Preoperative Prolactin Levels Research Articles

Preoperative treatment with dopamine agonist therapy influences surgical outcome in prolactinoma: a retrospective single-center on 159 patients

IntroductionProlactinoma account to the most common pituitary adenomas and current therapy regime constitutes of dopamine agonist therapy (DA) and surgery in selected cases [17]. Due to tumor fibrosis induced by previous DA therapy, surgical removal can be challenging though. Therefore, this study investigates how preoperative DA usage influences perioperative treatment and surgical outcome in prolactinoma and aims to ascertain whether a specific subgroup of prolactinoma patients could derive greater benefit from exclusive surgical intervention.MethodsWe retrospectively analyzed n = 159 surgically treated and histologically confirmed prolactinomas in the sella region from 2013–2022 in our institution. Clinical, radiological and surgical features were analyzed. Univariate and multivariate analyses were performed.ResultsOut of total of 159 prolactinoma patients, 83.6% received previous treatment with DA followed by surgery, while only 16.4% received exclusive surgery. Both groups presented similar initial tumor volumes (1.9cm3 vs. 1.5cm3, p = 0.59) and equal preoperative prolactin levels (PRL) (199.7 µg/l vs. 191.0 µg/l, p = 0.44). Surgical procedures took significantly longer when patients received prior DA treatment (79 min. vs. 70 min., p = 0.0479). Six months after surgery, pretreated patients revealed significantly higher PRL compared to non-treated (107 g/l vs. 8.64 µg/, p = 0.0009). Additionally, untreated microprolactinoma presented a remission of 100%, whereas pretreated exhibited a remission rate of 88.75%.ConclusionThe current study demonstrates that prior DA treatment is associated with significantly longer surgeries, higher recurrence rates and lower rates of normalization of PRL levels after surgery, particularly in microprolactinomas and support the latest recommendations of the Pituitary Society's Consensus Statement 2023, which favors the option of surgery alone as first-line therapy for microprolactinomas.

Gender Differences in Patients with Prolactinoma: Single-center Ukrainian Experience.

Prolactinomas are the most common type of pituitary gland tumors that secrete overly prolactin. They account for approximately 60% of all hormone-secreting hypophysis tumors. This study aims to analyze gender differences in patients with prolactinomas who were operated on transsphenoidal surgery and conduct a single-center retrospective analysis of patient data. This study evaluated the medical records of 109 patients (61 females and 48 males) from 2009 to 2019 at Feofaniya Clinical Hospital of the State Administration of Affairs in Kyiv, Ukraine. The primary criterion for including patients was a Serum Prolactin (PRL) level of over 100 ng/ml and the presence of a pituitary adenoma (PA) as observed on MRI. Additionally, the histological examination needed to confirm the presence of Prolactin-Secreting Pituitary Adenomas (PSPAs) without plurihormonal activity through both microscopy and immunohistochemical (IHC) staining. Significant differences in preoperative PRL levels were not observed. However, males had significantly larger tumor sizes and prevalence of macroadenomas. In male patients, the preoperative PLR levels showed a weak negative correlation with age (r=-0.304, p < 0.036) and a positive correlation with tumor size (r=0.555, p < 0.001) and cavernous sinus invasion (r=0.339, p < 0.018). In females, preoperative PRL was significantly associated only with tumor size and Knosp grade. Prolactin-Secreting Pituitary Adenomas (PSPAs) are more common in women than men and are characterized by larger and more invasive tumors with high PRL levels at diagnosis. The PRL level and tumor size before surgery can predict early biochemical remission in both males and females with an accuracy of 58.3% and 68.8%, respectively.

Alternations of Blood Pressure Following Surgical or Drug Therapy for Prolactinomas.

Several subtypes of pituitary neuroendocrine tumors (PitNETs), such as acromegaly and Cushing's disease, can result in hypertension. However, whether prolactinoma is associated with this complication remains unknown. Moreover, the effect of treatment with surgery or drugs on blood pressure (BP) is unknown. Herein, a retrospective study reviewed 162 patients with prolactinoma who underwent transsphenoidal surgery between January 2005 and December 2022. BP measurements were performed 1 day before and 5 days after surgery. Accordingly, patients' medical characteristics were recorded. In addition, in situ rat and xenograft nude-mice prolactinoma models have been used to mimic prolactinoma. In vivo BP and serum prolactin (PRL) levels were measured after cabergoline (CAB) administration in both rats and mice. Our data suggest that surgery can effectively decrease BP in prolactinoma patients with or without hypertension. The BP-lowering effect was significantly associated with several variables, including age, sex, disease duration, tumor size, invasion, dopamine agonists (DAs)-resistance, recurrence, and preoperative PRL levels. Moreover, in situ and xenograft prolactinomas induced BP elevation, which was alleviated by CAB treatment without and with a statistical difference in rats and mice, respectively. Thus, surgery or CAB can decrease BP in prolactinoma, indicating that pre- and postoperative BP management becomes essential.

