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Chugh AJS, Patel M, Chua L, Arafah B, Bambakidis NC, Ray A. Management of giant prolactinoma causing craniocervical instability: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2021; 1:CASE2158. [PMID: 36046515 PMCID: PMC9394694 DOI: 10.3171/case2158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/25/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Giant prolactinomas (>4 cm) are a rare entity, constituting less than 1% of all pituitary tumors. Diagnosis can usually be achieved through endocrinological analysis, but biopsy may be considered when trying to differentiate between invasive nonfunctioning pituitary adenomas and primary clival tumors such as chordomas. OBSERVATIONS The authors presented a rare case of a giant prolactinoma causing significant clival and occipital condyle erosion, which led to craniocervical instability. They provided a review of the multimodal management. Management involved medical therapy with dopamine agonists, and surgery was reserved for acute neural compression or dopamine agonist resistance, with the caveat that surgery was extremely unlikely to lead to normalization of serum prolactin in dopamine agonist-resistant tumors. LESSONS Adjunctive surgical therapy may be necessary in cases of skull base erosion, particularly when erosion or pathological fractures involve the occipital condyles. Modern posterior occipital-cervical fusion techniques have high rates of arthrodesis and can lead to symptomatic improvement. This procedure should be considered early in the multimodal approach to giant prolactinomas because of the often dramatic response to medical therapy and potential for further craniocervical instability.
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Affiliation(s)
| | | | - Lorayne Chua
- Endocrinology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Baha Arafah
- Endocrinology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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Lee JJ, Kim HY, Dhong HJ, Chung SK, Kong DS, Nam DH, So YK, Hong SD. Delayed Cerebrospinal Fluid Leakage After Treatment of Skull Base Tumors: Case Series of 9 Patients. World Neurosurg 2019; 132:e591-e598. [DOI: 10.1016/j.wneu.2019.08.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 12/01/2022]
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Česák T, Poczos P, Adamkov J, Náhlovský J, Kašparová P, Gabalec F, Čelakovský P, Choutka O. Medically induced CSF rhinorrhea following treatment of macroprolactinoma: case series and literature review. Pituitary 2018; 21:561-570. [PMID: 30116971 DOI: 10.1007/s11102-018-0907-1] [Citation(s) in RCA: 16] [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] [Indexed: 01/08/2023]
Abstract
PURPOSE Although several reports have addressed cerebrospinal fluid (CSF) rhinorrhea following dopamine agonist (DA) therapy of macroprolactinomas, further study is warranted for this relatively uncommon entity. Toward this aim, our retrospective series and review of literature further clarifies recommendations in treatment of this rare problem. METHODS We retrospectively reviewed all macroprolactinoma cases in our hospital for a 15-year period. Our systematic search of PubMed identified original articles and reviews of all macroprolactinoma cases with an associated medication-induced CSF leak. RESULTS Five patients with drug-induced CSF leak were identified; four of these patients received cabergoline therapy an average of 6 weeks before the onset of rhinorrhea and then underwent surgical repair of the CSF leak. Of 35 published studies included, we identified 60 patients with medication-induced CSF leak. Medical therapy included bromocriptine in 34 patients, cabergoline in 21 patients, and use of both DAs in two patients. Three cases did include complete diagnostic and treatment data. Median time from initiation of the DA treatment to occurrence of rhinorrhea was 6 weeks. For CSF rhinorrhea, 49 patients underwent surgical repair (38 by the transnasal approach) and seven patients were treated nonoperatively. CONCLUSION Baseline skull base erosion in macroprolactinomas in combination with subsequent tumor shrinkage induced by DA therapy may result in spontaneous CSF rhinorrhea. Therefore, such patients should be advised about and monitored for this potential setback. Once CSF leak is diagnosed, prompt treatment must be carried out to avoid infectious complications. Transnasal surgery appears the most effective therapeutic approach.
