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Stumpf MAM, Galliano SA, Bueno CBF, Glezer A. Long-term use of clomiphene in male macroprolactinomas with persistent hypogonadism. Endocrine 2024:10.1007/s12020-024-03817-0. [PMID: 38578401 DOI: 10.1007/s12020-024-03817-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/01/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Men with macroprolactinoma can present persistent hypogonadism despite normoprolactinemia achieved with clinical and/or neurosurgical treatment. Usually, testosterone replacement therapy is indicated. Nevertheless, although off-label, clomiphene citrate (CC), a selective estrogen receptor modulator, has also been used, mainly when fertility is an issue. The aim of this study is to evaluate the effectiveness of CC in recovering the gonadal axis in men with macroprolactinoma, with or without hyperprolactinemia, and evaluate its safety as a long-term therapy. METHODS This is a retrospective study including 10 men with macroprolactinoma on cabergoline treatment and persistent hypogonadism. All patients received initially 50 mg/d of CC. RESULTS The median age at diagnosis of prolactinomas was 34 (range, 26-60) years old. All patients were treated with cabergoline at a median maximum dose of 2 (1-7) mg/week, with a median time of treatment of 8.5 (2-15) years. Prolactin was still above the normal range when CC was introduced only in two patients. The mean duration of CC therapy was 3.2 (±2.8) years. Prolactin levels maintained stable (p = 0.252) and testosterone increased (p = 0.027) significantly on CC therapy. Tumor size remained stable. Eight patients (80%) maintained testosterone above 300 ng/dL and were classified as responders. Three responders succeeded in using a lower dose of CC and one of them completed withdrawal CC and maintained eugonadism. There were no side effects or safety concerns reported. CONCLUSION CC should be seen as a safe treatment option for men with macroprolactinoma and persistent hypogonadism.
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Affiliation(s)
- Matheo A M Stumpf
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of São Paulo Medical School Hospital, São Paulo, Brazil.
| | - Stefano A Galliano
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - Cristina B F Bueno
- Serviço de Endocrinologia e Metabologia, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Andrea Glezer
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of São Paulo Medical School Hospital, São Paulo, Brazil
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Dzialach L, Sobolewska J, Zak Z, Respondek W, Witek P. Prolactin-secreting pituitary adenomas: male-specific differences in pathogenesis, clinical presentation and treatment. Front Endocrinol (Lausanne) 2024; 15:1338345. [PMID: 38370355 PMCID: PMC10870150 DOI: 10.3389/fendo.2024.1338345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/22/2024] [Indexed: 02/20/2024] Open
Abstract
Prolactinomas (PRLomas) constitute approximately half of all pituitary adenomas and approximately one-fifth of them are diagnosed in males. The clinical presentation of PRLomas results from direct prolactin (PRL) action, duration and severity of hyperprolactinemia, and tumor mass effect. Male PRLomas, compared to females, tend to be larger and more invasive, are associated with higher PRL concentration at diagnosis, present higher proliferative potential, are more frequently resistant to standard pharmacotherapy, and thus may require multimodal approach, including surgical resection, radiotherapy, and alternative medical agents. Therefore, the management of PRLomas in men is challenging in many cases. Additionally, hyperprolactinemia is associated with a significant negative impact on men's health, including sexual function and fertility potential, bone health, cardiovascular and metabolic complications, leading to decreased quality of life. In this review, we highlight the differences in pathogenesis, clinical presentation and treatment of PRLomas concerning the male sex.