Efficacy and Safety of Endoscopic Transsphenoidal Resection for Prolactinoma: A Retrospective Multicenter Case-series

Endoscopic transsphenoidal surgery (ETSS) for prolactinoma is reserved for dopamine agonist (DA) resistance, intolerance, or apoplexy. High remission (overall 67%, microprolactinoma up to 90%), low recurrence (5-20%) rates highlighted that surgery might be first-line treatment. To report on outcomes of ETSS in a cohort of prolactinomas. Multicenter retrospective cohort of 137 prolactinoma patients (age 38.2 ± 13.7 years; 61.3% female, median follow-up 28.0 [15.0-55.5] months) operated between 2010-2019 with histopathological confirmation. Median preoperative prolactin levels were 166 (98-837 µg/L; males 996 [159-2145 µg/L] vs. females 129 [84-223 µg/L], p <0.001). 56 (40.9%) microprolactinomas, 69 (50.4%) macroprolactinomas, and 7 (5.1%) giant prolactinomas were included, whereas no adenoma was detected in 5 (3.6%) patients. Males had larger tumors (macroprolactinomas: 38, 71.7%) vs. 31 (36.9%), p <0.001; giant prolactinomas: 7 (13.2%) vs. 0 (0.0%), (p <0.001). Prolactinomas were graded as KNOSP-3 in 15 (11.5%), and KNOSP-4 in 20 (15.3%) patients. Primary indication was DA intolerance (59, 43.1%); males 14 (26.4%) vs. females 45 (53.6%), p=0.006. Long-term remission (i.e., DA-free prolactin level <1xULN) was achieved in 87 (63.5%) patients, being higher in intended complete resection (69/92 [75.0%]), and lower in males (25 [47.2%] vs. 62 females [73.8%], p=0.002). Transient DI (n=29, 21.2%) was the most frequent complication. Despite high proportions of macroprolactinoma and KNOSP 3-4, long-term remission rates were 63.5% overall, and 83.3% in microprolactinoma patients. Males had less favorable remission rate compared to females. These findings highlight that ETSS may be a safe and efficacious treatment to manage prolactinoma.

Perioperative hormone level changes and their clinical implications in patients with pituitary adenoma: a retrospective study of 428 cases at a single center.

This study employs case data analysis to elucidate alterations in hormone levels pre and post-surgery among patients with pituitary adenoma. Moreover, it investigates the influence of various associated factors on endocrine function. A retrospective analysis was conducted on clinical data from 428 patients who underwent surgical treatment within a short period at a single center. Statistical methods were employed to examine detailed hormone level fluctuations before and after surgery in patients with pituitary adenoma, along with their interrelations with different factors. Between January 2016 and October 2022, a total of 428 consecutive patients with pituitary adenoma underwent surgical treatment. Of these, 232 were males and 196 were females, with an average age of 45.91 years (range: 16-84, standard deviation: 12.18). Univariate analysis indicated that females exhibited a higher susceptibility to preoperative endocrine dysfunction (p < 0.05). Conversely, males, patients with larger tumor volumes, and older patients were more prone to preoperative pituitary insufficiency. Postoperatively, the most substantial remission rate occurred in prolactin (77.4%), followed by growth hormone (GH) (71.8%) and cortisol (4/6). The highest recovery rate in functions was observed in growth hormone secretion function (80%), followed by pituitary-adrenal axis hormone secretion function (56.3%) and pituitary-thyroid axis hormone secretion function (47.5%). The most noteworthy incidence of newly developed postoperative endocrine deficiencies was found in the pituitary-adrenal axis (31.8%), while the occurrence rates of deficiencies in other axes were relatively low. The elevated postoperative remission rate of growth hormone correlated with a higher surgical resection rate and lower preoperative growth hormone levels. Additionally, lower preoperative prolactin levels corresponded to a higher remission rate of prolactin postoperatively. Furthermore, the restoration of postoperative thyroid hormone secretion function was associated with higher preoperative free thyroxine levels. Reduced postoperative cortisol secretion function was linked to multiple surgeries and an extended interval between hormone retesting and surgery. Surgical intervention effectively ameliorates endocrine disorders in pituitary adenoma patients, thereby mitigating symptoms and enhancing their quality of life. Preoperative management of growth hormone and prolactin levels facilitates an increased remission rate of these hormones post pituitary adenoma surgery. Patients displaying preoperative thyroid hormone secretion dysfunction should be considered for active supplementation therapy. Whenever feasible, complete tumor resection is recommended. For patients undergoing reoperation or multiple surgeries, vigilant postoperative cortisol monitoring and supplementation should be thoughtfully administered.

