1
|
Andereggen L, Tortora A, Schubert GA, Musahl C, Frey J, Stieger A, Kobel B, Luedi MM, Roethlisberger M, Mariani L, Beck J, Christ E. Characteristics and outcomes of men with erectile dysfunction as the presenting symptom due to a lactotroph adenoma. Acta Neurochir (Wien) 2024; 166:314. [PMID: 39085672 PMCID: PMC11291538 DOI: 10.1007/s00701-024-06213-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/18/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Erectile dysfunction (ED) is frequently underreported in men suffering from prolactinomas and can be challenging to manage. Both dopamine agonists (DAs) and transsphenoidal surgery (TSS) correct hyperprolactinemia and restore gonadal function. However, there is scarce data regarding their effectiveness in correcting ED over the long term. METHODS This study is a retrospective single-center comparative cohort study analyzing men diagnosed with prolactinomas, both with and without confirmed erectile dysfunction (ED) at diagnosis. Independent risk factors for persistent ED over the long term were examined using multivariate logistic regression. RESULTS Among the 39 men with lactotroph adenomas, ED was one of the presenting symptoms in 22 (56%). The mean age at diagnosis was 45 ± 12 years. Surgery was the primary treatment in 6 (27%) ED patients and 8 (47%) non-ED patients. After a mean follow-up of 74 ± 48 months, remission from hyperprolactinemia was achieved in the majority (76%) of men: 71% in the non-ED cohort and 81% in the ED group (p = 0.70), regardless of the primary treatment strategy (surgical 84% versus medical 72%, p = 0.46). Long-term remission of ED was noted in 16 (73%) patients. Interestingly, high baseline BMI levels emerged as potential risk factors for persistent ED over the long term (OR 1.4, 95%CI 1.0-1.9; p = 0.04), while neither the initial adenoma size nor the primary treatment strategy (i.e., TSS vs. DAs) reached statistical significance. CONCLUSIONS Correcting hyperprolactinemia and its associated hypogonadism significantly improves ED in the majority of men with prolactinomas over the long term, regardless of the primary treatment strategy employed. In addition to addressing endocrine deficiencies, the early initiation of weight control programs may be considered for men with lactotroph adenomas and ED. Although our study suggests an association between BMI and the risk of persistent ED, further research is needed to establish any causal relationships.
Collapse
Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
- Faculty of Medicine, University of Bern, Bern, Switzerland.
| | - Angelo Tortora
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Gerrit A Schubert
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Deptartment of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Christian Musahl
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Janine Frey
- Department of Gynecology and Obstetrics, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andrea Stieger
- Department for Anesthesiology, Intensive, Rescue and Pain Medicine, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Béatrice Kobel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department for Anesthesiology, Intensive, Rescue and Pain Medicine, Kantonsspital St.Gallen, St.Gallen, Switzerland
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emanuel Christ
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Basel, Basel, Switzerland
| |
Collapse
|
2
|
Chen Z, Shou X, Ji L, Cheng H, Shen M, Ma Z, He W, Ye Z, Zhang Y, Qiao N, Zhang Q, Wang Y. Presurgical Medical Treatment in Prolactinomas: Surgical Implications and Pathological Characteristics From 290 Cases. J Clin Endocrinol Metab 2024; 109:1433-1442. [PMID: 38163969 DOI: 10.1210/clinem/dgad758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/30/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To review experience regarding the treatment of prolactinomas by endoscopic endonasal surgery focusing on the association between presurgical dopamine agonist (DA) treatment and perioperative outcomes, surgical morbidities, endocrine outcomes, and pathological characteristics. METHODS A single-center series of 290 cases was analyzed retrospectively and clinical data were collected. Intratumoral collagen content was assessed by Masson trichrome staining. RESULTS Tenacious tumor consistency (27.8% vs 9.8%, P < .001) was more common in DA-pretreated patients compared with patients who underwent initial surgery. Moreover, DA-pretreated macroadenomas presented more intraoperative blood loss (200 [100-400] mL vs 175 [100-300] mL; P = .014), longer surgical duration (177 ± 95 minutes vs 154 ± 57 minutes; P = .043), and more surgical morbidities (19.4% vs 8.9%; P = .034). Additionally, DA-pretreated macroadenomas presented a higher collagen volume fraction than that of the initial surgery group (23.6 ± 2.2% vs 13.2 ± 2.1%; P = .001). Correlation analysis revealed a close correlation between collagen volume fraction and the cumulative dose of bromocriptine (BRC) in macroadenomas (r = 0.438, P < .001). Regarding endocrine outcomes, DA-pretreated microadenomas showed a lower proportion of initial remission compared with patients who underwent initial surgery (86.7% vs 100%, P = .047). CONCLUSION This study described increased surgical difficulty and inferior endocrine outcomes associated with tumor fibrosis secondary to presurgical BRC treatment in prolactinomas. Neurosurgeons should note that presurgical BRC treatment may render subsequent surgery more challenging.
Collapse
Affiliation(s)
- Zhengyuan Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Xuefei Shou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Lijin Ji
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Haixia Cheng
- Department of Pathology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Ming Shen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Zengyi Ma
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Wenqiang He
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Zhao Ye
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Yichao Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Nidan Qiao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Qilin Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
- National Center for Neurological Disorders, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai 201100, China
- Neurosurgical Institute of Fudan University, Shanghai 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai 200040, China
| |
Collapse
|
3
|
Miao X, Fu Z, Luo X, Wang J, Yuan L, Zhao S, Feng Y, Huang S, Xiao S. A study on the correlations of PRL levels with anxiety, depression, sleep, and self-efficacy in patients with prolactinoma. Front Endocrinol (Lausanne) 2024; 15:1369729. [PMID: 38572480 PMCID: PMC10989272 DOI: 10.3389/fendo.2024.1369729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 02/29/2024] [Indexed: 04/05/2024] Open
Abstract
Purpose The purpose of this study was to explore the factors influencing PRL levels in patients with prolactinoma and to investigate the correlations between anxiety, depression, sleep, self-efficacy, and PRL levels. Methods This retrospective study included 176 patients with prolactinoma who received outpatient treatment at the Affiliated Hospital of Zunyi Medical University from May 2017 to August 2022. The general information questionnaire, Hospital Anxiety and Depression Scale (HADS), Athens Insomnia Scale (AIS), and General Self-Efficacy Scale (GSES) were used for data collection. A generalized estimating equation (GEE) model was used to analyze the factors influencing PRL levels in patients with prolactinoma. GEE single-effect analysis was used to compare PRL levels at different time points between anxiety group and nonanxiety group, between insomnia group and normal group, and between low, medium, and high self-efficacy groups. Results The median baseline PRL level and the PRL levels at 1, 3, 6, and 12 months of follow-up were 268.50 ng/ml, 122.25 ng/ml, 21.20 ng/ml, 19.65 ng/ml, and 16.10 ng/ml, respectively. Among patients with prolactinoma, 59.10% had anxiety (HADS-A score = 7.35 ± 3.34) and 28.98% had depression (HADS-D score = 5.23 ± 3.87), 9.10% had sleep disorders (AIS score = 6.10 ± 4.31) and 54.55% had low self-efficacy (GSES score = 2.13 ± 0.83). Educational level, tumor size, number of visits, sleep quality, anxiety level, and self-efficacy level were found to be factors influencing PRL levels in patients with prolactinoma (P<0.05). Higher PRL levels were observed in the anxiety group compared to the non-anxiety group (P<0.001), in the insomnia group compared to the normal group (P<0.05), and in the low self-efficacy group compared to the medium and high self-efficacy groups (P<0.05). Conclusion PRL levels in patients with prolactinoma are related to education level, tumor size, number of visits, anxiety, self-efficacy, and sleep but not depression. PRL levels were higher in patients with anxiety, low self-efficacy, and sleep disorders.
Collapse
Affiliation(s)
- Xiaoju Miao
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- The First Ward of the Neurosurgery Department, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhongmin Fu
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- The First Ward of the Neurosurgery Department, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xian Luo
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- The First Ward of the Neurosurgery Department, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jun Wang
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- The First Ward of the Neurosurgery Department, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Lili Yuan
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- The First Ward of the Neurosurgery Department, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shunjun Zhao
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- The First Ward of the Neurosurgery Department, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yi Feng
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shiming Huang
- Department of Nursing, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shunwu Xiao
- The First Ward of the Neurosurgery Department, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| |
Collapse
|
4
|
Cheng Y, Wang D, Tang H, Tong D, Zhao W, Lin S, Yao H, Lv W, Zhang X, Xue L, Shang H, Wu ZB. Alternations of Blood Pressure Following Surgical or Drug Therapy for Prolactinomas. Cancers (Basel) 2024; 16:726. [PMID: 38398117 PMCID: PMC10887374 DOI: 10.3390/cancers16040726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/25/2024] Open
Abstract
Several subtypes of pituitary neuroendocrine tumors (PitNETs), such as acromegaly and Cushing's disease, can result in hypertension. However, whether prolactinoma is associated with this complication remains unknown. Moreover, the effect of treatment with surgery or drugs on blood pressure (BP) is unknown. Herein, a retrospective study reviewed 162 patients with prolactinoma who underwent transsphenoidal surgery between January 2005 and December 2022. BP measurements were performed 1 day before and 5 days after surgery. Accordingly, patients' medical characteristics were recorded. In addition, in situ rat and xenograft nude-mice prolactinoma models have been used to mimic prolactinoma. In vivo BP and serum prolactin (PRL) levels were measured after cabergoline (CAB) administration in both rats and mice. Our data suggest that surgery can effectively decrease BP in prolactinoma patients with or without hypertension. The BP-lowering effect was significantly associated with several variables, including age, sex, disease duration, tumor size, invasion, dopamine agonists (DAs)-resistance, recurrence, and preoperative PRL levels. Moreover, in situ and xenograft prolactinomas induced BP elevation, which was alleviated by CAB treatment without and with a statistical difference in rats and mice, respectively. Thus, surgery or CAB can decrease BP in prolactinoma, indicating that pre- and postoperative BP management becomes essential.