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Affiliation(s)
- Tomáš Česák
- Department of Neurosurgery, University Hospital Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Pavel Poczos
- Department of Neurosurgery, University Hospital Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.
- Department of Anatomy, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.
| | - Jaroslav Adamkov
- Department of Neurosurgery, University Hospital Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Jiří Náhlovský
- Department of Neurosurgery, University Hospital Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Petra Kašparová
- The Fingerland Department of Pathology, University Hospital Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Filip Gabalec
- 4th Department of Internal Medicine - Haematology, University Hospital Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Petr Čelakovský
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Ondrej Choutka
- Saint Alphonsus Neuroscience Institute - Neurosurgery, Boise, ID, USA
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Andujar-Plata P, Villar-Taibo R, Ballesteros-Pomar MD, Vidal-Casariego A, Pérez-Corral B, Cabezas-Agrícola JM, Álvarez-Vázquez P, Serramito R, Bernabeu I. Long-term outcome of multimodal therapy for giant prolactinomas. Endocrine 2017; 55:231-238. [PMID: 27704480 DOI: 10.1007/s12020-016-1129-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
Abstract
Giant prolactinomas are rare tumors characterized by their large size, compressive symptoms, and extremely high prolactin secretion. The aim of this study is to describe our experience with a series of 16 giant prolactinomas cases in terms of clinical presentation, therapeutic decisions, and final outcomes. Retrospective analysis of adult patients diagnosed with giant prolactinomas at the endocrine departments of three university tertiary hospitals. We included 16 patients (43.7 % women); mean age at diagnosis: 42.1 ± 21 years. The most frequent presentation was compressive symptoms. The delay in diagnosis was higher in women (median of 150 months vs. 12 in men; p = 0.09). The mean maximum tumor diameter at diagnosis was 56.9 ± 15.5 mm, and mean prolactin levels were 10,995.9 ± 12,157.8 ng/mL. Dopamine agonists were the first-line treatment in 11 patients (mean maximum dose: 3.9 ± 3.2 mg/week). Surgery was the initial treatment in five patients and the second-line treatment in six. Radiotherapy was used in four cases. All patients but one, are still with dopamine agonists. After a mean follow-up of 9 years, prolactin normalized in 7/16 patients (43.7 %) and 13 patients (81 %) reached prolactin levels lower than twice the upper limit of normal. Mean prolactin level at last visit: 79.5 ± 143 ng/mL. Tumor volume was decreased by 93.8 ± 11.3 %, and final maximum tumor diameter was 18.4 ± 18.8 mm. Three patients are actually tumor free. Giant prolactinomas are characterized by a large tumor volume and extreme prolactin hypersecretion. Multimodal treatment is frequently required to obtain biochemical and tumor control.
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Affiliation(s)
- Paula Andujar-Plata
- Endocrinology Division, Complejo Hospitalario Universitario de Ourense (CHUO)-SERGAS, Ourense, 32005, Spain
| | - Rocio Villar-Taibo
- Complejo Asistencial Universitario de León (CAULE)-SACYL, León, 24008, Spain
| | | | | | - Begoña Pérez-Corral
- Complejo Asistencial Universitario de León (CAULE)-SACYL, León, 24008, Spain
| | - Jose Manuel Cabezas-Agrícola
- Endocrinology Division, Complejo Hospitalario Universitario de Santiago de Compostela (CHUS)-SERGAS, Santiago de Compostela, 15706, Spain
| | - Paula Álvarez-Vázquez
- Endocrinology Division, Complejo Hospitalario Universitario de Ourense (CHUO)-SERGAS, Ourense, 32005, Spain
| | - Ramón Serramito
- Neurosurgery Division, Complejo Hospitalario Universitario de Santiago de Compostela (CHUS)-SERGAS, Santiago de Compostela, 15706, Spain
| | - Ignacio Bernabeu
- Endocrinology Division, Complejo Hospitalario Universitario de Santiago de Compostela (CHUS)-SERGAS, Santiago de Compostela, 15706, Spain.
