Neurosurgery Presentation on most common Pituitary gland tumor "Prolactinoma"

2. PROLACTINOMA
By
Dr Pirah Korai
Neurosurgery Resident, R4
JPMC

3. OUTLINES
• Introduction
• Epidemiology
• Prolactin regulation
• Hyperprolactinemia
• Clinical Presentation
• Classification
• Investigation
• Management
• Pharmacotherapy
• Surgical resection
• Radiotherapy

5. EPIDEMIOLOGY

6. 35%
48%
10%
6%
1%
Nonfunctioning
adenoma
Prolactinoma
GH secreting
ACTH secreting
TSH

9. REMEMBER: Not all
hyperprolactinemia is due to a
prolactinoma

10. Causes of Hyperprolactinemia
• Hypothalamic Dopamine Deficiency
– Diseases of the hypothalamus( including tumors, arterio-venous
malformations, and inflammatory processes
– Drugs (e.g. alpha-methyldopa and reserpine)
• Defective Transport Mechanisms
– Section of the pituitary stalk
– Pituitary or stalk tumors

11. Causes of Hyperprolactinemia (continued)
• Lactotroph Insensitivity to Dopamine
– Dopamine-receptor-blocking agents: phenothiazines (e.g.
chlorpromazine), butyrophenones (haloperidol), and benzamides
(metoclopramide, sulpiride, and domperidone)
• Stimulation of Lactotrophs
– Hypothyroidism- increased TRH production (acts as a PRF)
– Estrogens: stimulate lactotrophs
– Injury to the chest wall: abnormal stimulation of the reflex
associated with the rise in prolactin that is seen normally in
lactating women during suckling

14. Clinical Presentation

16. • Hyperprolactinemia
– Amenorrhea-Galactorrhea syndrome
– Infertility
– Weight gain
– PCO
 Headache
 Mass effects
 Bitemporal hemianopia
 Hydrocephalus
 Cavernous signs
 Partial complex seizure
 Hypothalamic hypofunction
 Pituitary apoplexy

17.  Stalk effect
 Book effect

18. Classification
 On the basis of size
• Microadenoma
• Macroadenoma
 On the basis of Histopathology
• Typical Adenoma
• Atypical adenoma
• Pituitary CA
 On the basis of relation with Sella
• Hardy and Wilson classification
• Knop’s classification

19. • KNOP’s Classification

21. Investigations
 Hormonal workup
 Rule out pregnancy
 Visual Perimetry
 MRI pituitary protocol
 DCE images
 CT brain for surgical planning

25. Visual perimetry

26. Management of Pituitary Prolactinoma
• Pharmacotherapy
• Surgery
• Radiation Therapy

27. Pharmacotherapy
• Dopamine agonists
– Bromocriptine
– Pergolide
– Cabergoline
• Side effects include: postural hypotension, dizziness, nasal
stuffiness, GI side effects.

28. Shrinkage of Prolactinoma after
Bromocriptine
Abrahamson, M. UpToDate

29. J Clin Endocrinol Metab 50:1026 1033
Long-term Effects of Bromocriptine
Therapy

30. SURGICAL RESECTION

32. TRANSPHENOIDALAPPROACHES

33. Position of patient

34. Patient’s preparation
 Peri-operative broad spectrum antibiotics
 Nasal decongestion 0.05% Oxymetazoline soaked
guaze
 1% Lidocaine with adrenaline soaked guaze
 Prepare subumbilical/ Left lower quadrant of
abdomen for fat graft

36. PROCEDURE
PROCEDURE

38. Complications of Transsphenoidal
Surgery
Outcome Measure Incidence (%)
Mortality <0.5
Major complication (CSF leak,
meningitis, ischemic stroke,
intracranial hemorrhage,
vascular injury, visual loss)
1.5
Minor complication (sinus
disease, septal perforations,
epistaxis, wound infections
and hematomas)
6.5
John A. Jane, Jr., MD Edward R. Laws, Jr., MD, SURGICAL MANAGEMENT OF PITUITARY ADENOMAS
Chapter 13. http://www.endotext.com/neuroendo/neuroendo13/neuroendoframe13.htm

39. Outcome of Transsphenoidal
Surgery
Tumor Remission (%) Recurrence at 10 years (%)
Non-functioning adenoma Not applicable* 16
GH adenoma Microadenoma 88 1.3
Macroadenoma 65
PRL adenoma Microadenoma 87 13
Macroadenoma 56
ACTH adenoma
Microadenoma
91 12 (Adults), 42 (Pediatric)
Macroadenoma 65
*Visual improvement occurs in 87% of those with preoperative visual loss.
John A. Jane, Jr., MD Edward R. Laws, Jr., MD, SURGICAL MANAGEMENT OF PITUITARY ADENOMAS
Chapter 13. http://www.endotext.com/neuroendo/neuroendo13/neuroendoframe13.htm

40. TRANSCRANIALAPPROACHES

41. Subfrontal
Approach

42. SUPRAORBICALAPPROACH

43. Transcavernous approach

44. Radiation Therapy
• Reserved for patients with larger tumors and/or
persistent hormonal hyperfunction despite surgical
intervention
– Conventional radiotherapy
– Gamma knife radiosurgery