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Zulfaliyeva G, Demir AN, Cetintas SC, Ozaydin D, Tanriover N, Kadioglu P. Role of Medical and Surgical Treatment in Management of the Patients With Prolactinoma: A Single-Center Experience. Exp Clin Endocrinol Diabetes 2024. [PMID: 38991543 DOI: 10.1055/a-2364-6027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
BACKGROUND Current guidelines recommend dopamine agonists (DA) as the primary therapeutic approach for prolactinomas; however, emerging evidence suggests that surgical intervention can also yield favorable outcomes. OBJECTIVE To comprehensively evaluate prolactinoma patients undergoing surgical and medical treatments at our pituitary center. METHODS Retrospective review of mMedical records from prolactinoma patients treated between 2015 and 2022 was performedwere retrospectively reviewed. The study focused on treatment outcomes and remission rates while investigating factors influencing the success of both treatment modalities in achieving remission. RESULTS A total of 301 prolactinoma patients were included, of whom 199 were women. Among them, 235 were managed medically, while 66 underwent surgical intervention. The overall remission rates of patients treated with medical and surgery were similar at the final examination (Respectively respectively 82.9% and 81.8%, p=0.114). Factors associated with remission in both treatment modalities included female sex, low initial prolactin levels, small adenoma size, and absence of cavernous invasion. Compared to DA treatment, Ssurgical treatment demonstrated a higher rate of drug-free remission compared to DA treatment for microadenomas, and macroadenomas without cavernous invasion. In cases with cavernous invasion, standalone surgical treatment yielded a low rate of drug-free remission (7.7%); however, when combined with DA therapy post-surgery, remission rates increased to 66.7%. CONCLUSION Medical treatment with DAs remains the preferred option for macroadenomas with cavernous sinus invasion, and giant adenomas, with surgery reserved for selected cases to address complications. Conversely, surgery emerges as the most effective modality for achieving remission in patients with microadenomas, and macroadenomas confined to the sella. The recommendation of DAs as first-line therapy for all patients has been withdrawn in the current guidelines, and individual treatment approaches based on tumor characteristics are emphasized. Our results support this approach.
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Affiliation(s)
- Guldana Zulfaliyeva
- Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ahmet Numan Demir
- Department of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Semih Can Cetintas
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Dilan Ozaydin
- Department of Neurosurgery, Health Science University Kartal Dr Lutfi Kırdar City Hospital, Istanbul, Turkey
| | - Necmettin Tanriover
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Pinar Kadioglu
- Department of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Pascual-Corrales E, Acitores Cancela A, Baonza G, Madrid Egusquiza I, Rodríguez Berrocal V, Araujo-Castro M. Clinical presentation and surgical outcomes of very large and giant pituitary adenomas: 80 cases in a cohort study of 306 patients with pituitary adenomas. Acta Neurochir (Wien) 2024; 166:225. [PMID: 38772927 DOI: 10.1007/s00701-024-06107-w] [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: 02/23/2024] [Accepted: 04/28/2024] [Indexed: 05/23/2024]
Abstract
PURPOSE To identify differences in the presentation and surgical outcomes between very large (30-39 mm) and giant (≥ 40 mm) (LARGE group) pituitary adenomas (PAs) compared to the smaller group (< 30 mm) (non-LARGE group). METHODS Eighty patients with very large (n = 44) or giant (n = 36) PAs and 226 patients in the non-LARGE group who underwent tumor resection by pituitary surgery between 2008 and 2023 were studied. Hormonal, radiological, ophthalmological, and pathological data, and surgical outcomes were evaluated. RESULTS Preoperatively, patients of the LARGE group presented more frequently with visual impairment (82.5% vs. 22.1%, P < 0.001) and with pituitary apoplexy (15.0% vs. 2.7%, P < 0.001) than the non-LARGE group. Moreover, the LARGE group were more commonly associated with preoperative panhypopituitarism (28.8% vs. 6.2%, P < 0.001). This group presented cavernous sinus invasion more frequently (71.3% vs. 23.9%, P < 0.001). The non-LARGE group achieved surgical cure more often than the LARGE group (79.7% vs. 50.0%, P < 0.001), and the rate of major complications was higher in the latest (8.8% vs. 1.3%, P < 0.004). CONCLUSIONS PAs ≥ 30 mm are most frequently accompanied by hormonal dysfunction, cavernous sinus invasion, and visual impairment. All this implies lower resection rates and higher postoperative complications than the smaller adenomas, posing a real surgical challenge.
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Affiliation(s)
- Eider Pascual-Corrales
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9. PC: 28034, Madrid, Spain.
| | - Alberto Acitores Cancela
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Neurosurgery, Hospital Universitario HM Puerta del Sur, Madrid, Spain
| | - Gonzalo Baonza
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9. PC: 28034, Madrid, Spain
| | - Imanol Madrid Egusquiza
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9. PC: 28034, Madrid, Spain
| | - Víctor Rodríguez Berrocal
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Neurosurgery, Hospital Universitario HM Puerta del Sur, Madrid, Spain
| | - Marta Araujo-Castro
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9. PC: 28034, Madrid, Spain.
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Kumar S, Memon SS, Lila AR, Sarathi V, Sehemby M, Karlekar M, Sankhe S, Thakkar H, Patil VA, Shah N, Bandgar T. Giant prolactinoma in Asian-Indians: A single-center experience from Western India. ANNALES D'ENDOCRINOLOGIE 2023; 84:711-718. [PMID: 37866429 DOI: 10.1016/j.ando.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE Giant prolactinomas (GP) are rare tumors accounting for 4.3% of prolactinomas, with paucity of literature from India. We aim to describe clinical, biochemical, radiological, and treatment outcomes in a large series of Asian-Indian patients with GP. METHODS A single-center retrospective analysis of GPs (n=84), age-based (adults: 66 versus pediatric: 18) and gender-based (males: 64 versus females: 20) comparison was done. RESULTS The mean age at presentation was 34.1±13years, and 64 (76.2%) were males. Males were younger at presentation (32.1±12.2 versus 40.1±13.8years, P: 0.01). The majority presented with mass-effect-related manifestations (visual disturbances: 91.6%, headache: 84.5%) and/or hypogonadism (98.7%). At baseline, largest tumor dimension was 5.3±1.0cm, and serum prolactin was 8343 (3865.5-12,306) ng/mL; most (94.6%) had gonadal axis involvement. Dopamine-agonist (DA) as first-line therapy (45/67, 67.2%) achieved normoprolactinemia (maximum cabergoline dose: 2.0±1.2mg/week) in 36/45 (80%) and tumor response (≥50% reduction) in 36/37 (97.3%) patients at the last follow-up (median duration: 33 [14.5-53.5]months). Notably, gonadal axis recovery was poor (6/30, 20%) despite normoprolactinemia post-DA monotherapy. At latest follow-up, secondary hypothyroidism (32.5% versus 82.6%, P: 0.001) and central hypocortisolism (5.6% versus 42.9%, P: 0.007) were less frequent in DA monotherapy (n=43) than in multimodal therapy group (n=23). The proportion of males (94.4% versus 71.2%, P: 0.04) was higher in the pediatric age group, with DA-induced (first-line) normoprolactinemia observed in 66.7% of them. CONCLUSION GP has male predominance, DA as first-line therapy normalized prolactin in four-fifths of patients with better preservation of HPT and HPA axes in patients with DA monotherapy.
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Affiliation(s)
- Sandeep Kumar
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences, Research Centre, Bangalore, India
| | - Manjeetkaur Sehemby
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Shilpa Sankhe
- Department of Radiology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Hemangini Thakkar
- Department of Radiology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Virendra A Patil
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Nalini Shah
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India.
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Sosa-Eroza E, Espinosa-Cárdenas E. Long-term Discontinuation of Dopamine Agonist Treatment in Patients with Prolactinomas Revisited. Arch Med Res 2023; 54:102893. [PMID: 37806785 DOI: 10.1016/j.arcmed.2023.102893] [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: 05/31/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Abstract
The most common type of functioning pituitary adenomas is prolactinomas; unlike other types, they are treated medically with dopamine agonists (DA). This treatment aims to normalize PRL levels and decrease tumor size by 50% or more. These objectives are typically achieved by 90% of patients with microprolactinoma, two-thirds of those with macroprolactinomas, and about half of those with giant prolactinomas. Life-long pharmacological treatment implies costs, discomfort, and the possibility of side effects, therefore, it has been suggested that DA discontinuation could be attempted in some patients. Long-term remission seems more likely in who, after 2 years of therapy achieve clinical, biochemical, and imaging remission criteria: no evidence of hypogonadism, a normal PRL level (preferably <5 ng/mL), and a >50% of tumor size reduction. Long-term remission seems to be more likely if the patient has been treated with cabergoline (CBG) for a minimum of 2 years, the PRL levels have normalized, tumor size has decreased by at least 50%, and the DA dose can gradually be tapered down to 0.25-0.5 mg per week. After treatment withdrawal, about 65% of patients experience a recurrence of hyperprolactinemia within the first 12 months of DA discontinuation. Although in most patients in whom DA discontinuation has been attempted, the hyperprolactinemia will recur, not all of them will require re-initiation of treatment. A good clinical judgement is crucial to identify those patients who need life-long treatment.
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Affiliation(s)
- Ernesto Sosa-Eroza
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Etual Espinosa-Cárdenas
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Himonakos C, Burman P, Borg H, Dahlqvist P, Engström BE, Ekman B, Emilsson L, Olsson DS, Ragnarsson O, Wahlberg J, Åkerman AK, Höybye C, Berinder K. Long-term Follow-up of 84 Patients With Giant Prolactinomas-A Swedish Nationwide Study. J Clin Endocrinol Metab 2023; 108:e1506-e1514. [PMID: 37403202 PMCID: PMC10655522 DOI: 10.1210/clinem/dgad393] [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: 03/17/2023] [Revised: 06/22/2023] [Accepted: 06/30/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE To describe the clinical presentation and treatment outcomes in a nationwide cohort of patients with giant prolactinomas. METHODS Register-based study of patients with giant prolactinomas [serum prolactin (PRL) > 1000 µg/L, tumor diameter ≥40 mm] identified in the Swedish Pituitary Register 1991-2018. RESULTS Eighty-four patients [mean age 47 (SD ±16) years, 89% men] were included in the study. At diagnosis, the median PRL was 6305 µg/L (range 1450-253 000), the median tumor diameter was 47 mm (range 40-85), 84% of the patients had hypogonadotropic hypogonadism, and 71% visual field defects. All patients were treated with a dopamine agonist (DA) at some point. Twenty-three (27%) received 1 or more additional therapies, including surgery (n = 19), radiotherapy (n = 6), other medical treatments (n = 4), and chemotherapy (n = 2). Ki-67 was ≥10% in 4/14 tumors. At the last follow-up [median 9 years (interquartile range (IQR) 4-15)], the median PRL was 12 µg/L (IQR 4-126), and the median tumor diameter was 22 mm (IQR 3-40). Normalized PRL was achieved in 55%, significant tumor reduction in 69%, and combined response (normalized PRL and significant tumor reduction) in 43%. In the primary DA-treated patients (n = 79), the reduction in PRL or tumor size after the first year predicted the combined response at the last follow-up (P < .001 and P = .012, respectively). CONCLUSION DAs effectively reduced PRL and tumor size, but approximately 1 patient out of 4 needed multimodal treatment. Our results suggest that the response to DA after 1 year is useful for identifying patients who need more careful monitoring and, in some cases, additional treatment.