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Yecies D, Ajlan A, Ratliff J, Ziskin J, Hwang P, Vogel H, Katznelson L, Harsh G. Giant Prolactinoma Presenting with Neck Pain and Structural Compromise of the Occipital Condyles. J Neurol Surg Rep 2015; 76:e297-301. [PMID: 26623246 PMCID: PMC4648725 DOI: 10.1055/s-0035-1566124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/28/2015] [Indexed: 11/25/2022] Open
Abstract
Prolactinomas are the most common form of endocrinologically active pituitary adenoma; they account for ∼ 45% of pituitary adenomas encountered in clinical practice. Giant adenomas are those > 4 cm in diameter. Less than 0.5% of pituitary adenomas encountered in neurosurgical practice are giant prolactinomas. Patients with giant prolactinomas typically present with highly elevated prolactin levels, endocrinologic disturbances, and neurologic symptoms from mass-induced pressure. Described here is an unusual case of a giant prolactinoma presenting with neck pain and structural compromise of the occipital condyles. Transnasal biopsy of the nasopharyngeal portion of the mass obtained tissue consistent with an atypical prolactinoma with p53 reactivity and a high Ki-67 index of 5%. Despite the size and invasiveness of the tumor, the patient had resolution of his clinical symptoms, dramatic reduction of his hyperprolactinemia, and near-complete disappearance of his tumor following medical treatment.
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Affiliation(s)
- Derek Yecies
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Abdulrazag Ajlan
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - John Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Jennifer Ziskin
- Department of Pathology, Stanford University School of Medicine, Stanford, California, United States
| | - Peter Hwang
- Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
| | - Hannes Vogel
- Department of Pathology, Stanford University School of Medicine, Stanford, California, United States
| | - Laurence Katznelson
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States ; Department of Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Griffith Harsh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
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Moraes AB, Silva CMDS, Vieira Neto L, Gadelha MR. Giant prolactinomas: the therapeutic approach. Clin Endocrinol (Oxf) 2013; 79:447-56. [PMID: 23662975 DOI: 10.1111/cen.12242] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 04/03/2013] [Accepted: 05/07/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND Giant prolactinomas are an unusual subset of macroprolactinomas and are more commonly found in men. The goal of this review is to propose a giant prolactinoma definition and discuss the available therapeutic options for biochemical and tumour volume control. METHODS A comprehensive search of all published studies was performed between April and November 2012 in electronic databases (PubMed and Ovid). RESULTS A giant prolactinoma should be defined as an adenoma with a maximum diameter of more than 4 cm that is associated with serum prolactin above 5300 mIU/l. Regarding treatment, cabergoline is the preferred dopamine agonist for medical management of giant prolactinomas because of its excellent efficacy and tolerability. Normalization of prolactin level and significant tumour reduction may be achieved in the majority of patients. Combined therapy, particularly cabergoline and surgery, may be necessary due to the large tumour load. Radiotherapy and temozolomide may be used for patients with aggressive giant prolactinomas in whom tumour volume control is not achieved with cabergoline and surgery. CONCLUSION There is a scarcity of large studies about the management of giant prolactinoma. Cabergoline is the first-line treatment. However, caution should be exercised when comparing efficacy rates among the different treatment modalities due to the variability in study design and data quality. In this scenario, a 'standard' definition for giant prolactinomas and larger series may be helpful to assess the real efficacy and safety of each therapeutic modality.
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Affiliation(s)
- Aline B Moraes
- Department of Internal Medicine and Endocrine Unit, Medical School and Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, RJ, Brazil
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Lou XH, Wu ZB, Zhang YZ. Bromocriptine-induced brainstem angulation in a patient with invasive prolactinoma. J Clin Endocrinol Metab 2013; 98:867-8. [PMID: 23365124 DOI: 10.1210/jc.2012-3735] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Xiao Hui Lou
- Department of Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing 100050, China
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