, including reduction of prolactin and normalization of sex hormones; (2) radiographic tumor control, with a range including prevention of tumor growth, tumor regression, or complete tumor resolution; (3) resolution of preoperative symptoms, including those that are hormonal or neurologic; and (4) prevention of new hypopituitarism or new neurologic symptoms. AREAS COVERED In the following review, we performed a search of the literature using keywords 'prolactinoma,' 'dopamine agonist,' 'surgery,' 'cost-effectiveness,' 'recurrence,' and 'complication' to compare the relative merits of medical versus surgical therapy for prolactinoma, including special circumstances such as cystic tumors, pregnant patients, and the cost-effectiveness of different strategies. EXPERT COMMENTARY Medical therapy can offer a cure, but surgery provides an important adjunct to patients with resistance or intolerance to dopamine agonists, and offers excellent outcomes including when combined with continued postoperative medical therapy. Further head to head comparisons will benefit patients and practitioners weighing the relative risks and benefits of medical and surgical intervention, including the issue of their relative cost-effectiveness.
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Affiliation(s)
- Martin J Rutkowski
- a California Center for Pituitary Disorders, Department of Neurological Surgery , University of California , San Francisco , CA , USA
| | - Manish K Aghi
- a California Center for Pituitary Disorders, Department of Neurological Surgery , University of California , San Francisco , CA , USA
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Liu X, Tang C, Wen G, Zhong C, Yang J, Zhu J, Ma C. The Mechanism and Pathways of Dopamine and Dopamine Agonists in Prolactinomas. Front Endocrinol (Lausanne) 2018; 9:768. [PMID: 30740089 PMCID: PMC6357924 DOI: 10.3389/fendo.2018.00768] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/06/2018] [Indexed: 12/16/2022] Open
Abstract
Dopamine agonists such as bromocriptine and cabergoline are the predominant treatment drugs for prolactinoma by inhibiting prolactin secretion and shrinking tumor size. However, the pathways of either dopamine or its agonists that lead to the death of cells are incompletely understood and some are even conflicting conclusions. The main aim of this paper is to review the different pathways of dopamine and its agonists in prolactinomas to help to gain a better understanding of their functions and drug resistance mechanisms.
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Affiliation(s)
- Xiaoshuang Liu
- The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Engineering Research Center for MicroRNA Biology and Biotechnology, School of Life Science, NJU Advanced Institute for Life Sciences, Nanjing University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, School of Medicine, Jinling Hospital, Nanjing University, Nanjing, China
| | - Guodao Wen
- Tungwah Hospital of Sun Yat-Sen University, Dongguan, China
| | - Chunyu Zhong
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Chiyuan Ma
- Department of Neurosurgery, School of Medicine, Jinling Hospital, Nanjing University, Nanjing, China
- *Correspondence: Chiyuan Ma
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Gonzaga MDFDM, de Castro LF, Naves LA, Mendonça JL, Oton de Lima B, Kessler I, Casulari LA. Prolactinomas Resistant to Treatment With Dopamine Agonists: Long-Term Follow-Up of Six Cases. Front Endocrinol (Lausanne) 2018; 9:625. [PMID: 30542321 PMCID: PMC6277870 DOI: 10.3389/fendo.2018.00625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/01/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction: Prolactinomas are preferentially treated with dopamine agonists. However, a few adenomas are resistant to this treatment. Objective: To evaluate the characteristics of patients with resistance to dopamine agonists in the long-term. Method: A retrospective study of six cases was made. Patients who did not achieve normalized prolactin blood concentrations and a reduction of more than 50% of the tumor volume with the minimum dose of 3.5 mg per week of cabergoline for 3 months or the maximum supported dose of bromocriptine for 6 months were considered resistant to dopamine agonists. Patients were followed up at the Clinic of Neurology and Endocrinology or the University Hospital of Brasilia. Results: Six patients were selected. Three patients were initially treated with bromocriptine prior to treatment with cabergoline. Four patients were men, and two were women. At the time of diagnosis, ages ranged from 9 to 62 years. Initial prolactin concentrations ranged from 430 to 14,992 ng/mL and in the last assessment ranged from 29.6 to 2,169 ng/mL. The tumor volume ranged from 0.77 to 24.0 mm3. Tumor regression occurred in all patients, ranging from 20 to 100%, but total disappearance of the adenoma with an empty sella occurred in one patient. The maximum weekly doses of cabergoline ranged from 3.0 to 4.5 mg. Follow-up time ranged from seven to 17 years. Normalization of prolactin concentrations occurred only in one woman after 17 years of treatment. Three patients also underwent surgery, but only one woman was cured of the disease. Conclusion: This study confirms that tumors resistant to dopamine agonists are more aggressive, since we did not have any microadenoma; treatment with high dose of cabergoline may reduce the size of the tumor without its disappearance, and that normalization of prolactin concentration rarely occurs. To our knowledge, this is the longest follow-up of a series of cases with resistance to dopamine agonists.