FRI299 Efficacy And Safety Of Endoscopic Transsphenoidal Resection For Prolactinoma: A Retrospective Case-series

Abstract Disclosure: I.M. Zandbergen: None. K. Huntoon: None. T.G. White: None. F. de Vries: None. B. Moclair: None. W.R. Van Furth: None. I.C. Pelsma: None. A. Dehdashti: None. N.R. Biermasz: None. D.M. Prevedello: None. Introduction Endoscopic transsphenoidal surgery (ETSS) for prolactinoma is mainly reserved for patients with dopamine agonist (DA) resistance, intolerance, or apoplexy. Surgery as a first-line treatment remains a topic of debate. Therefore, published patient cohorts are often not representative for the total population, and lack long-term follow-up. High remission rates (overall 67%, microprolactinoma up to 90%) have been reported, with recurrence in 5-20%, and low complication rates. This study aimed to assess clinical efficacy and safety of ETSS in prolactinoma patients. Study design Multicenter retrospective chart review of 137 surgically treated prolactinoma patients (mean age 38.2±13.7 years; 61.3% female) from three tertiary care centers from the USA and the Netherlands. Clinical characteristics and outcomes of surgery, including long-term (&amp;gt;2 years postoperatively) biochemical remission, resolution of hypogonadism and visual deficiencies, and recurrence and complication rates were assessed. Main results Median highest preoperative prolactin levels -available for 115 patients- were 168.5 µg/L (97.5 - 836.5 µg/L) and were higher for males (996.4 µg/L (158.6 - 2145.0 µg/L) vs females 128.5 µg/L (83.7 - 223.0 µg/L), P&amp;lt;0.001). The cohort consisted of 56 (40.9%) microprolactinomas, 69 (50.4%) macroprolactinomas, and 7 (5.1%) giant prolactinomas, whereas in 5 (3.6%) patients no adenoma was detectable by MRI. Males had more macroprolactinomas: 38 (71.7%) vs 31 females (36.9%), P&amp;lt;0.001; and giant prolactinomas: 7 (13.2%) vs 0 females (0.0%), P&amp;lt;0.001. Pituitary deficiencies -available for 135 patients- were present in 51 (37.8%) patients, with 8 (5.9%) having panhypopituitarism, and 43 (31.9%) had deficiencies of LH and 41 (30.4%) in FSH. Males more often showed any pituitary deficiency: 32 (61.5%) vs 19 females (22.9%), P&amp;lt;0.001, with correspondingly higher rates of deficiencies of all pituitary axes. Most often reported indication for surgery was DA intolerance 59 (43.1%) patients; males 14 (26.4%) vs females 45 (53.6%), P=0.006, with complete resection being the intent of surgery in 109 (79.6%) patients (males 33, 62.3%; vs females 76, 90.5%, P&amp;lt;0.001). With a median follow-up of 28.0 (15.0 - 55.5) months, long-term DA free remission was achieved in 87 (63.5%) patients. Males had lower remission rates: 25 (47.2%) vs 62 females (73.8%), P=0.002, with similar median follow-up for males and females. Occurring in 29 (21.2%) patients, transient DI was the most frequently reported surgical complication, similar for males and females. Conclusions In this multinational retrospective case-series of 137 prolactinoma patients who underwent ETSS, with relatively high proportions of macroprolactinoma and KNOSP 3-4, long-term remission rates were 63.5%. Both preoperative clinical characteristics and remission rates were significantly different between males and females. Presentation: Friday, June 16, 2023

Operative treatment of cystic prolactinomas: a retrospective study

BackgroundThe optimal therapeutic approach for cystic prolactinomas remains unclear. This study aimed to evaluate the remission rates of prolactinoma patients after surgical treatment and the risk factors affecting postoperative remission in cystic prolactinoma patients.MethodsThe clinical data were retrospectively compiled from 141 patients with prolactinomas (including 41 cases of cystic prolactinomas, 21 cases of solid microprolactinomas and 79 cases of solid macroprolactinomas) who underwent transsphenoidal surgery (TSS) between April 2013 and October 2021 at the First Affiliated Hospital of Sun Yat-sen University.ResultsEarly postoperative remission was achieved in 65.83% (n = 27/41) of cystic prolactinomas, 80.95% (n = 17/21) of solid microprolactinomas and 40.51% (n = 32/79) of solid macroprolactinomas. The mean length of follow up in all patients was 43.95 ± 2.33 months (range: 6-105 months). The follow-up remission rates were 58.54%, 71.43% and 44.30% in cystic, solid micro- and solid macroprolactinomas, respectively. For cystic prolactinomas, the early postoperative remission rates in the patients with preoperative dopamine agonists (DA) treatment were significantly higher than those without preoperative DA treatment (p = 0.033), but the difference in the follow-up remission rates between these two groups was not significant (p = 0.209). Multivariate stepwise logistic regression analysis indicated that tumor size and preoperative prolactin (PRL) levels < 200 ng/ml were independent predictors for early postoperative remission in cystic prolactinomas.ConclusionFor cystic prolactinomas, tumor size and preoperative PRL levels were independent predictors of early postoperative remission. Preoperative DA therapy combined with TSS may be more beneficial to cystic prolactinoma patients.