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Affiliation(s)
- Lukasz Dzialach
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Sobolewska
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Zuzanna Zak
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Wioleta Respondek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Brodnowski Hospital, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
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3
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Saito N, Hirai N, Koyahara Y, Sato S, Hiramoto Y, Fujita S, Nakayama H, Hayashi M, Iwabuchi S. Evaluation of Treatment Strategies for Male Prolactin-Secreting Pituitary Neuroendocrine Tumors. Cureus 2024; 16:e54503. [PMID: 38516477 PMCID: PMC10955445 DOI: 10.7759/cureus.54503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 03/23/2024] Open
Abstract
Prolactin-secreting pituitary neuroendocrine tumors (PitNETs) are more common in women. Male patients may also have few symptoms and have macroadenomas extending outside the sella turcica. This study aimed to report the results of cabergoline treatment in male patients with prolactin-secreting PitNET. The study included nine male patients aged 26-65 years (median, 46 years) diagnosed with prolactin-secreting PitNETs. The age at onset, prolactin values, tumor size, symptoms, and treatment were assessed. The mean prolactin value at the initial presentation was 2734.6 ng/mL, and the mean maximum tumor diameter was 40.4 mm. Visual field disturbance was the most common symptom (44.4%), followed by headaches (33.3%), asymptomatic symptoms (11.1%), and galactorrhea (11.1%). Eight patients responded to cabergoline treatment with normalization of prolactin levels and tumor shrinkage. One patient did not respond to the cabergoline treatment and required surgical intervention. There were no cases of cerebrospinal fluid leakage. Cabergoline was found to be an effective treatment for male prolactin-secreting PitNETs.
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Affiliation(s)
- Norihiko Saito
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Nozomi Hirai
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Yuki Koyahara
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Sho Sato
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Yu Hiramoto
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Satoshi Fujita
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Haruo Nakayama
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
| | - Morito Hayashi
- Neurosurgery, Toho University Ohashi Medical Center, Tokyo, JPN
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Petersenn S, Fleseriu M, Casanueva FF, Giustina A, Biermasz N, Biller BMK, Bronstein M, Chanson P, Fukuoka H, Gadelha M, Greenman Y, Gurnell M, Ho KKY, Honegger J, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Lodish M, Maiter D, Marcus HJ, McCormack A, Molitch M, Muir CA, Neggers S, Pereira AM, Pivonello R, Post K, Raverot G, Salvatori R, Samson SL, Shimon I, Spencer-Segal J, Vila G, Wass J, Melmed S. Diagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement. Nat Rev Endocrinol 2023; 19:722-740. [PMID: 37670148 DOI: 10.1038/s41574-023-00886-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 09/07/2023]
Abstract
This Consensus Statement from an international, multidisciplinary workshop sponsored by the Pituitary Society offers evidence-based graded consensus recommendations and key summary points for clinical practice on the diagnosis and management of prolactinomas. Epidemiology and pathogenesis, clinical presentation of disordered pituitary hormone secretion, assessment of hyperprolactinaemia and biochemical evaluation, optimal use of imaging strategies and disease-related complications are addressed. In-depth discussions present the latest evidence on treatment of prolactinoma, including efficacy, adverse effects and options for withdrawal of dopamine agonist therapy, as well as indications for surgery, preoperative medical therapy and radiation therapy. Management of prolactinoma in special situations is discussed, including cystic lesions, mixed growth hormone-secreting and prolactin-secreting adenomas and giant and aggressive prolactinomas. Furthermore, considerations for pregnancy and fertility are outlined, as well as management of prolactinomas in children and adolescents, patients with an underlying psychiatric disorder, postmenopausal women, transgender individuals and patients with chronic kidney disease. The workshop concluded that, although treatment resistance is rare, there is a need for additional therapeutic options to address clinical challenges in treating these patients and a need to facilitate international registries to enable risk stratification and optimization of therapeutic strategies.
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany.
- University of Duisburg-Essen, Essen, Germany.
