Prolactinoma surgery: Difference between revisions

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{{Prolactinoma}}
{{Prolactinoma}}
{{CMG}} {{AE}}{{Faizan}}
{{CMG}}; {{AE}} {{Faizan}}, {{Anmol}}
==Overview==
==Overview==
Surgery is indicated in patients if medical therapy cannot be tolerated or if it fails to reduce [[prolactin]] levels, restore normal reproduction and [[pituitary]] function, and reduce tumor size.  If medical therapy is only partially successful, this therapy should continue, possibly combined with surgery or [[radiation]] treatment.
Surgery is not the first-line treatment option for patients with [[prolactinoma]]. [[Surgery]] is usually reserved for patients in whom medical therapy fails to reduce the size of the [[tumor]].


==Surgery==
==Surgery==


Surgery is indicated in patients if:
=== Indications ===
Medical therapy should be continued even if it is partially successful, possibly combined with surgery or [[radiation]]. Surgery is indicated in patients if medical therapy:<ref name="urlProlactinoma | NIDDK">{{cite web |url=https://www.niddk.nih.gov/health-information/endocrine-diseases/prolactinoma |title=Prolactinoma &#124; NIDDK |format= |work= |accessdate=}}</ref><ref name="pmid21423245">{{cite journal| author=Colao A, Savastano S| title=Medical treatment of prolactinomas. | journal=Nat Rev Endocrinol | year= 2011 | volume= 7 | issue= 5 | pages= 267-78 | pmid=21423245 | doi=10.1038/nrendo.2011.37 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21423245  }} </ref><ref name="pmid11761431">{{cite journal| author=Nomikos P, Buchfelder M, Fahlbusch R| title=Current management of prolactinomas. | journal=J Neurooncol | year= 2001 | volume= 54 | issue= 2 | pages= 139-50 | pmid=11761431 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11761431  }} </ref>
*Cannot be tolerated
*Fails to reduce [[ prolactin]] concentration
*Fails to restore normal [[reproductive]] and [[pituitary]] function
*Fails to reduce [[tumor]] size


*Medical therapy cannot be tolerated
===Transsphenoidal resection===
*Medical therapy fails to reduce [[ prolactin]] levels
{| align="right"
*Medical therapy fails restore normal reproduction and [[pituitary]] function
| [[image:Pituitary Tumor Removal.png|thumb|500px|Transsphenoidal approach to pituitary tumor - Source: Wikimedia.org<ref name=Delayed puberty "{{commons.wikimedia.org/wiki/User:BruceBlaus" title="User:BruceBlaus">BruceBlaus-Own work, <"https://commons.wikimedia.org/w/index.php?curid=61131794"></ref>]]
*Medical therapy fails to reduce tumor size.
|-|
If medical therapy is only partially successful, it should be continued, possibly combined with surgery or [[radiation]].
| {{#ev:youtube|_fioC34LZeg|500}}
|}


===Transsphenoidal Resection===
==== Endoscopic transsphenoidal surgery<ref name="pmid24533411">{{cite journal| author=Fan YP, Lv MH, Feng SY, Fan X, Hong HY, Wen WP et al.| title=Full Endoscopic Transsphenoidal Surgery for Pituitary Adenoma-emphasized on Surgical Skill of Otolaryngologist. | journal=Indian J Otolaryngol Head Neck Surg | year= 2014 | volume= 66 | issue= Suppl 1 | pages= 334-40 | pmid=24533411 | doi=10.1007/s12070-011-0317-4 | pmc=3918297 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24533411  }}</ref> ====
Most often, the tumor is removed through the nasal cavity. Rarely, if the tumor is large or has spread to nearby brain tissue, the surgeon will access the tumor through an opening in the skull.
* In this method, the [[pituitary tumor]] is excised through [[nostrils]] by means of a tiny fiber-optic [[endoscopic]] tube.
* First, bilateral [[nasal]] septal [[mucosa]] is incised in a C-shaped manner. The septal [[bone]] is approached through this incision.
* Then, [[sphenoidal]] rostrum and anterior wall of [[sphenoid sinus]] are gradually removed, a [[bone]] window is opened through the [[skull]] space.
* After that, the [[dura mater]] is passed and the lesion becomes visible.
* Finally, the [[tumor]] is removed using [[curette]] and basket with suction.
* '''Advantages:'''
** No harm to other parts of the [[brain]]
** High cure rate
** No visible [[scar]]
* '''Disadvantages''':
** Not for large [[tumors]]
** Recurrent [[sinusitis]] in the future
** Low cure rate in case of [[suprasellar]] adhesion to adjunct tissues