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Affiliation(s)
- Christos Himonakos
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Internal Medicine, Center for Endocrinology and Diabetes, Karlstad Central Hospital, 651 85, Karlstad, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, Lund University, 214 28, Malmö, Sweden
| | - Henrik Borg
- Department of Endocrinology, Skåne University Hospital, Lund University, 222 42, Lund, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University and Uppsala University Hospital, 751 85, Uppsala, Sweden
| | - Bertil Ekman
- Department of Endocrinology and Department of Health, Medicine and Caring Sciences, Linköping University, 581 83, Linköping, Sweden
| | - Louise Emilsson
- Department of General Practice, Institute of Health and Society, University of Oslo, 0318, Oslo, Norway
- Nysäter Health Care Center and Center for Clinical Research, County Council of Värmland, 651 85, Karlstad, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, 171 77, Stockholm, Sweden
| | - Daniel S Olsson
- Department of Endocrinology at Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, 430 51, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology at Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
| | - Jeanette Wahlberg
- Department of Medicine, Örebro University Hospital, 701 85, Örebro, Sweden
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 701 82, Örebro, Sweden
| | - Anna-Karin Åkerman
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Medicine, Örebro University Hospital, 701 85, Örebro, Sweden
| | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Katarina Berinder
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
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Lisa B, Arno V, Christophe DB, Heyning Paul VD, Carlien DH. Giant prolactinomas, a detailed analysis of 196 adult cases. Pituitary 2023; 26:529-537. [PMID: 37544978 DOI: 10.1007/s11102-023-01337-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE Giant prolactinomas are a rare entity, representing approximately 5% of all prolactinomas. A systematic review of 196 adult cases was performed. A comparison of the clinical, biochemical and radiological characteristics, management and therapeutic outcomes in men versus women is made. METHODS A structured search was conducted using the term 'giant prolactinoma'. Following inclusion criteria were used: diameter ≥ 40 mm, prolactin levels > 1000 ng/ml and no concomitant GH/ ACTH secretion. RESULTS 196 cases were included [age: 38 (28-50) years, F/M ratio: 1/3.6]. Median tumor diameter was 53 (43-69) mm. Pituitary deficiency was present in 91% of cases, with hypogonadotropic hypogonadism being the most frequent. Most common presenting symptoms were visual impairment (73%) and headache (50%) in men and amenorrhea (58%) in women. 82% of cases were treated with a dopamine agonist (DA) as first-line treatment which led to normoprolactinemia, tumor shrinkage and visual improvement in 51%, 88% and 85% of cases, respectively. Surgery was performed in 29% of cases and all showed tumor remnant and persistent hyperprolactinemia. Women had a lower prolactin level and a smaller tumor diameter at diagnosis but pituitary deficiencies were more frequent and outcome was worse. CONCLUSION Giant prolactinomas are rare and have a male predominance. Visual impairment is the most frequent presenting symptom in men and amenorrhea in women. The gender-related difference in tumor size and level of prolactin was confirmed in this analysis where men had a larger diameter and a higher baseline prolactin level. DAs are the treatment of choice, irrespective of tumor size and presence of visual impairment. As only half of the cases achieved normoprolactinemia we do not, in contrast to previous literature, state giant prolactinomas to be exquisitely sensitive to DAs. Patient characteristics associated with persistent hyperprolactinemia after treatment with a DA were female gender, higher baseline prolactin and larger tumor size . This analysis did show TSH- and ACTH-deficiency to be more frequent after surgery which was not seen for LH/FSH deficiency.
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Affiliation(s)
- Billion Lisa
- Department of Endocrinology, Diabetology & Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, B-2650, Belgium
| | - Verleye Arno
- Department of Nephrology, Antwerp University Hospital, Edegem, B-2650, Belgium
| | - De Block Christophe
- Department of Endocrinology, Diabetology & Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, B-2650, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, B-2610, Belgium
| | - Van de Heyning Paul
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, B-2610, Belgium
- Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem, B-2650, Belgium
| | - De Herdt Carlien
- Department of Endocrinology, Diabetology & Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, B-2650, Belgium.
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Stratakis CA. An update on, and genetics of refractory adenomas of childhood. Pituitary 2023:10.1007/s11102-023-01327-2. [PMID: 37318708 DOI: 10.1007/s11102-023-01327-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/16/2023]
Abstract
Pituitary adenomas in childhood tend to be more frequently due to germline genetic changes and are often diagnosed at late stages due to delayed recognition by pediatricians and other caretakers who are not familiar with this rare disease in childhood. As a result, often, pediatric pituitary adenomas are aggressive or remain refractory to treatment. In this review, we discuss germline genetic defects that account for the most common pediatric pituitary adenomas that are refractory to treatment. We also discuss some somatic genetic events, such as chromosomal copy number changes that characterize some of the most aggressive pituitary adenomas in childhood that end up being refractory to treatment.
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Affiliation(s)
- Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 20892, Bethesda, MD, USA.
- Human Genetics & Precision Medicine, IMMB, FORTH, Heraklion, Greece.
- ELPEN Research Institute, Athens, Greece.
- Medical Genetics, H. Dunant Hospital, Athens, Greece.
- Faculty of Medicine, European University of Cyprus, Nicosia, Cyprus.
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Li D, Wang Y, Tan H, Luo P, Yu Y. A giant invasive macroprolactinoma with recurrent nasal bleeding as the first clinical presentation: case report and review of literature. BMC Endocr Disord 2023; 23:107. [PMID: 37173679 PMCID: PMC10176701 DOI: 10.1186/s12902-023-01345-y] [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: 11/22/2021] [Accepted: 04/14/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Giant prolactinoma (> 4 cm in dimension) is a rare disorder. Invasive macroprolactinoma has the potential to cause base of skull erosion and extend into the nasal cavity or even the sphenoid sinus. Nasal bleeding caused by intranasal tumor extension is a rare complication associated with invasive giant prolactinoma. We report a case of giant invasive macroprolactinoma with repeated nasal bleeding as the initial symptom. CASE PRESENTATION A 24-year-old man with an invasive giant prolactinoma in the nasal cavity and sellar region who presented with nasal bleeding as the initial symptom, misdiagnosed as olfactory neuroblastoma. However, markedly elevated serum prolactin levels (4700 ng/mL), and a 7.8-cm invasive sellar mass confirmed the diagnosis of invasive giant prolactinoma. He was treated with oral bromocriptine. Serum prolactin was reduced to near normal after 6 months of treatment. Follow-up magnetic resonance imaging showed that the sellar lesion had disappeared completely and the skull base lesions were reduced. CONCLUSION This case is notable in demonstrating the aggressive nature of untreated invasive giant prolactinomas which can cause a diagnostic difficulty with potential serious consequences. Early detection of hormonal levels can avoid unnecessary nasal biopsy. Early identification of pituitary adenoma with nasal bleeding as the first symptom is particularly important.
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Affiliation(s)
- Danting Li
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, 610041, P.R. China
- Department of Health Management, Health Management Center, General Practice Center, West China Hospital of Sichuan University, Chengdu, 610041, P.R. China
| | - Yan Wang
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, 610041, P.R. China
| | - Huiwen Tan
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, 610041, P.R. China.
| | - Peiqiong Luo
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, 610041, P.R. China
| | - Yerong Yu
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, 610041, P.R. China
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Makarenko S, Alzahrani I, Karsy M, Deopujari C, Couldwell WT. Outcomes and surgical nuances in management of giant pituitary adenomas: a review of 108 cases in the endoscopic era. J Neurosurg 2022; 137:635-646. [PMID: 35061979 DOI: 10.3171/2021.10.jns21659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 10/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Giant (maximum diameter ≥ 4 cm) pituitary macroadenomas are complex tumors that require resection for decompression of optic nerves, relief of mass effect, and symptom improvement. Given the lack of surgical accessibility, the lateral extent of the lesions, and the invasion of the cavernous sinus, management presents a significant challenge. Transsphenoidal, transcranial, and combined approaches have been viable options for resection. The authors present their findings from a large series of patients to characterize giant pituitary adenomas, document outcomes, and outline surgical nuances in resection of these tumors. METHODS The authors reviewed 887 consecutive patients who underwent resection of pituitary adenomas at a single institution. From this group, 108 patients with giant pituitary adenomas who underwent resection between January 1, 2002, and December 31, 2020, were identified for inclusion in the study. The patient demographics, clinical presentation, tumor imaging characteristics, surgical approaches, and postoperative outcomes were analyzed using descriptive statistics. RESULTS The mean preoperative tumor diameter in this cohort was 4.6 ± 0.8 cm, with a mean volume of 25.9 ± 19.2 cm3. Ninety-seven patients underwent transsphenoidal approaches only, 3 underwent transcranial resection, and 8 patients underwent a combined approach. Gross-total resection was achieved in 42 patients. Tumor stability without a need for additional therapy was achieved in 77 patients, with 26 patients undergoing subsequent adjuvant radiotherapy. Among 100 patients with sufficient follow-up, 14 underwent adjuvant therapy-repeat operation and/or adjuvant radiation therapy-because of recurrence or tumor progression. Six patients with recurrence were observed without additional treatment. Overall, the morbidity associated with removal of these lesions was 11.1%; the most common morbidities were cerebrospinal fluid leak (5 patients, 4.6%) and hydrocephalus (4 patients, 3.7%). One death due to postoperative pituitary apoplexy of the residual tumor and malignant cerebral edema occurred in this cohort. CONCLUSIONS Giant pituitary tumors still represent a surgical challenge, with significant morbidity. Gross-total resection occurs in a minority of patients. Surgical goals for removal of giant pituitary tumors should include attempts at removal of most tumor tissue to minimize the risk of residual tumor apoplexy by tailoring the approach along the major axis of the tumor. Experience with both transsphenoidal and multiple transcranial techniques is necessary for minimizing complications and improving outcomes.