Collapse
Affiliation(s)
- Yijun Cheng
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
| | - Dapeng Wang
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
| | - Hao Tang
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
| | - Debing Tong
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou 213003, China
| | - Weiguo Zhao
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
| | - Shaojian Lin
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
| | - Hong Yao
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
| | - Wenwen Lv
- Clinical Research Center, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China
| | - Xun Zhang
- Neuroendocrine Research Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Li Xue
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
| | - Hanbing Shang
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
- Department of Neurosurgery, Ruijin-Hainan Hospital, Shanghai Jiao Tong University School of Medicine, Haikou 570312, China
| | - Zhe Bao Wu
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; (Y.C.); (D.W.)
| |
Collapse
|
5
|
Dzialach L, Sobolewska J, Zak Z, Respondek W, Witek P. Prolactin-secreting pituitary adenomas: male-specific differences in pathogenesis, clinical presentation and treatment. Front Endocrinol (Lausanne) 2024; 15:1338345. [PMID: 38370355 PMCID: PMC10870150 DOI: 10.3389/fendo.2024.1338345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/22/2024] [Indexed: 02/20/2024] Open
Abstract
Prolactinomas (PRLomas) constitute approximately half of all pituitary adenomas and approximately one-fifth of them are diagnosed in males. The clinical presentation of PRLomas results from direct prolactin (PRL) action, duration and severity of hyperprolactinemia, and tumor mass effect. Male PRLomas, compared to females, tend to be larger and more invasive, are associated with higher PRL concentration at diagnosis, present higher proliferative potential, are more frequently resistant to standard pharmacotherapy, and thus may require multimodal approach, including surgical resection, radiotherapy, and alternative medical agents. Therefore, the management of PRLomas in men is challenging in many cases. Additionally, hyperprolactinemia is associated with a significant negative impact on men's health, including sexual function and fertility potential, bone health, cardiovascular and metabolic complications, leading to decreased quality of life. In this review, we highlight the differences in pathogenesis, clinical presentation and treatment of PRLomas concerning the male sex.
Collapse
Affiliation(s)
- Lukasz Dzialach
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Sobolewska
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Zuzanna Zak
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Wioleta Respondek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Brodnowski Hospital, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
6
|
Shimon I. Prolactinomas Resistant to Dopamine Agonists: Pathophysiology and Treatment. Arch Med Res 2023; 54:102883. [PMID: 37689507 DOI: 10.1016/j.arcmed.2023.102883] [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: 06/11/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Abstract
Prolactinomas are the most common functional pituitary tumors, accounting for 40% of all pituitary adenomas. Medical treatment with dopamine agonists (DA), mainly cabergoline, is considered the primary therapy for these patients. Prolactin normalization is achieved in 80-90% of prolactinomas treated with cabergoline. Patients resistant to the standard dose can escalate the dose of cabergoline up to the maximum tolerated dose. The expression of dopamine (D2) receptors and dopamine affinity is decreased in aggressive and resistant prolactinomas. Patients with aggressive and DA-resistant adenomas or with rare PRL-secreting carcinomas can be treated off-label with temozolomide (TMZ), a DNA alkylating agent. TMZ is effective in 40-50% of treated lactotroph tumors showing at least a partial response. However, patients tend to escape from the effect of TMZ after a limited time of response. Other therapeutic options include aromatase inhibitors, the somatostatin receptor ligand pasireotide, peptide receptor radionuclide therapy (PRRT), immune-checkpoint inhibitors, tyrosine-kinase inhibitors, or everolimus, the mammalian target of rapamycin inhibitor. These experimental treatments were effective in some patients carrying refractory prolactinomas showing usually partial tumor control. However, the number of treated patients with any of these new therapeutic options is very limited and treatment results are inconsistent, thus additional experience with more patients is required.
Collapse
Affiliation(s)
- Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Petach-Tikva, and Sackler School of Medicine, Tel Aviv University, Israel.
| |
Collapse
|
7
|
Zandbergen IM, Huntoon KM, White TG, Bakker LEH, Verstegen MJT, Ghalib LM, van Furth WR, Pelsma ICM, Dehdashti AR, Biermasz NR, Prevedello DM. Efficacy and Safety of Endoscopic Transsphenoidal Resection for Prolactinoma: A Retrospective Multicenter Case-series. Arch Med Res 2023; 54:102919. [PMID: 38040527 DOI: 10.1016/j.arcmed.2023.102919] [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: 08/07/2023] [Revised: 11/03/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Endoscopic transsphenoidal surgery (ETSS) for prolactinoma is reserved for dopamine agonist (DA) resistance, intolerance, or apoplexy. High remission (overall 67%, microprolactinoma up to 90%), low recurrence (5-20%) rates highlighted that surgery might be first-line treatment. AIMS To report on outcomes of ETSS in a cohort of prolactinomas. METHODS Multicenter retrospective cohort of 137 prolactinoma patients (age 38.2 ± 13.7 years; 61.3% female, median follow-up 28.0 [15.0-55.5] months) operated between 2010-2019 with histopathological confirmation. RESULTS Median preoperative prolactin levels were 166 (98-837 µg/L; males 996 [159-2145 µg/L] vs. females 129 [84-223 µg/L], p <0.001). 56 (40.9%) microprolactinomas, 69 (50.4%) macroprolactinomas, and 7 (5.1%) giant prolactinomas were included, whereas no adenoma was detected in 5 (3.6%) patients. Males had larger tumors (macroprolactinomas: 38, 71.7%) vs. 31 (36.9%), p <0.001; giant prolactinomas: 7 (13.2%) vs. 0 (0.0%), (p <0.001). Prolactinomas were graded as KNOSP-3 in 15 (11.5%), and KNOSP-4 in 20 (15.3%) patients. Primary indication was DA intolerance (59, 43.1%); males 14 (26.4%) vs. females 45 (53.6%), p = 0.006. Long-term remission (i.e., DA-free prolactin level <1xULN) was achieved in 87 (63.5%) patients, being higher in intended complete resection (69/92 [75.0%]), and lower in males (25 [47.2%] vs. 62 females [73.8%], p = 0.002). Transient DI (n = 29, 21.2%) was the most frequent complication. CONCLUSIONS Despite high proportions of macroprolactinoma and KNOSP 3-4, long-term remission rates were 63.5% overall, and 83.3% in microprolactinoma patients. Males had less favorable remission rate compared to females. These findings highlight that ETSS may be a safe and efficacious treatment to manage prolactinoma.
Collapse
Affiliation(s)
- Ingrid Marijke Zandbergen
- Department of Neurosurgery, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands; Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands.
| | | | - Timothy G White
- Department of Neurosurgery, Hofstra University Northwell Health, Long Island, NY, USA
| | - Leontine Erica Henriëtte Bakker
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Luma Mudhafar Ghalib
- Department of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Wouter Ralph van Furth
- Department of Neurosurgery, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris Catharina Maria Pelsma
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra University Northwell Health, Long Island, NY, USA
| | - Nienke Ruurdje Biermasz
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH USA
| |
Collapse
|
8
|
Petersenn S, Fleseriu M, Casanueva FF, Giustina A, Biermasz N, Biller BMK, Bronstein M, Chanson P, Fukuoka H, Gadelha M, Greenman Y, Gurnell M, Ho KKY, Honegger J, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Lodish M, Maiter D, Marcus HJ, McCormack A, Molitch M, Muir CA, Neggers S, Pereira AM, Pivonello R, Post K, Raverot G, Salvatori R, Samson SL, Shimon I, Spencer-Segal J, Vila G, Wass J, Melmed S. Diagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement. Nat Rev Endocrinol 2023; 19:722-740. [PMID: 37670148 DOI: 10.1038/s41574-023-00886-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 09/07/2023]
Abstract
This Consensus Statement from an international, multidisciplinary workshop sponsored by the Pituitary Society offers evidence-based graded consensus recommendations and key summary points for clinical practice on the diagnosis and management of prolactinomas. Epidemiology and pathogenesis, clinical presentation of disordered pituitary hormone secretion, assessment of hyperprolactinaemia and biochemical evaluation, optimal use of imaging strategies and disease-related complications are addressed. In-depth discussions present the latest evidence on treatment of prolactinoma, including efficacy, adverse effects and options for withdrawal of dopamine agonist therapy, as well as indications for surgery, preoperative medical therapy and radiation therapy. Management of prolactinoma in special situations is discussed, including cystic lesions, mixed growth hormone-secreting and prolactin-secreting adenomas and giant and aggressive prolactinomas. Furthermore, considerations for pregnancy and fertility are outlined, as well as management of prolactinomas in children and adolescents, patients with an underlying psychiatric disorder, postmenopausal women, transgender individuals and patients with chronic kidney disease. The workshop concluded that, although treatment resistance is rare, there is a need for additional therapeutic options to address clinical challenges in treating these patients and a need to facilitate international registries to enable risk stratification and optimization of therapeutic strategies.