| | | | | | - Andrea Giustina
- San Raffaele Vita-Salute University, Milan, Italy
- IRCCS Hospital San Raffaele, Milan, Italy
| | | | | | | | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Monica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Yona Greenman
- Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Ken K Y Ho
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | | | | | - Ursula B Kaiser
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Maya Lodish
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Hani J Marcus
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ann McCormack
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Alberto M Pereira
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Kalmon Post
- Mount Sinai Health System, New York, NY, USA
| | - Gerald Raverot
- Department of Endocrinology, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est" Hospices Civils de Lyon, Bron, France
| | | | | | - Ilan Shimon
- Tel Aviv University, Tel Aviv, Israel
- Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- University of Oxford, Oxford, UK
- Churchill Hospital, Oxford, UK
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5
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Lisa B, Arno V, Christophe DB, Heyning Paul VD, Carlien DH. Giant prolactinomas, a detailed analysis of 196 adult cases. Pituitary 2023; 26:529-537. [PMID: 37544978 DOI: 10.1007/s11102-023-01337-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE Giant prolactinomas are a rare entity, representing approximately 5% of all prolactinomas. A systematic review of 196 adult cases was performed. A comparison of the clinical, biochemical and radiological characteristics, management and therapeutic outcomes in men versus women is made. METHODS A structured search was conducted using the term 'giant prolactinoma'. Following inclusion criteria were used: diameter ≥ 40 mm, prolactin levels > 1000 ng/ml and no concomitant GH/ ACTH secretion. RESULTS 196 cases were included [age: 38 (28-50) years, F/M ratio: 1/3.6]. Median tumor diameter was 53 (43-69) mm. Pituitary deficiency was present in 91% of cases, with hypogonadotropic hypogonadism being the most frequent. Most common presenting symptoms were visual impairment (73%) and headache (50%) in men and amenorrhea (58%) in women. 82% of cases were treated with a dopamine agonist (DA) as first-line treatment which led to normoprolactinemia, tumor shrinkage and visual improvement in 51%, 88% and 85% of cases, respectively. Surgery was performed in 29% of cases and all showed tumor remnant and persistent hyperprolactinemia. Women had a lower prolactin level and a smaller tumor diameter at diagnosis but pituitary deficiencies were more frequent and outcome was worse. CONCLUSION Giant prolactinomas are rare and have a male predominance. Visual impairment is the most frequent presenting symptom in men and amenorrhea in women. The gender-related difference in tumor size and level of prolactin was confirmed in this analysis where men had a larger diameter and a higher baseline prolactin level. DAs are the treatment of choice, irrespective of tumor size and presence of visual impairment. As only half of the cases achieved normoprolactinemia we do not, in contrast to previous literature, state giant prolactinomas to be exquisitely sensitive to DAs. Patient characteristics associated with persistent hyperprolactinemia after treatment with a DA were female gender, higher baseline prolactin and larger tumor size . This analysis did show TSH- and ACTH-deficiency to be more frequent after surgery which was not seen for LH/FSH deficiency.
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Affiliation(s)
- Billion Lisa
- Department of Endocrinology, Diabetology & Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, B-2650, Belgium
| | - Verleye Arno
- Department of Nephrology, Antwerp University Hospital, Edegem, B-2650, Belgium
| | - De Block Christophe
- Department of Endocrinology, Diabetology & Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, B-2650, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, B-2610, Belgium
| | - Van de Heyning Paul
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, B-2610, Belgium
- Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp University Hospital, Edegem, B-2650, Belgium
| | - De Herdt Carlien
- Department of Endocrinology, Diabetology & Metabolism, Faculty of Medicine, Antwerp University Hospital, Drie Eikenstraat 655, Edegem, B-2650, Belgium.
