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Sari R, Altinoz MA, Ozlu EBK, Sav A, Danyeli AE, Baskan O, Er O, Elmaci I. Treatment Strategies for Dopamine Agonist-Resistant and Aggressive Prolactinomas: A Comprehensive Analysis of the Literature. Horm Metab Res 2021; 53:413-424. [PMID: 34282593 DOI: 10.1055/a-1525-2131] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite most of the prolactinomas can be treated with endocrine therapy and/or surgery, a significant percentage of these tumors can be resistant to endocrine treatments and/or recur with prominent invasion into the surrounding anatomical structures. Hence, clinical, pathological, and molecular definitions of aggressive prolactinomas are important to guide for classical and novel treatment modalities. In this review, we aimed to define molecular endocrinological features of dopamine agonist-resistant and aggressive prolactinomas for designing future multimodality treatments. Besides surgery, temozolomide chemotherapy and radiotherapy, peptide receptor radionuclide therapy, estrogen pathway modulators, progesterone antagonists or agonists, mTOR/akt inhibitors, pasireotide, gefitinib/lapatinib, everolimus, and metformin are tested in preclinical models, anecdotal cases, and in small case series. Moreover, chorionic gonadotropin, gonadotropin releasing hormone, TGFβ and PRDM2 may seem like possible future targets for managing aggressive prolactinomas. Lastly, we discussed our management of a unique prolactinoma case by asking which tumors' proliferative index (Ki67) increased from 5-6% to 26% in two subsequent surgeries performed in a 2-year period, exerted massive invasive growth, and secreted huge levels of prolactin leading up to levels of 1 605 671 ng/dl in blood.
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Affiliation(s)
- Ramazan Sari
- Department of Neurosurgery, Acibadem Hospital, Maslak, Istanbul, Turkey
- Avrasya University, Health Sciences Faculty, Trabzon, Turkey
| | - Meric A Altinoz
- Department of Biochemistry, Acibadem University, Istanbul, Turkey
| | | | - Aydin Sav
- Department of Pathology, Yeditepe University, Istanbul, Turkey
| | - Ayca Ersen Danyeli
- Department of Pathology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Ozdil Baskan
- Department of Radiology, Memorial Hospital, Istanbul, Turkey
| | - Ozlem Er
- Department of Medical Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
| | - Ilhan Elmaci
- Department of Neurosurgery, Acibadem Hospital, Maslak, Istanbul, Turkey
- Department of Neurosurgery, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
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2
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Chanson P, Maiter D. The epidemiology, diagnosis and treatment of Prolactinomas: The old and the new. Best Pract Res Clin Endocrinol Metab 2019; 33:101290. [PMID: 31326373 DOI: 10.1016/j.beem.2019.101290] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Prevalence and incidence of prolactinomas are approximately 50 per 100,000 and 3-5 new cases/100,000/year. The pathophysiological mechanism of hyperprolactinemia-induced gonadotropic failure involves kisspeptin neurons. Prolactinomas in males are larger, more invasive and less sensitive to dopamine agonists (DAs). Macroprolactin, responsible for pseudohyperprolactinemia is a frequent pitfall of prolactin assay. DAs still represent the primary therapy for most prolactinomas, but neurosurgery has regained interest, due to progress in surgical techniques and a high success rate in microprolactinoma, as well as to some underestimated side effects of long-term DA treatment, such as impulse control disorders or impaired quality of life. Recent data show that the suspected effects of DAs on cardiac valves in patients with prolactinomas are reassuring. Finally, temozolomide has emerged as a valuable treatment for rare cases of aggressive and malignant prolactinomas that do not respond to all other conventional treatments.
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Affiliation(s)
- Philippe Chanson
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Hôpital de Bicêtre, F-94275, Le Kremlin-Bicêtre, France; UMR-S1185 Université Paris-Sud, Univ Paris-Saclay, F-94276, Le Kremlin-Bicêtre, France; Institut National de la Santé et de la Recherche Médicale (Inserm) U1185, F-94276, Le Kremlin Bicêtre, France.