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Affiliation(s)
- Serge Makarenko
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Ibrahim Alzahrani
- 2Division of Neurological Surgery, Neurosciences Department, King Faisal University Hospital and Research Center, Riyadh, Saudi Arabia; and
| | - Michael Karsy
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Chandrasekhar Deopujari
- 3Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences (BHIMS), Mumbai, India
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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10
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Kanj U, Lee SS, Wattegama M, Chavda S, Karavitaki N, Batra R. Foster Kennedy syndrome secondary to a giant prolactinoma with a remarkable response to cabergoline. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0261. [PMID: 36017805 PMCID: PMC9422260 DOI: 10.1530/edm-22-0261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 11/08/2022] Open
Abstract
Summary Pituitary adenomas are intracranial neoplasms, usually demonstrating a benign phenotype. We present the case of 21-year-old male with an 18-month history of reduced visual function (acuity and field) in the left eye. Based on neuroimaging and endocrine profile, a giant prolactinoma causing hypogonadotropic hypogonadism was diagnosed and cabergoline was commenced. After a month of treatment, the tumour size reduced, and visual function improved to normal; however, he developed Foster Kennedy syndrome with a swollen right optic disc. After almost 1 year of follow-up, he regained full visual functioning. Two years since his diagnosis, his prolactin remains normal with no adverse effects or further visual complications. Learning points Foster Kennedy syndrome is a rare entity but can be a feature of pituitary adenomas. Visual deterioration secondary to a compressive optic neuropathy can be reversible, provided that diagnosis and treatment are prompt. This case highlights the importance of frequent monitoring of visual function during follow-up of these lesions, particularly when there are deficits at diagnosis.
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Affiliation(s)
- Usama Kanj
- Department of Ophthalmology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Sam Sum Lee
- Department of Ophthalmology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Milanka Wattegama
- Department of Endocrinology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Swarupsinh Chavda
- Department of Neuroradiology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Niki Karavitaki
- Department of Endocrinology, University Hospitals Birmingham NHS Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Bimingham, Birmingham, UK
- Center for Endocrinology, Diabetes and Metabolism, Birmingham, UK
| | - Ruchika Batra
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Trust, Birmingham, UK
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11
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Rutland JW, Dullea JT, Oermann EK, Feng R, Villavisanis DF, Gilja S, Shuman W, Lander T, Govindaraj S, Iloreta AMC, Chelnis J, Post K, Bederson JB, Shrivastava RK. Post-operative vision loss: analysis of 587 patients undergoing endoscopic surgery for pituitary macroadenoma. Br J Neurosurg 2022; 36:494-500. [PMID: 35264032 DOI: 10.1080/02688697.2022.2047888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PURPOSE Vision loss following surgery for pituitary adenoma is poorly described in the literature and cannot be reliably predicted with current prognostic models. Detailed characterization of this population is warranted to further understand the factors that predispose a minority of patients to post-operative vision loss. MATERIALS AND METHODS The medical records of 587 patients who underwent endoscopic transsphenoidal surgery at the Mount Sinai Medical Centre between January 2013 and August 2018 were reviewed. Patients who experienced post-operative vision deterioration, defined by reduced visual acuity, worsened VFDs, or new onset of blurry vision, were identified and analysed. RESULTS Eleven out of 587 patients who received endoscopic surgery for pituitary adenoma exhibited post-operative vision deterioration. All eleven patients presented with preoperative visual impairment (average duration of 13.1 months) and pre-operative optic chiasm compression. Seven patients experienced visual deterioration within 24 h of surgery. The remaining four patients experienced delayed vision loss within one month of surgery. Six patients had complete blindness in at least one eye, one patient had complete bilateral blindness. Four patients had reduced visual acuity compared with preoperative testing, and four patients reported new-onset blurriness that was not present before surgery. High rates of graft placement (10/11 patients) and opening of the diaphragma sellae (9/11 patients) were found in this series. Four patients had hematomas and four patients had another significant post-operative complication. CONCLUSIONS While most patients with pituitary adenoma experience favourable ophthalmological outcomes following endoscopic transsphenoidal surgery, a subset of patients exhibit post-operative vision deterioration. The present study reports surgical and disease features of this population to further our understanding of factors that may underlie vision loss following pituitary adenoma surgery. Graft placement and opening of the diaphragma sellae may be important risk factors in vision loss following ETS and should be an area of future investigation.
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Affiliation(s)
- John W Rutland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan T Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric K Oermann
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dillan F Villavisanis
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shivee Gilja
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Travis Lander
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alfred M C Iloreta
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Chelnis
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kalmon Post
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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12
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Hacisahinogullari H, Canturk S, Dogansen S, Yarman S. Dopamine agonist for the rapid improvement of visual field defects in giant and macro-prolactinomas. J Fr Ophtalmol 2022; 45:511-518. [PMID: 35272874 DOI: 10.1016/j.jfo.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/10/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate effect of first-line dopamine agonist (DA) therapy as an alternative to surgery for visual field defect (VFD) recovery in giant and macro-prolactinoma. METHODS In this retrospective study, 125 patients with giant and macro-prolactinoma, except those with a history of previous surgery or radiotherapy, were evaluated. Those who underwent visual field examinations using the Humphrey Visual Field analyser upon initial assessment and after treatment were included for analysis. Twelve patients with VFD were included. The effects of DA therapy on both VFD and tumor size were evaluated within the first three months. RESULTS There were twelve patients analysed: three females and nine males, five giant and seven macroprolactinomas; eight patients received cabergoline (CAB) and four patients received bromocriptine (BRC). The mean adenoma diameter was 35±13mm (range 15-60), and the mean PRL level was 3,523ng/dL (range 312-11,703). Eight patients (67%) complained of blurred vision, while four patients (33%) reported no visual symptoms. After a median duration of three weeks, the VFD completely resolved in ten patients (83%) but only partially improved in two (17%). The mean initial doses of CAB and BRC that provided VFD improvement were 0.5±0.2mg/week and 6.3±1.4mg/day, respectively. After a mean duration of 2.2±0.9months, the mean decrease in adenoma size was 43.6±24.5% (range 10-95%). CONCLUSION The use of DA as a first-line treatment for at least one month before deciding on surgery is recommended in giant and macro-prolactinomas with VFD. Surgery should be considered only in cases with DA resistance or persistent visual impairment despite medical therapy.
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Affiliation(s)
- H Hacisahinogullari
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Çapa, Istanbul, Turkey.
| | - S Canturk
- Department of Ophthalmology, Istanbul University, Istanbul Faculty of Medicine, Çapa, Istanbul, Turkey
| | - S Dogansen
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - S Yarman
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul University, Istanbul Faculty of Medicine, Çapa, Istanbul, Turkey
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13
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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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14
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Sliwinska A, Jalil F, De La Portilla L, Baldwin M, Lorenzo J, Bulsara KR, Mirza FS. Giant Prolactinoma Presenting With Facial Nerve Palsy and Hemiparesis. J Endocr Soc 2021; 5:bvab069. [PMID: 34268462 PMCID: PMC8276890 DOI: 10.1210/jendso/bvab069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Giant prolactinomas are an exceedingly uncommon type of pituitary adenomas that usually occur in men, and cause extremely high prolactin levels and mass-related symptoms. Rarely, patients may experience neurological deficits resembling ischemic events. Methods We describe an unusual case of a young man who presented with stroke-like symptoms and was found to have a giant prolactinoma. Clinical Case A 25-year-old man presented with left facial droop and gradually progressing upper and lower extremity weakness for evaluation of stroke. He reported recent weight gain and erectile dysfunction. Physical examination revealed left homonymous hemianopsia, left VII nerve palsy, and left hemiparesis. Magnetic resonance imaging of the brain showed an enormous mass in the sella turcica, which invaded the sphenoid sinus and right side of the skull base. Prolactin level was elevated at 13 580 ng/mL, and the testosterone level was low. The patient was started on cabergoline and had marked improvement in his symptoms in a few months. Fifteen months after starting treatment, he has had more than 90% reduction in tumor volume and a 93% reduction in prolactin level. Conclusion Giant prolactinomas are uncommon and present with compressive symptoms that can be mistaken for a stroke. Our case is a unique report of a facial nerve palsy and hemiparesis secondary to giant prolactinoma in the absence of stroke or pituitary apoplexy.
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Affiliation(s)
| | - Fatima Jalil
- Department of Medicine, UCONN Health, Farmington, CT 06030, USA.,Division of Endocrinology and Metabolism, UCONN Health, Farmington, CT 06030, USA
| | - Lori De La Portilla
- Department of Medicine, UCONN Health, Farmington, CT 06030, USA.,Division of Endocrinology and Metabolism, UCONN Health, Farmington, CT 06030, USA
| | | | - Joseph Lorenzo
- Department of Medicine, UCONN Health, Farmington, CT 06030, USA.,Division of Endocrinology and Metabolism, UCONN Health, Farmington, CT 06030, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, UCONN Health, Farmington, CT 06030, USA
| | - Faryal S Mirza
- Department of Medicine, UCONN Health, Farmington, CT 06030, USA.,Division of Endocrinology and Metabolism, UCONN Health, Farmington, CT 06030, USA
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15
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Asuzu DT, Burke RM, Hakim J, Coss D, Park MS, Payne SC, Jane JA. Giant pituitary macroadenoma of stem cell origin: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2122. [PMID: 35855437 PMCID: PMC9241200 DOI: 10.3171/case2122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 01/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Giant pituitary macroadenomas with a diameter >4 cm are rare tumors, accounting for only about 5% of pituitary adenomas. They are more difficult to maximally resect safely owing to limited access as well as encasement of adjacent structures. Acidophil stem cell adenomas are rare immature neoplasms proposed to derive from common progenitor cells of somatotroph and lactotroph cells. These adenomas comprise about 4.3% of surgically removed pituitary adenomas. No previous reports have described acidophil stem cell adenomas that grow to the size of giant macroadenomas. This rare entity poses special challenges given the need for maximal safe resection in an immature neoplasm. OBSERVATIONS The authors report a 21-year-old female who presented with 3 years of progressive visual decline and a giant macroadenoma. She underwent endoscopic transsphenoidal surgery for decompression. Given the tumor size and involvement of adjacent critical structures, gross-total resection was not achieved. The authors review the literature on giant pituitary adenomas and provide a discussion on clinical management for this rare entity. LESSONS The authors present a very rare case of a giant pituitary adenoma of acidophil stem cell origin and discuss the technical and management challenges in this rare entity.
