Clinical Case Long-term Follow-up after Transcranial Hypophysectomy in Macroprolactinomas

Currently, transcranial hypophysectomy is infrequently used since the trans-sphenoidal approach is very effective and less invasive. Prolactinomas represent one of the rarest indications for pituitary surgery due to the spectacular effects of dopamine agonists as cabergoline. A 66-year-old female presented at age of 52 with headache, low blood pressure. The investigations revealed panhypopituitarism, high prolactin and a large pituitary mass with obstructive hydrocephalus at the left lateral ventricle. Transcranial surgery was performed through a right approach without complications. The pathological report confirmed a pituitary adenoma with intense cellular pleomorphism. A 29-year-old male was admitted at the age of 28 for severe headache, multiple episodes of vomiting, and hypotension. Pituitary insufficiency and hyperprolactinemia were correlated to the presence of an intrasellar tumor of 2/2 cm with extension to the right cavernous sinus, optic chiasm. The pathological report confirmed a pituitary adenoma. Transcranial pituitary surgery represents an option only in selected large macroprolactinomas. After procedure, a good outcome is expected despite the potential secondary eye field defects or pituitary insufficiency which needs medication. Sometime the panhypopituitarism caused first by the tumor itself persists after surgery (as in our first case) or it is corrected (as adrenal insufficiency in the second case). The presence of a residual prolactin producing tumor requires long term specific therapy with dopamine agonists.