| | - Dominique Maiter
- Service d'Endocrinologie et Nutrition, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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3
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Todeschini AB, Beer-Furlan A, Montaser AS, Jamshidi AO, Ghalib L, Chavez JA, Lehman NL, Prevedello DM. Pituitary carcinomas: review of the current literature and report of atypical case. Br J Neurosurg 2019; 34:528-533. [PMID: 30836020 DOI: 10.1080/02688697.2019.1582750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Pituitary carcinomas are poorly understood, rare entities. They are distinguished from adenomas not by histopathological features but rather by the presence of metastases.Objective: We discuss the diagnosis, mechanism of dissemination and pathogenesis based on a review of the literature and illustrated by a singular case.Case Report: A 59-year-old male presented with a dural-based posterior fossa lesion. He had been diagnosed with a pituitary chromophobe adenoma 43 years earlier that was treated at the time with surgery and radiation therapy. A presumptive diagnosis of a radiation-induced meningioma was made and surgery was recommended. At surgery the tumour resembled a pituitary adenoma. Histopathology, laboratory findings, and the patient's medical history confirmed the final diagnosis of a prolactin-secreting pituitary carcinoma. To our knowledge, this is the longest reported interval between the pituitary adenoma and metastatic lesion diagnosis (43 years).Conclusion: Management should be tailored to individual patient and may include a combination of treatments (surgery, radiation therapy, chemotherapy, and hormone-targeted therapy). Functionally active tumours may be monitored with hormone levels as tumour markers.
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Affiliation(s)
- Alexandre B Todeschini
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - André Beer-Furlan
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Alaa S Montaser
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Neurological Surgery, Ain Shams University, Cairo, Egypt
| | - Ali O Jamshidi
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Luma Ghalib
- Department of Internal Medicine - Division of Endocrinology, Diabetes and Metabolism, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jesus A Chavez
- Department of Pathology, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Norman L Lehman
- Department of Pathology, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Otolaryngology - Head and Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
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4
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Byrne S, Karapetis C, Vrodos N. A novel use of temozolomide in a patient with malignant prolactinoma. J Clin Neurosci 2009; 16:1694-6. [PMID: 19818629 DOI: 10.1016/j.jocn.2009.05.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 05/07/2009] [Accepted: 05/17/2009] [Indexed: 10/20/2022]
Abstract
We report a 64-year-old male who presented to our department in 2007 with bitemporal hemianopia secondary to a large recurrent pituitary prolactinoma in the sellar region and metastatic deposits elsewhere in his neuraxis. He underwent a transphenoidal excision of the large pituitary adenoma which was uncomplicated, although he did suffer from diabetes insipidus post-operatively. He had initially been diagnosed with prolactinoma some years before and had undergone multiple craniotomies to debulk recurrent metastatic lesions. As the patient had already undergone radiotherapy in the past, a novel approach to adjuvant therapy was necessary and he was started on a course of oral chemotherapy, temozolomide, with good results.
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Affiliation(s)
- Stephen Byrne
- Department of Neurosurgery, Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia 5042, Australia.
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Abstract
Any process interfering with dopamine synthesis, its transport to the pituitary gland, or its action at the level of lactotroph dopamine receptors can cause hyperprolactinemia. As described in this article, considering the complexity of prolactin regulation, many factors could cause hyperprolactinemia, and hyperprolactinemia can have clinical effects not only on the reproductive axis. Once any drug effects are excluded, prolactinomas are the most common cause of hyperprolactinemia. The most frequent symptom is hypogonadism in both genders. Medical and surgical therapies generally have excellent results, and most prolactinomas are well controlled or even cured in some cases.
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Affiliation(s)
- Tatiana Mancini
- Internal Medicine, San Marino Hospital, 47899, Republic of San Marino
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6
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Abstract
Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future.
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Affiliation(s)
- Mary P Gillam
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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7
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Negron-Soto JM, Kilpatrick M, Irani N, Castillo M. Case of the season: Metastatic pituitary carcinoma mimicking meningioma. Semin Roentgenol 2004; 39:519-21. [PMID: 15526535 DOI: 10.1016/j.ro.2004.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jose M Negron-Soto
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7510, USA
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8
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Noda M, Suzuki R, Moriya M, Itokawa H, Asai JI, Nagashima G, Fujimoto T. A case of prolactin-secreting pituitary carcinoma and its histological findings. Brain Tumor Pathol 2004; 21:149-54. [PMID: 15696977 DOI: 10.1007/bf02482191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pituitary carcinomas are very rare. The diagnosis of pituitary carcinoma is defined by evidence of craniospinal and/or systemic metastasis, rather than by histological malignancies. We report a case of prolactin-secreting pituitary macroadenoma invading the cavernous sinuses at the time of initial treatment, which later metastasized to the cerebellum, medulla oblongata, and spinal axis. The patient survived approximately nine years following the initial diagnosis of a pituitary tumor and two years following the diagnosis of metastatic disease. Histological examination of the metastatic cerebellar tumor showed an adenoma with high cellularity and hyperchromasia, but no mitoses.
