NLM CIT. ID: 20114083
TITLE: Indications for surgery in the treatment of hyperprolactinemia.
AUTHORS: Zacur HA
AUTHOR AFFILIATION:
Department of Gynecology and Obstetrics, Johns Hopkins University
School of Medicine, Baltimore, Maryland, USA.
PUBLICATION TYPES:
JOURNAL ARTICLE
LANGUAGES:
Eng
REGISTRY NUMBERS:
0 (Dopamine Agonists)
ABSTRACT:
Indications for pituitary surgery have been described in the medical
literature, but they do not necessarily apply to prolactin-secreting
(PRL-secreting) pituitary microadenomas or macroadenomas. Reviews of
pituitary surgery done for microprolactinomas and macroprolactinomas
have not demonstrated any significant beneficial effect on the
clinical course of the hyperprolactinemia. At the same time, such
surgery has been associated with definite risks, including an overall
mortality of 0.9%. There is even the possibility that surgery and
radiation for benign pituitary adenomas can facilitate malignant
transformation and metastasis. Therefore, medical treatment with a
dopamine agonist is the primary choice for all PRL-secreting
microadenomas and macroadenomas. Referral for surgical evaluation is
reserved for patients in whom neurologic deficits, such as visual
field impairment or cranial nerve deficits, do not improve with
medical therapy and for certain other, rare situations.
NLM PUBMED CIT. ID:
10649823
SOURCE: J Reprod Med 1999 Dec;44(12 Suppl):1127-31
UI - 99452055
AU - Brada M; Burchell L; Ashley S; Traish D
TI - The incidence of cerebrovascular accidents in patients with
pituitary adenoma.
SO - Int J Radiat Oncol Biol Phys 1999 Oct 1;45(3):693-8
AD - Neuro-oncology Unit, The Institute of Cancer Research and the Royal
Marsden NHS Trust, Sutton, Surrey, UK. mbrada@icr.ac.uk
BACKGROUND AND PURPOSE: Patients with pituitary adenomas are effectively
treated with a combination of surgery, radiotherapy, and medical therapy.
Nevertheless, long-term studies suggest increased mortality that is
independent of tumor control, with cerebrovascular accidents (CVA) as the
major contributing cause. The purpose of this study was to define the
frequency of CVAs in a cohort of patients with pituitary adenoma and
identify potential predisposing factors. PATIENTS AND METHODS: A cohort
of 331 United Kingdom (UK) residents with pituitary adenoma treated at
the Royal Marsden Hospital (RMH) between 1962 and 1986 was studied. The
frequency of CVA was assessed from RMH and referring hospital records and
clinicians, by postal questionnaire of referring hospitals and general
practitioners, and by examination of all death certificates. The data
were analyzed by actuarial methods, and risk factors were assessed by
multivariate analysis. The data were compared to the incidence of CVA in
the general population using a published UK population cohort. RESULTS:
Sixty-four of 331 patients developed CVA after primary treatment of
pituitary adenoma. The actuarial incidence of CVA was 4% (95% CI: 2-7%)
at 5 years, 11% (95% CI: 8-14%) at 10 years, and 21% (95% CI: 16-28%) at
20 years measured from the date of radiotherapy. The relative risk of CVA
compared to the general population in the UK was 4.1. Age was an
independent predictive factor for CVA. However, the relative risk in
comparison to the general population was independent of age. The relative
risk of developing CVA was higher in women compared to men, in patients
undergoing debulking surgery compared to less radical procedures, and in
patients diagnosed and treated in the 1980s compared to previous decades.
The dose of radiotherapy was an additional independent prognostic factor
on multivariate analysis. CONCLUSION: Patients with pituitary adenoma
treated with surgery and radiotherapy have a significantly increased risk
of CVA compared to the general population. The factors which may
contribute to the increased risk include the presence of pituitary
adenoma and consequent endocrine disturbances and the treatment,
particularly the extent of surgery and the dose of radiotherapy. When
assessing the value of treatment strategies, it is therefore important to
include not only intermediate endpoints of tumor and hormonal control,
but also late toxicity, including the incidence of CVA and overall
survival as the primary endpoint. The potential predisposing factors for
CVA need further elucidation to develop treatment strategies with lower
risk and consequently, reduced mortality
UI - 99404950
AU - Hensen J; Henig A; Fahlbusch R; Meyer M; Boehnert M; Buchfelder M
TI - Prevalence, predictors and patterns of postoperative polyuria and
hyponatraemia in the immediate course after transsphenoidal surgery for
pituitary adenomas.