Collapse
Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany.
- University of Duisburg-Essen, Essen, Germany.
| | | | | | - Andrea Giustina
- San Raffaele Vita-Salute University, Milan, Italy
- IRCCS Hospital San Raffaele, Milan, Italy
| | | | | | | | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Monica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Yona Greenman
- Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Ken K Y Ho
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | | | | | - Ursula B Kaiser
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Maya Lodish
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Hani J Marcus
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ann McCormack
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Alberto M Pereira
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Kalmon Post
- Mount Sinai Health System, New York, NY, USA
| | - Gerald Raverot
- Department of Endocrinology, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est" Hospices Civils de Lyon, Bron, France
| | | | | | - Ilan Shimon
- Tel Aviv University, Tel Aviv, Israel
- Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- University of Oxford, Oxford, UK
- Churchill Hospital, Oxford, UK
| | | |
Collapse
|
9
|
van Trigt VR, Zandbergen IM, Pelsma ICM, Bakker LEH, Verstegen MJT, van Furth WR, Biermasz NR. Care trajectories of surgically treated patients with a prolactinoma: why did they opt for surgery? Pituitary 2023; 26:611-621. [PMID: 37690076 PMCID: PMC10539430 DOI: 10.1007/s11102-023-01346-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE To describe care trajectories in patients with prolactinoma, aiming to clarify the rationale for surgery. METHODS Retrospective observational cohort study of consecutive patients with prolactinoma undergoing surgery from 2017 to 2019 at the referral center (RC), prior to surgery being considered a viable treatment option (i.e. PRolaCT study). Demographics and clinical data (type and duration of pretreatment and surgical indications, goals, and outcomes) were collected from patient records. Care trajectories were divided into three phases: (1) diagnosis and initial treatment, (2) endocrine treatment at the RC, and (3) surgical treatment. RESULTS 40 patients were included (31 females (77.5%), median age 26.5 (14-63) years. Indications for surgery were dopamine agonist (DA) intolerance (n = 31, 77.5%), resistance (n = 6, 15.0%), and patient/physician preference (n = 3, 7.5%). Patients were pretreated with DA (n = 39 (97.5%)), and surgery (n = 3 (7.5%)). Median disease duration at surgery was 4 (0-27) years. Primary surgical goal was total resection in 38 patients (95.0%), of which biochemical remission was achieved 6 months postoperatively in 23 patients (62.2%), and clinical remission in 6 patients (16.2%), missing data n = 1. CONCLUSION Care trajectories were highly individualized based on patient and tumor characteristics, as well as the multidisciplinary team's assessment (need for alternative treatment, surgical chances and risks). Most patients were pretreated pharmacologically and had broad variation in timing of referral, undergoing surgery as last-resort treatment predominantly due to DA intolerance. High quality imaging and multidisciplinary consultations with experienced neurosurgeons and endocrinologists enabling treatment tailored to patients' needs were prerequisites for adequate counseling in treatment of patients with prolactinoma.
Collapse
Affiliation(s)
- Victoria R van Trigt
- Division of Endocrinology, Department of Medicine, Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands.
| | - Ingrid M Zandbergen
- Division of Endocrinology, Department of Medicine, Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris C M Pelsma
- Division of Endocrinology, Department of Medicine, Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Leontine E H Bakker
- Division of Endocrinology, Department of Medicine, Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco J T Verstegen
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland, Leiden, The Netherlands
| | - Nienke R Biermasz
- Division of Endocrinology, Department of Medicine, Center for Endocrine Tumors Leiden, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
10
|
Kim EH, Kim J, Ku CR, Lee EJ, Kim SH. Surgical Treatment of Prolactinomas: Potential Role as a First-Line Treatment Modality. Yonsei Med J 2023; 64:489-496. [PMID: 37488700 PMCID: PMC10375245 DOI: 10.3349/ymj.2022.0406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 05/01/2023] [Accepted: 06/01/2023] [Indexed: 07/26/2023] Open
Abstract
PURPOSE Treatment with dopamine agonists (DAs) has been the first-line standard treatment for prolactinoma, and surgery has been reserved for drug intolerance and resistance for several decades. We evaluated whether surgery plays a primary role in prolactinoma management. MATERIALS AND METHODS We conducted a retrospective study of 210 prolactinoma patients who had received surgical treatment at our institution. We analyzed the treatment outcomes according to tumor extent, sex, and preoperative DA medication. RESULTS Overall hormonal remission was achieved in 164 patients (78.1%), and complete removal was achieved in 194 patients (92.4%). When the tumors were completely removed, the remission rate increased to 84.5%. Anterior pituitary function was normalized or improved in 94.6% of patients, whereas only 4.1% of patients showed worsening of hormone control. Hormonal remission was higher in patients who had not received DA preoperatively than in those who had received preoperative DA treatment. Smaller tumor size (<1 cm), no invasion into the cavernous sinus, and female sex were predictors of good surgical outcomes. CONCLUSION Although DAs remain the first-line standard treatment for prolactinomas, surgery can be an excellent option and should be considered as an alternative primary treatment modality when patients are predicted to achieve a good surgical outcome.
Collapse
Affiliation(s)
- Eui Hyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
- Yonsei Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Junhyung Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Cheol Ryong Ku
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
- Yonsei Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Jig Lee
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
- Yonsei Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Ho Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
11
|
Ottenhausen M, Conrad J, Wolters LM, Ringel F. Surgery as first-line treatment for prolactinoma? Discussion of the literature and results of a consecutive series of surgically treated patients. Neurosurg Rev 2023; 46:128. [PMID: 37249700 PMCID: PMC10229663 DOI: 10.1007/s10143-023-02033-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/21/2023] [Accepted: 05/14/2023] [Indexed: 05/31/2023]
Abstract
Initial treatment for prolactinoma is usually conservative with dopamine agonists. However, the duration of treatment is often lifelong and can be associated with significant side effects. Surgical outcomes are usually favorable and treatment complications low, raising the question whether surgical therapy should be included earlier in the treatment of prolactinoma. The aim of this study was to analyze the outcome of surgical resection of prolactinomas at our institution, to compare it with other published surgical and conservative series and to discuss the role of surgery in modern prolactinoma therapy. The authors reviewed a database of single-center consecutively operated prolactinoma cases and analyzed the extent of resection (EOR), endocrinological and neurological outcomes, and complications. Thirty patients were analyzed. Mean patient age was 37.2 ± 15.5 years (range 16-76) and consisted of 17 (56.7%) females and 13 (43.3%) males. Twenty-one patients (70%) failed medical therapy, the main reasons being intolerable side effects in 11 cases (52.4%) and insufficient response in 10 cases (47.6%). Nine patients (30%) received no medical treatment prior to surgery, of which five (55.6%) were operated because of pituitary apoplexy, two (22.2%) because of acute visual deterioration and two (22.2%) refused medical treatment and opted for surgery as first-line treatment. Of the 30 operated tumors, 56.7% (n = 17) were microadenomas, 30% (n = 9) were macroadenomas (≥ 10 mm), and 13.3% (n = 4) were giant adenomas (≥ 40 mm). GTR was achieved in 75% (n = 21) of cases. The overall remission rate was 63.3%. MRI showed a residual tumor in seven patients (25%), typically with invasive growth. Postoperative CSF leaks did not occur. Mean follow-up was 34.9 ± 60.3 months (range 0-246 months). Endocrine remission was defined as a morning fasting basal PRL level of 22.3 < ng/mL and measured at the last available follow-up. Postoperative Prolactine levels were missing in three patients. Our analysis describes a highly selected sample with a disproportionate number of larger, invasive tumors and emergency cases. Nevertheless, the results are satisfactory and comparable with other published series. The consistently good results of transphenoidal surgery, especially for microprolactinomas, have led to a greater acceptance of surgery in the treatment of prolactinomas in recent years. The timing of surgery in each individual case must be determined by a multidisciplinary team to ensure the best possible outcome.
Collapse
Affiliation(s)
- Malte Ottenhausen
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Jens Conrad
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Lea-Marie Wolters
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| |
Collapse
|
12
|
Gheorghe AM, Trandafir AI, Stanciu M, Popa FL, Nistor C, Carsote M. Challenges of Pituitary Apoplexy in Pregnancy. J Clin Med 2023; 12:jcm12103416. [PMID: 37240522 DOI: 10.3390/jcm12103416] [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: 03/31/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012-December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal-fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample-case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal-fetal outcomes from multidisciplinary insights.
