Bromocriptine treatment of invasive giant prolactinomas involving the cavernous sinus: results of a long-term follow up

Wu, Zhe; Yu, Chun Jiang; Su, Zhi Peng; Zhuge, Qǐ Chuan; Wu, Jin Sen; Zheng, Wei

doi:10.3171/jns.2006.104.1.54

Cited by 68 publications

(65 citation statements)

References 58 publications

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“…The therapeutic approach proposed when the response to cabergoline is insufficient has recently been reviewed elsewhere (26). It should be noticed that there are no data regarding the use of temozolomide in women with giant prolactinomas and that radiotherapy was performed in only two cases (see Table 1) but resulted in visual loss in one (9).…”

Section: Discussionmentioning

confidence: 99%

Giant prolactinomas in women

Delgrange

Raverot²,

Bex³

et al. 2014

European Journal of Endocrinology

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Objective: To characterise distinctive clinical features of giant prolactinomas in women. Design: A multicentre, retrospective case series and literature review. Methods: We collected data from 15 female patients with a pituitary tumour larger than 4 cm and prolactin levels above 1000 mg/l and identified 19 similar cases from the literature; a gender-based comparison of the frequency and age distribution was obtained from a literature review. Results: The initial PubMed search using the term 'giant prolactinomas' identified 125 patients (13 women) responding to the inclusion criteria. The female:male ratio was 1:9. Another six female patients were found by extending the literature search, while our own series added 15 patients. The median age at diagnosis was 44 years in women compared with 35 years in men (P!0.05). All cases diagnosed before the age of 15 years were boys. In women (nZ34), we observed a minor peak incidence during the third decade of life and a major peak during the fifth decade. Amenorrhoea was a constant feature with seven cases of primary amenorrhoea. In eight women with onset of secondary amenorrhoea before the age of 40 years, the diagnosis was made 2-31 years later (median 9 years) and in all but one because of tumour pressure symptoms. The prolactin levels were above 10 000 mg/l in 15/34 and misdiagnosis due to 'hook effect' occurred in two of them. Eighteen patients were treated with cabergoline; standard doses (!2.0 mg/week) were able to normalise prolactin in only 4/18 patients, and 7/18 patients were resistant to weekly doses ranging from 3.0 to 7.0 mg. Conclusion: Giant prolactinomas are rare in women, often resistant to dopamine agonists and seem to be distributed in two age groups, with a larger late-onset peak.

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Section: Discussionmentioning

confidence: 99%

Giant prolactinomas in women

Delgrange

Raverot²,

Bex³

et al. 2014

European Journal of Endocrinology

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“…While most non-surgical series published in the literature indeed used this criterion of 1000 mg/l (7,12,15,20,22,23,24), higher cut-off levels of 2000 mg/l (25), 3000 mg/l (8) or even 4000 mg/l (11) have also been used. At the opposite, lower and more conservative PRL thresholds of 200 or 250 mg/l, similar to those used for non-giant macroprolactinomas, have also been proposed previously (6,26), although assay problems were mentioned in the latter report and accurate PRL concentrations were not available in some cases. In a recent surgical series of ten men with a monohormonal giant prolactinoma (27), there were two cases with a serum PRL level below 1000 mg/l: the only non-invasive tumour (365 mg/l) and another one with a PRL value of 985 mg/l.…”

Section: Definition and Epidemiologymentioning

confidence: 97%

THERAPY OF ENDOCRINE DISEASE: The challenges in managing giant prolactinomas

Maiter

Delgrange

2014

European Journal of Endocrinology

158

166

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Giant prolactinomas are rare tumours, representing only 2-3% of all prolactin (PRL)-secreting tumours and raising special diagnostic and therapeutic challenges. Based on several considerations developed in this review, their definition should be restricted to pituitary adenomas with a diameter of 40 mm or more, significant extrasellar extension, very high PRL concentrations (usually above 1000 mg/l) and no concomitant GH or ACTH secretion. Giant prolactinomas are much more frequent in young to middle-aged men than in women, with a male to female ratio of about 9:1. Endocrine symptoms are often present but overlooked for a long period of time, and diagnosis is eventually made when neurologic complications arise from massive extension into the surrounding structures, leading to cranial nerve palsies, hydrocephalus, temporal epilepsy or exophthalmos. PRL concentrations are usually in the range of 1000-100 000 mg/l, but may be underestimated by the so-called 'high-dose hook effect'. As in every prolactinoma, dopamine agonists are the first-line treatment allowing rapid alleviation of neurologic symptoms in the majority of the cases, a significant reduction in tumour size in three-fourths of the patients and PRL normalization in 60-70%. These extensive tumours are usually not completely resectable and neurosurgery has significant morbidity and mortality. It should therefore be restricted to acute complications such as apoplexy or leakage of cerebrospinal fluid (often induced by medical treatment) or to patients with insufficient tumoural response or progression. Irradiation and temozolomide are useful adjuvant therapies in a subset of patients with aggressive/invasive tumours, which are not controlled despite combined medical and surgical treatments. Because of these various challenges, we advocate a multidisciplinary management of these giant tumours in expert centres.

