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Demir D, Demir AN, Sulu C, Zulfaliyeva G, Cetintas SC, Ozkaya HM, Kadioglu P, Gazioglu N, Tanriover N. The Combination of Dopamine Agonist Treatment and Surgery May Be the Best Option in Challenging Prolactinoma Cases: A Single-Centre Experience. World Neurosurg 2023; 175:e1166-e1174. [PMID: 37120141 DOI: 10.1016/j.wneu.2023.04.089] [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: 03/27/2023] [Accepted: 04/20/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To investigate the initial and long-term remission rates, factors related to remission, secondary treatments, and outcomes for patients with prolactinoma who underwent endoscopic transsphenoidal surgery (ETSS). METHODS The medical files of the 45 prolactinoma patients who underwent ETSS between 2015 and 2022 were retrospectively reviewed. Relevant demographic and clinical data were obtained. RESULTS Twenty-one (46.7%) patients were female. The median age of patients at ETSS was 35 (interquartile range, 22.5-50) years. The median clinical follow-up of patients was 28 (interquartile range 12-44) months. The initial surgical remission rate was 60%. Recurrence was detected in 7 patients (25.9%). Postoperative dopamine agonists were used in 25 patients, radiosurgery in 2, and second ETSS in 4 patients. After these secondary treatments, the long-term biochemical remission rate was 91.1%. The factors associated with failure in surgical remission are: male gender, older age, higher tumor size, advanced Knosp and Hardy stage, and elevated prolactin level at diagnosis. A prolactin level of <19 ng/mL in the first postoperative week predicted surgical remission with a sensitivity of 77.8% and a specificity of 70.6% in patients who received preoperative dopamine agonist treatment. CONCLUSIONS In macro adenomas and/or giant adenomas with cavernous sinus invasion, and significant suprasellar extension, which constitutes the difficult part of prolactinoma treatment, neither surgery nor medical treatment alone may be effective enough. Both treatment modalities should be carried out together by a team of neurosurgery and endocrinology in the management of these patients.
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Affiliation(s)
- Dilan Demir
- Department of Neurosurgery, Health Sciences University, Kartal Doktor Lütfi Kırdar City Hospital, Istanbul, Turkiye
| | - Ahmet Numan Demir
- Department of Endocrinology, Metabolism, and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkiye
| | - Cem Sulu
- Department of Endocrinology, Metabolism, and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkiye
| | - Guldana Zulfaliyeva
- Department of Internal Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkiye
| | - Semih Can Cetintas
- Department of Neurosurgery, Istanbul University-Cerrahpaşa, Istanbul, Turkiye
| | - Hande Mefkure Ozkaya
- Department of Endocrinology, Metabolism, and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkiye; Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkiye
| | - Pinar Kadioglu
- Department of Endocrinology, Metabolism, and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkiye; Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkiye
| | - Nurperi Gazioglu
- Department of Neurosurgery, Istinye University, Istanbul, Turkiye; Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkiye
| | - Necmettin Tanriover
- Department of Neurosurgery, Istanbul University-Cerrahpaşa, Istanbul, Turkiye; Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkiye.
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Andereggen L, Frey J, Andres RH, Luedi MM, El-Koussy M, Widmer HR, Beck J, Mariani L, Seiler RW, Christ E. First-line surgery in prolactinomas: lessons from a long-term follow-up study in a tertiary referral center. J Endocrinol Invest 2021; 44:2621-2633. [PMID: 33847973 PMCID: PMC8572196 DOI: 10.1007/s40618-021-01569-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/31/2021] [Indexed: 02/06/2023]
Abstract
CONTEXT Although consensus guidelines recommend dopamine agonists (DAs) as the first-line approach in prolactinomas, some patients may opt instead for upfront surgery, with the goal of minimizing the need for continuation of DAs over the long term. While this approach can be recommended in selected patients with a microprolactinoma, the indication for upfront surgery in macroprolactinomas remains controversial, with limited long-term data in large cohorts. We aimed at elucidating whether first-line surgery is equally safe and effective for patients with micro- or macroprolactinomas not extending beyond the median carotid line (i.e., Knosp grade ≤ 1). METHODOLOGY Retrospective study of patients with prolactinomas Knosp grade ≤ 1 treated with upfront surgery. The primary endpoint was patients' dependence on DAs at last follow-up. The secondary endpoint was postoperative complications. Independent risk factors for long-term dependence on DAs were analyzed. RESULTS A microadenoma was noted in 45 patients (52%) and a macroadenoma in 41 (48%), with 17 (20%) harboring a Knosp grade 1 prolactinoma. Median follow-up was 80 months. First-line surgery resulted in long-term remission in 31 patients (72%) with a microprolactinoma and in 18 patients (45%) with a macroprolactinoma (p = 0.02). DA therapy was ultimately required in 11 patients (24%) with microadenomas vs. 20 (49%) with macroadenomas (p = 0.03). As for the latter, DA was required in 13 patients (76%) with Knosp grade 1 macroadenomas vs. 7 patients (29%) with Knosp grade 0 macroadenomas (p = 0.004). There was no mortality, and morbidity was minimal. Knosp grade 1 prolactinomas (OR 7.3, 95% CI 1.4-37.7, p = 0.02) but not adenoma size (i.e., macroprolactinomas) were an independent predictor of long-term dependence on DAs. CONCLUSIONS First-line surgery in patients with microprolactinomas or macroprolactinomas Knosp grade 0 resulted in a good chance of non-dependency on DA therapy. However, in patients with prolactinomas Knosp grade 1, first-line surgery cannot be recommended, as adjuvant DA therapy after surgery is required in the majority of them over the long term.