Collapse
Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra-Ioana Trandafir
- Department of Endocrinology, Doctoral School of "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 50169 Sibiu, Romania
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy & Thoracic Surgery Department, "Dr. Carol Davila" Central Emergency University Military Hospital, 013058 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, "Carol Davila" University of Medicine and Pharmacy & "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| |
Collapse
|
13
|
Stumpf MAM, Pinheiro FMM, Silva GO, Cescato VAS, Musolino NRC, Cunha-Neto MBC, Glezer A. How to manage intolerance to dopamine agonist in patients with prolactinoma. Pituitary 2023:10.1007/s11102-023-01313-8. [PMID: 37027090 DOI: 10.1007/s11102-023-01313-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE Dopamine agonists (DA) are the gold-standard for prolactinoma and hyperprolactinemia treatment. Intolerance to DA leading to drug drop out occurs in 3 to 12% of cases. We provide here a review of published data about DA intolerance and present a case report concerning the use of intravaginal cabergoline. METHODS We review the literature on the definition, the pathogenesis, frequency and management of DA intolerance. In addition, the review provides strategies to enhance tolerability and avoid precocious clinical treatment withdrawal. RESULTS Cabergoline is often cited as the most tolerable DA and its side effects tend to ameliorate within days to weeks. Restarting the same drug at a lower dose or switching to another DA can be used in cases of intolerance. The vaginal route can be tried specifically if there are gastrointestinal side effects in the oral administration. Symptomatic treatment could be attempted, although mainly based on a strategy used in other diseases. CONCLUSIONS Due to limited data, no guidelines have been developed for the management of intolerance in DA treatment. The most frequent management is to perform transsphenoidal surgery. Nevertheless, this manuscript provides data derived from published literature and expert opinion, suggesting new approaches to this clinical issue.
Collapse
Affiliation(s)
- Matheo Augusto Morandi Stumpf
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil.
| | - Felipe Moura Maia Pinheiro
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil
| | - Gilberto Ochman Silva
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Valter Angelo Sperling Cescato
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Nina Rosa Castro Musolino
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Malebranche Berardo Carneiro Cunha-Neto
- Grupo de Neuroendocrinologia, Divisão de Neurocirurgia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Andrea Glezer
- Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, 05403- 010, SP, Brazil
| |
Collapse
|
14
|
Andereggen L, Tortora A, Schubert GA, Musahl C, Frey J, Luedi MM, Mariani L, Beck J, Christ E. Prolactinomas in adolescent and elderly patients-A comparative long-term analysis. Front Surg 2023; 10:967407. [PMID: 36814862 PMCID: PMC9939754 DOI: 10.3389/fsurg.2023.967407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 01/16/2023] [Indexed: 02/09/2023] Open
Abstract
Objectives Prolactinomas represent the most common type of secreting pituitary adenomas, yet are rarely encountered in adolescent-onset (AO; i.e. <18 years) or elderly-onset (EO; i.e. ≥65 years) cohorts. As a result, it is not clear whether long-term strategies should be focused differently at both age extremes when comparing their therapeutic outcomes. We aimed at investigating long-term endocrinological outcomes, looking for differences between the two cohorts and evaluating the dependence on continued dopamine agonist (DA) therapy. Methods Retrospective cross-sectional comparative study analyzing prolactinoma patients with a follow-up of ≥4 years. Clinical, radiological and biochemical characteristics were assessed at diagnosis and last follow-up. Longitudinal endocrinological outcomes between groups of extreme ages (i.e. AO and EO) and middle age (i.e. ≥18 years to 65 years) were compared. Independent risk factors for long-term dependence on DAs were calculated. Results Follow-up at ≥4 years was recorded for 108 prolactinoma patients; 10 patients with AO and 10 patients with EO. Compared to AO patients, EO patients were predominantly men (p = 0.003), and presented with significantly higher prolactin (PRL) levels (p = 0.05) and higher body mass index (p = 0.03). We noted a significant positive correlation between patients' PRL values and their age (r = 0.5, p = 0.03) or BMI (r = 0.6, p = 0.03). After a median follow-up of 115 months, remission was noted in 87 (83%) patients; 9 (90%) in AO patients, and 7 (70%) in EO patients (p = 0.58). Continuation of DAs was required in 4 patients (40%) with AO and 7 patients (70%) with EO (p = 0.37). Patients with elderly-onset were an independent predictor of long-term dependence on DAs (HR 2.8, 95% CI 1.1-7.2, p = 0.03). Conclusions Long-term control of hyperprolactinemia and hypogonadism does not differ between members of the AO and EO cohorts, and can be attained by the majority of patients. However, adjuvant DAs are often required, independent of the age of onset. Considering the clinical significance of persistent DA therapy for the control of hyperprolactinemia in many patients at both extremes of age, long-term monitoring may become recommended, in particular in patients with elderly-onset.
Collapse
Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland,Faculty of Medicine, University of Bern, Bern, Switzerland,Correspondence: Lukas Andereggen
| | - Angelo Tortora
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Christian Musahl
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Janine Frey
- Department of Gynecology and Obstetrics, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Markus M. Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Jürgen Beck
- Faculty of Medicine, University of Bern, Bern, Switzerland,Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Emanuel Christ
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Basel, Basel, Switzerland
| |
Collapse
|
15
|
Surgical Technique and Efficacy Analysis of Extra-pseudocapsular Transnasal Transsphenoidal Surgery for Pituitary Microprolactinoma. Curr Med Sci 2022; 42:1140-1147. [PMID: 36547872 DOI: 10.1007/s11596-022-2678-1] [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: 08/11/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To elucidate the role of transsphenoidal surgery in the treatment of pituitary microprolactinoma. METHODS The clinical data of 107 prolactinoma cases treated by extra-pseudocapsular transnasal transsphenoidal surgery (ETTS) for different indications in our department since 2011 was retrospectively analyzed. RESULTS The most common indication was the ineffectiveness of oral medication (41.1%), followed by the personal willingness of the patient (35.5%), and 20.6% of the patients were young women with clear tumor boundaries. The pseudocapsule was not observed in 63 cases (58.9%), incomplete pseudocapsule was observed in 26 cases (24.3%), and complete pseudocapsule in 18 cases (16.8%). A total of 97 patients (90.7%) obtained 1-year post-operation remission. According to the relative location of the adenoma and pituitary gland on the MRI scan, 46 patients were classified into a central type, 59 a lateral type, and 2 a supra-pituitary type. Two patients developed hypogonadism, one patient developed hypocortisolism, and one patient developed post-operative hypothyroidism. Two patients were administrated with hormone replacement treatment, and the treatment was stopped within one week. There was no permanent hypopituitarism. Further investigation demonstrated that the adenoma types could affect the remission rates of hyperprolactinemia and gross total resection rate in microprolactinoma. CONCLUSION ETTS was an effective treatment for pituitary microprolactinomas. This could be the first choice for patients who presented enclosed adenoma on the MRI and were potentially curable in a preoperative evaluation. Maximal safe removal of the adenoma by ETTS with the aim to increase the sensitivity of the drugs was also recommended for patients with invasive dopamine agonist resistant prolactinomas and patients with difficulty in childbirth.
Collapse
|
16
|
Mamelak A. Surgery as a first-line option for prolactinomas. Expert Rev Endocrinol Metab 2022; 17:485-498. [PMID: 36200144 DOI: 10.1080/17446651.2022.2131531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/28/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Treatment of prolactinomas with dopamine agonists has been the established first-line treatment option for many years, with surgery reserved for refractory cases or medication intolerance. This approach may not be the best option in many cases. AREAS COVERED Review of the epidemiology, biology, and treatment options available for prolactinomas, including best available data on outcomes, costs, and morbidities for each therapy. These data are then used to propose a 'surgery-first' treatment approach for a subset of prolactinomas as an alternative to primary medical management. EXPERT OPINION Based on the available data, there is a strong rationale that transsphenoidal surgery should be considered a first-line treatment option for both micro- and macro-prolactinomas that do not demonstrate high grade cavernous sinus invasion on MRI imaging, with dopamine agonists administered as a secondary therapy for tumors not in remission following surgery, and for giant tumors. This 'surgery-first' approach assumes the availability of skilled and experienced pituitary surgeons to ensure optimal outcomes. This approach should result in high cure rates and reduced DA requirements for patients not cured from initial surgery. Further, it will reduce medical costs over a patient's lifetime and the chronic morbidities associated with protracted dopamine agonist usage.
