J Neurol Surg A Cent Eur Neurosurg 2018; 79(S 01): S1-S27
DOI: 10.1055/s-0038-1660711
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Georg Thieme Verlag KG Stuttgart · New York

Should Primary Pituitary Surgery for Prolactinomas be Limited to Selected Patients with Microadenomas?

L. Andereggen
1   Kantonsspital Aarau, Aarau, Switzerland
,
J. Frey
2   Kantonsspital Luzern, Luzern, Switzerland
,
R. Andres
3   Inselspital, University Hospital Bern, Bern, Switzerland
,
M. El-Koussy
3   Inselspital, University Hospital Bern, Bern, Switzerland
,
M. Luedi
3   Inselspital, University Hospital Bern, Bern, Switzerland
,
J. Beck
3   Inselspital, University Hospital Bern, Bern, Switzerland
,
L. Mariani
4   University Hospital of Basel, Basel, Switzerland
,
J. Fandino
1   Kantonsspital Aarau, Aarau, Switzerland
,
E. Christ
4   University Hospital of Basel, Basel, Switzerland
› Author Affiliations
Further Information

Publication History

Publication Date:
23 May 2018 (online)

 

Aims: Consensus guidelines recommend dopamine (DA-) agonists as the first-line approach for treating prolactinomas. Although consideration of a primary surgical approach in selected patients with microadenomas is warranted, upfront surgery in patients with macroprolactinomas remains controversial, wherefore data from studies in large cohorts are sparse. In the present audit of practice in a dedicated tertiary referral center, we, therefore, investigated whether tumor size impacts on the long-term control of hyperprolactinemia following primary pituitary surgery with the aim of identifying risk factors for persistent long-term hyperprolactinemia and dependence on DA-agonists.

Methods: Retrospective case-note study of prospectively collected data on patients with micro- and macroprolactinomas treated with primary pituitary surgery without prior DA-agonists. The clinical, biochemical, and radiological responses to first-line surgery were analyzed. The primary end point was patients’ dependence of DA-agonists at last follow-up. The secondary end point was postoperative complications. Independent risk factors for persistent long-term hyperprolactinemia and dependence on DA-agonists were calculated using multivariate logistic regression.

Results: A microadenoma was noted in 46 (54%) and macroadenoma in 40 (46%) patients. Median follow-up was 80 (range, 13–408) months. Long-term prolactin levels significantly decreased in all patients, independent of the initial tumor size. Long-term remission was obtained in 82% of patients with a micro- and 75% of patients with a macroprolactinoma (p = 0.60). Control of hyperprolactinemia required DA-agonists in 26% of patients with micro- versus 48% of those with macroadenomas (p = 0.05). There was no surgical related mortality and morbidity was minimal. Cavernous sinus invasion (odds ratio [OR] 6.2, 95% confidence interval [CI] 1.2–31.9, p = 0.03) but not tumor size (OR 1.2, 95% CI 0.4–4.1, p = 0.72) was an independent predictor for long-term dependence on DA-agonists following primary surgery.

Conclusion: Our data indicate that in a dedicated tertiary referral center first-line surgery is a valuable alternative not only for micro- but also for macroprolactinomas that have not infiltrated the cavernous sinus.