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Affiliation(s)
- David T. Asuzu
- Department of Neurosurgery,
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | - Spencer C. Payne
- Department of Otolaryngology, Head and Neck Surgery, University of Virginia, Charlottesville, Virginia; and
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16
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Cohen-Cohen S, Brown DA, Himes BT, Wheeler LP, Ruff MW, Major BT, Singh Ospina NM, Atkinson JLD, Meyer FB, Bancos I, Young WF, Van Gompel JJ. Pituitary adenomas in the setting of multiple endocrine neoplasia type 1: a single-institution experience. J Neurosurg 2021; 134:1132-1138. [PMID: 32244213 DOI: 10.3171/2020.1.jns193538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Multiple endocrine neoplasia type 1 (MEN1) is a rare, autosomal-dominant tumor disorder characterized by the development of pituitary tumors and other endocrine neoplasms. Diagnosis is made clinically based on the development of 2 or more canonical lesions (parathyroid gland, anterior pituitary, and enteropancreatic tumors) or in family members of a patient with a clinical diagnosis of MEN1 and the occurrence of one of the MEN1-associated tumors. The goal of this study was to characterize pituitary tumors arising in the setting of MEN1 at a single institution. The probability of tumor progression and the likelihood of surgical intervention in patients with asymptomatic nonfunctional pituitary adenomas were also analyzed. METHODS A retrospective review of a prospectively maintained institutional database was performed for patients with MEN1 diagnosed from 1970 to 2017. Data included patient demographics, tumor characteristics, treatment strategies, and outcomes. RESULTS A review of the database identified 268 patients diagnosed with MEN1, of whom 158 (59%) were female. Among the 268 patients, 139 (51.8%) had pituitary adenomas. There was a higher prevalence in women than in men (65% vs 35%, p < 0.005). Functional adenomas (57%) were more common. Prolactin-secreting adenomas were the most common functional tumors. Macroadenomas were seen in 27% of patients and were more likely to be symptomatic and locally aggressive (p < 0.001). Forty-nine patients (35%) underwent transsphenoidal resection at some point during their disease course. In 52 patients who were initially observed with MEN1 asymptomatic nonfunctional adenomas, only 5 (10%) progressed to need surgery. In MEN1 patients, an initial parathyroid lesion is most likely followed in order by pituitary, pancreatic, adrenal, and, finally, rare carcinoid tumors. CONCLUSIONS Asymptomatic nonfunctional pituitary adenomas in patients with MEN1 may be followed safely with MRI. In this series, parathyroid tumors developed at the lowest median age of all cardinal tumors, and development of additional cardinal MEN1 lesions followed a predictable pattern. This pattern of disease progression could have significant implications for disease surveillance in clinical practice and may help to target clinical resources to the lesions most likely to develop next. This may aid with early detection and treatment and warrants further study.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Jamie J Van Gompel
- Departments of1Neurological Surgery
- 5Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
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17
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Patel A, Gozal YM, Abou-Al-Shaar H, Taussky P, Couldwell W. Spontaneous Cerebrospinal Fluid Rhinorrhea from a Prolactin-Secreting Pituitary Macroadenoma. Cureus 2021; 13:e13111. [PMID: 33728130 PMCID: PMC7935238 DOI: 10.7759/cureus.13111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cerebrospinal fluid (CSF) rhinorrhea is a rare complication of macroprolactinomas that, in the vast majority of cases, is subsequent to either medical or surgical intervention. Here, we present the successful management of a rare case of spontaneous, noniatrogenic CSF rhinorrhea in a patient with an untreated macroprolactinoma. A 27-year-old man with no significant medical history presented with six months of persistent CSF rhinorrhea, which was confirmed by testing for beta-2-transferrin. He had had decreased libido since adolescence and impaired growth of secondary sexual characteristics. Workup revealed an elevated prolactin level, and imaging demonstrated erosion of the anterior sellar floor and soft tissue within the sphenoid sinus, concerning for tumor. The patient underwent surgical repair of the CSF leak via a transnasal transsphenoidal approach, with resection and biopsy of tumor material within the sinus. No tumor was noted within the sella itself. The patient tolerated the procedure well and had subsequent normalization of his prolactin level with no further CSF egress. Spontaneous noniatrogenic CSF rhinorrhea, although rare, should be considered in the differential diagnosis of invasive pituitary macroadenomas, especially prolactinomas. The mechanism of CSF leak from a prolactinoma is not completely understood, but the CSF leak should be urgently repaired through a transnasal transsphenoidal approach. Concurrently, tumor resection should be performed and a postoperative lumbar puncture or lumbar drain should be considered to reinforce the skull base reconstruction.
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Affiliation(s)
- Aneek Patel
- Neurosurgery, New York University, New York, USA
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18
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Astafyeva LI, Shishkina LV, Kadashev BA, Kalinin PL, Sidneva JG, Sharipov OI, Melnichenko GA. [Changes in the morphological structure of giant prolactinoma during treatment with cabergoline]. ACTA ACUST UNITED AC 2020; 66:15-21. [PMID: 33351334 DOI: 10.14341/probl12368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 11/06/2022]
Abstract
Currently, cabergoline therapy is the main method of treatment with prolactin. The use of the drug in most cases leads to tumor regression, normalization of prolactin levels and restoration of gonadotropic function. The mechanism of its impact on tumor cells in vivo, which is dynamically traced in the same human tumor, is the case of considerable interest. We observed a 30-year-old patient who was operated on twice for a giant prolactinoma before and on treatment by cabergoline. The morphological study after the first surgery (before introducing of cabergoline therapy) revealed a prolactin-positive pituitary tumor with a Ki-67 labeling index of 8% and with strong expression of dopamine type 2 receptors (D2R), CD31 and CD34. After 4 months, during which the patient received cabergoline at a dose starting from 0.5 mg to 1.5 mg per week, a second transsphenoidal surgery was performed with subtotal removal of residual tumor tissue. During the morphological study of the second biopsy sample, the tumor retained a pronounced immunopositivity to prolactin and D2R, with a decrease in the labeling index Ki-67 to 2%, as well as a decrease in the expression of CD31 and CD34. Subsequent cabergoline therapyresulted in persistent normoprolactinemia, restoration of androgen (and reproductive) status, and no tumor recurrence over a 10-year period on cabergoline treatment. Thus, one of the mechanisms of effect of cabergoline that leads to tumor regression is a decrease in the proliferative index and angiogenesis of the tumor.
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Affiliation(s)
| | | | | | - Pavel L Kalinin
- N.N. Burdenko national medical research center of neurosurgery
| | - Julia G Sidneva
- N.N. Burdenko national medical research center of neurosurgery
| | - Oleg I Sharipov
- N.N. Burdenko national medical research center of neurosurgery
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19
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Almalki MH, Aljohani N, Alzahrani S, Almohareb O, Ahmad MM, Alrashed AA, Alshahrani F, Mahmood Buhary B. Clinical Features, Therapeutic Trends, and Outcome of Giant Prolactinomas: A Single-Center Experience Over a 12-Year Period. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2020; 13:1179551420926181. [PMID: 32547285 PMCID: PMC7273563 DOI: 10.1177/1179551420926181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/19/2020] [Indexed: 01/06/2023]
Abstract
Background: Management of giant prolactinomas presents a different challenge than the
management of traditional prolactinomas. Objective: The aim of this study was to report the largest long-term single-center study
of giant prolactinomas to analyze their clinical features; define
epidemiological characteristics, comorbidities, complications, treatment
outcomes; and to demonstrate our experience with long-term cabergoline (CAB)
treatment of these giant tumors. Methods: A retrospective case study and clinical review of patients presenting with
giant prolactinomas in the pituitary clinic at King Fahad Medical City
(KFMC), Riyadh, Saudi Arabia, in the period between 2006 and 2018 were
included in the study. Of the charts reviewed, 33 patients (24 men; 9 women)
with age of diagnosis between 18 and 63 years (mean = 37.21 years) met the
selection criteria for giant prolactinomas. Result: The most common presenting features include headache (87.8%), visual defects
(69.7%), and hypogonadism (51.5%). The baseline means serum prolactin (PRL)
level was extremely high for both sexes (95 615.03 nmol/L), which eventually
decreased by as much as 95.4% after CAB treatment. Serum PRL concentrations
completely normalized in 11 patients and significantly reduced in 22
patients. The mean tumor volume at baseline was 42.87 cm3,
whereas the mean posttreatment tumor volume was 3.42 cm3 (no
residual tumor in 2 patients, while in others, it ranged from 0.11 to
16.7 cm3) at the last follow-up visit. The mean change in
tumor volume was 88.84%. Tumor volume decreased by an average of 92% for men
and 80.4% for women. One patient had no tumor size change with CAB (3.5 mg
thrice a week) or radiotherapy and required surgery. The response rate
(remission after medical therapy alone) in this series was 84.84%. Conclusions: Findings reinforce results from our previous study that CAB provides dramatic
clinical improvements with an excellent safety profile. The CAB should,
therefore, be considered as the primary therapy for giant prolactinomas.
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Affiliation(s)
- Mussa H Almalki
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.,King Fahad Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Naji Aljohani
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.,King Fahad Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Saad Alzahrani
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.,King Fahad Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ohoud Almohareb
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Abdullah A Alrashed
- Department of Neuroimaging and Intervention, Medical Imaging Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fahad Alshahrani
- King Abdulaziz Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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20
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Abstract
Aggressive pituitary tumors (APTs) represent rare pituitary adenomas (PAs) with local invasion of surrounding tissues, increased risk for multiple recurrence, rapid tumor growth, or resistance to standard therapies. The most common APTs in children and adolescents are giant prolactinomas and somatotropinomas. Few cases of Crooke's cell adenomas, silent corticotroph adenomas and pituitary carcinomas have also been reported in the literature. Pediatric patients with APTs have higher risk of harboring germline genetic defects, most commonly in the MEN1 and AIP genes. Since certain genetic defects confer a more aggressive behavior to PAs, genetic testing should be considered in tumors with young onset and positive family history. The management of pediatric APTs involves usually a combination of standard therapies (surgical, medical, radiation). Newer agents, such as temozolomide, have been used in few cases of pediatric pituitary tumors with promising results. In the elderly, PAs are more commonly non-functioning. Their management often poses dilemmas given the coexistence of age-related comorbidities. However, standard surgical treatment and temozolomide seem to be safe and well tolerated in elderly patients.
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Affiliation(s)
- Christina Tatsi
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, NIH-Clinical Research Center, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA
| | - Constantine A Stratakis
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, 10 Center Drive, Building 10, NIH-Clinical Research Center, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA.
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21
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Astaf'eva L, Shishkina L, Kalinin P, Kadashev B, Melnichenko G, Tserkovnay D, Sharipov O. Decrease of Proliferative Potential and Vascular Density of Giant Prolactinoma in Patients Treated with Cabergoline. Asian J Neurosurg 2020; 15:385-390. [PMID: 32656137 PMCID: PMC7335146 DOI: 10.4103/ajns.ajns_16_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/08/2020] [Accepted: 03/11/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction: Currently, cabergoline therapy is the main treatment for prolactinomas. The use of the drug in most cases leads to regression of the tumor, normalization of prolactin (PRL) levels, and restoration of gonadotropic function. The mechanism of its action in tumor cells “in vivo” tracked in dynamics in the same human tumor is of considerable interest. Materials and Methods: A 30-year-old male was admitted to N.N. Burdenko National Medical Research Center of Neurosurgery. An magnetic resonance imaging (MRI) revealed a giant pituitary adenoma. The level of PRL was more than 5000 mU/l (30-360) (serum dilution was not used to determine PRL). Transcranial microsurgical removal of the tumor was performed. He was treated by cabergoline after surgery. Endoscopic transsphenoidal approach was repeated with subtotal removal of the rest of the tumor. Morphological and immunohistochemical studies of the tumor were done. Results: A morphological study revealed PRL-positive tumor with a Ki-67 LI of 8% with a distinctive expression of D2R, CD31, and CD34 markers. Control MRI in 3 months after surgery revealed remnants of a tumor of endoinfrasellar localization, the tumor remainders were found in endoinfrasellar localization. The tumor retained pronounced immunopositivity to PRL and D2R and a decrease in the Ki-67 to 2% and in the expression of CD31 and CD34. Subsequent therapy with cabergoline resulted in persistent normoprolactinemia, restoration of androgenic function, and absence of tumor recurrence during the 10-year follow-up period. Conclusions: Cabergoline is an effective treatment for prolactinoma, which leads to tumor regression. One of its mechanisms is the reduction of the proliferative index and tumor angiogenesis.
