WO WEEK 2

TREATMENT FOR PITUITARY ADENOMAS:

1. Surgical treatment:
 Transsphenoidal microsurgical approach to the sella tursica with endoscope
 Incise anterior-inferior sellar floor through sphenoidal sinus lewat hidung
 90% success rates di micro adenomas
 Komplikasi: post operative hemorrhage, CSF leak, meningitis, visual impairment
2. Radiotherapy
 Conventional irradiation:
o Doses of 4000-5000cGy of total dose: 180-200 cGy daily
o Efek radiation sangat slow: 5-10 years baru berasa efeknya
o 80% success di acromegaly patients, 55-60% di Cushing’s disease
o Hypopituitarism at 5-10 years: 50-60%
 Gamma knife radiosurgery
o Stereotactic CT-guided cobalt-60 gamma radiation
o Remission rates: 43-78%
 Proton stereotactic radiotherapy:
o Kurang penelitian
o Efektif di 52% pasien Cushing

1. Prolactinoma:
1. Microadenoma:
 Paling baik di pasien dengan PRL >200ng/mL dan amenorrhea selama <5 years
 PRL di betulin, gonadal function akan kembali normal
2. Macroadenoma:
 Rata-rata dikasih dopamine agonist aja karena success ratenya rendah
 Tergantung tumor size and basal PRL:
o Kalo tumor 1-2cm in diameter -> success rate 25-55%
o Kalo basal PRL <200ng/mL -> success rate 80%
3. Radiotherapy:
 Diberikan di orang dengan macroadenoma yang ga merespon terhadap therapy
 4000-5000cGy to prevent progression
 May cause anterior pituitary impairment (50-60%)
4. Medical treatment: DOPAMINE AGONIST
a. Bromocriptine:
 Efek di hypothalamus and pituitary
 Inhibit PRL secretion of tumor
 2.5-5mg per day
 b. Cabergoline:
 New nonergot dopamine agonist
 Once or twice per week better side effects than bromocriptine
 Efektif di pasien dengan resistensi bromocriptine
 Initial dose: 0.25mg, 2x per week or 0.5mg 2x per week
o Microadenoma:
 Sukses di 90% pasien yang ga ada resistensi
 Orang hamil minum obat ini gapapa
 Stop obat kalo skip menstruasi 1x or kalo lagi menjalani pregnancy test
o Macroadenoma:
 Efektif di terms of control
 Bisa as initial therapy or control sisa-sisa operasi
 Ga boleh diberikan untuk stimulate ovulation and or pregnancy di orang
dengan untreated macroadenoma karena bisa promote tumor expansion.
 Reduce tumor size and normalizes PRL secretion di 60-70% of patients

2. Acromegaly:
1) Considerations:
a. Mortality meningkat di pasien dengan GH >2.5ng/mL
b. Sukses therapy if:
i. Fasting GH: 1ng/mL or less
ii. Glucose suppressed GH 1ng/mL or less
iii. Normal levels of IGF-1
2) Surgical treatment:
 Transsphenoidal selective adenoma removal
 Craniotomy kalo sudah suprasellar extension
 Successful reduction in 60-80% of patients with tumors <2cm
3) Medical treatment:
 Octreotide acetate -> somatostatin merupakan first line therapy against acromegaly
(100-500µg 3dd1).
 May cause impaired glucose tolerance.
4) Radiotherapy:
 Conventional therapy jangan dilakukan karena GH levels may return to normal 10-15
years after therapy -> KELAMAAN
 Gamma knife buat tumor yang ada di sella tursica.
3. Cushing’s Disease:
1) Surgical treatment:
 Transsphenoidal resection of adenoma
 Exploration of intrasellar contents
 Microadenoma biasanya sukses untuk nurunin hypercortisolism
 Kalo macroadenoma, transsphenoidal cuma 25% success rate
 Bisa total adrenalectomy untuk permanent hypercortisolism
2) Radiotherapy:
 Conventional radiotherapy untuk recurrent or persistent Cushing after microsurgery
 Gamma knife: 65-75% remission
3) Medical treatment:
 Ketoconazole: 600-1200mg/day
 Metyrapone: nurunin adrenal secretion of cortisol
 Mitotane: stimulate adrenal atrophy of zona fasiculata and reticularis -> 80% remission
 Etomidate: IV and kalo gawat darurat akibat hypercortisolism