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6
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Auriemma RS, Pirchio R, Pivonello C, Garifalos F, Colao A, Pivonello R. Approach to the Patient With Prolactinoma. J Clin Endocrinol Metab 2023; 108:2400-2423. [PMID: 36974474 PMCID: PMC10438891 DOI: 10.1210/clinem/dgad174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 03/03/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
Prolactinomas are the most common pituitary tumor histotype, with microprolactinomas being prevalent in women and macroprolactinomas in men. Hyperprolactinemia is among the most common causes of hypogonadotropic hypogonadism in both sexes, prompting medical advice for hypogonadism (infertility, oligo-amenorrhea, impotence, osteoporosis/osteopenia) in both sexes, and for signs and symptoms of mass effects (hypopituitarism, visual loss, optic chiasm compression, cranial nerve deficits, headaches) predominantly in men. Diagnostic workup involves a single prolactin measurement and pituitary imaging, but some laboratory artifacts (ie, the "hook effect" and macroprolactin) can complicate or delay the diagnosis. The treatment of choice for prolactinomas is represented by dopamine agonists, mainly cabergoline, which are able to induce disease control, restore fertility in both sexes, and definitively cure one-third of patients, thus permitting treatment discontinuation. Pregnancy and menopause may promote spontaneous prolactin decline and anticipate cabergoline discontinuation in women. Surgery and/or radiotherapy are indicated in case of resistance to cabergoline not overcome by the increase in drug dose up to the maximally tolerated or the patient's personal choice of surgery. The evidence of resistance to cabergoline in invasive and proliferative tumors may indicate biological aggressiveness, thus requiring alternative therapeutic approaches mainly based on temozolomide use as monotherapy or combined with radiotherapy. In uncontrolled patients, new medical approaches (alternative hormonal treatments, cytotoxic drugs, peptide receptor radionuclide therapy, mTOR/Akt inhibitors, tyrosine kinase inhibitors, or immunotherapy) may be offered but the experience collected to date is still very scant. This article reviews different facets of prolactinomas and discusses approaches to the condition in more common clinical situations.
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Affiliation(s)
- Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Sanità Pubblica, Università Federico II di Napoli, 80131 Naples, Italy
| | - Francesco Garifalos
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, “Federico II” University, 80131 Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, 80131 Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, “Federico II” University, 80131 Naples, Italy
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7
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Bioletto F, Berton AM, Varaldo E, Cuboni D, Bona C, Parasiliti-Caprino M, Prencipe N, Ghigo E, Grottoli S, Maccario M, Gasco V. Development and internal validation of a predictive score for the diagnosis of central adrenal insufficiency when morning cortisol is in the grey zone. J Endocrinol Invest 2023; 46:535-543. [PMID: 36161398 PMCID: PMC9938019 DOI: 10.1007/s40618-022-01926-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/17/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND When evaluating a patient for central adrenal insufficiency (CAI), there is a wide range of morning cortisol values for which no definite conclusion on hypothalamus-pituitary-adrenal (HPA) axis function can be drawn; in these cases, a stimulation test is required. Aim of this study was to develop an integrated model for CAI prediction when morning cortisol is in the grey zone, here defined as 40.0-160.0 μg/L. METHODS Overall, 119 patients with history of sellar tumour which underwent insulin tolerance test (ITT) for the evaluation of HPA axis were enrolled. Supervised regression techniques were used for model development. RESULTS An integrated predictive model was developed and internally validated, and showed a significantly better diagnostic performance than morning cortisol alone (AUC 0.811 vs 0.699, p = 0.003). A novel predictive score (CAI-score) was retrieved, on a 5.5-point scale, by considering morning cortisol (0 points if 130.1-160.0 μg/L, 1 point if 100.1-130.0 μg/L, 1.5 points if 70.1-100.0 μg/L, 2.5 points if 40.0-70.0 μg/L), other pituitary deficits (2 points if ≥ 3 deficits), and sex (1 point if male). A diagnostic algorithm integrating CAI-score and ITT was finally proposed, with an overall accuracy of 99%, and the possibility to avoid the execution of stimulation tests in 25% of patients. CONCLUSIONS This was the first study that proposed an integrated score for the prediction of CAI when morning cortisol is in the grey zone. This score might be helpful to reduce the number of patients who need a stimulation test for the assessment of HPA axis function.