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Affiliation(s)
- Ludmila Astaf'eva
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Ludmila Shishkina
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Pavel Kalinin
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Boris Kadashev
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | | | - Dariia Tserkovnay
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Oleg Sharipov
- N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
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Lin S, Zhang A, Zhang X, Wu ZB. Treatment of Pituitary and Other Tumours with Cabergoline: New Mechanisms and Potential Broader Applications. Neuroendocrinology 2020; 110:477-488. [PMID: 31597135 DOI: 10.1159/000504000] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022]
Abstract
Cabergoline is a dopamine agonist that has been used as the first-line treatment option for prolactin-secreting pituitary adenomas for several decades. It not only suppresses hormone production from these prolactinomas, but also causes tumour shrinkage. Recent studies revealed some novel mechanisms by which cabergoline suppresses tumour cell proliferation and induces cell death. In this article, we review the most recent findings in cabergoline studies, focusing on its anti-tumour function. These studies suggest the potential broader clinical use of cabergoline in the treatment of other tumours such as breast cancer, pancreatic neuroendocrine tumours, and lung cancer.
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Affiliation(s)
- Shaojian Lin
- Center of Pituitary Tumour, Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Anke Zhang
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xun Zhang
- Neuroendocrine Research Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Zhe Bao Wu
- Center of Pituitary Tumour, Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,
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23
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Kuo AH, Nuñez DB. Giant Pituitary Adenoma With Inferior Petrosal Sinus, Jugular Foramen, and Hypoglossal Canal Extension. JAMA Otolaryngol Head Neck Surg 2020; 146:82-84. [PMID: 31556924 DOI: 10.1001/jamaoto.2019.2686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anderson H Kuo
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Diego B Nuñez
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Baker C, Karsy M, Couldwell WT. Resection of Pituitary Tumor with Lateral Extension to the Temporal Fossa: The Toothpaste Extrusion Technique. Cureus 2019; 11:e5953. [PMID: 31799094 PMCID: PMC6863590 DOI: 10.7759/cureus.5953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/18/2019] [Indexed: 11/29/2022] Open
Abstract
Transsphenoidal resection of the sellar and suprasellar lesions, whether microscopic or endoscopic, has been traditionally limited by tumors extending laterally to the carotid artery and cavernous sinus. Extended endoscopic or transmaxillary approaches may be warranted depending on these tumor extensions. We describe the use of an intraoperative Valsalva maneuver as a surgical adjunct to the transsphenoidal approach to improve the extent of resection for a favorable outcome. The patient was a 65-year-old woman who underwent resection of a giant pituitary tumor that extended laterally to the cavernous sinus to occupy a volume within the middle fossa. It was the senior author's impression that the lateral cavernous wall was intact at the time of surgery although this is difficult to determine definitively. After a transsphenoidal intrasellar resection of the intrasellar tumor, side-angled endoscopic visualization enabled identification of the breach in the medial cavernous wall where the tumor had invaded the cavernous sinus and ultimately grown into the middle fossa. A Valsalva maneuver was then applied, and the tumor was extruded from the cavernous sinus lateral to the carotid. The significant tumor was removed under direct visualization of the abducens nerve, which was well preserved. Postoperative imaging showed a sufficient extent of resection, and there were no postoperative complications. An intraoperative Valsalva maneuver can be a potentially useful technique for extending tumor resection in cases with a soft tumor and visualization of the opening within the cavernous sinus wall.
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Affiliation(s)
- Cordell Baker
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - Michael Karsy
- Neurosurgery, University of Utah School of Medicine, Salt Lake City, USA
| | - William T Couldwell
- Neurosurgery, University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City, USA
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Giant prolactinoma, a case report and review of the literature. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2019. [DOI: 10.1016/j.jecr.2019.100048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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26
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Hamidi O, Van Gompel J, Gruber L, Kittah NE, Donegan D, Philbrick KA, Koeller KK, Erickson D, Natt N, Nippoldt TB, Young WF, Bancos I. MANAGEMENT AND OUTCOMES OF GIANT PROLACTINOMA: A SERIES OF 71 PATIENTS. Endocr Pract 2019; 25:340-352. [PMID: 30995432 DOI: 10.4158/ep-2018-0392] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective: To describe outcomes of patients with giant prolactinoma (≥4 cm) and identify predictors of therapeutic response. Methods: In this retrospective study, complete biochemical and structural response were defined as prolactin (PRL) ≤25 ng/mL and no visible tumor at follow-up, respectively. Results: Giant prolactinoma (median size, 4.8 cm [range, 4 to 9.8 cm]; median PRL, 5,927 ng/mL [range, 120 to 100,000 ng/mL]) was diagnosed in 71 patients. Treatments included: dopamine agonists (DAs) (n = 70, 99%), surgery (n = 30, 42%), radiation (n = 10, 14%), and somatostatin analogs (n = 2, 3%). Patients treated with DA monotherapy were older compared with those who received subsequent therapies (47 years vs. 28 years; P = .003) but had similar initial PRL and tumor size. Surgically managed patients were younger compared with the nonsurgical group (35 years vs. 46 years; P = .02) and had lower initial PRL (3,121 ng/mL vs. 6,920 ng/mL; P = .02), yet they had similar tumor response. Hypopituitarism was more common following surgery compared to medical management: adrenal insufficiency (69% vs. 27%; P<.001), hypothyroidism (67% vs. 38%; P = .02), growth hormone deficiency (24% vs. 6%; P = .04), and diabetes insipidus (17% vs. 3%; P = .04). Therapeutic response did not correlate with sex, age, initial PRL, tumor size, or first-line therapy mode. At median follow-up of 4.8 years, the median PRL was 18.3 ng/mL (range, 0.6 to 12,680 ng/mL), and final volume was 0.9 cm3 (range, 0 to 43.0 cm3). In those with available data, 36/65 (55%) patients achieved PRL normalization, and 16/61 (26%) had no visible tumor at follow-up. Conclusion: Most patients with giant prolactinoma have excellent response to DA. Sex, age, initial PRL, and tumor size do not predict therapeutic response. Abbreviations: BRC = bromocriptine; CAB = cabergoline; CSF = cerebrospinal fluid; DA = dopamine agonist; MRI = magnetic resonance imaging; PRL = prolactin.
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Bromocriptine and cabergoline induce cell death in prolactinoma cells via the ERK/EGR1 and AKT/mTOR pathway respectively. Cell Death Dis 2019; 10:335. [PMID: 31000722 PMCID: PMC6472389 DOI: 10.1038/s41419-019-1526-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 02/11/2019] [Accepted: 03/13/2019] [Indexed: 12/31/2022]
Abstract
The treatment of hyperprolactinemia is based on the use of dopamine agonists, mainly bromocriptine (BRC) and cabergoline (CAB). They reduce tumour size effectively and restore gonadal function. However, there is a difference in drug sensitivity between CAB and BRC in patients with prolactinoma, although the underlying mechanisms are still unknown. Thus, we investigated whether there are differences in tumour sensitivity to CAB and BRC and their possible differential mechanisms in two prolactinoma cell lines. In our study, we found that GH3 cells are more sensitive to BRC and that MMQ cells are more sensitive to CAB. Moreover, BRC and CAB elicited cell death via different pathways; BRC induced prolactinoma cell death mainly through the apoptosis pathway, and CAB induced pituitary prolactinoma cell death mainly via the autophagic cell death pathway. Using gene microarray analysis, we found that BRC induces the apoptosis of prolactinoma cells through the ERK/EGR1 signalling pathway, whereas CAB induces autophagic death by inhibiting the AKT/mTOR signalling pathway. Our study showed the difference in tumour sensitivity and differential mechanisms in BRC- and CAB-treated prolactinoma cells, which provides a theoretical basis for the accurate treatment of prolactinoma.
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Untreated Giant Macroprolactinoma with Chronic Cerebrospinal Fluid Leakage: An Unusual Complication. Case Rep Endocrinol 2019; 2019:4825357. [PMID: 30766735 PMCID: PMC6350591 DOI: 10.1155/2019/4825357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/25/2018] [Accepted: 12/31/2018] [Indexed: 12/04/2022] Open
Abstract
Macroprolactinoma has the potential to cause base of skull erosion and often extends into the sphenoid sinus. Rapid shrinkage of this invasive tumor following dopamine agonist therapy has been postulated to cause unplugging of the eroded area, leading to cerebrospinal fluid leakage. To the best of our knowledge, the occurrence of spontaneous cerebrospinal fluid leak in treatment-naive prolactinomas is very rare, the majority of which involve undiagnosed macroprolactinomas. We describe here a lady presented late with giant macroprolactinoma, complicated by cerebrospinal fluid leakage. This case raised the dilemma in the management pertaining to the role of either pharmacotherapy or surgical intervention, or combination of both. As she strictly refused surgery, she was treated with bromocriptine which was later changed to cabergoline. On follow-up, there was cessation of cerebrospinal fluid leak, marked reduction of serum prolactin level, and imaging evidence of tumor shrinkage. The majority of patients with medically induced cerebrospinal fluid leakage will require surgical procedures to overcome this complication; however, there are isolated cases of leakage resolution on continuing dopamine agonist therapy while awaiting surgery. The use of dopamine agonist does not necessarily cause worsening of cerebrospinal fluid leakage and instead may produce spontaneous resolution as in this case.
