Outcomes of Transsphenoidal Microsurgery for Prolactinomas – A Contemporary Series of 162 Cases

Introduction Renewed interest in transsphenoidal surgery (TSS) as a therapeutic option for prolactinomas has emerged. This study is aimed at defining the current role of pituitary surgery in the management of prolactinomas. Materials and Methods In this retrospective, consecutive single-center study, 162 patients who underwent primary microscopic TSS for prolactinomas between 2006 and 2019 were analyzed regarding surgical indication, previous dopamine-agonist (DA) treatment, early remission rates (3 months postoperatively), surgical complications and pituitary function. Results Seventy-four microprolactinomas and 88 macroprolactinomas were operated by TSS. 62.3% of the patients had received prior DA treatment. For microprolactinomas, the predominant indication for surgery was patient’s wish (41.9%), while indications for macroprolactinomas varied. For enclosed microprolactinomas, the initial remission rate was 92.1%, while for macroprolactinomas, the rate was 70.4%. No significant difference of remission rates was found between DA-pretreated (65.3%) and non-pretreated (72.1%) patients (p=0.373).None of the patients suffered a significant complication. Re-operation for a postoperative cerebrospinal fluid leak was required in one patient (0.6%). Permanent postoperative deterioration of pituitary function was only observed in one of 158 patients with surgery for a prolactinoma (0.6%). Improvement of pituitary function was observed in 8 of 25 patients (32%) with preoperative deficits. Conclusion Transsphenoidal microsurgery is safe and efficient for treatment of prolactinomas. It is particularly suitable for enclosed prolactinomas. The patient should be well informed of the pros and cons of the treatment options, which include DA medication and TSS, and the patient’s preference should be taken into account during decision-making.

Hyperprolactinemia

Hyperprolactinemia is frequently diagnosed endocrine problem in routine clinical practice. Once hyperprolactinemia is suspected, repeat test for s prolactin can be done with appropriate precondition for sampling like rest, single prick, adequate light etc. to exclude macroprolactinemia specially in asymptomatic or unrelated symptoms. Once diagnosed as Hyper prolactinemia, secondary causes should be ruled out by history, specially drugs. Pregnancy should be excluded by history and if indicated, by test. Mild elevation of s prolactin can be also due to Polycystic Ovary Syndrome (PCOS), hypothyroidisom, CKD, CLD etc. Of course Hook Effect should be kept in mind. Contrast MRI should be done to see if there is any prolactinoma or hyperplasia. Sometimes Growth Hormone (GH) secreting tumors may be associated. Rarely extra pituitary tumors or disconnection of hypothalamus-pituitary may be seen. In symptomatic patient (hypogonadism, infertility, menstrual disturbances, sexual weakness, unexplained low bone mass and sometimes galactorrhoea etc) and specially if s prolactin is more than 2-3 times of upper limit of reference range, MRI with contrast should be done. Medical therapy with dopamine agonist is the treatment of choice for symptomatic any level of s prolactin and with prolactinoma. Cabergoline may be tried as a first line of treatment because it is more effective and better tolerated than bromocryptine. Though cabergoline is coming up with safety issues, bromocriptine has the largest safety database in pregnancy till date. All patient should be tried with medical treatment, specially cabergoline irrespective of symptoms and size of the tumor. Transsphenoidal microsurgery remains second option when medical treatment is ineffective. Radiotherapy may be the last adjuvant in the management . Rarely malignant prolactinoma may be found and have poor response to medical treatment. Birdem Med J 2013; 3(2): 99-105 DOI: http://dx.doi.org/10.3329/birdem.v3i2.17214

Norman Dott, Gerard Guiot, and Jules Hardy: key players in the resurrection and preservation of transsphenoidal surgery

Developed over a century ago, the transsphenoidal approach to access lesions of the pituitary gland and sella turcica has transformed the field of neurosurgery, largely due to the work of Oskar Hirsch and Harvey Cushing. Furthermore, its use and modification in the early 1900s was perhaps one of Cushing's greatest legacies to skull base surgery. However, Cushing, who had worked relentlessly to improve the transsphenoidal route to the pituitary region, abandoned the approach by 1929 in his pursuit to master transcranial approaches to the suprasellar region. Hirsch and a few other surgeons continued to perform transsphenoidal operations, but they were unable to maintain the popularity of the approach among their peers. During a time when transsphenoidal surgery was on the brink of extinction, a critical lineage of 3 key surgeons—Norman Dott, Gerard Guiot, and Jules Hardy—would resurrect the art, each working to further improve the procedure. Dott, Cushing's apprentice from 1923 to 1924, brought his experiences with transsphenoidal surgery to Edinburgh, Scotland, and along the way, developed the lighted nasal speculum to provide better illumination in the narrow working area. Guiot, inspired by Dott, adopted his technique and used intraoperative radiofluoroscopic technique for image guidance. Hardy, a fellow of Guiot, from Montreal, Canada, revolutionized transsphenoidal microsurgery with the introduction of the binocular microscope and selective adenomectomy. The teachings of these pioneers have endured over time and are now widely used by neurosurgeons worldwide. In this paper, we review the lineage and contributions of Dott, Guiot, and Hardy who served as crucial players in the preservation of transsphenoidal surgery.

Transsphenoidal Surgery for Cushing Disease

BACKGROUND This is a retrospective study of 136 patients with Cushing disease treated with transsphenoidal microsurgery. OBJECTIVE To evaluate factors influencing immediate postoperative results and long-term outcomes. METHODS Data regarding clinical presentation, endocrine evaluation, imaging studies, surgical technique, immediate postoperative biochemical remission (IPBR), and long-term results were entered into a database and analyzed statistically. IPBR was based on biochemical evidence of adrenal cortical insufficiency and clinical evidence of such insufficiency. RESULTS IPBR for the entire series was 83.4%. In microadenomas, IPBR was 89.8% with a mean immediate postoperative plasma cortisol (IPPC) of 2.1 μg/dL (range, <0.5-5.3). Positive magnetic resonance imaging (MRI) was associated with 18 times greater odds of finding microadenoma at surgery (P > .001) and with 4.1 times greater odds of IPBR (P = .07). In patients with a negative MRI, a positive inferior petrosal sinus sampling (IPSS) test was associated with 93% of IPBR (P = .004). IPBR in macroadenomas was 30.7%. Of patients followed for 12 months or longer, 34.8% required glucocorticoid replacement for the duration of follow-up. The mean follow-up in microadenomas was 68.4 months with a 9.67% incidence of recurrences. The estimated actuarial incidence of recurrences increased with the passage of time and IPPC of greater than 2 μg/dL was associated with higher incidence of recurrences, although without statistical significance (P = .08). CONCLUSION In microadenomas, a positive MRI and positive IPSS test were associated with a higher incidence of IPBR. Recurrences increased with the passage of time, and an IPPC of greater than 2 μg/dL may be associated with higher incidence of recurrences.