The results of surgery depend a great deal on [[tumor]] size and prolactin levels as well as the skill and experience of the neurosurgeon. The higher the prolactin level before surgery, the lower the chance of normalizing serum prolactin. In the best medical centers, surgery corrects prolactin levels in about 80 percent of patients with small tumors and a serum [[prolactin]] less than 200 nanograms per milliliter (ng/ml).  A surgical cure for large tumors is lower, at 30 to 40 percent. Even in patients with large tumors that cannot be completely removed, drug therapy may be able to return serum prolactin to the normal range-20 ng/ml or less-after [[surgery]].  Depending on the size of the tumor and how much of it is removed, studies show that 20 to 50 percent will recur, usually within 5 years<ref>http://www.niddk.nih.gov/health-information/health-topics/endocrine/prolactinoma/Pages/fact-sheet.aspx</ref>.
==== Craniotomy<ref name="pmid15987585">{{cite journal |vauthors=Youssef AS, Agazzi S, van Loveren HR |title=Transcranial surgery for pituitary adenomas |journal=Neurosurgery |volume=57 |issue=1 Suppl |pages=168–75; discussion 168–75 |year=2005 |pmid=15987585 |doi= |url=}}</ref> ====
 
* Although the preferred procedure to excise the [[pituitary tumors]] is a trans-sphenoidal approach, but in some cases (1-4%) the size of the tumor or any [[suprasellar]] adhesion may require trans-cranial method.
==Radiation Therapy==
* Situations requiring transcranial method include:
 
** Isolation by a narrow waist at the [[diaphragma sellae]]
Rarely, radiation therapy is used if medical therapy and surgery fail to reduce prolactin levels.  Depending on the size and location of the tumor, radiation is delivered in low doses over the course of 5 to 6 weeks or in a single high dose. [[Radiation]] therapy is effective about 30 percent of the time.
** Containment within the [[cavernous sinus]] lateral to the [[carotid artery]]
** Projection anteriorly onto the planum sphenoidal
** Projection laterally into the middle fossa
* [[Skull]] base surgical procedure is also the option for [[pituitary tumor]] treatment but may encounter the problems that transsphenoidal method is faced with.  
* '''Advantages:'''
** Resection of large [[tumors]]
** Ability to excise the tumors with [[suprasellar]] specific conditions
* '''Disadvantages:'''
** Long duration of post-operation recovery
** Damage to other parts of the [[brain]]


== References ==
== References ==
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Latest revision as of 23:50, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Faizan Sheraz, M.D. [2], Anmol Pitliya, M.B.B.S. M.D.[3]

Overview

Surgery is not the first-line treatment option for patients with prolactinoma. Surgery is usually reserved for patients in whom medical therapy fails to reduce the size of the tumor.

Surgery

Indications

Medical therapy should be continued even if it is partially successful, possibly combined with surgery or radiation. Surgery is indicated in patients if medical therapy:[1][2][3]

Transsphenoidal resection

Transsphenoidal approach to pituitary tumor - Source: Wikimedia.org
_fioC34LZeg|500}}

Endoscopic transsphenoidal surgery[4]

  • In this method, the pituitary tumor is excised through nostrils by means of a tiny fiber-optic endoscopic tube.
  • First, bilateral nasal septal mucosa is incised in a C-shaped manner. The septal bone is approached through this incision.
  • Then, sphenoidal rostrum and anterior wall of sphenoid sinus are gradually removed, a bone window is opened through the skull space.
  • After that, the dura mater is passed and the lesion becomes visible.
  • Finally, the tumor is removed using curette and basket with suction.
  • Advantages:
    • No harm to other parts of the brain
    • High cure rate
    • No visible scar
  • Disadvantages:

Craniotomy[5]

  • Although the preferred procedure to excise the pituitary tumors is a trans-sphenoidal approach, but in some cases (1-4%) the size of the tumor or any suprasellar adhesion may require trans-cranial method.
  • Situations requiring transcranial method include:
  • Skull base surgical procedure is also the option for pituitary tumor treatment but may encounter the problems that transsphenoidal method is faced with.
  • Advantages:
    • Resection of large tumors
    • Ability to excise the tumors with suprasellar specific conditions
  • Disadvantages:
    • Long duration of post-operation recovery
    • Damage to other parts of the brain

References

  1. ↑ "Prolactinoma | NIDDK".
  2. ↑ Colao A, Savastano S (2011). "Medical treatment of prolactinomas". Nat Rev Endocrinol. 7 (5): 267–78. doi:10.1038/nrendo.2011.37. PMID 21423245.
  3. ↑ Nomikos P, Buchfelder M, Fahlbusch R (2001). "Current management of prolactinomas". J Neurooncol. 54 (2): 139–50. PMID 11761431.
  4. ↑ Fan YP, Lv MH, Feng SY, Fan X, Hong HY, Wen WP; et al. (2014). "Full Endoscopic Transsphenoidal Surgery for Pituitary Adenoma-emphasized on Surgical Skill of Otolaryngologist". Indian J Otolaryngol Head Neck Surg. 66 (Suppl 1): 334–40. doi:10.1007/s12070-011-0317-4. PMC 3918297. PMID 24533411.
  5. ↑ Youssef AS, Agazzi S, van Loveren HR (2005). "Transcranial surgery for pituitary adenomas". Neurosurgery. 57 (1 Suppl): 168–75, discussion 168–75. PMID 15987585.


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