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MACROPROLACTINOMA in MRI compressing OPTIC CHIASMA. Is surgery needed?

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I have a person in family that was diagnosed with prolactinoma. The size is about 2,4cm x 2,3 cm, so it is a macroprolactinoma. The optic chiasm is being compressed but there is no cavernous sinus invasion, and the MRI report says that the prolactinoma has not increased in size since the last CT (one month ago). The neurosurgeon wants to do a surgery (sublabial approach) just to reduce the optic chiasm compression, he doesn't wants to completely remove, and then treat the prolactinoma with cabergoline. I have some questions:

- Does it make sense ? I mean, doing a surgery and then treating it with cabergoline ?

- Do you think that the surgery should be the first option or we should try cabergoline first ?

- Is the surgery too risky ? (considering he is not trying to remove it completely, just doing the surgery to reduce chiasm compression)

Category: Neurosurgeon

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Category: Spine Surgeon
Dr. Goutham Cugati is online now

Expert:  Dr. Goutham Cugati replied 4 Days.

Dear Sir,
Thank you for your query at DoctorSpring.com

Prolactinomas are tumours of the pituitary gland. They can be treated with cabergoline or bromocriptine. his is the medical management. The dose of the medication will be titrated based on the response of the patient as assessed by the prolactin levels.

If the prolactinoma is big enough to cause compression on the optic chiasma(as in your case) resulting in visual defects(details not available), we don't wait till the tumour shrinks with medicines. We will have to operate and debulk the tumour. However the maximum results which can be achieved is gross total excision(GTE) or many a times it is sub total excision(STE). In both the cases, there is chances of recurrence of the tumour after many years which cannot be accurately predicted. So cabergoline will have to be given in appropritate doses as required.

Answering your questions
1. It does make sense. This is the right decision
2. Surgery is the first option, followed by cabergoline
3. Any surgery has its set of complication, whether it is GTE or STE. I am sure the surgeon will mention it to you before surgery. There are many approaches to this tumour. Sublabial approach is one of the standard approaches.

Dr Goutham Cugati

Consultant Neurosurgeon

Patient replied :

Dr. Goutham Cugati,
Your reply was almost 100% satisfactory, thank you. But I am a little worried and I have to insist about the surgery risks. I know that every surgery has possible complications, but I just want to know if the risks for this kind of surgery are high. If I did understand correctly, in that case the surgery would be a sub total excision. I have two more questions:

- Is sub total excision surgery time shorter than gross total excision ?
- Does sub total excision has less risks than gross total excision ?

Expert:  Dr. Goutham Cugati replied 3 Days.

Dear Sir,

The risks involve

Common - not so serious:
Bleeding from operative site

Serious - not so common:
CSF leak from nose
Intracranial bleed
Injury to the optic nerves
Hormonal imbalance

I think you can have this list for guiding you for a pre-surgery discussion with your neurosurgeon.


Dr Goutham Cugati

Patient replied :

Can't you really answer the other two questions ?

- Is sub total excision surgery time shorter than gross total excision ? - Does sub total excision has less risks than gross total excision ?

Expert:  Dr. Goutham Cugati replied 2 Days.

Dear Sir,

The decision of subtotal or gross total excision is an on-table decision. The ideal term would be Maximum safe resection. Time is not at all a criterion in brain surgeries. Safety if of topmost concern


Dr Goutham Cugati

Patient replied :

Dr. Goutham Cugati,

I'm sorry, but I'm not talking about the decision to do a sub total excision or a gross total excision. I just want to know if the surgery time of a subtotal excision is shorter than the surgery time of a gross total excision. Plus, I want to know if there are less risks involved when doing a sub total excision. And just to clarify: I was told that pituitary surgeries are not brain surgeries. Why did you say "brain surgery" ?

Expert:  Dr. Goutham Cugati replied 1 Day.

Dear sir,

The duration for subtotal and gross total excision will be same.

Pituitary gland is part of brain. And tumour of pituitary gland are considered tumours of the skull base. And I don't understand why should someone say that surgery of pituitary tumour is not a brain surgery.

Dr. Goutham Cugati
Category: Spine Surgeon
Residency: Neurosurgery, the Post-Graduate Institute of Neurological Surgery, Dr. Achanta Lakshmipathi Neuro surgical Center, VHS Hospital, Chennai, 2011

Postgraduate in Neurosugery: DNB, National Board of Examinations,
Part 1 - 2008, Part 2 -  2010

Medical School: Bachelor of Medicine, Bachelor of Surgery, JSS Medical College, 2004
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