What is the role of surgery in the treatment of prolactinomas?

Answer

Transsphenoidal pituitary adenomectomy is the preferred surgical treatment in patients with microprolactinoma and in most patients with macroprolactinoma.^[2]A transcranial approach is used only in patients with large extrapituitary extension. A transcranial pituitary tumor resection is more hazardous, being associated with higher mortality and morbidity rates.

A combination of surgery followed by postoperative medical treatment with BEC or one of the other agents is used in patients with incomplete resolution of elevated PRL levels and in persons with residual tumors seen on follow-up imaging studies.

In surgical series of patients with microadenomas, normalization of PRL levels is reported in approximately 70-75% of patients. Recurrence rates of approximately 17% are reported. This surgery is associated with low mortality and morbidity rates (approximately 0.3% and 0.4%, respectively).

Data from a tertiary center indicate an initial cure rate of approximately 90% and a recurrence rate of 16% for microprolactinomas.^[38]However, results vary with the experience of the neurosurgeon and the duration of follow-up. Complications include hypopituitarism, bleeding, cerebrospinal fluid rhinorrhea, and diabetes insipidus (see Complications).

In patients with macroprolactinomas, normalization of the PRL level occurs initially in approximately 30% of patients, and the recurrence rate is about 15-20%. Mortality and morbidity rates are less than 1% and 6%, respectively.

Indications for surgery are as follows:

Women who have a microadenoma, desire pregnancy, and cannot tolerate BEC should undergo surgical treatment.
Patients who do not wish to take BEC or one of the other drugs long-term should be considered for surgical treatment.
Patients who do not respond to medical treatment or those who show progression after an initial response to medical treatment should receive surgical treatment.

A retrospective study of male patients by Andereggen et al indicated that in men with prolactinomas, impaired bone density remains a problem even after medical (DA agonist) or surgical treatment. The two types of therapy each successfully controlled hyperprolactinemia and hypogonadism. However, at median long-term follow-up (63 mo), bone density pathology was found in 37% of patients, being high in both the medical and surgical cohorts, compared with 27% at baseline.^[39]

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