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Ilovayskaya IA, Dreval' AV, Krivosheeva YG, Glazkov AA, Astaf'eva LI, Stashuk GA. [Clinical and functional characteristics of giant pituitary adenomas in the population of patients in the Moscow region]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 82:76-81. [PMID: 30721220 DOI: 10.17116/neiro20188206176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Benign pituitary tumors are the most common sellar neoplasms. Lesions larger than 39 mm in the maximum dimension are called giant. They are rare, and, therefore, there are few data on the clinical and morphological features of giant pituitary tumors with different hormonal activity. AIM The aim of this study was to identify the clinical and functional features of giant pituitary tumors with different hormonal activity. MATERIAL AND METHODS We analyzed data of clinical, laboratory, and instrumental examinations of 351 patients diagnosed with pituitary macroadenomas at the Moscow Regional Research Clinical Institute in the period between 2008 and 2017: there were 144 hormonally inactive pituitary adenomas and 207 hormonally active pituitary adenomas (65 prolactinomas and 142 somatotropinomas). RESULTS AND DISCUSSION Among 351 patients with pituitary macroadenomas, there were 32 (9.1%) giant adenoma cases: 18 (12.5%) 144 patients with hormonally inactive pituitary adenomas and 14 (6.8%) 207 patients with hormonally active pituitary adenomas 6 (3.9%) 65 prolactinomas and 6 (2.9%) 142 somatotropinomas. The volume of giant adenomas was somewhat larger among somatotropinomas 48 926 [35 067; 97 650] mm3 and prolactinomas 36 872 [15 281; 75 102] mm3 compared to that of hormonally inactive pituitary adenomas 26 933 [21 910; 42 895] mm3. Tumors had predominant suprasellar and posterosellar growth (31 (97.8%) and 29 (90.6%) cases, respectively). The most common first patient complaints were visual impairments (59.4%) and headache and/or dizziness (43.8%). Correspondingly, due to these complaints, 16 (50%) patients first consulted an ophthalmologist. Hypopituitarism detected before any treatment was present in 16 (50%) patients. CONCLUSION In most cases, visual impairments and headaches/dizziness were the first manifestations of giant pituitary adenomas; therefore, ophthalmologists and neurologists should always refer patients with these complaints to MRI. Patients with identified giant pituitary tumors should be referred to an endocrinologist for exclusion of hypopituitarism and, if necessary, timely prescription of hormonal therapy.
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Affiliation(s)
- I A Ilovayskaya
- Moscow Regional Researh and Clinical Institute, Moscow, Russia
| | - A V Dreval'
- Moscow Regional Researh and Clinical Institute, Moscow, Russia
| | | | - A A Glazkov
- Moscow Regional Researh and Clinical Institute, Moscow, Russia
| | | | - G A Stashuk
- Moscow Regional Researh and Clinical Institute, Moscow, Russia
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Tavakol S, Hasan A, Wedemeyer MA, Bakhsheshian J, Liu CSJ, Shiroishi MS, Mathew A, Carmichael JD, Zada G. Calcified Prolactinoma of the Pituitary Gland: Illustrative Case Reports Highlighting Medical versus Surgical Intervention. J Neurol Surg B Skull Base 2019; 81:22-29. [PMID: 32021746 DOI: 10.1055/s-0039-1677678] [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] [Received: 07/19/2018] [Accepted: 12/15/2018] [Indexed: 10/27/2022] Open
Abstract
The presence of calcification is uncommon in pituitary adenomas, and often lends support to other diagnoses including craniopharyngioma. The majority of calcified pituitary adenomas are prolactin-secreting tumors. We report two patients with calcified macroprolactinomas, one that was treated medically with a biochemical response and partial tumor response, and one that was treated successfully via an endoscopic endonasal transsphenoidal approach. Suspected calcified prolactinomas can be initially managed medically as per standard treatment for typical prolactinomas; however, the presence of diffuse calcification may hinder tumor shrinkage. Tumors that are refractory to medical treatment can be safely managed with surgery.
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Affiliation(s)
- Sherwin Tavakol
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Asma Hasan
- Division of Endocrinology and Diabetes, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Michelle A Wedemeyer
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Chia-Shang J Liu
- Division of Neuroradiology, Department of Radiology, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Mark S Shiroishi
- Division of Neuroradiology, Department of Radiology, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Anna Mathew
- Department of Pathology, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - John D Carmichael
- Division of Endocrinology and Diabetes, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Gabriel Zada
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, United States
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Dantas NCB, Soares CEL, Martins MRA, Lourenço DM, Quidute ARP. Giant Prolactinoma Causing Hydrocephalus and Intracranial Hypertension as First Manifestations of Multiple Endocrine Neoplasia Type 1. Front Endocrinol (Lausanne) 2019; 10:582. [PMID: 31555208 PMCID: PMC6722186 DOI: 10.3389/fendo.2019.00582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/09/2019] [Indexed: 11/13/2022] Open
Abstract
Context: Overall, giant prolactinomas are rare tumors (4%), especially those larger than 60 mm (1%). Despite the predominance of macroadenoma documented in multiple endocrine neoplasia type 1 (MEN1)-related prolactinoma, only three giant prolactinoma cases were described so far (size > 40 mm and prolactin > 1,000 ng/mL). None of them was larger than 60 mm or presented hydrocephalus or intracranial hypertension (ICH) as initial manifestation of MEN1. Case Description: A 21-years-old man presented with ICH as the first clinical manifestation of MEN1. He harbored a MEN1 germline mutation but refused periodic vigilance after normal hormonal screening at age 14 years. During investigation, magnetic resonance imaging (MRI) of the skull showed an expansive sellar/parasellar lesion (75 × 44 × 36 mm) with moderate to severe supratentorial obstructive hydrocephalus and an extremely high serum prolactin (PRL) of 10,800 ng/mL, without combined hypersecretion of other pituitary hormones. He was diagnosed with giant prolactinoma, and cabergoline was initiated. The patient evolved with early improvement of clinical complaints for hydrocephalus and ICH and PRL reached normal values (11 ng/mL) in association with significant tumoral shrinkage after 18 months on cabergoline. After 2 months of cabergoline, cerebrospinal fluid leakage was diagnosed and corrective surgery was provided. The mean dose of cabergoline was 3 mg/week throughout treatment. Conclusion: We reported the first case with hydrocephalus and ICH as the initial clinical manifestation of a giant prolactinoma in MEN1. From our knowledge, this is the largest MEN1-related prolactinoma reported so far. Notably, all four MEN1-related giant prolactinomas cases reported were younger than 21 years strengthening the importance to routine MEN1 genetic testing for prolactinoma in this age group. Also, they all had initial effective response with dopamine agonist ensuring this drug as first-line treatment for MEN1-related giant prolactinoma. However, the scarce number of treated patients and progression of cabergoline resistance in two of them suggest strict surveillance.
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Affiliation(s)
- Naiara C. B. Dantas
- Walter Cantídio University Hospital, Federal University of Ceará, Fortaleza, Brazil
| | - Carlos E. L. Soares
- Faculty of Medicine, Drug Research and Development Center (NPDM), Federal University of Ceará (UFC), Fortaleza, Brazil
| | - Manoel R. A. Martins
- Walter Cantídio University Hospital, Federal University of Ceará, Fortaleza, Brazil
| | - Delmar M. Lourenço
- Endocrine Genetics Unit (LIM-25), Endocrinology Division, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
- Endocrine Oncology Division, Institute of Cancer of the State of São Paulo, São Paulo, Brazil
| | - Ana R. P. Quidute
- Walter Cantídio University Hospital, Federal University of Ceará, Fortaleza, Brazil
- Faculty of Medicine, Drug Research and Development Center (NPDM), Federal University of Ceará (UFC), Fortaleza, Brazil
- *Correspondence: Ana R. P. Quidute
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Abstract
Prolactin-secreting adenomas (prolactinomas) are the most common secreting adenomas of the pituitary. Microprolactinomas (diameter <10 mm) are frequently diagnosed in women, whereas macroprolactinomas (maximum diameter ≥10 mm) are generally seen in men. Most macroprolactinomas measure between 10 and 40 mm. Giant prolactinomas, measuring >40 mm, are rare, accounting for only 1-5% of all prolactinomas. Although generally benign, giant prolactinomas are aggressive and invasive, extending into the suprasellar region and also involving the cavernous sinuses. The optic chiasm is frequently involved, which leads to visual damage, and patients occasionally suffer from ophthalmoplegia. Long-term (usually lifetime) therapy with high-dose dopamine agonists (cabergoline or bromocriptine), together with pituitary surgery in some cases and radiotherapy if required, can achieve biochemical remission, tumor control, and clinical improvement in most patients.
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Affiliation(s)
- Ilan Shimon
- Institute of Endocrinology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
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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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Iglesias P, Rodríguez Berrocal V, Díez JJ. Giant pituitary adenoma: histological types, clinical features and therapeutic approaches. Endocrine 2018; 61:407-421. [PMID: 29909598 DOI: 10.1007/s12020-018-1645-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 05/29/2018] [Indexed: 12/23/2022]
Abstract
Giant pituitary adenomas comprise about 6-10% of all pituitary tumors. They are mostly clinically non-functioning adenomas and occur predominantly in males. The presenting symptoms are usually secondary to compression of neighboring structures, but also due to partial or total hypopituitarism. Functioning adenomas give rise to specific symptoms of hormonal hypersecretion. The use of dopamine agonists is considered a first-line treatment in patients with giant macroprolactinomas. Somatostatin analogs can also be used as primary treatment in cases of growth hormone and thyrotropin producing giant adenomas, although remission of the disease is not achieved in the vast majority of these patients. Neurosurgical treatment, either through transsphenoidal or transcranial surgery, continues to be the treatment of choice in the majority of patients with giant pituitary adenomas. The intrinsic complexity of these tumors requires the use of different therapies in a combined or sequential way. A multimodal approach and a therapeutic strategy involving a multidisciplinary team of expert professionals form the basis of the therapeutic success in these patients.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology. Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.
| | | | - Juan José Díez
- Department of Endocrinology. Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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Vilar L, Abucham J, Albuquerque JL, Araujo LA, Azevedo MF, Boguszewski CL, Casulari LA, Cunha Neto MBC, Czepielewski MA, Duarte FHG, Faria MDS, Gadelha MR, Garmes HM, Glezer A, Gurgel MH, Jallad RS, Martins M, Miranda PAC, Montenegro RM, Musolino NRC, Naves LA, Ribeiro-Oliveira Júnior A, Silva CMS, Viecceli C, Bronstein MD. Controversial issues in the management of hyperprolactinemia and prolactinomas - An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:236-263. [PMID: 29768629 PMCID: PMC10118988 DOI: 10.20945/2359-3997000000032] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 08/09/2017] [Indexed: 11/23/2022]
Abstract
Prolactinomas are the most common pituitary adenomas (approximately 40% of cases), and they represent an important cause of hypogonadism and infertility in both sexes. The magnitude of prolactin (PRL) elevation can be useful in determining the etiology of hyperprolactinemia. Indeed, PRL levels > 250 ng/mL are highly suggestive of the presence of a prolactinoma. In contrast, most patients with stalk dysfunction, drug-induced hyperprolactinemia or systemic diseases present with PRL levels < 100 ng/mL. However, exceptions to these rules are not rare. On the other hand, among patients with macroprolactinomas (MACs), artificially low PRL levels may result from the so-called "hook effect". Patients harboring cystic MACs may also present with a mild PRL elevation. The screening for macroprolactin is mostly indicated for asymptomatic patients and those with apparent idiopathic hyperprolactinemia. Dopamine agonists (DAs) are the treatment of choice for prolactinomas, particularly cabergoline, which is more effective and better tolerated than bromocriptine. After 2 years of successful treatment, DA withdrawal should be considered in all cases of microprolactinomas and in selected cases of MACs. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) is to provide a review of the diagnosis and treatment of hyperprolactinemia and prolactinomas, emphasizing controversial issues regarding these topics. This review is based on data published in the literature and the authors' experience.