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Affiliation(s)
| | | | - Luciana Ansaneli Naves
- Endocrinology Service, Brasilia University Hospital, Brasília, Brazil
- Medical Clinic Service, Brasilia University Hospital, Brasília, Brazil
| | | | | | - Iruena Kessler
- Medical Clinic Service, Brasilia University Hospital, Brasília, Brazil
- Institute of Cardiology of the Federal District, University Foundation of Cardiology, Brasília, Brazil
- University of Brasilia, Brasília, Brazil
| | - Luiz Augusto Casulari
- Endocrinology Service, Brasilia University Hospital, Brasília, Brazil
- Clinic of Neurology and Endocrinology, Brasília, Brazil
- *Correspondence: Luiz Augusto Casulari
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Ma Q, Su J, Li Y, Wang J, Long W, Luo M, Liu Q. The Chance of Permanent Cure for Micro- and Macroprolactinomas, Medication or Surgery? A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2018; 9:636. [PMID: 30410470 PMCID: PMC6209637 DOI: 10.3389/fendo.2018.00636] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/08/2018] [Indexed: 12/19/2022] Open
Abstract
Background: This meta-analysis aims to evaluate the long-term efficacy of medication treatment vs. surgery treatment in patients with prolactinomas. Methods: An electronic literature search was performed using MEDLINE, EMBASE and Web of Science databases for studies dated before July in 2018. Patients with prolactinomas received primary dopamine agonists (DAs) treatment or primary surgical interventions were included in this study. A systematic review and meta-analysis were performed in pertinent studies meeting eligible criteria. The clinical outcome was measured by the long-term remission rate of prolactin (PRL) in each cohort. The pooled data was analyzed according to a random effect model. Results: Thirteen publications with total 809 patients were included in the final meta-analysis. In the overall patients with prolactinomas, long-term remission rate was achieved in 88% patients treated with surgeries and in 52% patients treated with DAs (P = 0.001). The long-term remission rates in surgery cohort were also significantly higher than medication cohort in both microprolactinomas and macroprolactinomas (91 vs. 60%, P = 0.002; 77 vs. 43%, P = 0.003). Conclusions: Patients with prolactinomas, especially microprolactinomas, can consider transsphenoidal surgery as an alternative first-line treatment strategy. After receiving primary surgical intervention, administration of DAs should be considered based on the postoperative PRL level to achieve the best long-term remission rate.
