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neurosurgeons are successful in normalizing prolactin in 87% of patients; the 10-year recurrence rate is 13% Pituitary function can be preserved in over 95% of cases However, the surgical success rate for macroprolactinomas is much lower, and the complication rates are higher Craniotomy is rarely indicated, since even large tumors can usually be decompressed via the transsphenoidal approach
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Radiation therapy is reserved for patients with macroadenomas that are growing despite treatment with dopamine agonists A single gamma knife or cyberknife treatment is preferable for certain patients whose optic chiasm is clear of tumor, since it is generally safer and more convenient than conventional radiation therapy Conventional radiation therapy must be given over 5 weeks and carries a high risk of eventual hypopituitarism Other possible side effects include some degree of memory impairment and an increased longterm risk of second tumors and small vessel ischemic strokes After radiation therapy, patients are advised to take low-dose aspirin to reduce their stroke risk
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Colao A et al Outcome of cabergoline treatment in men with prolactinoma: effects of a 24-month treatment on prolactin levels, tumor mass, recovery of pituitary function, and semen analysis J Clin Endocrinol Metab 2004 Apr;89(4):1704 11 [PMID: 15070934] Delgrange E Cabergoline and mitral regurgitation N Engl J Med 2006 Jan 26;354(4):420 [PMID: 16436779] Gibney J et al The impact on clinical practice of routine screening for macroprolactin J Clin Endocrinol Metab 2005 Jul;90(7):3927 32 [PMID: 15811931] Haddad PM et al Antipsychotic-induced hyperprolactinaemia: mechanisms, clinical features and management Drugs 2004; 64(20):2291 314 [PMID: 15456328] Molitch ME Medication-induced hyperprolactinemia Mayo Clin Proc 2005 Aug;80(8):1050 7 [PMID: 16092584] Sodi R et al Testosterone replacement-induced hyperprolactinaemia: case report and review of the literature Ann Clin Biochem 2005 Mar;42(Pt 2):153 9 [PMID: 15829128]
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Assays for FT4, total triiodothyronine (T3), and free triiodothyronine (FT3) have largely supplanted measurements of total T4, resin T3 uptake (RT3U), and free thyroxine index (FT4I) It is particularly important to determine free serum levels (FT4 and FT3) in conditions associated with high circulating levels of thyroid binding globulin, such as during pregnancy or therapy with oral estrogen Ultrasensitive assays for serum TSH have largely replaced older TSH assays Table 26 3 shows the appropriate use of thyroid tests
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Transsphenoidal pituitary surgery may be urgently required for large tumors undergoing apoplexy or those severely compromising visual fields It is also used electively for patients who do not tolerate or respond to dopamine agonists Pituitary transsphenoidal surgery is generally well-tolerated, with a surgical mortality rate of less than 05% Complications, such as cerebrospinal fluid leakage, meningitis, stroke, or visual loss, occur in about 3% of cases; sinusitis, nasal septal perforation, or infection complicates about 65% of surgeries Postoperative hyponatremia occurs quite commonly, and it is advisable to monitor serum sodium levels for the first 2 weeks postoperatively For pituitary microprolactinomas, skilled
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Many factors affect thyroid function tests, causing misleading laboratory evidence of hypothyroidism (Table 26 4) or
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Table 26 3 Appropriate use of thyroid tests
Test Screening Serum thyroid-stimulating hormone (TSH) (sensitive assay) Free thyroxine (FT4) Serum TSH Antithyroglobulin and antithyroperoxidase antibodies Serum TSH (sensitive assay) Triiodothyronine (T3) (radioiodine) 123 I uptake and scan Antithyroglobulin and antimicrosomal antibodies Thyroid-stimulating immunoglobulin (TSI); TSH receptor antibody (TSH-R Ab [stim]) Fine-needle aspiration (FNA) biopsy 123 I uptake and scan 99m Tc scan Ultrasonography Comment Most sensitive test for primary hypothyroidism and hyperthyroidism Excellent test High in primary and low in secondary hypothyroidism Elevated in Hashimoto s thyroiditis Suppressed except in TSH-secreting pituitary tumor or pituitary hyperplasia (rare) Elevated Increased uptake; diffuse versus hot areas on scan Elevated in Graves disease Usually (65%) positive in Graves disease Best diagnostic method for thyroid cancer Cancer is usually cold ; less reliable than FNA biopsy Vascular versus avascular Useful to assist FNA biopsy Useful in assessing the risk of malignancy (multinodular goiter or pure cysts are less likely to be malignant) Useful to monitor nodules and patients after thyroid surgery for carcinoma
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