Collapse
Affiliation(s)
- Adam Mamelak
- Surgical Director, Pituitary Center & Center for Minimally Invasive Skull Base Surgery, Cedars-Sinai Medical Center, Los Angeles
| |
Collapse
|
17
|
Inder WJ, Jang C. Treatment of Prolactinoma. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081095. [PMID: 36013562 PMCID: PMC9413135 DOI: 10.3390/medicina58081095] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 05/14/2023]
Abstract
Prolactinomas are the commonest form of pituitary neuroendocrine tumor (PitNET), representing approximately half of such tumors. Dopamine agonists (DAs) have traditionally been the primary treatment for the majority of prolactinomas, with surgery considered the second line. The aim of this review is to examine the historical and modern management of prolactinomas, including medical therapy with DAs, transsphenoidal surgery, and multimodality therapy for the treatment of aggressive prolactinomas and metastatic PitNETs, with an emphasis on the efficacy, safety, and future directions of current therapeutic modalities. DAs have been the mainstay of prolactinoma management since the 1970s, initially with bromocriptine and more recently with cabergoline. Cabergoline normalizes prolactin in up to 85% of patients and causes tumor shrinkage in up to 80%. Primary surgical resection of microprolactinomas and enclosed macroprolactinomas performed by experienced pituitary neurosurgeons have similar remission rates to cabergoline. Aggressive prolactinomas and metastatic PitNETS should receive multimodality therapy including high dose cabergoline, surgery, radiation therapy (preferably using stereotactic radiosurgery where suitable), and temozolomide. DAs remain a reliable mode of therapy for most prolactinomas but results from transsphenoidal surgery in expert hands have improved considerably over the last one to two decades. Surgery should be strongly considered as primary therapy, particularly in the setting of microprolactinomas, non-invasive macroprolactinomas, or prior to attempting pregnancy, and has an important role in the management of DA resistant and aggressive prolactinomas.
Collapse
Affiliation(s)
- Warrick J. Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba 4102, Australia
- Academy for Medical Education, Faculty of Medicine, The University of Queensland, Herston 4029, Australia
- Correspondence: ; Tel.: +61-7-3176-9563
| | - Christina Jang
- Department of Endocrinology and Diabetes, Royal Brisbane and Women’s Hospital, Herston 4029, Australia
- Faculty of Medicine, The University of Queensland, Herston 4029, Australia
| |
Collapse
|
18
|
Bashari WA, van der Meulen M, MacFarlane J, Gillett D, Senanayake R, Serban L, Powlson AS, Brooke AM, Scoffings DJ, Jones J, O'Donovan DG, Tysome J, Santarius T, Donnelly N, Boros I, Aigbirhio F, Jefferies S, Cheow HK, Mendichovszky IA, Kolias AG, Mannion R, Koulouri O, Gurnell M. 11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy. Pituitary 2022; 25:573-586. [PMID: 35608811 PMCID: PMC9345820 DOI: 10.1007/s11102-022-01229-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 10/29/2022]
Abstract
PURPOSE To assess the potential for 11C-methionine PET (Met-PET) coregistered with volumetric magnetic resonance imaging (Met-PET/MRCR) to inform clinical decision making in patients with poorly visualized or occult microprolactinomas and dopamine agonist intolerance or resistance. PATIENTS AND METHODS Thirteen patients with pituitary microprolactinomas, and who were intolerant (n = 11) or resistant (n = 2) to dopamine agonist therapy, were referred to our specialist pituitary centre for Met-PET/MRCR between 2016 and 2020. All patients had persistent hyperprolactinemia and were being considered for surgical intervention, but standard clinical MRI had shown either no visible adenoma or equivocal appearances. RESULTS In all 13 patients Met-PET/MRCR demonstrated a single focus of avid tracer uptake. This was localized either to the right or left side of the sella in 12 subjects. In one patient, who had previously undergone surgery for a left-sided adenoma, recurrent tumor was unexpectedly identified in the left cavernous sinus. Five patients underwent endoscopic transsphenoidal selective adenomectomy, with subsequent complete remission of hyperprolactinaemia and normalization of other pituitary function; three patients are awaiting surgery. In the patient with inoperable cavernous sinus disease PET-guided stereotactic radiosurgery (SRS) was performed with subsequent near-normalization of serum prolactin. Two patients elected for a further trial of medical therapy, while two declined surgery or radiotherapy and chose to remain off medical treatment. CONCLUSIONS In patients with dopamine agonist intolerance or resistance, and indeterminate pituitary MRI, molecular (functional) imaging with Met-PET/MRCR can allow precise localization of a microprolactinoma to facilitate selective surgical adenomectomy or SRS.
Collapse
Affiliation(s)
- W A Bashari
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - M van der Meulen
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - J MacFarlane
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - D Gillett
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
- Department of Nuclear Medicine, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - R Senanayake
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - L Serban
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - A S Powlson
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - A M Brooke
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - D J Scoffings
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - J Jones
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - D G O'Donovan
- Department of Neuropathology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - J Tysome
- Department of Otolaryngology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - T Santarius
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - N Donnelly
- Department of Otolaryngology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - I Boros
- Wolfson Brain Imaging Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - F Aigbirhio
- Wolfson Brain Imaging Centre, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - S Jefferies
- Department of Oncology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - H K Cheow
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
- Department of Nuclear Medicine, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - I A Mendichovszky
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
- Department of Nuclear Medicine, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
- Department of Radiology, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - A G Kolias
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - R Mannion
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - O Koulouri
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - M Gurnell
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK.
| |
Collapse
|
19
|
Update in Pathogenesis, Diagnosis, and Therapy of Prolactinoma. Cancers (Basel) 2022; 14:cancers14153604. [PMID: 35892862 PMCID: PMC9331865 DOI: 10.3390/cancers14153604] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary This review updates recent advances in the pathogenesis, diagnosis, and therapy of prolactinoma. Prolactinomas, comprising 30–50% of all pituitary neuroendocrine tumors, frequently occur in females aged 20 to 50 and cause hypogonadism and infertility. In typical cases, female patients exhibit galactorrhea and amenorrhea due to serum prolactin (PRL) elevation, and during pregnancy, they should be carefully treated. During diagnosis, other causes of hyperprolactinemia must be excluded, and an MRI is useful for detecting pituitary neuroendocrine tumors. For the treatment of prolactinoma, dopamine agonists are effective in decreasing PRL levels and shrinking tumor size in most patients. Surgical treatment is recommended for patients who are resistant or intolerant to dopamine agonists. This review also discusses giant and malignant prolactinomas, prolactinoma-associated pregnancy, and new therapeutic approaches. Abstract Prolactinomas comprise 30–50% of all pituitary neuroendocrine tumors, frequently occur in females aged 20 to 50, and cause hypogonadism and infertility. In typical cases, female patients exhibit galactorrhea and amenorrhea due to serum prolactin (PRL) elevation, and patients during pregnancy should be carefully treated. During diagnosis, other causes of hyperprolactinemia must be excluded, and an MRI is useful for detecting pituitary neuroendocrine tumors. For treating prolactinoma, dopamine agonists (DAs) are effective for decreasing PRL levels and shrinking tumor size in most patients. Some DA-resistant cases and the molecular mechanisms of resistance to a DA are partially clarified. The side effects of a DA include cardiac valve alterations and impulse control disorders. Although surgical therapies are invasive, recent analysis shows that long-term remission rates are higher than from medical therapies. The treatments for giant or malignant prolactinomas are challenging, and the combination of medication, surgery, and radiation therapy should be considered. Regarding pathogenesis, somatic SF3B1 mutations were recently identified even though molecular mechanisms in most cases of prolactinoma have not been elucidated. To understand the pathogenesis of prolactinomas, the development of new therapeutic approaches for treatment-resistant patients is expected. This review updates the recent advances in understanding the pathogenesis, diagnosis, and therapy of prolactinoma.
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Overview of Pituitary Surgery. Otolaryngol Clin North Am 2022; 55:205-221. [DOI: 10.1016/j.otc.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
22
|
Cozzi R, Ambrosio MR, Attanasio R, Battista C, Bozzao A, Caputo M, Ciccarelli E, De Marinis L, De Menis E, Faustini Fustini M, Grimaldi F, Lania A, Lasio G, Logoluso F, Losa M, Maffei P, Milani D, Poggi M, Zini M, Katznelson L, Luger A, Poiana C. Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors. Eur J Endocrinol 2022; 186:P1-P33. [PMID: 35000899 PMCID: PMC8859924 DOI: 10.1530/eje-21-0977] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022]
Abstract
Prolactinomas are the most frequent pituitary adenomas. Prolactinoma may occur in different clinical settings and always require an individually tailored approach. This is the reason why a panel of Italian neuroendocrine experts was charged with the task to provide indications for the diagnostic and therapeutic approaches that can be easily applied in different contexts. The document provides 15 recommendations for diagnosis and 54 recommendations for treatment, issued according to the GRADE system. The level of agreement among panel members was formally evaluated by RAND-UCLA methodology. In the last century, prolactinomas represented the paradigm of pituitary tumors for which the development of highly effective drugs obtained the best results, allowing to avoid neurosurgery in most cases. The impressive improvement of neurosurgical endoscopic techniques allows a far better definition of the tumoral tissue during surgery and the remission of endocrine symptoms in many patients with pituitary tumors. Consequently, this refinement of neurosurgery is changing the therapeutic strategy in prolactinomas, allowing the definitive cure of some patients with permanent discontinuation of medical therapy.