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Affiliation(s)
- Qianquan Ma
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Jun Su
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Ying Li
- Department of Ophthalmology, Emory University, Atlanta, GA, United States
| | - Jiaxing Wang
- Department of Ophthalmology, Emory University, Atlanta, GA, United States
| | - Wenyong Long
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Mei Luo
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Qing Liu
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Qing Liu
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Zaidi HA, De Los Reyes K, Barkhoudarian G, Litvack ZN, Bi WL, Rincon-Torroella J, Mukundan S, Dunn IF, Laws ER. The utility of high-resolution intraoperative MRI in endoscopic transsphenoidal surgery for pituitary macroadenomas: early experience in the Advanced Multimodality Image Guided Operating suite. Neurosurg Focus 2016; 40:E18. [PMID: 26926058 DOI: 10.3171/2016.1.focus15515] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endoscopic skull base surgery has become increasingly popular among the skull base surgery community, with improved illumination and angled visualization potentially improving tumor resection rates. Intraoperative MRI (iMRI) is used to detect residual disease during the course of the resection. This study is an investigation of the utility of 3-T iMRI in combination with transnasal endoscopy with regard to gross-total resection (GTR) of pituitary macroadenomas. METHODS The authors retrospectively reviewed all endoscopic transsphenoidal operations performed in the Advanced Multimodality Image Guided Operating (AMIGO) suite from November 2011 to December 2014. Inclusion criteria were patients harboring presumed pituitary macroadenomas with optic nerve or chiasmal compression and visual loss, operated on by a single surgeon. RESULTS Of the 27 patients who underwent transsphenoidal resection in the AMIGO suite, 20 patients met the inclusion criteria. The endoscope alone, without the use of iMRI, would have correctly predicted extent of resection in 13 (65%) of 20 cases. Gross-total resection was achieved in 12 patients (60%) prior to MRI. Intraoperative MRI helped convert 1 STR and 4 NTRs to GTRs, increasing the number of GTRs from 12 (60%) to 16 (80%). CONCLUSIONS Despite advances in visualization provided by the endoscope, the incidence of residual disease can potentially place the patient at risk for additional surgery. The authors found that iMRI can be useful in detecting unexpected residual tumor. The cost-effectiveness of this tool is yet to be determined.
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Affiliation(s)
| | | | | | | | | | | | - Srinivasan Mukundan
- Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Reyes L, García S, Torales J, Halperín I, Alobid I, Hanzu F, Mora M, Valero R, Enseñat J. [Endoscopic endonasal surgery for sellar region pathology. An analysis of our first 200 patients. What we have learned]. Neurocirugia (Astur) 2016; 27:229-36. [PMID: 27012678 DOI: 10.1016/j.neucir.2016.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 01/25/2016] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Pituitary and sellar region tumours account for 10-15% of intracranial benign tumours, with pituitary adenoma being the most common one. In this article, a review is presented on 9 years of experience in surgical treatment using an endoscopic approach of sellar region lesions. The main features of our surgical technique will be explained, as well as the results in clinical and hormonal terms. MATERIAL AND METHODS A retrospective analysis was conducted on 200 patients operated on due to sellar lesions by the same neurosurgeon (J.E.) using an endoscopic endonasal transsphenoidal approach between February 2006 and February 2015. The cases excluded were, those requiring extended approaches of the skull base, as well as craniopharyngiomas, inflammatory, metastatic, or malignant lesions. RESULTS Of the 200 patients treated (59.5% women, mean age of 51.7 years, range: 18-82 years old), there were: 7 Rathke cysts and 193 adenomas (26 micro-adenomas and 165 macro-adenomas). All of them sub-classified according to the degree of invasion of the cavernous sinus (Knosp 0, 1, and 2: 129 cases and Knosp 3 and 4: 71 cases). Total resection was achieved in 143 patients (71.5%), subtotal resection in 39 (19.5%), and partial resection in 18 (9%). In the group of higher occupancy of the cavernous sinus (Knosp 3 and 4) complete resection was achieved in 55.5% (40 of 71 patients). Hormonal remission was achieved in 34 patients with acromegaly (85%), 23 patients with prolactinomas (76%), and 30 patients with Cushing's disease (86%). CONCLUSION The results obtained in our series, due to the centralisation of pathology and experience, are comparable to those achieved in pituitary surgery reference centres. Early surgical exploration of cerebrospinal fluid leaks reduces the risk of post-surgical meningitis.