Correlation between tumor volume and serum prolactin and its effect on surgical outcomes in a cohort of 219 prolactinoma patients.

Prolactinoma is the most common pituitary adenoma and can be managed medically or surgically. The authors assessed the correlation between tumor volume and prolactin level and its effect on surgical outcomes. The authors reviewed 219 patients who underwent transsphenoidal prolactinoma resection at a single institution from 2012 to 2019. Outcomes were compared between patients with and without biochemical remission. Tumor volumes were quantified with BrainLab Smartbrush. Correlation analysis and linear regression were used to examine the association between tumor volume and serum prolactin level. Volume-adjusted prolactin level was defined as serum prolactin level divided by tumor volume. The authors utilized receiver operating characteristic (ROC) curve analysis to determine the thresholds for predicting biochemical remission status. The mean tumor volume was 5.66 cm3, and the mean preoperative prolactin level was 752.3 µg/L. Men had larger prolactinomas than women (mean volume 11.32 vs 2.54 cm3; p < 0.001), and women had a greater volume-adjusted prolactin level (mean 412.5 vs 175.9 µg/L/cm3, p < 0.001). In total, 66.7% of surgical patients achieved biochemical remission 6 weeks after surgery, whereas a similar cohort of medically treated patients during the same time frame demonstrated a 69.4% remission rate. Pearson correlation and linear regression analysis revealed a strong association between preoperative tumor volume and prolactin levels, with an increase in serum prolactin level of 101.31 µg/L per 1-cm3 increase in tumor volume (p < 0.001). This held true for men (R = 0.601, p < 0.001) and women (R = 0.935, p < 0.001), with women demonstrating a greater increase in prolactin level per 1-cm3 increase in volume (185.70 vs 79.77 µg/L, p < 0.001). Patients who achieved remission exhibited a 66.08-µg/L increase in preoperative prolactin level per 1 cm3 of preoperative tumor volume (p < 0.001), which was less than the 111.46-µg/L increase per 1 cm3 in patients without remission (p < 0.001). Patients who failed to achieve remission had residual tumors with a 77.77-µg/L increase in prolactin per 1 cm3 of remaining tumor volume after resection (p < 0.001). ROC curve analysis revealed significant thresholds that optimally predicted lack of postoperative remission on the basis of preoperative prolactin and tumor volume. These thresholds were rendered nonsignificant in patients with documented Knosp grade ≥ 3. Although the authors found a correlation between prolactinoma volume and serum prolactin level, patients without remission had a greater increase in serum prolactin level per increase in preoperative tumor volume than those who achieved remission, suggesting unique tumor composition. The authors also identified prolactin and tumor volume thresholds that optimally predicted biochemical remission status. The authors hope that their results can be used to identify prolactinomas for which surgery could achieve remission as an alternative to medical management.

Diagnostic criteria of small sellar lesions with hyperprolactinemia: Prolactinoma or else.

ObjectiveTo evaluate the combined predictive value of MRI criteria with the prolactin-volume-ratio (PVR) to differentiate prolactinoma from non-prolactinoma, in small sellar lesions with hyperprolactinemia.MethodsRetrospective analysis of 55 patients with sellar lesions of ≤15 mm diameter on MRI and hyperprolactinemia of ≤150 ng/mL, surgically treated between 2003 and 2020 at the Medical University of Vienna, with a conclusive histopathological report. Serum prolactin levels, extent of pituitary stalk deviation, size and volume of the lesion were assessed. The PVR was calculated by dividing the preoperative prolactin level by tumor volume.ResultsOur study population consisted of 39 patients (71%) with a prolactin-producing pituitary adenoma (group A), while 16 patients (29%) had another type of sellar lesion (group B). Patients in group A were significantly younger (p=0.012), had significantly higher prolactin levels at diagnosis (p<0.001) as well as smaller tumor volume (p=0.036) and lower degree of pituitary stalk deviation (p=0.009). The median PVR was significantly higher in group A (243 ng/mL per cm3) than in group B (83 ng/mL per cm3; p=0.002). Furthermore, the regression operating characteristics analysis revealed a PVR >100 ng/mL per cm3 to be predictive for distinguishing prolactin-producing lesions from other small sellar lesions.ConclusionIn patients with small sellar lesions, Prolactin-Volume-Ratios >100 represents a possible predictive marker for the diagnosis of prolactin-producing pituitary adenomas.

The role of endoscopic endonasal surgery in the management of prolactinomas based on their invasiveness into the cavernous sinus.