Collapse
Affiliation(s)
- Renato Cozzi
- Division of Endocrinology, Niguarda Hospital, Milan, Italy
- Correspondence should be addressed to R Cozzi;
| | - Maria Rosaria Ambrosio
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Claudia Battista
- Endocrinology Unit, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo (FG), Italy
| | - Alessandro Bozzao
- Neuroradiology, S. Andrea Hospital, NESMOS Department (Neuroscience, Mental Health, Sensorial Organs), Sapienza University of Rome, Rome, Italy
| | - Marco Caputo
- Laboratorio Analisi Cliniche e Microbiologia, Synlab SRL, Calenzano, Florence, Italy
| | | | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | | | | | - Franco Grimaldi
- AME President, Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Udine, Italy
| | - Andrea Lania
- Department of Biomedical Sciences, Endocrinology Unit, Rozzano, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | | | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Maffei
- Department of Medicine (DIMED), 3rd Medical Clinic, Padua University Hospital, Padua, Italy
| | - Davide Milani
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Maurizio Poggi
- Endocrinology, Department of Clinical and Molecular Medicine, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Michele Zini
- Endocrinology Unit, Azienda Ospedaliera S. Maria Nuova IRCCS, Reggio Emilia, Italy
| | | | - Anton Luger
- Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - Catalina Poiana
- ‘Carol Davila’ University of Medicine and Pharmacy – Endocrinology, “C.I. Parhon” National Institute of Endocrinology – Pituitary and Neuroendocrine Disorders, Bucharest, Romania
| | | |
Collapse
|
23
|
De Sousa SMC. Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management? ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R31-R50. [PMID: 37435462 PMCID: PMC10259306 DOI: 10.1530/eo-21-0038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 04/20/2022] [Indexed: 07/13/2023]
Abstract
The current treatment paradigm for prolactinomas involves dopamine agonist (DA) therapy as the first-line treatment, with surgical resection reserved for cases where there is DA failure due to resistance or intolerance. This review highlights how DA therapy can be optimised to overcome its increasingly recognised pitfalls, whilst also addressing the potential for expanding the use of surgery in the management of prolactinomas. The first part of the review discusses the limitations of DA therapy, namely: DA resistance; common DA side effects; and the rare but serious DA-induced risks of cardiac valvulopathy, impulse control disorders, psychosis, CSF rhinorrhoea and tumour fibrosis. The second part of the review explores the role of surgery in prolactinoma management with reference to its current second-line position and recent calls for surgery to be considered as an alternative first-line treatment alongside DA therapy. Randomised trials comparing medical vs surgical therapy for prolactinomas are currently underway. Pending these results, a low surgical threshold approach is herein proposed, whereby DA therapy remains the default treatment for prolactinomas unless there are specific triggers to consider surgery, including concern regarding DA side effects or risks in vulnerable patients, persistent and bothersome DA side effects, emergence of any serious risks of DA therapy, expected need for long-term DA therapy, as well as the traditional indications for surgery. This approach should optimise the use of DA therapy for those who will most benefit from it, whilst instituting surgery early in others in order to minimise the cumulative burden of prolonged DA therapy.
Collapse
Affiliation(s)
- Sunita M C De Sousa
- Endocrine & Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
- South Australian Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
| |
Collapse
|
24
|
Valea A, Sandru F, Petca A, Dumitrascu MC, Carsote M, Petca RC, Ghemigian A. Aggressive prolactinoma (Review). Exp Ther Med 2021; 23:74. [PMID: 34934445 DOI: 10.3892/etm.2021.10997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/05/2021] [Indexed: 12/22/2022] Open
Abstract
Aggressive prolactinoma (APRL) is a subgroup of aggressive pituitary tumors (accounting for 10% of all hypophyseal neoplasia) which are defined by: invasion based on radiological and/or histological features, a higher proliferation profile when compared to typical adenomas and rapidly developing resistance to standard medication/protocols in addition to an increased risk of early recurrence. This is a narrative review focusing on APRL in terms of both presentation and management. Upon admission, the suggestive features may include increased serum prolactin with a large tumor diameter (mainly >4 cm), male sex, early age at diagnosis (<20 years), and genetic predisposition [multiple endocrine neoplasia type 1 (MEN1), aryl hydrocarbon receptor interacting protein (AIP), succinate dehydrogenase (SDHx) gene mutations]. Potential prognostic factors are indicated by assessment of E-cadherin, matrix metalloproteinase (MMP)-9, and vascular endothelial growth factor (VEGF) status. Furthermore, during management, APRL may be associated with dopamine agonist (DA) resistance (described in 10-20% of all prolactinomas), post-hypophysectomy relapse, mitotic count >2, Ki-67 proliferation index ≥3%, the need for radiotherapy, lack of response in terms of controlling prolactin levels and tumor growth despite multimodal therapy. However, none of these as an isolated element serves as a surrogate of APRL diagnosis. A fourth-line therapy is necessary with temozolomide, an oral alkylating chemotherapeutic agent, that may induce tumor reduction and serum prolactin reduction in 75% of cases but only 8% have a normalization of prolactin levels. Controversies surrounding the duration of therapy still exist; also regarding the fifth-line therapy, post-temozolomide intervention. Recent data suggest alternatives such as somatostatin analogues (pasireotide), checkpoint inhibitors (ipilimumab, nivolumab), tyrosine kinase inhibitors (TKIs) (lapatinib), and mTOR inhibitors (everolimus). APRL represents a complex condition that is still challenging, and multimodal therapy is essential.
Collapse
Affiliation(s)
- Ana Valea
- Department of Endocrinology, 'I. Hatieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania.,Department of Endocrinology, Clinical County Hospital, 400000 Cluj-Napoca, Romania
| | - Florica Sandru
- Department of Dermatology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Dermatology, 'Elias' University Emergency Hospital, 011461 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Obstetrics and Gynecology, 'Elias' University Emergency Hospital, 011461 Bucharest, Romania
| | - Mihai Cristian Dumitrascu
- Department of Obstetrics and Gynecology, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Obstetrics and Gynecology, University Emergency Hospital, 050098 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Endocrinology, 'C. I. Parhon' National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Razvan-Cosmin Petca
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Urology, 'Prof. Dr. Theodor Burgele' Clinical Hospital, 061344 Bucharest, Romania
| | - Adina Ghemigian
- Department of Endocrinology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Department of Endocrinology, 'C. I. Parhon' National Institute of Endocrinology, 011863 Bucharest, Romania
| |
Collapse
|
25
|
Andereggen L, Frey J, Andres RH, Luedi MM, El-Koussy M, Widmer HR, Beck J, Mariani L, Seiler RW, Christ E. First-line surgery in prolactinomas: lessons from a long-term follow-up study in a tertiary referral center. J Endocrinol Invest 2021; 44:2621-2633. [PMID: 33847973 PMCID: PMC8572196 DOI: 10.1007/s40618-021-01569-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/31/2021] [Indexed: 02/06/2023]
Abstract
CONTEXT Although consensus guidelines recommend dopamine agonists (DAs) as the first-line approach in prolactinomas, some patients may opt instead for upfront surgery, with the goal of minimizing the need for continuation of DAs over the long term. While this approach can be recommended in selected patients with a microprolactinoma, the indication for upfront surgery in macroprolactinomas remains controversial, with limited long-term data in large cohorts. We aimed at elucidating whether first-line surgery is equally safe and effective for patients with micro- or macroprolactinomas not extending beyond the median carotid line (i.e., Knosp grade ≤ 1). METHODOLOGY Retrospective study of patients with prolactinomas Knosp grade ≤ 1 treated with upfront surgery. The primary endpoint was patients' dependence on DAs at last follow-up. The secondary endpoint was postoperative complications. Independent risk factors for long-term dependence on DAs were analyzed. RESULTS A microadenoma was noted in 45 patients (52%) and a macroadenoma in 41 (48%), with 17 (20%) harboring a Knosp grade 1 prolactinoma. Median follow-up was 80 months. First-line surgery resulted in long-term remission in 31 patients (72%) with a microprolactinoma and in 18 patients (45%) with a macroprolactinoma (p = 0.02). DA therapy was ultimately required in 11 patients (24%) with microadenomas vs. 20 (49%) with macroadenomas (p = 0.03). As for the latter, DA was required in 13 patients (76%) with Knosp grade 1 macroadenomas vs. 7 patients (29%) with Knosp grade 0 macroadenomas (p = 0.004). There was no mortality, and morbidity was minimal. Knosp grade 1 prolactinomas (OR 7.3, 95% CI 1.4-37.7, p = 0.02) but not adenoma size (i.e., macroprolactinomas) were an independent predictor of long-term dependence on DAs. CONCLUSIONS First-line surgery in patients with microprolactinomas or macroprolactinomas Knosp grade 0 resulted in a good chance of non-dependency on DA therapy. However, in patients with prolactinomas Knosp grade 1, first-line surgery cannot be recommended, as adjuvant DA therapy after surgery is required in the majority of them over the long term.