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Affiliation(s)
- Luis Reyes
- Servicio de Neurocirugía, Hospital Clínic i Provincial de Barcelona, Barcelona, España.
| | - Sergio García
- Servicio de Neurocirugía, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Jorge Torales
- Servicio de Neurocirugía, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Irene Halperín
- Servicio de Endocrinología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Isam Alobid
- Servicio de Otorrinolaringología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Felicia Hanzu
- Servicio de Endocrinología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Mireia Mora
- Servicio de Endocrinología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Ricard Valero
- Servicio de Anestesiología y Reanimación, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Joaquim Enseñat
- Servicio de Neurocirugía, Hospital Clínic i Provincial de Barcelona, Barcelona, España
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Pennacchietti V, Garzaro M, Grottoli S, Pacca P, Garbossa D, Ducati A, Zenga F. Three-Dimensional Endoscopic Endonasal Approach and Outcomes in Sellar Lesions: A Single-Center Experience of 104 Cases. World Neurosurg 2016; 89:121-5. [PMID: 26836697 DOI: 10.1016/j.wneu.2016.01.049] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 01/17/2016] [Accepted: 01/19/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pituitary tumors account for approximately 15% of primary intracranial neoplasms and often are diagnosed incidentally. Common sellar lesions are pituitary adenomas, craniopharyngiomas, and Rathke cleft cysts. Currently endoscopic transsphenoidal approaches are largely used, and many centers also use 3-dimensional (3D) technology, although additional results of long-term follow-up are still being accumulated. METHODS We present a retrospective analysis of 104 patients with sellar lesions (57 male and 47 female, mean age 52 years) who underwent 3D endoscopic transsphenoidal surgery in our center from December 2011 to March 2015 and were followed up for a mean time of 18 months. RESULTS A total of 16 patients were diagnosed with growth hormone-secreting adenomas, 9 with adrenocorticotropic hormone-secreting, 5 with prolactin-secreting, and 2 with thyroid-stimulating hormone-secreting tumors and 58 with nonsecreting pituitary adenomas. Five patients had Rathke cleft cysts, 5 craniopharyngiomas, 2 fibrous solitary tumors, 1 a metastasis, and 1 a chordoma. At baseline, 47 patients (45.2%) had hormonal changes and 52 (50%) had visual field changes. Complete resection was achieved in 73 patients (70.1%). Follow-up evaluation detected hormonal remission in 7 patients with Cushing disease (77.7%) and in 11 patients with acromegaly (68.7%). Complications were cerebrospinal fluid leak in 5 cases (4.8%) and transient diabetes insipidus in 6 cases (5.7%). A total of 55 patients (52.9%) were discharged less than 72 hours after surgery. CONCLUSIONS The use of an endoscopic endonasal approach with 3D technology provides several advantages relating to patient length of stay, rate of complications, postoperative recovery, and novice surgeons' training. Advantages of 3D endoscopy and long-term follow-up still need further elucidation.
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Affiliation(s)
- Valentina Pennacchietti
- Division of Neurosurgery, Department of Neurosciences, A. O. U. Città della Salute e della Scienza di Torino, Turin, Italy.
| | - Massimiliano Garzaro
- Division of Ear, Nose and Throat 1, Department of Surgical Sciences, A. O. U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Silvia Grottoli
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, A. O. U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Paolo Pacca
- Division of Neurosurgery, Department of Neurosciences, A. O. U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Diego Garbossa
- Division of Neurosurgery, Department of Neurosciences, A. O. U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Alessandro Ducati
- Division of Neurosurgery, Department of Neurosciences, A. O. U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Francesco Zenga
- Division of Neurosurgery, Department of Neurosciences, A. O. U. Città della Salute e della Scienza di Torino, Turin, Italy
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Wu ZR, Zhang Y, Cai L, Lin SJ, Su ZP, Wei YX, Shang HB, Yang WL, Zhao WG, Wu ZB. Long-Term Clinical Outcomes of Invasive Giant Prolactinomas after a Mean Ten-Year Followup. Int J Endocrinol 2016; 2016:8580750. [PMID: 27999593 PMCID: PMC5141542 DOI: 10.1155/2016/8580750] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/24/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. The aim of this study is to observe clinical outcomes after more than ten years of followup in a group of patients with invasive giant prolactinomas (IGPs) treated with dopamine agonists (DAs). Methods. Twenty-five patients met the criteria of IGPs, among which 16 patients primarily received bromocriptine (BRC) and the other nine had undergone unsuccessful microsurgery prior to BRC treatment. Results. After a mean follow-up period of 135.5 ± 4.7 months, the clinical symptoms in all patients improved by different degrees. Tumor volume was decreased by a mean of 98.6%, and the tumors of 19 patients had almost completely disappeared. The mean duration of treatment at maximal doses of BRC was 48.5 months. At the last follow-up visit, nineteen patients had normal PRL levels, and 14 of these patients had received the low-dose BRC treatment (at an average of 2.9 ± 0.3 mg/d). Younger patients < 25 years had a significantly higher rate of persistent hyperprolactinemia after long-term BRC treatment (p = 0.043). Conclusion. DAs are a first-line therapy for IGPs because they can effectively achieve long-term control in both shrinking tumor volume and normalizing the PRL level, and majority of patients need low-dose DA maintenance. Younger patients are prone to persistent hyperprolactinemia despite long-term DA treatment.