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Affiliation(s)
- Masayuki Noda
- Department of Neurosurgery, Showa University, Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama 227-8501, Japan
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9
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Abstract
Pituitary carcinomas, defined as distant metastases of a pituitary neoplasm, are rare; fewer than 140 reports exist in the English literature. The initial presenting pituitary tumor is usually a secreting, invasive macroadenoma, with adrenocorticotropic hormone (ACTH)--and prolactin (PRL)--secreting tumors being the most common. The latency period between the diagnosis of a pituitary tumor and the diagnosis of a pituitary carcinoma is 9.5 years for ACTH-producing lesions and 4.7 years for PRL-secreting tumors. Survival after documentation of metastatic disease is poor; 66% of patients die within 1 year. Treatment options include additional surgery, radiotherapy, and chemotherapy, all of which are associated with poor results. Future studies will focus on identifying those invasive pituitary tumors most likely to metastasize and treating them aggressively before they progress to pituitary carcinomas.
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Affiliation(s)
- Brian T Ragel
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah 84132, USA
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10
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Abstract
This article reviews published evidence on the diagnosis and classification of pituitary gland tumours and the relevance of histological and genetic features to prognosis. Much of the literature is devoted to the histological, ultrastructural, and immunocytochemical classification of pituitary adenomas (extensively supported by multicentre studies), with little consensus on the identification of prognostic features in adenomas, particularly in relation to invasion. There is a lack of correspondence between clinical and pathological criteria to identify and classify invasion, and a need to reassess the nomenclature and diagnostic criteria for invasive adenomas and carcinomas. Recent cytogenetic, genetic, and molecular biological studies have identified no consistent abnormalities in relation to pituitary tumour progression, although many genes are likely to be involved. In light of these uncertainties, an approach to the diagnosis and classification of pituitary adenomas is suggested, based on robust criteria from earlier studies and incorporating provisional data that require reassessment in large prospective studies with an adequate clinicopathological database.
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Affiliation(s)
- J W Ironside
- Division of Pathology, School of Clinical and Molecular Medicine, University of Edinburgh, Western General Hospital, Edingurgh EH4 2XU, UK.
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11
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Gaffey TA, Scheithauer BW, Lloyd RV, Burger PC, Robbins P, Fereidooni F, Horvath E, Kovacs K, Kuroki T, Young WF, Sebo TJ, Riehle DL, Belzberg AJ. Corticotroph carcinoma of the pituitary: a clinicopathological study. Report of four cases. J Neurosurg 2002; 96:352-60. [PMID: 11838811 DOI: 10.3171/jns.2002.96.2.0352] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To understand the relationship between pituitary adenoma and carcinoma, four adrenocorticotropic hormone-producing pituitary adenomas and corresponding metastatic carcinomas were studied. All were functional macroadenomas (three cases of Nelson syndrome and one of Cushing disease) that initially invaded the sella turcica and occurred in women ranging in age from 17 to 66 years (mean 45 years). Metastases (two craniospinal and two systemic) occurred after latency periods of 6 to 13 years. Histological specimens were immunostained for pituitary hormones, Ki-67 antigen (MIB-1), p53 and p27 proteins, D-type cyclins, and glucocorticoid receptor messenger (m)RNA. The DNA content of the specimens was assessed using Feulgen stain. Reactivities were quantified by digital image analysis. Primary/recurrent lesions and metastatic tumors differed according to their respective mean mitotic indices (1.2/10 hpf compared with 4.3/10 hpf), MIB-1 labeling (1.7% compared with 8%), p53 staining (37.3% compared with 49.9%), and p27 labeling (48% compared with 25%). Cyclin D, immunoreactivity provided no prognostically significant information. Glucocorticoid receptor mRNA was detected in all cases. Results of a ploidy analysis were variable and nonprognostic. In keeping with the 2000 World Health Organization classification of endocrine neoplasms, our findings support the concept that primary tumors that exhibit mitotic activity, an increased (> 3%) MIB-1 labeling index, and/or p53 immunoreactivity should be termed "atypical adenomas" to denote their aggressive potential and the possibility of future malignant transformation.