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Affiliation(s)
- L Andereggen
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
| | - J Frey
- Department of Endocrinology, Diabetes, Nutrition and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Gynecology and Obstetrics, Kantonsspital Lucerne, Lucerne, Switzerland
| | - R H Andres
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - M M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M El-Koussy
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - H R Widmer
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - J Beck
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - L Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - R W Seiler
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - E Christ
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Basel, Basel, Switzerland
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Penn MC, Cardinal T, Zhang Y, Abt B, Bonney PA, Lorenzo P, Lin M, Rosner J, Weiss M, Zada G, Carmichael JD. Cure and Hormonal Control After Prolactinoma Resection: Case Series and Systematic Review. J Endocr Soc 2021; 5:bvab074. [PMID: 34466765 PMCID: PMC8402931 DOI: 10.1210/jendso/bvab074] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Indexed: 11/19/2022] Open
Abstract
Context Surgical management of prolactinomas is an important treatment for patients intolerant of dopamine agonist therapy. However, predictors of postoperative outcomes remain unclear. Object While transsphenoidal surgical resection (TSSR) is important second-line therapy in prolactinoma patients, predictors of surgical cure and biochemical remission following TSSR remain sparse. Methods A retrospective review of prolactinoma patients undergoing TSSR at the USC Pituitary Center from 1995 to 2020 was conducted. Participants were categorized as surgical cure (normalization of serum prolactin without medical treatment), surgical noncure, biochemical control (prolactin normalization with or without adjuvant therapy), and nonbiochemical control. A systematic review of the outcomes of surgically managed prolactinomas was performed. Results The 40 female and 16 male participants had an average age of 35.6 years. Prior treatment included transsphenoidal resection (6, 11%) and dopamine agonist treatment (47, 84%). The 40 macroadenomas and 15 microadenomas exhibited suprasellar extension (24, 43%) and parasellar invasion (20, 36%). Fifteen (27%) were purely intrasellar. Gross total resection was achieved in 25 patients (45%) and subtotal in 26 (46%). Surgical cure was achieved in 25 patients (46%) and biochemical control in 35 (64%). Surgical cure was more likely in smaller, noninvasive tumors, those that were fully resected, and patients with lower preoperative (< 1000 ng/mL) and immediately postoperative (< 7.6 ng/mL) prolactin levels. Ten of 26 patients (38%) undergoing adjuvant therapy achieved biochemical control, which was less likely in men and those with higher preoperative prolactin or invasive tumors. Conclusion Surgical resection of prolactinomas is a safe procedure that, when offered judiciously, can achieve symptom and/or biochemical control in a majority of patients. A variety of predictors may be useful in advising patients on likelihood of postoperative remission.