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Affiliation(s)
- Ze Rui Wu
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yong Zhang
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Lin Cai
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Shao Jian Lin
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhi Peng Su
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yong Xu Wei
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Han Bing Shang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wen Lei Yang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wei Guo Zhao
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhe Bao Wu
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- *Zhe Bao Wu:
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Cohen-Inbar O, Xu Z, Schlesinger D, Vance ML, Sheehan JP. Gamma Knife radiosurgery for medically and surgically refractory prolactinomas: long-term results. Pituitary 2015; 18:820-30. [PMID: 25962347 DOI: 10.1007/s11102-015-0658-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Prolactinomas are the most common functioning pituitary adenomas. Dopamine agonists (DA) are generally very effective in treating prolactinomas by inducing tumor volume regression and endocrine remission. A minority of patients do not respond to DA or are intolerant because of side-effects. Microsurgical resection when possible is the next treatment option, but cavernous sinus, dural, or bone involvement may not allow for complete resection. OBJECTIVE We reviewed the outcome of patients with medically and surgically refractory prolactinomas treated with Gamma Knife radiosurgery (GKRS) during a 22 years follow-up period. METHODS We reviewed the patient database at the University of Virginia Gamma Knife center during a 25-year period (1989-2014), identifying 38 patients having neurosurgical, radiological and endocrine follow-up. RESULTS Median age at GKRS treatment was 43 years. Median follow-up was 42.3 months (range 6-207.9). 55.3 % (n = 21) were taking a dopamine agonist at time of GKRS. 63.2 % (n = 24) had cavernous sinus tumor invasion. Endocrine remission (normal serum prolactin off of a dopamine agonist) was achieved in 50 % (n = 19). GKRS induced hypopituitarism occurred in 30.3 % (n = 10). Cavernous sinus involvement was shown to be a significant negative prognosticator of endocrine remission. Taking a dopamine agonist drug at the time of GKRS showed a tendency to decrease the probability for endocrine remission. CONCLUSION GKRS for refractory prolactinomas can lead to endocrine remission in many patients. Hypopituitarism is the most common side effect of GKRS.
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Affiliation(s)
- Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA.
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | - Mary Lee Vance
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA.