To review our institutional experience with thesurgical management of prolactinomas through the endoscopic endonasal approach with specific focus on cavernous sinus invasion. Clinical and radiographic data were collected retrospectively from the electronic medical record of 78 consecutive patients with prolactinomas undergoing endoscopic endonasal resection from 2002 to 2019. Immediate and late post-operative remission were defined as prolactin < 20ng/mL within 14days and 1-year of surgery without adjuvant therapy, respectively. Cavernous sinus invasion was quantified by Knosp score. A total of 78 patients with prolactinoma, 59% being male, underwent surgical resection with a mean age of 37 ± 13years. Indications for surgery were medication resistance in 38 patients (48.7%), medication intolerance in 11 (14.1%), and patient preference in 29 (37.2%). Patients with Knosp 0-2 achieved higher immediate remission rates (83.8%) compared to patients with Knosp 3 (58.8%) and Knosp 4 (41.7%) patients (p = 0.003). Long-term remission rates were 48.7% and increased to 71.8% when combined with adjuvant treatments. Knosp 4 prolactinomas had significantly higher tumor volumes, higher preoperative prolactin levels, higher recurrence rates, higher rates of adjuvant therapy utilization, and were more likely to have failed dopamine agonist therapy compared to other tumor grades (p < 0.05). We encountered 18 complications in our series, and no cerebrospinal fluid leaks. The endoscopic endonasal approach is a safe and effective modality that can be employed in properly selected patients with invasive prolactinomas. It is associatedwith improved control and remission rates despite cavernous sinus invasion, though at a lower rate than without invasion.

Surgery and Medical Treatment in Microprolactinoma: A Systematic Review and Meta-Analysis.

Objective Dopamine agonists (DAs) are recommended as the first-line treatment for prolactinomas; however, tumour recurrence after drug withdrawal remains a clinical problem. Recent studies have reported high remission rates via surgery in microprolactinomas. The aim of this systematic review and meta-analysis was to compare the clinical result of DA treatment with surgery as initial therapy in patients with treatment-naive microprolactinoma. Methods A comprehensive literature search for studies and reports regarding microprolactinoma patients treated with DAs and/or surgery published between January 1970 and November 2020 was conducted using four electronic databases (PubMed, Embase, Google Scholar, and the Cochrane Library). Clinical treatment outcome was evaluated by the biochemical remission of serum prolactin level to normal after treatment. The I2 statistic was used to quantify heterogeneity. Pooled data were analysed according to a random effect model. Results Eighteen studies with 661 patients were included for analysis. The DA treatment group achieved a higher remission rate at ≥12 months follow-up (96% vs. 86%; P=0.019). Surgery showed a higher remission rate than the DA treatment group after the treatment withdrawal (78% vs. 44%; P=0.003). Patients with preoperative prolactin level of ≤200 ng/mL had a higher remission rate than patients with preoperative prolactin level of >200 ng/mL (92% vs. 40%; P=0.029). Conclusion Surgery showed a high remission rate in treatment-naive microprolactinoma patients after treatment withdrawal and may be an alternative first-line treatment strategy in addition to DAs, particularly in patients with a preoperative prolactin level of ≤200 ng/mL.

Outcomes of transsphenoidal surgery in dopamine agonist-resistant prolactinomas: a retrospective study.

Dopamine agonists (DA) comprise first-line treatment for prolactinomas. However, some patients show no response to DA and are considered resistant. In this study, we retrospectively analyzed the outcomes of DA-resistant prolactinoma patients after transsphenoidal surgery (TSS). A total of 94 consecutive patients with DA-resistant prolactinomas who underwent TSS were retrospectively enrolled in the present study. Early postoperative remission rate, prolactin (PRL) levels, and recurrence rate were analyzed. Of 94 DA-resistant patients, 47 (50%) achieved early remission 1week post-surgery, including 41.18% of macroprolactinoma patients and 73.08% of microprolactinoma patients. PRL levels on the first postoperative day were significantly lower than preoperative PRL levels (p < 0.001). Total resection rate in macro- and microprolactinomas were, respectively, 75 and 96.15%. A recurrence of hyperprolactinemia and tumor was, respectively, found in 31.91 and 19.15% of patients with a follow-up of 39.53 ± 2.172months (range 3-86). A higher hyperprolactinemia recurrence was observed in patients with invasive prolactinomas (p = 0.021) or preoperative PRL levels ≥ 200ng/ml (p = 0.029). Univariate logistic regression indicated that larger maximum tumor diameter (p = 0.045), invasive prolactinomas (p = 0.002), and absence of early postoperative remission (p = 0.004) were significant predictors of tumor recurrence. However, using multivariate stepwise logistic regression, only invasiveness and early postoperative remission remained significant. Tumor invasiveness and preoperative PRL levels were significant predictors of hyperprolactinemia recurrence after TSS. For tumor recurrence, invasiveness and early postoperative remission were independent predictors.