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Affiliation(s)
- F Bioletto
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
| | - A M Berton
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - E Varaldo
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - D Cuboni
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - C Bona
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Parasiliti-Caprino
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - N Prencipe
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - E Ghigo
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - S Grottoli
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Maccario
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - V Gasco
- Endocrinology, Diabetology and Metabolism; Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
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8
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Andereggen L, Tortora A, Schubert GA, Musahl C, Frey J, Luedi MM, Mariani L, Beck J, Christ E. Prolactinomas in adolescent and elderly patients-A comparative long-term analysis. Front Surg 2023; 10:967407. [PMID: 36814862 PMCID: PMC9939754 DOI: 10.3389/fsurg.2023.967407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 01/16/2023] [Indexed: 02/09/2023] Open
Abstract
Objectives Prolactinomas represent the most common type of secreting pituitary adenomas, yet are rarely encountered in adolescent-onset (AO; i.e. <18 years) or elderly-onset (EO; i.e. ≥65 years) cohorts. As a result, it is not clear whether long-term strategies should be focused differently at both age extremes when comparing their therapeutic outcomes. We aimed at investigating long-term endocrinological outcomes, looking for differences between the two cohorts and evaluating the dependence on continued dopamine agonist (DA) therapy. Methods Retrospective cross-sectional comparative study analyzing prolactinoma patients with a follow-up of ≥4 years. Clinical, radiological and biochemical characteristics were assessed at diagnosis and last follow-up. Longitudinal endocrinological outcomes between groups of extreme ages (i.e. AO and EO) and middle age (i.e. ≥18 years to 65 years) were compared. Independent risk factors for long-term dependence on DAs were calculated. Results Follow-up at ≥4 years was recorded for 108 prolactinoma patients; 10 patients with AO and 10 patients with EO. Compared to AO patients, EO patients were predominantly men (p = 0.003), and presented with significantly higher prolactin (PRL) levels (p = 0.05) and higher body mass index (p = 0.03). We noted a significant positive correlation between patients' PRL values and their age (r = 0.5, p = 0.03) or BMI (r = 0.6, p = 0.03). After a median follow-up of 115 months, remission was noted in 87 (83%) patients; 9 (90%) in AO patients, and 7 (70%) in EO patients (p = 0.58). Continuation of DAs was required in 4 patients (40%) with AO and 7 patients (70%) with EO (p = 0.37). Patients with elderly-onset were an independent predictor of long-term dependence on DAs (HR 2.8, 95% CI 1.1-7.2, p = 0.03). Conclusions Long-term control of hyperprolactinemia and hypogonadism does not differ between members of the AO and EO cohorts, and can be attained by the majority of patients. However, adjuvant DAs are often required, independent of the age of onset. Considering the clinical significance of persistent DA therapy for the control of hyperprolactinemia in many patients at both extremes of age, long-term monitoring may become recommended, in particular in patients with elderly-onset.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland,Faculty of Medicine, University of Bern, Bern, Switzerland,Correspondence: Lukas Andereggen
| | - Angelo Tortora
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Christian Musahl
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Janine Frey
- Department of Gynecology and Obstetrics, Kantonsspital Lucerne, Lucerne, Switzerland
| | - Markus M. Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Jürgen Beck
- Faculty of Medicine, University of Bern, Bern, Switzerland,Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Emanuel Christ
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Basel, Basel, Switzerland
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9
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Muacevic A, Adler JR. Prolactinoma: Clinical Characteristics, Management and Outcome. Cureus 2022; 14:e29822. [PMID: 36337795 PMCID: PMC9626374 DOI: 10.7759/cureus.29822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2022] [Indexed: 12/31/2022] Open