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Current indications for the surgical treatment of prolactinomas. J Clin Neurosci 2015; 22:1785-91. [PMID: 26277642 DOI: 10.1016/j.jocn.2015.06.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 06/01/2015] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to examine the current indications for transsphenoidal surgery in the prolactinoma patient population, and to determine the outcomes of patients who undergo such operations. Transsphenoidal surgery may be indicated in prolactinoma patients who are resistant and/or intolerant to dopamine agonist (DA) therapy. We performed a retrospective review of the medical records of prolactinoma patients over a 6 year period (April 2008 to April 2014) at a large volume academic center. The median follow-up time was 12.0 months (range: 3-69). All patients who were included in the study (n=66) were treated with DA therapy and subsequently underwent an endonasal transsphenoidal operation. Of the 66 patients, 44 were women (mean age 34.2 years) and 22 were men (mean 41.7 years). There were 29 (43.9%) intolerant patients and 29 (43.9%) resistant patients. Postoperatively, 18 intolerant patients (66.7%) had normalized prolactin levels without the need for DA therapy, and five (17.2%) required DA to normalize their prolactin levels (p=0.02). Six patients (20.6%) had persistently elevated prolactin levels but were no longer receiving DA treatment (p<0.001). Postoperatively, 10 resistant patients (35.7%) had normal prolactin levels without DA therapy, and seven patients (25%) were treated with DA therapy to normalize their prolactin levels (p=0.22). Eight patients (28.6%) had supraphysiologic prolactin levels but were no longer taking a DA (p<0.001). Three patients (10.7%) were hyperprolactinemic, despite postoperative treatment with DA (p<0.001). After an appropriate treatment interval with multiple DA, radiographic follow-up, and careful clinical evaluation, prolactinoma patients can be offered surgery as an effective therapeutic option.
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Prolactinomas in children under 14. Clinical presentation and long-term follow-up. Childs Nerv Syst 2015; 31:909-16. [PMID: 25771923 DOI: 10.1007/s00381-015-2679-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Pediatric prolactinomas are rare, especially in children under 14 years of age. In this study, we evaluated the clinical presentation and microsurgical outcome of prolactinomas in prepubertal children. METHODS Nine patients with prolactinomas who had undergone surgical removal of the tumor before the age of 14 years were included in this retrospective study. Data on their clinical presentation, medications, physical and laboratory evaluations, radiological findings, and long-time follow-up were obtained from their medical records. RESULTS The main presenting symptom in the four female patients was galactorrhea (n = 4, 100%), whereas the five male patients most commonly presented with headache (n = 4, 80%) and growth retardation (n = 3, 60%). Six (66.6%) of the patients who had undergone transsphenoidal surgery were medication-free postoperatively. In three (33.3%) patients with giant adenomas, complete resection of the tumor was not achieved. One (11.1%) patient received radiotherapy after failed surgical and medical treatment. Postoperatively, electrolyte disturbances occurred in five (55.6%) patients, diabetes insipidus in two (22.2%), and thyroid dysfunction in two (22.2%). These complications resolved spontaneously. During follow-up, growth and puberty were usually normal. CONCLUSIONS Tumor compressive symptoms and/or gonadal and growth arrest may be the primary clinical presentations of pediatric prolactinoma. Patients who are not candidates for dopamine agonist therapy are best treated surgically, based on the low mortality and high cure rates. Hypopituitarism is a rare complication and may resolve spontaneously. Following successful treatment of a prolactinoma, growth and puberty in these children are normal.
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The Expanding Spectrum of Disease Treated by the Transnasal, Transsphenoidal Microscopic and Endoscopic Anterior Skull Base Approach: A Single-Center Experience 2008-2015. World Neurosurg 2015; 84:899-905. [PMID: 26008142 DOI: 10.1016/j.wneu.2015.05.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/15/2015] [Accepted: 05/16/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The transsphenoidal approach was initially developed in neurosurgical practice as an operative approach to the pituitary gland. The introduction of the operating endoscope has improved the versatility of the transsphenoidal approach, broadening the spectrum of lesions that can be treated effectively with this operative strategy. METHODS We performed a retrospective review of all patients who underwent transnasal, transsphenoidal operations at Brigham and Women's Hospital from April 2008 to February 2015 and categorized each case by pathologic diagnosis. RESULTS A total of 792 transnasal, transsphenoidal operations (512 endoscopic) were performed by 9 neurosurgeons for 33 pathologies over a 7-year period. Pituitary adenomas (535, 67.55%) were the most common impetus for a transsphenoidal operation. Others included Rathke cleft cysts (86, 10.86%), craniopharyngiomas (25, 3.16%), lympocytic hypophysitis/pituitary inflammation (21, 2.65%), arachnoid cysts (8, 1.01%), spindle cell oncocytoma (4, 0.51%), colloid cysts (4, 0.51%), and pituicytoma (2, 0.25%). Pituitary hyperplasia was treated in 9 cases (1.14%) and pituitary apoplexy in 7 (0.88%). Nineteen operations were undertaken for postoperative repairs (2.40%) and 3 for abscesses (0.38%). Other diseases treated transsphenoidally included chordomas (12, 1.52%), metastases (9, 1.14%), meningiomas (5, 0.63%), clival lesions (4, 0.51%), germinomas (3, 0.38%), granulomas (2, 0.25%), dermoid tumors (2, 0.25%), and 1 (0.13%) each of esthesioneuroblastoma, granular cell tumor, Wegener granulomatosis, olfactory neuroblastoma, glioneuronal tumor, chondromyxoid fibroma, epidermoid, meningoencephalocele, aneurysm, neuroendocrine carcinoma, chondrosarcoma, and lymphoma. CONCLUSIONS Although initially devised in neurosurgical practice for tumors of the pituitary gland, developments in technology now make the transsphenoidal approach an effective operative strategy for a wide range of anterior skull base lesions.