Causes of Hyperprolactinemia in Acromegalic Patients and Clinical Correlations

Hyperprolactinemia in acromegalic patients may result either from cosecretion of growth hormone and prolactin by the tumour or from pituitary stalk compression. The occurrence of both conditions is possible. This study was designed aiming 1) to estimate the prevalence of each cause of hyperprolactinemia and its respective clinical course; 2) to compare the outcomes of patients with tumours staining only for growth hormone against tumours staining for both growth hormone and prolactin. 75 acromegalic patients submitted to transsphenoidal surgery between 1989 and 2018 were included. Patients were divided based on preoperative prolactin levels and immunostaining pattern. Statistical analysis was performed with SPSS version 23. Hyperprolactinemia was documented in 22 out of 36 patients (61%). Stalk compression was the only underlying cause of hyperprolactinemia in 45% of cases. The levels of prolactin were not associated with the immunostaining pattern for prolactin. Clinical differences were not observed between hyperprolactinemic and normoprolactinemic patients, except for a higher frequency of cavernous sinus invasion (64% vs 29%, p=0,064), that reached the level of significance for the subgroup with macroadenomas staining exclusively for growth hormone (p=0,031). In the present series, no clinical differences were noticed between patients with tumours staining only for growth hormone or staining for both growth hormone and prolactin. Hyperprolactinemia resulting from stalk compression is likely to anticipate a less favourable course of disease, since it is associated with larger tumours and a higher frequency of cavernous sinus invasion. On the contrary, positive immunostaining for prolactin was not a marker of worse prognosis.

Changes in the Options for Management of Prolactin Secreting Pituitary Adenomas.

Objectives Initial therapy for the management of prolactinomas has long been maintained to be medical, consisting of a dopamine agonist. These therapies may have troublesome side effects, and some prolactinomas are resistant to medical therapy regarding lowering prolactin levels or shrinking the tumor. These issues have revived interest in surgery for prolactin-secreting adenomas as an early therapeutic option. We report our analysis of surgery for prolactin microadenomas in women, using the transsphenoidal endoscopic approach. Design We reviewed a contemporary series of 33 women (mean age = 31.8 years) with microprolactinomas who underwent early surgical intervention, which was a three-dimensional transnasal transsphenoidal endoscopic operation. Setting The study was conducted at a tertiary academic referral center for pituitary tumors. Main Outcome Measures Preoperative and postoperative prolactin. Results Overall, 28 patients had received preoperative dopamine agonists, 24 of these experienced a variety of drug-related side effects, and 4 had tumors that were resistant to lowering prolactin or tumor shrinkage. Preoperative prolactin levels averaged 90.3 ng/mL (range = 30.7-175.8 ng/mL). We observed a 94% normalization rate in postoperative prolactin (mean = 10.08 ng/mL, range = 0.3-63.1 ng/mL). During the follow-up (mean = 33.9 months), five patients had elevated prolactin; four required reinitiation of medical therapy, two had surgical reexploration, and none received radiation therapy. Complications included syndrome of inappropriate antidiuretic hormone secretion ( n = 3), transient diabetes insipidus ( n = 1), postoperative epistaxis ( n = 1), and fat graft site infection ( n = 1). Conclusion This review supports the consideration of transsphenoidal surgery as an early intervention for some women with prolactin-secreting microadenoma. Indications include significant side effects of medical therapy and tumors that do not respond to standard medical management.

Hyperprolactinemia in clinical non-functional pituitary macroadenomas: A STROBE-compliant study.

Hyperprolactinemia is a prevalent endocrine disorder presented in patients with non-functional pituitary adenomas (NFPAs). However, the mechanism involved in hyperprolactinemia in NFPA is not fully illustrated. The current study aims to investigate predictors for hyperprolactinemia in NFPA via analyzing relevant clinical features. Thus, in this study, a cohort of 214 cases with integrated medical records was retrospectively analyzed concerning clinical, pathological, and endocrinological studies before and after surgery.Hyperprolactinemia happened in 93 cases (43.5%). Women (adjust odds ratio [OR] = 3.093; P < .01), age of patients (adjust OR = 0.951; P < .01), and serum free tetraiodothyronine (FT4) level (adjust OR = 0.882; P = .02) were independent predictors for developing preoperative hyperprolactinemia. Tumor size and hypopituitarism had no impact on hyperprolactinemia. During a median follow-up of 43.5 (range, 22–80) months, 83.9% patients with preoperative hyperprolactinemia experienced prolactin (PRL) normalization. Preoperative PRL level (adjusted OR = 1.741, P = .03) was the exclusive predictor for PRL normalization after adjusting for tumor volume, preoperative serum FT4 concentration, and postoperative residual. The PRL normalization rate of patients with lower PRL level (<2.35-fold upper limit of normal range) was 95.2% and decreased to 65.5% for patients with higher PRL level.In conclusion, our results suggest existence of potentially alternative mechanisms underlying hyperprolactinemia in NFPAs, like the discrepancy of sex and age and the negative feedback of FT4. Preoperative PRL is a predictor for postoperative PRL normalization, which is of clinically relevant for postoperative management of NFPAs.