SO - Clin Endocrinol (Oxf) 1999 Apr;50(4):431-9
AD - Department of Medicine, University of Erlangen-Nuremberg, Germany.
johannes.hensen@t-online.de
OBJECTIVE: Disturbances of osmoregulation, leading to diabetes insipidus
and hyponatraemia are well known complications after surgery in the sella
region. This study was performed to examine the prevalence and predictors
of polyuria and hyponatraemia after a complete and selective removal of
pituitary adenomas was attempted via the transnasal-transsphenoidal
approach. DESIGN: 1571 patients with pituitary adenomas (238 Cushing's
disease, 405 acromegaly, 534 hormonally inactive adenomas, 358
prolactinoma, 23 Nelson's syndrome, and 13 thyrotropinoma) were daily
examined within a 10-day postoperative inpatient observation period.
Prevalence of patterns of polyuria (> 2500 ml) and oliguria/hyponatraemia
(< 132 mmol/l) were surveyed as well as predictors of postoperative
morbidity. RESULTS: 487 patients (31%) developed immediate postoperative
hypotonic polyuria, 161 patients (10%) showed prolonged polyuria and 37
patients (2.4%) delayed hyponatraemia. A biphasic (polyuria-
hyponatraemia) and triphasic (polyuria-hyponatraemia-polyuria) pattern
was seen in 53 (3.4%) and 18 (1.1%) patients, respectively. Forty-one
patients (2.6%) displayed immediate postoperative (day 1) hyponatraemia.
Altogether, 8.4% of patients developed hyponatraemia at some time up to
the 10th day postoperative, with symptomatic hyponatraemia in 32 patients
(2.1%). Risk analysis showed that patients with Cushing's disease had a
fourfold higher risk of polyuria than patients with acromegaly and a 2.8-
fold higher risk for postoperative hyponatraemia. Younger age, male sex,
and intrasellar expansion were associated with a higher risk of hypotonic
polyuria, but this was not considered clinically relevant. CONCLUSIONS:
The analysis illustrates that disturbances in osmoregulation resulting in
polyuria and pertubations of serum sodium concentration are of very high
prevalence and need observation even after selective transsphenoidal
surgery for pituitary adenomas, especially in patients with Cushing's
disease.
NLM CIT. ID: 99154854
TITLE: Trans-sphenoidal surgery for microprolactinoma: an acceptable
alternative to dopamine agonists?
AUTHORS: Turner HE; Adams CB; Wass JA
AUTHOR AFFILIATION:
Department of Endocrinology, Radcliffe Infirmary, Oxford, UK.