Collapse
Affiliation(s)
- L Andereggen
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
| | - J Frey
- Department of Endocrinology, Diabetes, Nutrition and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Gynecology and Obstetrics, Kantonsspital Lucerne, Lucerne, Switzerland
| | - R H Andres
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - M M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M El-Koussy
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - H R Widmer
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - J Beck
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - L Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - R W Seiler
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - E Christ
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Basel, Basel, Switzerland
| |
Collapse
|
26
|
Park JY, Choi W, Hong AR, Yoon JH, Kim HK, Jang WY, Jung S, Kang HC. Surgery is a safe, effective first-line treatment modality for noninvasive prolactinomas. Pituitary 2021; 24:955-963. [PMID: 34189717 DOI: 10.1007/s11102-021-01168-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Dopamine agonists (DAs) have long been the recommended first-line treatment for prolactinoma. Given the remarkable developments in surgical techniques, however, surgery is on the rise. We compared the treatment outcomes of patients with noninvasive prolactinomas receiving two different initial treatments (DAs and transsphenoidal surgery). METHODS We reviewed 745 patients with hyperprolactinemia or pituitary tumors treated from 2004 to 2020 at Chonnam National University Hwasun Hospital and identified 310 with prolactinomas. After selecting patients who had pituitary tumors with Knosp grade 0 to 1 with follow-up period over 1 year, 70 patients (29 who underwent surgery and 41 who received DAs as the initial treatment) were finally included for a comparative study. RESULTS The surgery group exhibited better outcomes in terms of DA-free remission and the structural response, although the tumor size was significantly larger than in the DA group. The groups exhibited comparable results in terms of symptom control and the biochemical response. Univariate and multivariate analyses indicated that surgery as the initial treatment modality provided significantly better clinical outcomes in terms of DA-free remission. In the surgery group, a postoperative prolactin level < 10 ng/mL was the only significant predictor of DA-free remission. CONCLUSIONS Transsphenoidal surgery showed comparable clinical outcomes in patients with prolactinomas, and low complication rates. The decision regarding the first-line treatment modality for non-invasive prolactinomas should be made on an individual basis.
Collapse
Affiliation(s)
- Ji Yong Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| | - Wonsuk Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| | - A Ram Hong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| | - Jee Hee Yoon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| | - Hee Kyung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea.
| | - Woo-Youl Jang
- Department of Neurosurgery, Chonnam National University Medical School, Gwangju, Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Medical School, Gwangju, Korea
| | - Ho-Cheol Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chonnam National University Medical School, 264 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, 58128, Korea
| |
Collapse
|
27
|
Wildemberg LE, Fialho C, Gadelha MR. Prolactinomas. Presse Med 2021; 50:104080. [PMID: 34687915 DOI: 10.1016/j.lpm.2021.104080] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 08/31/2021] [Accepted: 10/12/2021] [Indexed: 12/28/2022] Open
Abstract
Hyperprolactinemia, defined by a level of serum prolactin above the standard upper limit of normal range, is a common finding in clinical practice and prolactinomas are the main pathological cause. Prolactinomas lead to signs and symptoms of hormone oversecretion, such as galactorrhea and hypogonadism, as well as symptoms of mass effect, including visual impairment, headaches and intracranial hypertension. Diagnosis involves prolactin measurement and sellar imaging, but several pitfalls are involved in this evaluation, which may difficult the proper management. Treatment is medical in the majority of cases, consisting of dopamine agonists, which present high response rates, with a very favorable safety profile. Major adverse effects that should be monitored consist of cardiac valvulopathy and impulse control disorders. Other treatment options include surgery and radiotherapy. Temozolomide may be used for aggressive or malignant carcinomas. Finally, pregnancy outcomes are similar to general population even when dopamine agonist treatment is maintained.
Collapse
Affiliation(s)
- Luiz Eduardo Wildemberg
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Christhiane Fialho
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Monica R Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
| |
Collapse
|
28
|
McCormack A. Childhood-onset prolactinomas-Should earlier surgery be considered? Clin Endocrinol (Oxf) 2021; 95:571-573. [PMID: 33876444 DOI: 10.1111/cen.14477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Ann McCormack
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Garvan Institute of Medical Research, Sydney, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, UNSW Sydney, Sydney, NSW, Australia
| |
Collapse
|
29
|
Andereggen L, Frey J, Andres RH, Luedi MM, Gralla J, Schubert GA, Beck J, Mariani L, Christ E. Impact of primary medical or surgical therapy on prolactinoma patients' BMI and metabolic profile over the long-term. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2021; 24:100258. [PMID: 34195008 PMCID: PMC8237353 DOI: 10.1016/j.jcte.2021.100258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/09/2021] [Indexed: 11/23/2022]
Abstract
High prolactin (PRL) levels are associated with weight gain and impaired metabolic profiles. Long-term control of hyperprolactinemia can be attained by first-line surgery and medical therapy. Normalization of PRL improves patients’ BMI and fasting glucose levels. Marginal changes in patients’ metabolic profiles are noted regardless of the primary therapy. Not dopamine agonists per se, but rather the control of hyperprolactinemia plays a role in metabolic profile alterations.
Objectives High prolactin levels have been associated with weight gain and impaired metabolic profiles. While treatment with dopamine agonists (DAs) has been shown to improve these parameters, there is a lack of surgical series on its comparative effect in prolactinoma patients. Methods In this retrospective, comparative study, consecutive patients with a prolactinoma were enrolled if treated with first-line transsphenoidal surgery (TSS) or with DAs. Patients with prolactinomas of Knosp grade >2 and those with a follow-up <24 months were excluded, as were patients with missing laboratory metabolic parameters at baseline and over the long-term. Effects of either treatment on BMI and the metabolic profile were analyzed, and independent risk factors for long-term obesity were calculated. Results Primary treatment was TSS for 12 patients (40%) and DAs for 18 patients (60%). At diagnosis, no significant differences between the two cohorts were observed with regard to adenoma size, Knosp grading, baseline prolactin (PRL) levels, prevalence of hypogonadism, or laboratory metabolic parameters. Mean follow-up was 51.9 months (range, 24–158). Over the long-term, both TSS and DAs led to the control of hyperprolactinemia (92% vs. 72%) and hypogonadism (78% vs. 83%) in the majority of patients. While a significant decrease in patients’ BMI and fasting glucose were observed, changes in the lipid profile were marginal and independent of the treatment modality. At baseline, increased BMI—but not the primary treatment strategy—was an independent predictor of long-term obesity. Conclusions Over the long-term, patients’ BMI and FG improve, but changes in the metabolic profile are marginal and independent of the primary treatment. It is presumable that not DAs per se, but rather the control of hyperprolactinemia plays a role in patients’ metabolic profile alterations.
Collapse
Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.,Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Janine Frey
- Department of Gynecology and Obstetrics, Kantonsspital Lucerne, Lucerne, Switzerland
| | | | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jan Gralla
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Emanuel Christ
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Basel, Basel, Switzerland
| |
Collapse
|
30
|
van der Meulen M, Zamanipoor Najafabadi AH, Lobatto DJ, van den Hout WB, Andela CD, Zandbergen IM, Pereira AM, van Furth WR, Vliet Vlieland TPM, Biermasz NR. Healthcare utilization and costs among prolactinoma patients: a cross-sectional study and analysis of determinants. Pituitary 2021; 24:79-95. [PMID: 33025546 PMCID: PMC7864816 DOI: 10.1007/s11102-020-01089-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Prolactinomas are the most prevalent functioning pituitary adenomas. They affect gonadal function as well as health-related quality of life (HRQoL). This study aimed to report healthcare utilization and costs, including their determinants, for prolactinoma patients. METHODS Cross-sectional study of 116 adult prolactinoma patients in chronic care in a Dutch tertiary referral center. Patients completed four validated questionnaires, assessing healthcare utilization and costs over the previous 12 months (Medical Consumption Questionnaire), disease bother and needs (Leiden Bother and Needs Questionnaire Pituitary), HRQoL (Short Form-36), and self-reported health status (EuroQol 5D). Regression analyses were used to assess associations between disease-related characteristics and healthcare utilization and costs. RESULTS Mean age was 52.0 years (SD 13.7) and median follow-up was 15.0 years (IQR 7.6-26.1). Patients visited the endocrinologist (86.2%), general practitioner (37.9%), and ophthalmologist (25.0%) most frequently. Psychological care was used by 12.9% of patients and 5% were admitted to hospital. Mean annual healthcare costs were €1928 (SD 3319), mainly for pituitary-specific medication (37.6% of total costs), hospitalization (19.4%) and specialist care (16.1%). Determinants for higher healthcare utilization and costs were greater disease bother and needs for support, lower HRQoL, elevated prolactin, and longer disease duration, while tumor size, hypopituitarism and adrenal insufficiency were not significantly associated with healthcare utilization and costs. CONCLUSION Healthcare utilization and costs of prolactinoma patients are related to patient-reported HRQoL, bother by disease and needs for support. Therefore, addressing patients' HRQoL and needs is a way forward to improve efficiency of care and patients' health status.
