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Thyroid, Pregnenolone, Progesterone, DHEA, etc
Thyroid, DHEA, Pregnenolone, Progesterone, etc
Surgery as a first-line option for prolactinomas
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<blockquote data-quote="madman" data-source="post: 238217" data-attributes="member: 13851"><p><strong>Surgery as a first-line option for prolactinomas (2022)</strong></p><p><em>Adam Mamelak</em></p><p></p><p></p><p><strong>ABSTRACT </strong></p><p><strong></strong></p><p><strong>Introduction:</strong> <em>Treatment of prolactinomas with dopamine agonists has been the established first-line treatment option for many years, with surgery reserved for refractory cases or medication intolerance. This approach may not be the best option in many cases. </em></p><p></p><p><strong>Areas covered:</strong> <em>Review of the epidemiology, biology, and treatment options available for prolactinomas, including the best available data on outcomes, costs, and morbidities for each therapy. These data are then used to propose a ‘surgery-first’ treatment approach for a subset of prolactinomas as an alternative to primary medical management.</em></p><p></p><p><strong>Expert opinion: </strong><em>Based on the available data, there is a strong rationale that transsphenoidal surgery should be considered a first-line treatment option for both micro- and macro-prolactinomas that do not demonstrate high-grade cavernous sinus invasion on MRI imaging, with dopamine agonists administered as a secondary therapy for tumors not in remission following surgery, and for giant tumors. This ‘surgery-first’ approach assumes the availability of skilled and experienced pituitary surgeons to ensure optimal outcomes. This approach should result in high cure rates and reduced DA requirements for patients not cured from the initial surgery. Further, it will reduce medical costs over a patient’s lifetime and the chronic morbidities associated with protracted dopamine agonist usage.</em></p><p></p><p></p><p></p><p></p><p><strong>1. Introduction </strong></p><p></p><p><em>Despite prolactinoma being the most common hormone-secreting pituitary tumor [1], it is often among the least commonly operated, ranging from 7% to 20% of tumors in several large series [2–5].<strong> This observation is historically attributed to both the efficacy of non-surgical treatment by dopamine agonists (DA) as well as a prevalence for later-term recurrence following initial remission. The goal of this review is to reevaluate the most current data on this topic and determine if indeed the role for surgery has been underestimated.</strong></em></p><p></p><p></p><p></p><p></p><p><strong>2. Epidemiology and clinical presentation</strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>3. Overview of prolactin biology </strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>4. Causes of hyperprolactinemia</strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>5. Treatment options</strong></p><p><strong></strong></p><p><strong>5.1. Observation </strong></p><p><strong></strong></p><p><strong>5.2. Dopamine agonists</strong></p><p><em>5.2.1. Bromocriptine</em></p><p><em>5.2.2. Cabergoline </em></p><p></p><p><strong>5.3. Dopamine agonist side effects</strong></p><p><strong></strong></p><p><strong>5.4. Withdrawal of dopamine agonists </strong></p><p><strong></strong></p><p><strong>5.5. Dopamine resistance</strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>6. Surgery</strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>7. Cost of surgical versus medical therapy</strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>8. Radiation therapy </strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>9. Expert opinion</strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong></strong></p><p><strong>10. Conclusion</strong></p><p><strong></strong></p><p><strong><em>There is currently relative equivalency between the outcomes of transsphenoidal surgery and medical therapy for prolactinomas without high-grade cavernous sinus invasion.<u> Assuming there is an experienced, and competent pituitary neurosurgeon available, surgical therapy should no longer be relegated to second-line therapy in appropriately selected cases, and in fact, should be considered a first-line option offered to patients upfront</u>. <u>A prospective randomized trial comparing primary surgical and primary medical therapy would be the ideal way to resolve this issue</u>. As a shift toward primary surgery occurs, careful reevaluation of data will prove invaluable to make a final determinant of the benefits of each approach.</em></strong></p></blockquote><p></p>
[QUOTE="madman, post: 238217, member: 13851"] [B]Surgery as a first-line option for prolactinomas (2022)[/B] [I]Adam Mamelak[/I] [B]ABSTRACT Introduction:[/B] [I]Treatment of prolactinomas with dopamine agonists has been the established first-line treatment option for many years, with surgery reserved for refractory cases or medication intolerance. This approach may not be the best option in many cases. [/I] [B]Areas covered:[/B] [I]Review of the epidemiology, biology, and treatment options available for prolactinomas, including the best available data on outcomes, costs, and morbidities for each therapy. These data are then used to propose a ‘surgery-first’ treatment approach for a subset of prolactinomas as an alternative to primary medical management.[/I] [B]Expert opinion: [/B][I]Based on the available data, there is a strong rationale that transsphenoidal surgery should be considered a first-line treatment option for both micro- and macro-prolactinomas that do not demonstrate high-grade cavernous sinus invasion on MRI imaging, with dopamine agonists administered as a secondary therapy for tumors not in remission following surgery, and for giant tumors. This ‘surgery-first’ approach assumes the availability of skilled and experienced pituitary surgeons to ensure optimal outcomes. This approach should result in high cure rates and reduced DA requirements for patients not cured from the initial surgery. Further, it will reduce medical costs over a patient’s lifetime and the chronic morbidities associated with protracted dopamine agonist usage.[/I] [B]1. Introduction [/B] [I]Despite prolactinoma being the most common hormone-secreting pituitary tumor [1], it is often among the least commonly operated, ranging from 7% to 20% of tumors in several large series [2–5].[B] This observation is historically attributed to both the efficacy of non-surgical treatment by dopamine agonists (DA) as well as a prevalence for later-term recurrence following initial remission. The goal of this review is to reevaluate the most current data on this topic and determine if indeed the role for surgery has been underestimated.[/B][/I] [B]2. Epidemiology and clinical presentation 3. Overview of prolactin biology 4. Causes of hyperprolactinemia 5. Treatment options 5.1. Observation 5.2. Dopamine agonists[/B] [I]5.2.1. Bromocriptine 5.2.2. Cabergoline [/I] [B]5.3. Dopamine agonist side effects 5.4. Withdrawal of dopamine agonists 5.5. Dopamine resistance 6. Surgery 7. Cost of surgical versus medical therapy 8. Radiation therapy 9. Expert opinion 10. Conclusion [I]There is currently relative equivalency between the outcomes of transsphenoidal surgery and medical therapy for prolactinomas without high-grade cavernous sinus invasion.[U] Assuming there is an experienced, and competent pituitary neurosurgeon available, surgical therapy should no longer be relegated to second-line therapy in appropriately selected cases, and in fact, should be considered a first-line option offered to patients upfront[/U]. [U]A prospective randomized trial comparing primary surgical and primary medical therapy would be the ideal way to resolve this issue[/U]. As a shift toward primary surgery occurs, careful reevaluation of data will prove invaluable to make a final determinant of the benefits of each approach.[/I][/B] [/QUOTE]
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Thyroid, Pregnenolone, Progesterone, DHEA, etc
Thyroid, DHEA, Pregnenolone, Progesterone, etc
Surgery as a first-line option for prolactinomas
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