PUBLICATION TYPES:
JOURNAL ARTICLE
LANGUAGES:
Eng
REGISTRY NUMBERS:
0 (Dopamine Agonists)
9002-62-4 (Prolactin)
ABSTRACT:
AIMS: Reported cure rates following trans-sphenoidal surgery for
microprolactinoma are variable and recurrence rates in some series
are high. We wished to examine the cure rate of trans-sphenoidal
surgery for microprolactinoma, and to assess the long-term
complications and recurrence rate. DESIGN: A retrospective review of
the outcome of trans-sphenoidal surgery for microprolactinoma,
performed by a single neurosurgeon at a tertiary referral centre
between 1976 and 1997. PATIENTS: All thirty-two patients operated on
for microprolactinoma were female, with a mean age of 31 years (range
16-49). Indications for surgery were intolerance of dopamine agonists
in ten (31%), resistance in six (19%) and resistance and intolerance
in four (12.5%). Two patients were from countries where dopamine
agonists were unavailable. RESULTS: The mean pre-operative prolactin
level was 2933 mU/l (range 1125-6000). All but 1 had amenorrhoea or
oligomenorrhoea, with galactorrhoea in 15 (46.9%). Twenty-five (78%)
were cured by trans-sphenoidal surgery, as judged by a post-operative
serum prolactin in the normal range. During a mean follow-up of 70
months (range 2 months to 16 years) there was one recurrence at 12
years. Post-operatively, one patient became LH deficient, two
patients became cortisol deficient and two became TSH deficient. Out
of 21 patients tested for post-operative growth hormone deficiency, 6
(28.6%) were deficient. Five patients developed post-operative
diabetes insipidus which persisted for greater than 6 months. There
were no other complications of surgery. The estimated cost of
uncomplicated trans-sphenoidal surgery, and follow-up over 10 years,
was similar to that of dopamine agonist therapy. CONCLUSION: In
patients with hyperprolactinaemia due to a pituitary
microprolactinoma, transsphenoidal surgery by an experienced
pituitary surgeon should be considered as a potentially curative
procedure. The cost of treatment over a 10 year period is similar in
uncomplicated cases to long-term dopamine agonist therapy.
NLM PUBMED CIT. ID:
10037250
SOURCE: Eur J Endocrinol 1999 Jan;140(1):43-7
NLM CIT. ID: 99129658
TITLE: Transsphenoidal microsurgical therapy of prolactinomas: initial
outcomes and long-term results.
AUTHORS: Tyrrell JB; Lamborn KR; Hannegan LT; Applebury CB
Wilson CB
AUTHOR AFFILIATION:
Department of Medicine, University of California, San Francisco
94143-0350, USA.
PUBLICATION TYPES:
JOURNAL ARTICLE
LANGUAGES:
Eng
ABSTRACT:
OBJECTIVE: Prolactinomas are frequently treated primarily with
dopamine agonists; however, these agents have disadvantages and
require life-long therapy. We therefore reassessed transsphenoidal
microsurgery as an alternative therapy. METHODS: We reviewed the data
for 121 female patients treated surgically for prolactinomas between
1976 and 1979 (Group 1) and 98 patients treated between 1988 and 1992
(Group 2). RESULTS: Of 219 women, 92% with preoperative prolactin
(PRL) values of < or = 100 ng/ml and 91% with intrasellar
microadenomas experienced initial remission; 80 to 88% of patients
with intrasellar macroadenomas or macroadenomas showing moderate
suprasellar extension or focal sphenoid sinus invasion experienced
remission. Women with PRL values of > 200 ng/ml and those with
larger and more invasive adenomas experienced poorer outcomes (37-41%
remission). Lower preoperative PRL values and adenoma stage were the
best predictors of initial surgical outcomes. At the most recent
evaluations, 89% of women who experienced initial remission continued
to experience clinical remission; 85% exhibited normal PRL values,
and 5% demonstrated mild, asymptomatic, recurrent hyperprolactinemia
(PRL values of < 34 ng/ml). In Group 1, 84% of patients continued
to experience remission (82% with normal PRL values) after a median
follow-up period of 15.6 years. In Group 2, 97% of patients continued
to experience remission (88% with normal PRL values) after a median
follow-up period of 3.2 years. Lower postoperative PRL values were
the best predictors of long-term remission. CONCLUSION:
Transsphenoidal microsurgery is an effective alternative to long-term
medical therapy for selected patients with prolactinomas. Successful
outcomes and long-term remission were achieved in patients with
microadenomas and noninvasive macroadenomas.
NLM PUBMED CIT. ID:
9932878
SOURCE: Neurosurgery 1999 Feb;44(2):254-61; discussion 261-3
UI - 98374136
AU - Hofle G ; Gasser R ; Mohsenipour I ; Finkenstedt G
TI - Surgery combined with dopamine agonists versus dopamine agonists
alone in long-term treatment of macroprolactinoma: a retrospective study.
SO - Exp Clin Endocrinol Diabetes 1998;106(3):211-6
AD - Department of Internal Medicine, University of Innsbruck, Austria.