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12
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Sironi M, Cenacchi G, Cozzi L, Tonnarelli G, Iacobellis M, Treré D, Assi A. Progression on metastatic neuroendocrine carcinoma from a recurrent prolactinoma: a case report. J Clin Pathol 2002; 55:148-51. [PMID: 11865014 PMCID: PMC1769584 DOI: 10.1136/jcp.55.2.148] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A 54 year old man was referred to the department of neurosurgery for frontal headache and vomiting. The patient was known in the department because of previous multiple surgery for a locally invasive pituitary prolactinoma (eight years, three years, and one year previously). The neurological examination revealed a frontal mass, which adhered to the dura, suggesting a meningioma. One year later, a left temporal metastasis was removed. Three months later, the patient died, with spinal metastases, of massive lung embolism. Histology revealed a progression of adenohypophyseal prolactinoma on neuroendocrine carcinoma, with an increase in proliferating indexes and modification of hormone production. This study documents a 10 year history of a rare prolactin producing pituitary carcinoma, which metastasised via liquoral flow.
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Affiliation(s)
- M Sironi
- Department of Pathology, Legnano General Hospital, Legnano, Milano, Italy
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13
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Karcioglu ZA, Aden LB, Cruz AAV, Zaslow L, Saloom RJ. Orbital invasion with prolactinoma: a clinical review of four patients. Ophthalmic Plast Reconstr Surg 2002; 18:64-71. [PMID: 11910327 DOI: 10.1097/00002341-200201000-00010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To present four patients with invasive prolactin-secreting pituitary adenomas extending in the orbit. METHODS Retrospective, noncomparative case series. RESULTS In all cases, the tumor was a large, invasive prolactin-secreting adenoma. In three cases, significant permanent vision loss occurred and severe disfigurement resulted; two of these patients died of tumor-related complications. In one case, the tumor responded well to medical treatment, and the orbital symptoms improved significantly. CONCLUSION Although it is rare for a pituitary adenoma to invade the orbit, devastating consequences to the integrity of the globe and ocular adnexa may result. Therefore, early recognition and proper treatment of orbital pituitary tumors are of utmost importance to minimize ocular and orbital damage.
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Affiliation(s)
- Zeynel A Karcioglu
- Department of Ophthalmology, Tulane Cancer Center, Tulane University Health Sciences Center, New Orleans, Louisiana 70112-2699, USA
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Pichard C, Gerber S, Laloi M, Kujas M, Clemenceau S, Ponvert D, Bruckert E, Turpin G. Pituitary carcinoma: report of an exceptional case and review of the literature. J Endocrinol Invest 2002; 25:65-72. [PMID: 11883868 DOI: 10.1007/bf03343963] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pituitary carcinomas are exceptional tumors and constitute 0.1 to 0.2% of pituitary tumors. Their definition includes well-established criteria but distant metastasis is the hallmark required for diagnosis. We report the fourth case of gonadotropic pituitary carcinoma described in the literature. This case illustrates the dramatic outcome of these tumors. The most interesting feature of our case was the loss of differentiation with time, established by retrospective analysis of the primary tumor surgically treated 15 years earlier. Most of the previously reported cases exhibited a majority of adrenocoticotropin and non-functioning pituitary tumors. However, the frequency of non-functioning tumors seems smaller than previously believed. In the discussion, we stress the need to detect these very aggressive tumors as early as possible and identify treatments to improve the dramatic course of these carcinomas.
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Affiliation(s)
- C Pichard
- Department of Endocrinology, Groupe Hospitalier La Pitié Salpetriêre, Paris, France.
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Ohtakara K, Matsubara T, Kojima T, Taki W, Waga S. Cerebrospinal fluid rhinorrhea associated with untreated prolactinoma--case report. Neurol Med Chir (Tokyo) 2000; 40:413-8. [PMID: 10979264 DOI: 10.2176/nmc.40.413] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
An 80-year-old female presented with non-traumatic cerebrospinal fluid (CSF) rhinorrhea due to untreated prolactinoma, with simultaneous development of bilateral leg pains and gait disturbance due to lumbar canal stenosis. Neuroimaging showed an intrasellar mass extending into the sphenoid sinus, right cavernous sinus, and suprasellar cistern. Computed tomography cisternography clearly showed the CSF pathway through the tumor. Subtotal removal of the tumor and reconstruction of the sellar floor via a transsphenoidal approach resulted in resolution of the CSF rhinorrhea. Both the invasive features and/or spontaneous shrinkage of the tumor might have created the abnormal CSF pathway. The clinical manifestation of lumbar canal stenosis might be triggered by such profound CSF leakage.
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Affiliation(s)
- K Ohtakara
- Department of Neurosurgery, Mie University School of Medicine, Tsu, Japan
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