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Affiliation(s)
- Lucio Vilar
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Julio Abucham
- Unidade de Neuroendócrino, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp/EPM), São Paulo, SP, Brasil
| | - José Luciano Albuquerque
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Luiz Antônio Araujo
- Centro de Endocrinologia e Diabetes de Joinville (Endoville), Joinville, SC, Brasil
| | - Monalisa F Azevedo
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Cesar Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia, Hospital de Clínicas, Universidade Federal do Paraná (SEMPR), Curitiba, PR, Brasil
| | - Luiz Augusto Casulari
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Malebranche B C Cunha Neto
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Felipe H G Duarte
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manuel Dos S Faria
- Serviço de Endocrinologia, Hospital Universitário Presidente Dutra, Universidade Federal do Maranhão (UFMA), São Luís, MA, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brasil
| | - Heraldo M Garmes
- Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (FCM/Unicamp), Campinas, SP, Brasil
| | - Andrea Glezer
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Maria Helane Gurgel
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Raquel S Jallad
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manoel Martins
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Paulo A C Miranda
- Serviço de Endocrinologia e Metabologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
| | - Renan M Montenegro
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Nina R C Musolino
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | | | - Cíntia M S Silva
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil
| | - Camila Viecceli
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Marcello D Bronstein
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
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Huang HY, Lin SJ, Zhao WG, Wu ZB. Cabergoline versus bromocriptine for the treatment of giant prolactinomas: A quantitative and systematic review. Metab Brain Dis 2018; 33:969-976. [PMID: 29546691 DOI: 10.1007/s11011-018-0217-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 03/09/2018] [Indexed: 10/17/2022]
Abstract
The aim of this study is to compare the efficacy of bromocriptine (BRC) versus cabergoline (CAB) in patients with giant prolactinomas. We searched MEDLINE, EMBASE, CENTRAL and Clinical Trials.gov for studies dated before March 1st, 2016, that used BRC or CAB for the treatment of patients with giant prolactinomas. Specific eligibility criteria were set to identify articles and cases. The selected articles were reviewed, and the data were extracted for analysis. The compared outcomes included tumor shrinkage, tumor response, normalization of prolactin (PRL) level, and visual field defect (VFD) improvement. Gender differences were also considered. Differences between the groups were assessed using Student's t test and the chi-square test. Two hundred and forty-five records were identified, and 10 articles and 104 cases met the inclusion criteria. Based on our analysis, CAB is significantly better than BRC in normalizing PRL levels in patients, especially males, with giant prolactinomas (69.4% versus 31.7%, p = 0.01). However, there was no significant difference between the two drugs in terms of tumor shrinkage, tumor response and VFD improvement (p > 0.05) in male or female patients. CAB exhibits significantly better efficacy than BRC in the normalization of PRL levels in male patients with giant prolactinomas. Regarding tumor reduction and VFD improvement, both drugs are comparably effective for patients of both genders. This quantitative and systematic review provides preliminary evidence in favor of CAB as a medical therapy for treating giant prolactinomas in male patients, especially those with extremely high PRL levels.
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Affiliation(s)
- Hai Yan Huang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197# Ruijin Er Road, Shanghai, 200025, China
| | - Shao Jian Lin
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197# Ruijin Er Road, Shanghai, 200025, China
| | - Wei Guo Zhao
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197# Ruijin Er Road, Shanghai, 200025, China
| | - Zhe Bao Wu
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197# Ruijin Er Road, Shanghai, 200025, China.
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Elabd SS, Ahmad MM, Qetab SQ, Almalki MH. Cabergoline-Induced Pneumocephalus Following Treatment for Giant Invasive Macroprolactinoma Presenting With Spontaneous Cerebrospinal Fluid Rhinorrhea. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2018; 11:1179551418758640. [PMID: 29467589 PMCID: PMC5815410 DOI: 10.1177/1179551418758640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 01/19/2018] [Indexed: 11/16/2022]
Abstract
Cerebrospinal fluid (CSF) rhinorrhea is rarely reported as the first presenting feature of giant invasive macroprolactinomas. Cerebrospinal fluid rhinorrhea is usually reported as a complication of trauma, neurosurgical, and skull-based procedures (such as pituitary surgery or radiations), and less frequently after medical treatment with dopamine agonists (DAs) for macroprolactinomas. This phenomenon results from fistula creation that communicates between the subarachnoid space and the nasal cavity. Meanwhile, pneumocephalus is another well-recognized complication after transsphenoidal surgery for pituitary macroadenomas. This entity may present with nausea, vomiting, headache, dizziness, and more seriously with seizures and/or a decreased level of consciousness if tension pneumocephalus develops. Case reports about the occurrence of spontaneous pneumocephalus after medical treatment with DAs without prior surgical interventions are scarce in the literature. Our index case is a young man who was recently diagnosed with a giant invasive prolactin-secreting pituitary macroadenoma with skull base destruction. A few months before this diagnosis, he presented with spontaneous CSF rhinorrhea with no history of previous medical or surgical treatment. In this case report, we report an uncommon presentation for giant invasive macroprolactinoma with a CSF leak treated with cabergoline that was subsequently complicated by meningitis and pneumocephalus. This is a very rare complication of cabergoline therapy, which occurred approximately 1 month after treatment initiation.
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Affiliation(s)
- Souha S Elabd
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Sameer Q Qetab
- King Hussein Medical City,Internal Medicine Department, Amman, Jordan
| | - Mussa Hussain Almalki
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia.,King Fahad Medical City and College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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38
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Ahmad S, Joseph J. VISUAL VIGNETTE. Endocr Pract 2017; 23:1487. [PMID: 29144819 DOI: 10.4158/ep-2017-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Shazia Ahmad
- From the Division of Endocrinology, Albany Medical Center, Albany, New York
| | - Jalaja Joseph
- From the Division of Endocrinology, Albany Medical Center, Albany, New York
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Briet C, Bernard F, Rodien P. Lesson to be remembered from a skull base tumor. Neurochirurgie 2017; 63:334-335. [PMID: 28882600 DOI: 10.1016/j.neuchi.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 04/05/2017] [Accepted: 04/21/2017] [Indexed: 11/17/2022]
Abstract
The natural history of giant prolactinomas is not known. While it is commonly accepted that the enlargement of microadenoma is rare and more limited than macroadenoma, it is so far uncommon that macroadenoma progress to giant adenoma. Thus, spontaneous enlargement of adenomas is poorly documented. We report the unusual history of undiagnosed microprolactinoma, revealed 12years later at the stage of a giant adenoma presenting as a skull base tumor. This unique observation provides information on the natural history of giant adenomas and arguments for particular attention to microadenomas with signs of invasion. Moreover, this clinical case highlights the need for a prolactin dosage for all midline skull base tumors.
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Affiliation(s)
- C Briet
- Institut Mitovasc, unité CNRS 6214/Inserm1083, université d'Angers, 49100 Angers, France; Service d'endocrinologie diabétologie nutrition, centre de référence des maladies rares de la réceptivité hormonale, CHU d'Angers, Angers, France
| | - F Bernard
- Service de neurochirurgie, CHU d'Angers, 49100 Angers, France
| | - P Rodien
- Institut Mitovasc, unité CNRS 6214/Inserm1083, université d'Angers, 49100 Angers, France; Service d'endocrinologie diabétologie nutrition, centre de référence des maladies rares de la réceptivité hormonale, CHU d'Angers, Angers, France.
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40
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Mankahla N, Peya B, Semple P, Ross I. A giant invasive prolactinoma complicated by a cerebrospinal fluid leak: A short case report. INTERDISCIPLINARY NEUROSURGERY 2017. [DOI: 10.1016/j.inat.2017.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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41
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Giant Prolactinoma Presenting As a Base of Skull Tumor With Nasopharyngeal Extension: A Potential Diagnostic Pitfall in Neuroendocrine Lesions of the Base of Skull. Head Neck Pathol 2017; 11:537-540. [PMID: 28197925 PMCID: PMC5677065 DOI: 10.1007/s12105-017-0782-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
Pituitary adenomas presenting in uncommon anatomical locations are commonly misdiagnosed. Dramatic clinical presentation with hemorrhage and infarction, along with a lack of endocrine symptoms may further confound the diagnosis in some patients as illustrated in one of our two previously reported cases of non-small cell neuroendocrine carcinoma of the sinonasal tract and nasopharynx. This report presents the clinical progress of case number 2, which has a revised diagnosis of giant lactotroph pituitary adenoma. Common clinical, radiological and pathological pitfalls in diagnosis of neuroendocrine neoplasms of the sinonasal tract and base of skull are discussed.
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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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43
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Zamora C, Castillo M. Sellar and Parasellar Imaging. Neurosurgery 2016; 80:17-38. [DOI: 10.1093/neuros/nyw013] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 10/18/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
The skull base is a complex anatomical region that harbors many important neurovascular structures in a relatively confined space. The pathology that can develop at this site is varied, and many disease processes may present with similar clinical and neuroimaging findings. While computed tomography maintains a role in the evaluation of many entities and can, for instance, delineate osseous erosion with great detail and characterize calcified tumor matrices, magnetic resonance imaging (MRI) is the mainstay in the neuroimaging assessment of most pathology occurring at the skull base. Various MRI sequences have proven to be robust tools for tissue characterization and can provide information on the presence of lipids, paramagnetic and diamagnetic elements, and tumor cellularity, among others. In addition, currently available MRI techniques are able to generate high spatial resolution images that allow visualization of cranial nerves and their involvement by adjacent pathology. The information obtained from such examinations may aid in the distinction of these disease processes and in the accurate delineation of their extent prior to biopsy or treatment planning.
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Berriel MRDS, Lima GAB, Melo ASAD, Santos MLVD, Rahhal H, Taboada GF. Prolactinomas may have unusual presentations resulting from massive extrasellar tumor extension. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:544-8. [PMID: 27487374 DOI: 10.1590/0004-282x20160083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/16/2016] [Indexed: 11/22/2022]
Abstract
The purpose of this case series is to report eight patients with giant prolactinomas emphasizing presentations and a treatment complication. The study group included six men and two women. The median age was 29 years (18-54 years); median serum prolactin level was 4,562 ng/ml (1,543-18,690 ng/ml); three patients (37.5%) had panhypopituitarism; median tumor diameter was 50 mm (41-60 mm). Five patients (62.5%) had visual field defects and three had improvement during treatment; six patients (75%) reached prolactin normalization, with a median time of 10.5 months (7-84 months) and median dose of 2.0 mg/week (1.0 to 3.0 mg/week). One patient presented as a true incidentaloma. One patient presented a cerebrospinal fluid leakage during medical treatment and refused surgery, however this resolved with conservative measures. This case series illustrate a rare subtype of macroprolactinomas, the importance of considering unusual presentations at the diagnosis, the effectiveness of pharmacological treatment and its possible complications.