Guenter.Hoefle@uibk.ac.at
We retrospectively analysed the long-term treatment results (median 8
years) of 31 patients with macroprolactinoma. 17 patients were treated by
pituitary surgery (group 1) followed by long-term dopamine agonist
therapy whereas 14 patients received long-term dopamine agonist therapy
alone (group 2). 2 patients of group 1 and 1 patient of group 2 had
external pituitary irradiation because of progressive disease. The two
groups were comparable with respect to age, gender and initial prolactin
(PRL) levels. At the end of the observation period dopamine agonist
dosage could be reduced by 50% in group 1 and by 39.3% in group 2.
Pituitary function did not change substantially during therapy. Complete
remissions (no visible tumour in CT or MRI, normal PRL levels under
current dopamine agonist medication) were achieved in 23.5% of group 1
vs. 21.4% of group 2, partial remissions (reduction of PRL and tumour
size) in 35.3% vs. 64.3%, stable disease in 23.5% vs. 7.1% and
progressive disease in 17.7% vs. 7.1% (differences not significant).
Visual field defects showed 28.4% remissions (complete and partial) in
group 1 versus 50% in group 2. Dopamine agonist therapy could be stopped
definitively in only 1 patient of group 2 with an invasive
macroprolactinoma. Initial surgical reduction of tumour load followed by
medical therapy does not seem to guarantee a better long-term outcome
than dopamine agonist therapy alone if the patient responds to and
tolerates dopamine agonist therapy. Surgery should be reserved for non-
responders, drug-intolerant or non-compliant patients, and for those with
acute severe neurological compromise.
UI - 97160354
AU - Ciric I; Ragin A; Baumgartner C; Pierce D
TI - Complications of transsphenoidal surgery: results of a national survey,
review of the literature, and personal experience.
SO - Neurosurgery 1997;40(2):225-36; discussion 236-7
AD - Division of Neurosurgery, Evanston Hospital, Northwestern University
Medical School, Illinois, USA.
AB - OBJECTIVE: The primary objectives of this report were, first, to
determine the number and incidence of complications of transsphenoid-
al surgery performed by a cross-section of neurosurgeons in the
United States and, second, to ascertain the influence of the
surgeon's experience with the procedure on the occurrence of these
complications. The secondary objective was to review complications of
transsphenoidal surgery from the standpoint of their causation,
treatment, and prevention. METHODS: Questionnaires regarding 14
specific complications of transsphenoidal surgery were mailed to 3172
neurosurgeons. The data reported were analyzed from the 958
respondents (82%) who reported performing the operation. The
neurosurgeons surveyed were asked to estimate the number of
transsphenoidal operations performed, to identify any complications
observed, and to estimate the percentage of operations that had
resulted in any of the 14 specific complications. The 958 respondents
were placed into three experience groups, based on the number of
transsphenoidal operations performed. The data were analyzed by using
chi 2 tests and Spearman correlation coefficients. The secondary
objectives were met through a detailed review of the literature, in
light of our experience. RESULTS: Of the respondents, 87.3% reported
having performed < 200 operations and 9.7% reported 200 to 500
previous operations. The remaining 3% reported more than 500 previous
operations. More extensive previous experience with transsphenoidal
surgery was associated with a greater likelihood of having witnessed
each specific complication. The mean operative mortality rate for all
three groups was 0.9%. Anterior pituitary insufficiency (19.4%) and
diabetes insipidus (17.8%) were complications with the highest
incidence of occurrence. The overall incidence of cerebrospinal fluid
fistulas was 3.9%. Other significant complications, such as carotid
artery injuries, hypothalamic injuries, loss of vision, and
meningitis, occurred with incidence rates between 1 and 2%. An
inverse relationship was found between the experience group and the
likelihood of complications, as indicated by significant negative
Spearman correlation coefficients for all but 2 of the 14 complicati-
ons listed in the survey (P < 0.05). Thus, increased experience with
transsphenoidal surgery seems to be associated with a decreased
percentage of operations resulting in complications. Some caution
should be exercised in interpreting these data, because they are
based on the respondents' estimates. CONCLUSION: Transsphenoidal
surgery seems to be a reasonably safe procedure, with a mortality
rate of less than 1%. However, a significant number of complications
do occur. The incidence of these complications seems to be higher,
with statistical significance, in the hands of less experienced
surgeons. The learning curve seems to be relatively shallow, because
a statistically significantly decreased incidence of morbidity and
death could be documented after 200 and even 500 transsphenoidal
operations. Better understanding of the indications for transsphenoi-
dal surgery and improved familiarity with the regional anatomy should
further lower the incidence of death and morbidity resulting from
this procedure in the hands of all neurosurgeons. (101 Refs)
UI - 96306025
AU - Otten P; Rilliet B; Reverdin A; Demierre B; Berney J
TI - [Pituitary adenoma secreting prolactin. Results of their surgical
treatment]
SO - Neurochirurgie 1996;42(1):44-53
AD - Clinique de Neurochirurgie, Hopital Cantonal Universitaire de Geneve,
Suisse.
