Surgery is a safe, effective first-line treatment modality for noninvasive prolactinomas

Park, Ji Yong; Choi, Wonsuk; Hong, A Ram; Yoon, Jee Hee; Kim, Hee Kyung; Jang, Won Young; Jung, Shin; Kang, Ho‐Cheol

doi:10.1007/s11102-021-01168-x

Cited by 14 publications

(15 citation statements)

References 48 publications

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“…• In the absence of gross total remission, debulking surgery may be sufficient to achieve eugonadism and to cease DA therapy or to require lower DA doses that are safer and more tolerable (Cho & Liau 2002, Kars et al 2009, Vroonen et al 2012). • Surgery carries a low risk of surgical complications and negligible mortality (Zamanipoor Najafabadi et al 2020, Andereggen et al 2021a, Park et al 2021). • Both endoscopic and microscopic transsphenoidal surgery involve minimally invasive techniques with reduced nasal discomfort compared to historical procedures (Honegger et al 2020).…”

Section: Revival Of Surgery As a First-line Treatmentmentioning

confidence: 99%

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

Sousa

2022

Endocrine Oncology

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The current treatment paradigm for prolactinomas involves dopamine agonist (DA) therapy as the first-line treatment, with surgical resection reserved for cases where there is DA failure due to resistance or intolerance. This review highlights how DA therapy can be optimised to overcome its increasingly recognised pitfalls, whilst also addressing the potential for expanding the use of surgery in the management of prolactinomas. The first part of the review discusses the limitations of DA therapy, namely: DA resistance; common DA side effects; and the rare but serious DA-induced risks of cardiac valvulopathy, impulse control disorders, psychosis, CSF rhinorrhoea and tumour fibrosis. The second part of the review explores the role of surgery in prolactinoma management with reference to its current second-line position and recent calls for surgery to be considered as an alternative first-line treatment alongside DA therapy. Randomised trials comparing medical versus surgical therapy for prolactinomas are currently underway. Pending these results, a low surgical threshold approach is herein proposed, whereby DA therapy remains the default treatment for prolactinomas unless there are specific triggers to consider surgery, including concern regarding DA side effects or risks in vulnerable patients, persistent and bothersome DA side effects, emergence of any serious risks of DA therapy, expected need for long-term DA therapy, as well as the traditional indications for surgery. This approach should optimise the use of DA therapy for those who will most benefit from it, whilst instituting surgery early in others in order to minimise the cumulative burden of prolonged DA therapy.

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Section: Revival Of Surgery As a First-line Treatmentmentioning

confidence: 99%

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

Sousa

2022

Endocrine Oncology

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“…In support of this, several groups have reported on the effectiveness and safety of prolactinoma surgery [ 21 – 24 , 29 , 54 – 62 ]: after a follow-up of 13.5–102 months, overall remission rates ranged from 26 to 92%, with most estimates around 70%, although not all studies have provided clarity on whether patients required ongoing dopamine agonist therapy to achieve postoperative remission. Not surprisingly, most studies have reported higher remission rates for microprolactinomas compared to macroprolactinomas, and adenomas that are enclosed within the gland may have a more favourable outcome compared with adenomas located at the lateral margins [ 29 , 60 ].…”

Section: Discussionmentioning

confidence: 99%

11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy

et al. 2022

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Purpose To assess the potential for 11C-methionine PET (Met-PET) coregistered with volumetric magnetic resonance imaging (Met-PET/MRCR) to inform clinical decision making in patients with poorly visualized or occult microprolactinomas and dopamine agonist intolerance or resistance. Patients and methods Thirteen patients with pituitary microprolactinomas, and who were intolerant (n = 11) or resistant (n = 2) to dopamine agonist therapy, were referred to our specialist pituitary centre for Met-PET/MRCR between 2016 and 2020. All patients had persistent hyperprolactinemia and were being considered for surgical intervention, but standard clinical MRI had shown either no visible adenoma or equivocal appearances. Results In all 13 patients Met-PET/MRCR demonstrated a single focus of avid tracer uptake. This was localized either to the right or left side of the sella in 12 subjects. In one patient, who had previously undergone surgery for a left-sided adenoma, recurrent tumor was unexpectedly identified in the left cavernous sinus. Five patients underwent endoscopic transsphenoidal selective adenomectomy, with subsequent complete remission of hyperprolactinaemia and normalization of other pituitary function; three patients are awaiting surgery. In the patient with inoperable cavernous sinus disease PET-guided stereotactic radiosurgery (SRS) was performed with subsequent near-normalization of serum prolactin. Two patients elected for a further trial of medical therapy, while two declined surgery or radiotherapy and chose to remain off medical treatment. Conclusions In patients with dopamine agonist intolerance or resistance, and indeterminate pituitary MRI, molecular (functional) imaging with Met-PET/MRCR can allow precise localization of a microprolactinoma to facilitate selective surgical adenomectomy or SRS.

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“…With the employment of the surgical plane, normal pituitary tissue may be under better protection, using cotton-plat during dissection. Complication rates are low in centers with dedicated pituitary surgeons, as outcomes depend on surgical expertise, tumor size, and invasiveness [14,23,24]. Extra-pseudocapsule dissection also has obvious disadvantages.…”

Section: Discussionmentioning

confidence: 99%

“…In contrast, transsphenoidal surgery (TSS) for prolactinomas is only accepted as a second-line treatment, recommended to symptomatic patients who cannot tolerate high dose of DA or are resistant to it, although the published surgical rates of PRL level normalization in some centers, especially for microprolactinoma, are excellent, or at least comparable with medical therapy [9][10][11][12]. Thus, long-term medication for young female patients, as the "gold-standard" treatment, is arguable nowadays [13,14].…”

Section: Introductionmentioning

confidence: 99%

Extra-Pseudocapsular Transsphenoidal Surgery for Microprolactinoma in Women

Chen

Guo

Zhang

et al. 2022

JCM

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A recall for histological pseudocapsule (PS) and reappraisal of transsphenoidal surgery (TSS) as a viable alternative to dopamine agonists in the treatment algorithm of prolactinomas are getting vibrant. We hope to investigate the effectiveness and risks of extra-pseudocapsular transsphenoidal surgery (EPTSS) for young women with microprolactinoma, and to look into the factors that influenced remission and recurrence, and thus to figure out the possible indication shift for primary TSS. We proposed a new classification method of microprolactinoma based on the relationship between tumor and pituitary position, which can be divided into hypo-pituitary, para-pituitary and supra-pituitary groups. We retrospectively analyzed 133 patients of women (<50 yr) with microprolactinoma (≤10 mm) who underwent EPTSS in a tertiary center. PS were identified in 113 (84.96%) microadenomas intraoperatively. The long-term surgical cure rate was 88.2%, and the comprehensive remission rate was 95.8% in total. There was no severe or permanent complication, and the surgical morbidity rate was 4.5%. The recurrence rate with over 5 years of follow-up was 9.2%, and a lot lower for the tumors in the complete PS group (0) and hypo-pituitary group (2.1%). Use of the extra-pseudocapsule dissection in microprolactinoma resulted in a good chance of increasing the surgical remission without increasing the risk of CSF leakage or endocrine deficits. First-line EPTSS may offer a greater opportunity of long-term cure for young female patients with microprolactinoma of hypo-pituitary located and Knosp grade 0-II.

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Surgery is a safe, effective first-line treatment modality for noninvasive prolactinomas

Cited by 14 publications

References 48 publications

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy

Extra-Pseudocapsular Transsphenoidal Surgery for Microprolactinoma in Women

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