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The role of endoscopic endonasal surgery in the management of prolactinomas based on their invasiveness into the cavernous sinus

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Abstract

Purpose

To review our institutional experience with the surgical management of prolactinomas through the endoscopic endonasal approach with specific focus on cavernous sinus invasion.

Methods

Clinical and radiographic data were collected retrospectively from the electronic medical record of 78 consecutive patients with prolactinomas undergoing endoscopic endonasal resection from 2002 to 2019. Immediate and late post-operative remission were defined as prolactin < 20 ng/mL within 14 days and 1-year of surgery without adjuvant therapy, respectively. Cavernous sinus invasion was quantified by Knosp score.

Results

A total of 78 patients with prolactinoma, 59% being male, underwent surgical resection with a mean age of 37 ± 13 years. Indications for surgery were medication resistance in 38 patients (48.7%), medication intolerance in 11 (14.1%), and patient preference in 29 (37.2%). Patients with Knosp 0–2 achieved higher immediate remission rates (83.8%) compared to patients with Knosp 3 (58.8%) and Knosp 4 (41.7%) patients (p = 0.003). Long-term remission rates were 48.7% and increased to 71.8% when combined with adjuvant treatments. Knosp 4 prolactinomas had significantly higher tumor volumes, higher preoperative prolactin levels, higher recurrence rates, higher rates of adjuvant therapy utilization, and were more likely to have failed dopamine agonist therapy compared to other tumor grades (p < 0.05). We encountered 18 complications in our series, and no cerebrospinal fluid leaks.

Conclusion

The endoscopic endonasal approach is a safe and effective modality that can be employed in properly selected patients with invasive prolactinomas. It is associated with improved control and remission rates despite cavernous sinus invasion, though at a lower rate than without invasion.

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Data availability

All authors confirm the appropriateness of all dataset and software used for supporting the conclusion. All data generated or analyzed during this study are included in this published article.

Code availability

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Acknowledgements

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Hussam Abou-Al-Shaar, Arka N. Mallela, Aneek Patel, Paul A. Gardner & Georgios A. Zenonos

  2. Neuroendocrinology Unit, Division of Endocrinology and Metabolism, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Rimsha K. Shariff & Pouneh K. Fazeli

  3. Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA

    Samuel S. Shin

  4. Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, USA

    Phillip A. Choi

  5. Department of Neurosurgery, Houston Methodist, Houston, TX, USA

    Amir H. Faraji

  6. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA

    Tina Costacou

  7. Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Eric W. Wang & Carl H. Snyderman

  8. Department of Neurosurgery, Stanford University, Palo Alto, CA, USA

    Juan C. Fernandez-Miranda

Authors
  1. Hussam Abou-Al-Shaar
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  14. Georgios A. Zenonos
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Corresponding author

Correspondence to Georgios A. Zenonos.

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The study was approved by the IRB at the University of Pittsburgh Medical Center.

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Abou-Al-Shaar, H., Mallela, A.N., Patel, A. et al. The role of endoscopic endonasal surgery in the management of prolactinomas based on their invasiveness into the cavernous sinus. Pituitary 25, 508–519 (2022). https://doi.org/10.1007/s11102-022-01221-3

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