Abstract
Aim Prolactinoma, a prolactin (PRL) secreting functioning pituitary tumor, is the most common of all pituitary adenomas (PA) accounting for 40-60% and dopamine agonists (DA) are the cornerstone of treatment. The aim of this study was to review the clinical presentation, treatment modalities and therapeutic outcomes of patients with prolactinomas in the South Asia region. Methods This retrospective study was conducted in the Endocrinology Department of Shaukat Khanum Memorial Cancer Hospital and Research Centre from December 2011 till December 2019. Medical records were used to retrieve for patient's demographics, clinical features at diagnosis, PRL levels and size of prolactinoma on MRI at diagnosis and after start of dopamine agonists and outcome of medical management. Results A total of 107 patients were included in this study. Mean age at diagnosis was 35 (22-54) years for men and 32 (18-50) years for women and 66.4% (71) of the patients were females. Our study included 38 (35.5%) microadenoma, 50 (46.7%) macroadenoma and 19 (17.8%) giant adenomas. At presentation, the most common symptom among females was menstrual irregularity/amenorrhea seen in 73.2% of females and among males was visual disturbance (80.6%). A significant reduction in PRL levels was seen within six to 12 months of treatment. Mean PRL levels decreased from 3162.8 ng/ml to 1.52 ng/ml. A notable decrease in tumor size was seen with medical management, mean adenoma size decreased from 2.18 cm to 1.04 cm. With cabergoline (CAB) 83.3% biochemical cure was seen compared to bromocriptine (BRC) which has 60.4%. The radiological response rate in CAB and BRC groups was 65.45% and 60%, respectively. Complete resolution of adenoma was seen in 13 patients (nine were microadenoma, two macro and two giant adenomas). The prolactin level at diagnosis was positively correlated with maximum tumor diameter (r = 0.469, P = 0.001). Two patients developed cerebrospinal fluid (CSF) rhinorrhea and the defect was repaired in both patients. Median follow-up duration was 40 (12-288) months. Conclusion Clinical presentation and demographics of prolactinoma are the same in our region when compared to the rest of the world. Cabergoline is superior to bromocriptine in prolactin normalization and tumor shrinkage but still bromocriptine is being used in a significant number of patients in low-income countries as first-line due to its low cost.
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Inder WJ, Jang C. Treatment of Prolactinoma. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081095. [PMID: 36013562 PMCID: PMC9413135 DOI: 10.3390/medicina58081095] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 05/14/2023]
Abstract
Prolactinomas are the commonest form of pituitary neuroendocrine tumor (PitNET), representing approximately half of such tumors. Dopamine agonists (DAs) have traditionally been the primary treatment for the majority of prolactinomas, with surgery considered the second line. The aim of this review is to examine the historical and modern management of prolactinomas, including medical therapy with DAs, transsphenoidal surgery, and multimodality therapy for the treatment of aggressive prolactinomas and metastatic PitNETs, with an emphasis on the efficacy, safety, and future directions of current therapeutic modalities. DAs have been the mainstay of prolactinoma management since the 1970s, initially with bromocriptine and more recently with cabergoline. Cabergoline normalizes prolactin in up to 85% of patients and causes tumor shrinkage in up to 80%. Primary surgical resection of microprolactinomas and enclosed macroprolactinomas performed by experienced pituitary neurosurgeons have similar remission rates to cabergoline. Aggressive prolactinomas and metastatic PitNETS should receive multimodality therapy including high dose cabergoline, surgery, radiation therapy (preferably using stereotactic radiosurgery where suitable), and temozolomide. DAs remain a reliable mode of therapy for most prolactinomas but results from transsphenoidal surgery in expert hands have improved considerably over the last one to two decades. Surgery should be strongly considered as primary therapy, particularly in the setting of microprolactinomas, non-invasive macroprolactinomas, or prior to attempting pregnancy, and has an important role in the management of DA resistant and aggressive prolactinomas.