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A predictive algorithm for evaluating elevated serum prolactin in patients with a sellar mass. J Clin Neurosci 2015; 22:155-60. [DOI: 10.1016/j.jocn.2014.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/06/2014] [Indexed: 11/23/2022]
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Abstract
Prolactinomas account for approximately 40 % of all pituitary adenomas. Over 95 % of prolactinomas are microadenomas (< 10 mm diameter). Treatment is indicated to correct hypogonadism, restore other hormonal deficits, and alleviate local mass effects. Dopamine agonists (DA) are highly effective in achieving these goals and are well-tolerated. The vast majority of prolactinomas will respond to conventional doses of cabergoline (≤2 mg/week) that do not carry an increased risk of cardiac valvular abnormalities. DA therapy may be successful withdrawn in a subset of patients and thus is not necessarily a lifelong commitment. Although transsphenoidal surgery (TSS) is an option for prolactinoma treatment, it is less effective than medical management, carries considerably more risk, and is more expensive. The benefit/risk ratio for DA therapy compared to TSS actually becomes increasingly more favorable as tumor size increases. Therefore DA should remain the clear treatment of choice for essentially all patients with prolactinomas, reserving TSS as a second-line option for the very small number of patients that do not tolerate or are completely resistant to DA therapy.
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Affiliation(s)
- Eve Bloomgarden
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave., Suite 530, Chicago, IL, 60611, USA
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Abstract
Giant prolactinomas are rare tumours, representing only 2-3% of all prolactin (PRL)-secreting tumours and raising special diagnostic and therapeutic challenges. Based on several considerations developed in this review, their definition should be restricted to pituitary adenomas with a diameter of 40 mm or more, significant extrasellar extension, very high PRL concentrations (usually above 1000 μg/l) and no concomitant GH or ACTH secretion. Giant prolactinomas are much more frequent in young to middle-aged men than in women, with a male to female ratio of about 9:1. Endocrine symptoms are often present but overlooked for a long period of time, and diagnosis is eventually made when neurologic complications arise from massive extension into the surrounding structures, leading to cranial nerve palsies, hydrocephalus, temporal epilepsy or exophthalmos. PRL concentrations are usually in the range of 1000-100,000 μg/l, but may be underestimated by the so-called 'high-dose hook effect'. As in every prolactinoma, dopamine agonists are the first-line treatment allowing rapid alleviation of neurologic symptoms in the majority of the cases, a significant reduction in tumour size in three-fourths of the patients and PRL normalization in 60-70%. These extensive tumours are usually not completely resectable and neurosurgery has significant morbidity and mortality. It should therefore be restricted to acute complications such as apoplexy or leakage of cerebrospinal fluid (often induced by medical treatment) or to patients with insufficient tumoural response or progression. Irradiation and temozolomide are useful adjuvant therapies in a subset of patients with aggressive/invasive tumours, which are not controlled despite combined medical and surgical treatments. Because of these various challenges, we advocate a multidisciplinary management of these giant tumours in expert centres.