Endoscopic Transsphenoidal Surgery of Microprolactinomas: A Reappraisal of Cure Rate Based on Radiological Criteria.

Current standard treatment of microprolactinomas is dopamine agonist therapy. As this drug treatment is lifelong in up to 80% of cases, many patients consult pituitary surgeons regarding a surgical alternative. To identify prognostic criteria for surgical remission, we reviewed outcomes of our series of microprolactinomas treated with endoscopic transsphenoidal surgery, with a special emphasis on magnetic resonance adenoma delineation and position. Our study cohort comprises a single center series of 60 patients operated for histopathologically verified magnetic resonance imaging unequivocally identifiable endosellar microprolactinoma between 2003 and 2017. In 31 patients the adenoma was enclosed by pituitary gland (group ENC), in 29 patients the adenoma was located lateral to the gland adherent to the medial cavernous sinus wall (group LAT). After a mean follow-up of 37 mo (range 4-143 mo), remission rate was significantly higher in adenomas enclosed by pituitary gland (group ENC) than adenomas located lateral to the gland (group LAT), with 87% vs 45%, P=.01. Intraoperatively, 4 patients showed signs of invasiveness. Preoperative prolactin levels did not differ between the groups (mean 155 and 187 ng/ml in group ENC and LAT, respectively).A binary logistic regression model revealed that only the radiological criteria applied showed a significant correlation (P=.003) with endocrine remission. According to our results, remission rate is significantly higher in microprolactinomas enclosed by the pituitary gland. However, the decision for surgery should take into account surgeons experience and possibility of complications.

SUN-443 Surgical Management of Cystic Prolactinomas

Purpose: Treatment of prolactinomas with a predominantly cystic component remains controversial. This study assessed remission rates in surgically-treated cystic prolactinomas, compared to solid micro- and macroprolactinomas. Methods: Charts were retrospectively analyzed for 57 patients who underwent transsphenoidal resection (TSS) for prolactinomas, from 2004 to 2018, by two experienced neurosurgeons. Tumors were subdivided into: cystic prolactinomas (n=17, >50% initial cystic component), microprolactinomas (n=10, <10 mm) and macroprolactinomas (n=30, ≥10 mm). Patients underwent TSS primarily for reasons of dopamine agonist (DA) intolerance, non-responders or patient preference. Remission was defined as either immediate postoperative (POD #1-3) prolactin (PRL) level of <10 ng/dl, or a normalized PRL level at a later time point. Results: 30 females and 27 males were included in the study, with a mean age of 33.5 yrs. Median tumor size for the cystic, micro- and macroprolactinomas were 15 mm, 7 mm and 22 mm, respectively. The median duration for DA treatment for the cystic, micro- and macroprolactinoma groups, prior to TSS, were 6, 24 and 12 months, respectively. Median pre-operative PRL levels were lowest with cystic prolactinomas, compared to the micro- and macroprolactinomas at 23.9 ng/ml (Standard deviation (SD)-136.7 ng/ml), 87.9 ng/ml (SD 80 ng/ml) and 229 ng/ml (SD 471.1 ng/ml), respectively (p=0.015). Immediate post-op PRL levels were significantly lower for cystic prolactinomas (n=10, 2.65 ng/ml, SD 4.72 ng/ml) than macroprolactinomas (n=19, 57 ng/ml, SD 159.4 ng/ml) (p=0.025) and for microprolactinomas (n=9.4 ng/ml, SD 3.9 ng/ml) than macroprolactinomas (p=0.030). At the last post-op f/u, no microprolactinoma patient required DA treatment, while 4 patients (24%) with cystic prolactinomas and 18 patients (60%) with macroprolactinomas still required DA therapy. Remission was ultimately achieved in 76% (n=13/17) of surgically-treated cystic prolactinomas, 100% (n=10/10) of microprolactinomas and 23% (n=7/30) of macroprolactinoma patients, at a median f/u of 6, 2.5 and 25 months, respectively. Conclusions: Surgical treatment for cystic prolactinomas, despite their macroadenoma size, resulted in high remission rates (76%), which was comparable to surgically-resected microprolactinomas and superior to macroprolactinomas. This case series supports TSS for this subset of prolactinoma patients.