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Affiliation(s)
| | | | | | | | - Hassan Rahhal
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Unidade de Endocrinologia, Niterói RJ, Brasil
| | - Giselle Fernandes Taboada
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Unidade de Endocrinologia, Niterói RJ, Brasil
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45
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Gruppetta M, Vassallo J. Epidemiology and radiological geometric assessment of pituitary macroadenomas: population-based study. Clin Endocrinol (Oxf) 2016; 85:223-31. [PMID: 26998693 DOI: 10.1111/cen.13064] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 01/22/2016] [Accepted: 03/07/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Pituitary adenomas are relatively common tumours with diverse clinical features. Epidemiological data are important to help quantify health burden. OBJECTIVE To provide in-depth epidemiological data on macroadenomas and radiologically characterize macroadenomas. DESIGN Population-based retrospective analysis, Prevalence as at 2014; Incidence based on data from 2000 to 2014, Retrospective analysis of baseline MRI. SETTING The Maltese islands. PATIENTS 173/136 patients with macroadenomas for prevalence/incidence estimates respectively, 122 baseline MRI for radiological characterization. MAIN OUTCOME MEASURES Prevalence rates, Standardized Incidence rates (SIR), MRI findings. RESULTS The prevalence for macroadenomas was 40·67/100 000 people and the SIR was 1·90/100 000/year. Giant pituitary adenomas (>40 mm) constituted 4·8% of the whole cohort of PAs and the SIR was 0·18/100 000/year. Giant prolactinomas constituted 4·7% of all the prolactinomas and the SIR was 0·07/100 000/year, while giant NFPA constituted 6·0% of all NFPA and the SIR was 0·12/100 000/year. There was a statistically significant difference in the degree of suprasellar extension (P < 0·001) and infrasellar extension (P = 0·028) between the different macroadenoma subtypes and in the vertical extension indices (median vertical extension index NFPA 3·0 mm; PRLoma -7·7 mm; GH-secreting PA -1·7 mm; P < 0·001). Pituitary macroadenomas with cavernous sinus invasion were statistically significantly larger than those without cavernous sinus invasion (P < 0·001). NFPA had predominantly a superior extension into the cavernous sinus (63·6%) compared to the functional PAs which had predominantly an inferior extension into the cavernous sinus (59·1%) (P = 0·032). CONCLUSIONS The various macroadenoma subtypes' epidemiological data are presented and differences between growth patterns among the various subtypes are highlighted.
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Affiliation(s)
- Mark Gruppetta
- Department of Medicine, Faculty of Medicine and Surgery, University of Malta, Mater Dei Hospital, Msida, Malta
- Neuroendocrine Clinic, Mater Dei Hospital, Msida, Malta
| | - Josanne Vassallo
- Department of Medicine, Faculty of Medicine and Surgery, University of Malta, Mater Dei Hospital, Msida, Malta
- Neuroendocrine Clinic, Mater Dei Hospital, Msida, Malta
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46
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Shimon I, Sosa E, Mendoza V, Greenman Y, Tirosh A, Espinosa E, Popovic V, Glezer A, Bronstein MD, Mercado M. Giant prolactinomas larger than 60 mm in size: a cohort of massive and aggressive prolactin-secreting pituitary adenomas. Pituitary 2016; 19:429-36. [PMID: 27138902 DOI: 10.1007/s11102-016-0723-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Prolactin (PRL)-secreting macroadenomas usually measure between 10 and 40 mm. Giant (adenoma size ≥40 mm) PRL-tumors are not common, and larger prolactinomas (maximal diameter ≥60 mm) are rare, and their management outcomes have not been well characterized. METHODS We have identified 18 subjects (16 men, 2 females) with giant PRL-adenomas (size ≥60 mm; PRL > 1000 ng/ml) and summarized their characteristics and response to treatment. RESULTS Mean age was 36.3 ± 13.5 years (range 12-59 years). Mean adenoma size was 71.8 ± 10.2 mm (60-92 mm). Complaints at presentation included headaches in 11 patients, visual deterioration in 9, sexual dysfunction in 9 males, and behavioral changes in two. Fourteen (78 %) had visual field defects. Mean PRL at presentation was 28,465 ng/ml (range 1300-270,000). All patients were treated with cabergoline (3.9 ± 2.0 mg/week), except for one who received bromocriptine. Treatment achieved PRL normalization in 11/18 patients within a median interval of 20 months. Visual improvement occurred in 12/14 patients with pre-treatment visual abnormalities. Nine patients underwent surgery (transsphenoidal, 7; transcranial, 2). None of the seven patients with elevated PRL before surgery achieved remission post-operatively. After a follow-up of 7.8 ± 5.1 years, 15/18 patients had significant adenoma shrinkage. Eleven patients are normoprolactinemic, 3 are partially controlled (PRL < 3 × ULN), and 4 remain with significantly elevated PRL. Most patients reported disappearance or improvement of their complaints. CONCLUSIONS These enormous PRL-adenomas are invasive but respond fairly well to medical treatment. Long-term therapy with high dose cabergoline together with a pituitary surgery in some patients was the key for their successful management, achieving biochemical and clinical remission in most patients.
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Affiliation(s)
- Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, 49100, Petah Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ernesto Sosa
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
| | - Victoria Mendoza
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
| | - Yona Greenman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Amit Tirosh
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, 49100, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Etual Espinosa
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
| | - Vera Popovic
- University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Andrea Glezer
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Moises Mercado
- Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
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47
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Espinosa E, Sosa E, Mendoza V, Ramírez C, Melgar V, Mercado M. Giant prolactinomas: are they really different from ordinary macroprolactinomas? Endocrine 2016; 52:652-9. [PMID: 26561015 DOI: 10.1007/s12020-015-0791-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 10/27/2015] [Indexed: 11/26/2022]
Abstract
Giant prolactinomas (gPRLomas) are rare tumors of the lactotroph defined by an unusually large size (>4 cm) and serum PRL levels >1000 ng/mL. The purpose of this study is to characterize the clinical spectrum of gPRLomas comparing them with non-giant prolactinomas. This is a retrospective study at a large referral center. Data from patients harboring gPRLomas and macroprolactinomas were retrieved from medical records of the Prolactinoma Clinic. Analysis was focused on clinical, biochemical, and tumor volume characteristics, as well as on the response to treatment with dopamine agonists. Among 292 patients with prolactinomas followed between 2008 and 2015, 47 (16 %) met the diagnostic criteria for gPRLomas (42 males). The most common complaint was a visual field defect; headache was reported by 79 % and sexual dysfunction was present in over half of the patients. Median basal PRL level and tumor volume were 6667 ng/mL (3750-10,000) and 32 cm(3) (20-50), respectively; hypogonadotropic hypogonadism was documented in 87 %. Cabergoline treatment resulted in the normalization of PRL levels in 68 % and in the reduction of >50 % in tumor volume in 87 % of the gPRLoma patients. The composite goal of PRL normalization and >50 % tumor reduction was achieved by 55 % (n = 26) of patients with gPRL and by 66 % (n = 100) of patients with no giant macroprolactinomas (p = 0.19). Recovery of hypogonadism and improvement of visual fields defects occurred in 32 % and 68 % of the patients, respectively. Cabergoline treatment was equally effective in patients with gPRLoma and those with macroprolactinomas in regard of achieving treatment goals, although the median CBG dose was slightly higher in the gPRLoma group (2 vs. 1.5 mg/w). Six patients required surgery. Beyond their impressive dimensions and the huge amount of PRL they secrete, the clinical behavior of gPRLoma is not different from macroprolactinomas. These tumors are highly responsive to cabergoline treatment, and pituitary surgery is seldom required.
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Affiliation(s)
- Etual Espinosa
- Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico
| | - Ernesto Sosa
- Endocrinology Service Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico.
| | - Victoria Mendoza
- Endocrinology Service Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico
| | - Claudia Ramírez
- Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico
- ABC Hospital Neurological Center, México City, Mexico
| | | | - Moisés Mercado
- Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico
- ABC Hospital Neurological Center, México City, Mexico
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48
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Akhtar S, Patel L, Bakhach M, Haider A, Gonzalez-Martinez J, Rogers D, Tsilianidis L, Raissouni N, Schweiger M. Fifteen-Year-Old Female With Delayed Progression of Puberty and Visual Disturbances. Clin Pediatr (Phila) 2016; 55:664-7. [PMID: 26581351 DOI: 10.1177/0009922815614359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Abstract
The operative management of giant pituitary prolactinoma represents a significant challenge for neurosurgeons, due to the degree of local tumor infiltration into adjacent structures such as cavernous sinus. The degree of parasellar tumor extension can be classified according to the Knosp grading system’ while suprasellar extension is qualified in accordance with the modified Hardys classification system. This report describes the case of a male patient with a giant pituitary prolactinoma in which a partial tumor resection via a subfrontal approach was achieved. Typically, resection rates of less than 50% have been reported following surgery on giant pituitary adenomas. Prolactin levels were very high, consistent with invasive giant prolactinoma. Our patient was treated with Cabergoline which eventually normalized the prolactin level and significantly reduced the size of the residual tumor. This case serves to illustrate that in the presence of significant suprasellar and parasellar extension, multi-modal treatment strategies with surgery and dopamine agonist, is the gold standard in the management of locally aggressive pituitary prolactinomas.
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50
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Akin S, Isikay I, Soylemezoglu F, Yucel T, Gurlek A, Berker M. Reasons and results of endoscopic surgery for prolactinomas: 142 surgical cases. Acta Neurochir (Wien) 2016; 158:933-42. [PMID: 26970763 DOI: 10.1007/s00701-016-2762-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND We report herein a retrospective analysis of the results of 142 consecutive prolactinoma cases operated upon using an endoscopic endonasal trans-sphenoidal approach over a period of 6 years. METHODS Medical records of 142 cases were analysed with respect to indications for surgery, duration of hospital stay, early remission rates, failures and recurrence rates during a median follow-up of 36 months. RESULTS On the basis of magnetic resonance imaging (MRI) data, 19 patients (13.4 %) had microadenoma, 113 (79.6 %) had macroadenoma, and the remaining 10 (7.0 %) had giant adenomas. Cavernous sinus invasion was identified in 25 patients by MRI and confirmed during surgery. Atypical adenoma was diagnosed in 16 patients. Sparsely granulated prolactin adenoma was identified in 99 patients (69.7 %). Our results demonstrate that male sex and higher preoperative prolactin levels are independent factors predicting persistent disease. The post-surgical complications are as follows: 2.8 % patients had meningitis, 2.1 % patients had postoperative cerebrospinal fluid leak and 2.1 % patients had panhypopituitarism. At the end of follow-up, 74.6 % patients went into remission. During follow-up period, five patients who had initial remission developed recurrence. CONCLUSIONS Our series together with literature data suggest that an endoscopic endonasal trans-sphenoidal approach in the treatment of proloctinomas has a favourable rate of remission. According to the findings of this study, endoscopic endonasal trans-sphenoidal surgery might be an appropriate therapy choice for patients with prolactinoma who could not have been managed with recommended therapeutic modalities.
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