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Affiliation(s)
- Dominique Maiter
- Department of EndocrinologyCliniques Universitaires Saint-LucCentre Hospitalier Universitaire de Mont-GodinneMont-sur-Meuse, Université catholique de Louvain, Avenue Hippocrate 54.74, 1200 Brussels, Belgium
| | - Etienne Delgrange
- Department of EndocrinologyCliniques Universitaires Saint-LucCentre Hospitalier Universitaire de Mont-GodinneMont-sur-Meuse, Université catholique de Louvain, Avenue Hippocrate 54.74, 1200 Brussels, Belgium
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Huan C, Lu C, Xu GM, Qu X, Qu YM. Retrospective Analysis of Cushing's Disease with or without Hyperprolactinemia. Int J Endocrinol 2014; 2014:919704. [PMID: 25506361 PMCID: PMC4259137 DOI: 10.1155/2014/919704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 10/27/2014] [Indexed: 11/18/2022] Open
Abstract
Objective. We compared the characteristics of patients with Cushing's disease alone with those of patients with Cushing's disease and hyperprolactinemia. Methods. Eighty-four patients were enrolled between 2002 and 2011, in a hospital in China. Clinical, endocrinological, and histopathological data, MRI scans, and surgical outcomes were reviewed throughout the follow-up period. Results. Patients with Cushing's disease and hyperprolactinemia had a younger age at diagnosis (30.28 ± 14.23 versus 36.08 ± 10.91 years; P = 0.037) and a larger adenoma maximal diameter (2.44 ± 1.32 versus 1.44 ± 1.05 cm; P < 0.001) than patients with Cushing's disease alone. Menstrual disorders (P = 0.027) and visual field defects (P = 0.021) were more common and progressive obesity (P = 0.009) and hypertension (P < 0.001) were less common in patients with Cushing's disease and hyperprolactinemia. The rate of normalization of hormonal levels was lower (41.7% versus 91.7%; P < 0.001) and the recurrence rate was higher (36.1% versus 8.3%; P < 0.001) in patients with Cushing's disease and hyperprolactinemia. Conclusions. Careful long-term follow-up is needed of patients with Cushing's disease and hyperprolactinemia.
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Affiliation(s)
- Cheng Huan
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
| | - Chao Lu
- Department of Laboratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
| | - Guang-ming Xu
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
| | - Xin Qu
- Department of Intensive Care Unit, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
| | - Yuan-ming Qu
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250000, China
- *Yuan-ming Qu:
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Molitch ME. Management of medically refractory prolactinoma. J Neurooncol 2013; 117:421-8. [PMID: 24146188 DOI: 10.1007/s11060-013-1270-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/09/2013] [Indexed: 11/24/2022]
Abstract
Resistance to dopamine agonists is defined here as failure to normalize prolactin levels and failure to decrease macroprolactinoma size by ≥50 %. Failure to normalize prolactin levels is found in about 25 % of patients treated with bromocriptine and 10-15 % of those treated with cabergoline. Failure to achieve at least a 50 % reduction in tumor size occurs in about one-third of those treated with bromocriptine and 10-15 % of those treated with cabergoline. Treatment approaches for patients resistant to dopamine agonists include changing to another dopamine agonist and increasing the dose of the drug as long as there is continued response to the dose increases and no adverse effects with higher doses. Transsphenoidal surgery is also an option. Clomiphene, gonadotropins, and GnRH can be used if fertility is desired. For those not desiring fertility, estrogen replacement may be used unless there is a macroadenoma, in which case control of tumor growth is also an issue and dopamine agonists are generally necessary. In many patients modest or even no reduction in tumor size may be acceptable as long as there is not tumor growth. Hormone replacement [estrogen or testosterone] may cause a decrease in efficacy of the dopamine agonist. Reduction of endogenous estrogen, use of selective estrogen receptor modulators, and aromatase inhibitors are potential experimental approaches. Temozolomide may be useful as a last resort for aggressive, invasive tumors refractory to other medical and ablative therapies.
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, Chicago, IL, 60611, USA,
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