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“…44 Because of the ease of application and its practical relevance, a classification proposed previously 44 has become a grading system for surgeons and radiologists. 13,19,26,40,41,56,67,73 It is based on coronal sections of T1-weighted contrast-enhanced MRI scans, in which the circular cuts of the ICAs serve as easily detectable radiological landmarks for medial, center, and lateral tangents. 14 At the time that these studies were published, the microscopic technique was standard for transsphenoidal surgery, although drawbacks included a limited lateral view toward the medial wall and problems removing tumor tissue compressing or invading the compartments of the space of the CS and the ICA itself.…”

mentioning

confidence: 99%

Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification

Micko¹,

Wöhrer

Wolfsberger³

et al. 2015

JNS

399

281

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abbreviatioNs CS = cavernous sinus; ER = endocrinological remission; GTR = gross-total resection; ICA = internal carotid artery. submitted May 22, 2014. accepted December 2, 2014. iNclude wheN citiNg Published online February 6, 2015; DOI: 10.3171/2014.12.JNS141083. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. obJect An important prognostic factor for the surgical outcome and recurrence of a pituitary adenoma is its invasiveness into parasellar tissue, particularly into the space of the cavernous sinus (CS). The aims of this study were to reevaluate the existing parasellar classifications using an endoscopic technique and to evaluate the clinical and radiological outcomes associated with each grade. methods The authors investigated 137 pituitary macroadenomas classified radiologically at least on one side as Grade 1 or higher (parasellar extension) and correlated the surgical findings using an endoscopic technique, with special reference to the invasiveness of the tumor into the CS. In each case, postoperative MRI was performed to evaluate the gross-total resection (GTR) rate and the rate of endocrinological remission (ER) in functioning adenomas. results The authors found a 16% rate of CS invasion during surgery for these macroadenomas. Adenomas radiologically classified as Grade 1 were found to be invasive in 1.5%, and the GTR/ER rate was 83%/88%. For Grade 2 adenomas, the rate of invasion was 9.9%, and the GTR/ER rate was 71%/60%. For Grade 3 adenomas, the rate of invasion was 37.9%, and the GTR/ER rate was 75%/33%. When the superior compartment of the CS (Grade 3A) was involved, the authors found a rate of invasion that was lower (p < 0.001) than that when the inferior compartment was involved (Grade 3B). The rate of invasion in Grade 3A adenomas was 26.5% with a GTR/ER rate of 85%/67%, whereas for Grade 3B adenomas, the rate of surgically observed invasion was 70.6% with a GTR/ER rate of 64%/0%. All of the Grade 4 adenomas were invasive, and the GTR/ER rate was 0%. A comparison of microscopic and endoscopic techniques revealed no difference in adenomas with Grade 1 or 4 parasellar extension. In Grade 2 adenomas, however, the CS was found by the endoscopic technique to be invaded in 9.9% and by microscopic evaluation to be invaded in 88% (p < 0.001); in Grade 3 adenomas, the difference was 37.9% versus 86%, respectively (p = 0.002). Grade 4 adenomas had a statistically significant lower rate of GTR than those of all the other grades. In case of ER only, Grade 1 adenomas had a statistically significant higher rate of remission than did Grade 3B and Grade 4 adenomas. coNclusioNs The proposed classification proved that with increasing grades, the likelihood of surgically observed invasion rises and the chance of GTR and ER decreases. The direct endoscopic view confirmed the low rate of invasion of Grade 1 adenomas but showed significantly lower rates of invasion in Grade 2 and 3 adenomas than those previousl...

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Bromocriptine treatment of invasive giant prolactinomas involving the cavernous sinus: results of a long-term follow up

Cited by 68 publications

References 58 publications

Giant prolactinomas in women

Giant prolactinomas in women

THERAPY OF ENDOCRINE DISEASE: The challenges in managing giant prolactinomas

Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification

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