Low Preoperative Prolactin Levels Predict Non-Organ Confined Prostate Cancer in Clinically Localized Disease

Introduction: To evaluate the association between preoperative serum prolactin (PRL) levels and risk of non-organ confined prostate cancer (PCa) in clinically localized disease. Materials and Methods: From December 2007 to December 2011, 124 patients with clinically localized PCa were retrospectively evaluated. Non-organ confined disease in the surgical specimen was defined according to extra-capsular extension, seminal vesicle invasion, positive surgical margins, and lymph node invasion. The association between clinical factors and serum levels of pituitary-testis hormones with the risk of non-organ confined disease was evaluated. Results: Perioperative factors associated with non-organ confined disease include prostatic-specific antigen (OR 1.144; p = 0.025), proportion of biopsy positive cores (BPC, OR 36.702; p = 0.007), bioptical Gleason Score > 6 (OR 2.785; p = 0.034), and PRL (OR 0.756, p < 0.0001). The association was strong for BPC (area under the curve [AUC] 0.704; p < 0.0001) and PRL (AUC 0.299; p < 0.0001). When we dichotomized according to median value, PRL ≤7.7 µg/L was an independent predictor of extraprostatic disease (OR 6.571; p < 0.0001) with fair discrimination power (AUC 0.704; p < 0.0001). Conclusion: Low preoperative PRL levels predict the risk of non-organ confined PCa in clinically localized disease.

Retrospective analysis of 52 patients with prolactinomas following endoscopic endonasal transsphenoidal surgery.

Background:Prolactinomas affect patients’ quality of life and even endanger lives. The study aimed to investigate the effect of the endoscopic endonasal transsphenoidal approach (EETA) on 52 patients with prolactinomas.Methods:A total of 52 patients with prolactinomas who had previously undergone EETA in the People's Hospital of Xinjiang Uygur Autonomous Region between January 2013 and December 2017 were retrospectively analyzed. Factors affecting the extent of resection and postoperative remission rates were also investigated.Results:All the patients were pathologically diagnosed with prolactinomas. Compared with giant adenomas, the total removal rate of microadenomas and macroadenomas was significantly increased (P < .05). In addition, the total removal rate of patients with noninvasive prolactin adenomas was significantly higher than patients with invasive prolactinadenomas (P < .05). Furthermore, there were no significant differences in postoperative remission rates among patients with prolactin adenomas from different ethnic groups (P > .05). Also preoperative administration of bromocriptine and preoperative prolactin (PRL) levels did not significantly affect therapeutic outcomes postsurgery (P > .05). Postoperative menstruation was improved or normalized in 20 (38.5%) female patients, vision was improved or normalized in 15 (28.8%) patients, and headaches were improved or normalized in 22 (42.3%) patients. Sexual function was improved in 2 male patients following surgery. A total of 6 patients exhibited a recurrence following surgery. A number of patients suffered from postoperative complications, including transient diabetes insipidus in 5 (9.6%) patients and postoperative transient cerebrospinal fluid leakage in 2 (3.8%) patients.Conclusion:The results of this study demonstrated that tumor size, preoperative PRL levels, and invasion of adenomas represent independent factors that can affect the success of surgery. The results suggested that EETA represents a therapeutic strategy for the treatment of patients with prolactinoma with high remission rates and low complication rates. Therefore, EETA should be considered a primary treatment for patients with prolactinomas who are not responsive to treatment with medical therapy.

Clinical and Radiographic Characteristics Related to Hyperprolactinemia in Nonfunctioning Pituitary Adenomas

Hyperprolactinemia in patients with nonfunctioning pituitary adenomas (NFPAs) has been explained by the stalk compression of large pituitary adenomas. However, not all large NFPAs are associated with high serum prolactin levels. We aimed to elucidate and compare clinical, hormonal, and radiographic characteristics of NFPAs with and without hyperprolactinemia. We included 201 patients with clinically NFPAs who underwent transsphenoidal surgery performed by a single surgeon during 2010-2017 at a single center in Korea. We measured the three-dimensional diameters (anteroposterior [AP], width, height) and volumes of NFPA on magnetic resonance imaging. We conducted morning basal hormone measurements and dynamic tests preoperatively and 3 months postoperatively. All NFPAs were macroadenomas, and mean tumor volume was 10.4 ± 7.7 cm3. Of 201 patients, 59 (29.4%) had preoperative hyperprolactinemia. Hormone recovery rate was higher in patients with hyperprolactinemia compared with patients without hyperprolactinemia after age, sex, body mass index, tumor volume, and gross total resection adjustments (odds ratio [95% confidence interval]: 2.55 [1.10-5.92]). Tumor width/AP diameter ratio positively correlated with serum prolactin levels (r= 0.186, P= 0.008). Tumor volume was not significantly different between the 2 groups. Preoperative prolactin level is a useful marker to predict hormone recovery after surgery. Patients with NFPA and hyperprolactinemia tended to have a higher width/AP diameter ratio. Hyperprolactinemia of NFPA is more likely affected by tumor growth pattern, such as width/AP diameter ratio, than tumor volume.