Collapse
Affiliation(s)
- Merel van der Meulen
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands.
| | - Amir H Zamanipoor Najafabadi
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | - Daniel J Lobatto
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | - Wilbert B van den Hout
- Department of Medical Decision Making & Quality of Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelie D Andela
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Ingrid M Zandbergen
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter R van Furth
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | - Thea P M Vliet Vlieland
- Department of Orthopedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
31
|
Giese S, Nasi-Kordhishti I, Honegger J. Outcomes of Transsphenoidal Microsurgery for Prolactinomas - A Contemporary Series of 162 Cases. Exp Clin Endocrinol Diabetes 2021; 129:163-171. [PMID: 33461233 DOI: 10.1055/a-1247-4908] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Renewed interest in transsphenoidal surgery (TSS) as a therapeutic option for prolactinomas has emerged. This study is aimed at defining the current role of pituitary surgery in the management of prolactinomas. MATERIALS AND METHODS In this retrospective, consecutive single-center study, 162 patients who underwent primary microscopic TSS for prolactinomas between 2006 and 2019 were analyzed regarding surgical indication, previous dopamine-agonist (DA) treatment, early remission rates (3 months postoperatively), surgical complications and pituitary function. RESULTS Seventy-four microprolactinomas and 88 macroprolactinomas were operated by TSS. 62.3% of the patients had received prior DA treatment. For microprolactinomas, the predominant indication for surgery was patient's wish (41.9%), while indications for macroprolactinomas varied. For enclosed microprolactinomas, the initial remission rate was 92.1%, while for macroprolactinomas, the rate was 70.4%. No significant difference of remission rates was found between DA-pretreated (65.3%) and non-pretreated (72.1%) patients (p=0.373).None of the patients suffered a significant complication. Re-operation for a postoperative cerebrospinal fluid leak was required in one patient (0.6%). Permanent postoperative deterioration of pituitary function was only observed in one of 158 patients with surgery for a prolactinoma (0.6%). Improvement of pituitary function was observed in 8 of 25 patients (32%) with preoperative deficits. CONCLUSION Transsphenoidal microsurgery is safe and efficient for treatment of prolactinomas. It is particularly suitable for enclosed prolactinomas. The patient should be well informed of the pros and cons of the treatment options, which include DA medication and TSS, and the patient's preference should be taken into account during decision-making.
Collapse
Affiliation(s)
- Sabrina Giese
- Department of Neurosurgery, University of Tübingen, Tübingen
| | | | - Jürgen Honegger
- Department of Neurosurgery, University of Tübingen, Tübingen
| |
Collapse
|
32
|
Andereggen L, Christ E. Commentary: "Prolactinomas: Prognostic Factors of Early Remission After Transsphenoidal Surgery". Front Endocrinol (Lausanne) 2021; 12:695498. [PMID: 34054739 PMCID: PMC8160469 DOI: 10.3389/fendo.2021.695498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
- *Correspondence: Lukas Andereggen, , orcid.org/0000-0003-1764-688X
| | - Emanuel Christ
- Department of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, Basel, Switzerland
| |
Collapse
|
33
|
Hage C, Salvatori R. Predictors of the Response to Dopaminergic Therapy in Patients With Prolactinoma. J Clin Endocrinol Metab 2020; 105:5905932. [PMID: 32930718 DOI: 10.1210/clinem/dgaa652] [Citation(s) in RCA: 9] [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: 07/07/2020] [Accepted: 09/11/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE Withdrawal of dopamine agonist (DA) therapy in patients with prolactinoma who are controlled by a small dose of medication is recommended by several guidelines. So far, the likelihood of reaching withdrawal conditions based on baseline characteristics remains uncertain. METHODS We retrospectively examined early clinical, radiological, or biochemical features that may predict the likelihood of reaching withdrawal conditions in prolactinoma patients. Data were obtained in a single academic medical center in the United States from patients seen between 2000 and 2018. Using multiple logistic regression, we compared patients who reached withdrawal conditions with those who did not. RESULTS Of 213 patients, 78 (36.6%) reached withdrawal conditions after at least 2 years of DA treatment. Initial maximal tumor diameter was significantly smaller in those who reached withdrawal conditions than in those who did not. Percent prolactin change at the first check from initiation of DA therapy and parasellar invasiveness were predictors of reaching withdrawal conditions. With constant independent variables, there was a 7% increase in odds for reaching withdrawal conditions for every 1% decrease in percent prolactin change at first check after DA therapy start (P = 0.0000). Parasellar invasion decreased the odds of reaching withdrawal conditions by 84% (P = 0.0000). CONCLUSIONS DA remains a potential life-long treatment modality for most prolactinoma patients. Patients with parasellar invasiveness and low prolactin percent change from baseline to first prolactin check are more likely to require long-term treatment.
Collapse
Affiliation(s)
- Camille Hage
- Division of Endocrinology and Metabolism, and Pituitary Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland USA
| | - Roberto Salvatori
- Division of Endocrinology and Metabolism, and Pituitary Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland USA
| |
Collapse
|
34
|
van Furth WR, de Vries F, Lobatto DJ, Kleijwegt MC, Schutte PJ, Pereira AM, Biermasz NR, Verstegen MJT. Endoscopic Surgery for Pituitary Tumors. Endocrinol Metab Clin North Am 2020; 49:487-503. [PMID: 32741484 DOI: 10.1016/j.ecl.2020.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Endoscopic transsphenoidal surgery for pituitary adenoma is a safe and highly effective first-line treatment that is well tolerated by patients. Potential complications are plenty, and there is a large variation in complexity of surgery. This article presents the philosophy, surgical techniques, and outcomes of a high-volume pituitary adenoma center. Three surgical videos illustrate some procedures. The experience has reinforced the authors' belief that experience and surgical volume are key to high quality of care.
Collapse
Affiliation(s)
- Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center J11-86, Center for Endocrine Tumors Leiden, PO-Box 9600, Leiden 2300 RC, the Netherlands.
| | - Friso de Vries
- Department of Endocrinology, Leiden University Medical Center, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Daniel J Lobatto
- Department of Neurosurgery, Leiden University Medical Center J11-86, Center for Endocrine Tumors Leiden, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Maarten C Kleijwegt
- Department of Ear Nose and Throat - Head and Neck Cancer, Leiden University Medical Center, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Pieter J Schutte
- Department of Neurosurgery, Leiden University Medical Center J11-86, Center for Endocrine Tumors Leiden, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Alberto M Pereira
- Department of Endocrinology, Leiden University Medical Center, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Nienke R Biermasz
- Department of Endocrinology, Leiden University Medical Center, PO-Box 9600, Leiden 2300 RC, the Netherlands
| | - Marco J T Verstegen
- Department of Neurosurgery, Leiden University Medical Center J11-86, Center for Endocrine Tumors Leiden, PO-Box 9600, Leiden 2300 RC, the Netherlands
| |
Collapse
|
35
|
Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Erik-Blumenfeld-Platz 27a, 22587, Hamburg, Germany.
| | - Andrea Giustina
- Endocrinology Unit, Ospedale San Raffaele and Università Vita-Salute San Raffaele, Milan, Italy
| |
Collapse
|
36
|
Zielinski G, Ozdarski M, Maksymowicz M, Szamotulska K, Witek P. Prolactinomas: Prognostic Factors of Early Remission After Transsphenoidal Surgery. Front Endocrinol (Lausanne) 2020; 11:439. [PMID: 32733387 PMCID: PMC7358351 DOI: 10.3389/fendo.2020.00439] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/04/2020] [Indexed: 12/20/2022] Open
Abstract
Background and Objective: Most patients with prolactinomas receive pharmacological treatment only, resulting in limited research on the predictors of successful prolactinoma surgery. In this study, we analyzed whether early postoperative serum prolactin concentrations and selected tumor characteristics could predict early, hormonal remission after removal of prolactinomas. Methods: We prospectively enrolled 48 consecutive patients with prolactinomas who underwent transsphenoidal resection performed by the same surgeon. Early remission, defined as a lack of hyperprolactinemia symptoms and normalization of serum prolactin concentration, was ascertained in all patients at 3 months. We evaluated the invasiveness of prolactinomas on the Knosp grading scale and measured serum prolactin concentrations on the first postoperative day. Routine immunohistochemical analysis, evaluation for plurihormonality, and assessment of the Ki-67 proliferation index (<3 or ≥3% of positive nuclei) were performed in all tumor samples. Results: Of 48 patients, 38 (79%) achieved early biochemical remission at 3 months. Patients in early remission at 3 months had lower serum prolactin concentrations on the first postoperative day than patients with recurrent or persistent hyperprolactinemia (p < 0.001). Using univariate logistic regression, larger maximum tumor diameter (p = 0.014), higher Knosp grade (p < 0.001), and plurihormonality predicted remission at 3 months (p = 0.021). However, using multivariate stepwise logistic regression, only the Knosp grade remained significant (p < 0.001). Conclusions: Radiological assessment of prolactinoma invasiveness (Knosp grades) and early postoperative serum prolactin concentrations are important predictors of early remission following transsphenoidal prolactinoma resection.
Collapse
Affiliation(s)
- Grzegorz Zielinski
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
- *Correspondence: Grzegorz Zielinski
| | - Marcin Ozdarski
- Military Outpatient Clinic, Nowy Dwór Mazowiecki, Poland
- Marcin Ozdarski
| | - Maria Maksymowicz
- Department of Pathology and Laboratory Diagnostics, Maria Curie-Skłodowska Memorial, National Institute of Oncology, Warsaw, Poland
| | - Katarzyna Szamotulska
- Department of Epidemiology and Biostatistics, Institute of Mother and Child, Warsaw, Poland
| | - Przemysław Witek
- Department of Gastroenterology, Endocrinology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
- Department of Internal Diseases, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|