AB - A retrospective study of 75 patients operated for pituitary
prolactin-secreting adenomas between 1972 and 1992 is presented. 57
were women, 18 males. The major symptom was amenorrhea for women and
impotence for men. Prolactinemia is correlated to the size of adenoma
and thus permits a prediction of surgical results. Most of the
patients with a prolactinemia under 300 ng/ml were cured by surgery
alone. Surgical treatment alone at the-term follow-up cure 87% of the
micro-adenomas, 17% of the enclosed adenomas, and none of the
invasive adenomas. In this study there is only 7% of true recurrence.
According to the high cure rate and low frequency recurrence after
transphenoidal surgery for micro-adenomas we suggest this approach as
the first choice treatment. On the other hand the best treatment for
macro-prolactinomas is medicamentous.
UI - 96336113
AU - Soule SG; Farhi J; Conway GS; Jacobs HS; Powell M
TI - The outcome of hypophysectomy for prolactinomas in the era of dopamine
agonist therapy.
SO - Clin Endocrinol (Oxf) 1996;44(6):711-6
AD - Department of Medicine, UCL Medical School, Middlesex Hospital, London,
UK.
AB - OBJECTIVE: Dopamine agonists are the primary therapeutic modality for
the majority of patients with prolactinomas, with pituitary surgery
reserved for those patients intolerant of or resistant to these
agents. Most published surgical series, however, contain patients
treated by surgery as the primary therapeutic modality. Previous
exposure to dopamine agonists or the selection of patients with
prolactinomas resistant to conventional therapy may potentially
compromise the surgical success rate. The purpose of this study was
to evaluate the efficacy and safety of pituitary surgery for
prolactinomas in a tertiary referral centre where the majority of
patients were operated on after treatment with dopamine agonists.
DESIGN: A retrospective review of the outcome of pituitary surgery
for prolactinomas performed at a tertiary neurosurgical centre by a
single neurosurgeon. PATIENTS: Twenty-three patients underwent
excision of a macro and 11 excision of a micro-prolactinoma.
MEASUREMENTS: Pituitary tumour diameter was determined by CT or MRI
imaging. Pre and post-operative measurements were made of serum PRL
concentration (off dopamine agonist therapy), free T4, free T3, LH
and testosterone (males). Post-operative restoration of a menstrual
cycle was taken to indicate resolution of hypogonadism in female
patients. RESULTS: The majority (73.9%) of the patients with macro
and all with micro-prolactinomas had received dopamine agonists
preoperatively. Of the 23 patients with macroprolactinomas, in whom
the median preoperative PRL concentration was 13255 mU/l, 17 (73.9%)
had radiological evidence of suprasellar extension and 5 (21.7%)
cavernous sinus invasion. Only 4 (17.4%) of the patients with
macroprolactinomas had a normal serum PRL post-operatively, although
there was an improvement in visual fields in 66% of those with
preoperative defects. The median preoperative PRL concentration was
4309 mU/l in the patients with microprolactinomas, significantly
lower than in the macroprolactinoma group (P = 0.02). Despite a
significant fall in serum PRL postoperatively (median PRL 860 mU/l, P
= 0.0001), only 45.5% of patients had a normal serum PRL concentrati-
on after surgery. CONCLUSIONS: The cure rate following pituitary
surgery for prolactinomas in a tertiary referral centre was low when
compared with previous series in which surgery was used as the
primary therapeutic modality. We suggest this may result both from
dopamine agonist pretreatment and the referral of prolactinomas
resistant to conventional therapy. The outcome is probably a more
realistic reflection of the results of pituitary surgery for
prolactinomas as currently practised in the majority of neuroendocri-
ne centres.