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Affiliation(s)
- Marisa C Penn
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Yanchen Zhang
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Brittany Abt
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Patricia Lorenzo
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Michelle Lin
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Jack Rosner
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Martin Weiss
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California 90033, USA.,USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, California 90033, USA
| | - John D Carmichael
- Division of Endocrinology, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California 90033, USA.,USC Pituitary Center, Keck School of Medicine of USC, Los Angeles, California 90033, USA
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Eren E, Törel Ergür A, İşgüven ŞP, Çelebi Bitkin E, Berberoğlu M, Şıklar Z, Baş F, Yel S, Baş S, Söbü E, Bereket A, Turan S, Sağlam H, Atay Z, Ercan O, Güran T, Atabek ME, Korkmaz HA, Kılınç Uğurlu A, Akıncı A, Döğer E, Şimşek E, Akbaş ED, Abacı A, Gül Ü, Acar S, Mengen Uçaktürk E, Yıldız M, Ünal E, Tarım Ö. Clinical and Laboratory Characteristics of Hyperprolactinemia in Children and Adolescents: National Survey. J Clin Res Pediatr Endocrinol 2019; 11:149-156. [PMID: 30396878 PMCID: PMC6571533 DOI: 10.4274/jcrpe.galenos.2018.2018.0206] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE We aimed to report the characteristics at admission, diagnosis, treatment, and follow-up of cases of pediatric hyperprolactinemia in a large multicenter study. METHODS We reviewed the records of 233 hyperprolactinemic patients, under 18 years of age, who were followed by different centers. The patients were divided as having microadenomas, macroadenomas, drug-induced hyperprolactinemia and idiopathic hyperprolactinemia. Complaints of the patients, their mode of treatment (medication and/or surgery) and outcomes were evaluated in detail. RESULTS The mean age of the patients with hyperprolactinemia was 14.5 years, and 88.4% were females. In terms of etiology, microadenomas were observed in 32.6%, macroadenomas in 27%, idiopathic hyperprolactinemia in 22.7% and drug-induced hyperprolactinemia in 6.4%. Other causes of hyperprolactinemia were defined in 11.3%. Common complaints in females (n=206) were sorted into menstrual irregularities, headaches, galactorrhea, primary or secondary amenorrhea and weight gain, whereas headache, gynecomastia, short stature and blurred vision were common in males (n=27). Median prolactin levels were 93.15 ng/mL, 241.8 ng/mL, 74.5 ng/mL, 93.2 ng/mL, and 69 ng/mL for microadenomas, macroadenomas, idiopathic hyperprolactinemia, drug-induced hyperprolactinemia, and other causes of hyperprolactinemia, respectively. Of 172 patients with hyperprolactinemia, 77.3% were treated with cabergoline and 13.4% with bromocriptine. 20.1% of the patients with pituitary adenomas underwent pituitary surgery. CONCLUSION We present the largest cohort of children and adolescents with hyperprolactinemia in the literature to date. Hyperprolactinemia is more common in females and cabergoline is highly effective and practical to use in adolescents, due to its biweekly dosing. Indications for surgery in pediatric cases need to be revised.
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Affiliation(s)
- Erdal Eren
- Uludağ University Faculty of Medicine, Department of Pediatric Endocrinology, Bursa, Turkey,* Address for Correspondence: Uludağ University Faculty of Medicine, Department of Pediatric Endocrinology, Bursa, Turkey Phone: +90 505 768 69 47 E-mail:
| | - Ayça Törel Ergür
- Kırıkkale University Faculty of Medicine, Department of Pediatric Endocrinology, Kırıkkale, Turkey
| | - Şükriye Pınar İşgüven
- Sakarya University Faculty of Medicine, Department of Pediatric Endocrinology, Sakarya, Turkey
| | - Eda Çelebi Bitkin
- Ondokuz Mayıs University Faculty of Medicine, Department of Pediatric Endocrinology, Samsun, Turkey
| | - Merih Berberoğlu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Zeynep Şıklar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Firdevs Baş
- İstanbul University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, İstanbul, Turkey
| | - Servet Yel
- Yüzüncü Yıl University Faculty of Medicine, Department of Pediatric Endocrinology, Van, Turkey
| | - Serpil Baş
- Marmara University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Elif Söbü
- Uludağ University Faculty of Medicine, Department of Pediatric Endocrinology, Bursa, Turkey
| | - Abdullah Bereket
- Marmara University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Serap Turan
- Marmara University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Halil Sağlam
- Uludağ University Faculty of Medicine, Department of Pediatric Endocrinology, Bursa, Turkey
| | - Zeynep Atay
- Marmara University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Oya Ercan
- İstanbul University Cerrahpaşa Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Tülay Güran
- Marmara University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | - Mehmet Emre Atabek
- Necmettin Erbakan University Faculty of Medicine, Department of Pediatric Endocrinology, Konya, Turkey
| | - Hüseyin Anıl Korkmaz
- Balıkesir Atatürk State Hospital, Clinic of Pediatric Endocrinology, Balıkesir, Turkey
| | - Aylin Kılınç Uğurlu
- Gazi University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Ayşehan Akıncı
- İnönü University Faculty of Medicine, Department of Pediatric Endocrinology, Malatya, Turkey
| | - Esra Döğer
- Gazi University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Enver Şimşek
- Osmangazi University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, Eskişehir, Turkey
| | - Emine Demet Akbaş
- Gazi University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Ayhan Abacı
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Ülkü Gül
- Erciyes University Faculty of Medicine, Department of Pediatric Endocrinology, Kayseri, Turkey
| | - Sezer Acar
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Eda Mengen Uçaktürk
- Çukurova University Faculty of Medicine, Department of Pediatric Endocrinology, Adana, Turkey
| | - Melek Yıldız
- Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Pediatric Endocrinology, İstanbul, Turkey
| | - Edip Ünal
- Dicle University Faculty of Medicine, Department of Pediatric Endocrinology, Diyarbakır, Turkey
| | - Ömer Tarım
- Uludağ University Faculty of Medicine, Department of Pediatric Endocrinology, Bursa, Turkey
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