UI - 96336296
AU - Giovanelli M; Losa M; Mortini P; Acerno S; Giugni E
TI - Surgical results in microadenomas.
SO - Acta Neurochir Suppl (Wien) 1996;65:11-2
AD - Department of Neurosurgery, San Raffaele IRCCS, University of Milano,
Italy.
AB - Pituitary microadenomas are small tumors whose maximal diameter is
less than 1 cm. The aim of surgical removal of microadenomas should
be not only the reversal of hormone hypersecretion but also the
preservation of normal anterior pituitary function. Our series
includes 230 patients with a microadenoma who had their first
operation in our department: 45 were GH-secreting, 92 were PRL-
secreting, 90 were ACTH-secreting, and 3 were TSH-secreting.
Remission of disease was achieved in 81%, 77%, 91%, and 100% of GH-,
PRL-, ACTH-, and TSH-secreting adenomas, respectively. There was no
perioperative mortality and only 5 patients experienced a major
complication. A total of 7 patients had diabetes insipidus for at
least 6 months after operation. Hypopituitarism, not present in any
patients before operation, developed in 3.5% of the cases. Our
experience confirms that patients with microadenomas have the best
chances of a successful operation. Since tumor size should gradually
increase with time, we underscore the need of early diagnosis and
treatment in patients with pituitary adenomas.
UI - 96358472
AU - Giovanelli M; Losa M; Mortini P
TI - Surgical therapy of pituitary adenomas.
SO - Metabolism 1996;45(8 Suppl 1):115-6
AD - IRCCS San Raffaele, University of Milano, Italy.
AB - In a series of approximately 1,000 patients with pituitary adenoma
who were operated on at our institution from 1970 to 1994, 932 were
operated on for the first time. Most microadenomas were corticotropin
(ACTH)-secreting, whereas all nonfunctioning adenomas were macroaden-
omas, reflecting internal surgical policy. Only 48 of 932 patients
(5.1%) had transcranial surgery. Using stringent criteria for the
definition of a cure, we obtained remission of disease in 54.9%,
87.3%, 66.7%, and 46.2% of all patients with growth hormone (GH)-,
ACTH-, thyrotropin (TSH)-, and prolactin (PRL)-secreting adenomas,
respectively. The good result in patients with Cushing's disease is
related to the higher percentage of microadenomas (approximately
equal to 80%) in this group. Unfavorable prognostic characteristics
for all adenomas are increasing tumor size, invasiveness, infiltrati-
on, and high serum levels of the hypersecreted hormone. The absence
of a reliable tumor marker makes it difficult to assess the results
of surgery in patients with nonfunctioning pituitary adenoma, but
normalization or improvement of visual defects occurred in 72.4% of
patients. Permanent worsening of vision was detected in 2.2%, mostly
operated on through the transcranial approach, but they had large
tumors and so were at greater risk. Accordingly, there was a higher
death rate in patients who received the transcranial operation (two
of 48; 4.2%) than in patients operated on through the trans-
sphenoidal route (seven of 884; 0.8%). However, between 1970 and
1980, the mortality rate was 1.6% (six of 367 patients), while
between 1981 and 1994, it was 0.5% (three of 565 patients), stressing
the importance of surgical experience and perioperative medical
management in improving the safety of pituitary surgery. (7 Refs)
Return to my Treatment of Prolactinomas page
This Page Last Updated on 6th. July, 2000