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Affiliation(s)
- Warrick J. Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba 4102, Australia
- Academy for Medical Education, Faculty of Medicine, The University of Queensland, Herston 4029, Australia
- Correspondence: ; Tel.: +61-7-3176-9563
| | - Christina Jang
- Department of Endocrinology and Diabetes, Royal Brisbane and Women’s Hospital, Herston 4029, Australia
- Faculty of Medicine, The University of Queensland, Herston 4029, Australia
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11
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Eshkoli T, Fraenkel M, Zaid D, Cohen D, Yoel U, Tsvetov G, Gorshtein A, Goldbart A, Greenman Y, Shimon I. Resistant prolactinomas: a case series of 26 patients. Endocrine 2022; 77:349-356. [PMID: 35604631 DOI: 10.1007/s12020-022-03080-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Prolactin (PRL)-secreting tumors are the most common functional pituitary adenomas. They usually respond to dopamine agonist (DA) treatment, with PRL normalization and adenoma shrinkage. Our aim was to characterize patients with prolactinoma resistant to DA treatment. METHODS This retrospective case series included patients diagnosed with DA-resistant prolactinomas between 1993-2017 in three medical centers. Resistance was defined as PRL levels above three times the upper limit of normal (ULN) despite a weekly dose of ≥2 mg cabergoline (CAB). Clinical and biochemical information, and response to treatment, were retrieved from medical records. RESULTS Twenty-six patients were identified; 20 males. Of 25 macroadenomas, three were giant tumors (>40 mm) and 15 (57.7%) were invasive. The mean age at diagnosis was 31.8 ± 14.9 years (range: 13-62). The median maximal CAB dose was 3.5 mg/week (IQR, 2.5-5). Half the patients received only CAB in escalating doses, nine received CAB and underwent transsphenoidal surgery, and four underwent surgery and radiotherapy in addition to CAB treatment. PRL levels at baseline between patients treated only with CAB and those operated were (91.6 [51.1-296.7] vs. 73.1 [22.6-170.9] XULN p = 0.355), and under maximal CAB dose PRL levels between patients treated only with CAB and those operated were similar (5.77 [1.27-11.27] vs 5.27 (2.9-26) XULN p = 0.317). At the last visit patients who received combined therapy achieved lower PRL levels than those treated with DA only (5.22 [1.7-21.6] vs 1.1 [0.44-3.99] XULN p = 0.017) PRL normalization was attained in seven patients and levels below 3 × ULN in fourteen patients; the overall response was 56%. CONCLUSIONS Resistant prolactinomas usually require a multi-modal treatment strategy. We were able to control 14/25 (56%) of resistant tumors.
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Affiliation(s)
- Tamar Eshkoli
- Endocrine Unit, Soroka Medical Center, Beer-Sheva, Israel.
- Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Merav Fraenkel
- Endocrine Unit, Soroka Medical Center, Beer-Sheva, Israel
- Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dana Zaid
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Dayana Cohen
- Endocrine Unit, Soroka Medical Center, Beer-Sheva, Israel
| | - Uri Yoel
- Endocrine Unit, Soroka Medical Center, Beer-Sheva, Israel
- Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gloria Tsvetov
- Endocrine Institute, Rabin-Beilinson Medical Center, Petah-Tiqva, Israel
| | - Alexander Gorshtein
- Endocrine Institute, Rabin-Beilinson Medical Center, Petah-Tiqva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Adi Goldbart
- Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yona Greenman
- Institute of Endocrinology, Diabetes, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilan Shimon
- Endocrine Institute, Rabin-Beilinson Medical Center, Petah-Tiqva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Szmygin H, Szydełko J, Matyjaszek-Matuszek B. Dopamine Agonist-Resistant Microprolactinoma—Mechanisms, Predictors and Management: A Case Report and Literature Review. J Clin Med 2022; 11:jcm11113070. [PMID: 35683457 PMCID: PMC9181764 DOI: 10.3390/jcm11113070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/10/2022] [Accepted: 05/27/2022] [Indexed: 01/09/2023] Open
Abstract
Objective: Prolactinomas are the most common type of functional, hormone-secreting pituitary adenomas that account for about 40% of total pituitary adenomas. Typical clinical presentations include loss of menstrual periods (amenorrhea) and galactorrhoea in women and sexual dysfunction in men. Prolactinomas are preferentially treated with dopamine agonists and respond to such therapy with hormonal normalisation and tumour shrinkage. However, about 10–20% of prolactinomas are resistant to dopamine agonists. The management of dopamine agonist-resistant prolactinomas poses a therapeutic challenge and includes several possible approaches. Design and Methods: In this study, we present a case report of a woman diagnosed with microprolactinoma at the age of 27 who did not fully respond either to treatment with dopamine agonists nor to transsphenoidal surgery. This was followed by a review of literature on the current state of knowledge about the mechanisms, predictors, and management of dopamine agonist-resistant prolactinomas on the basis of recent scientific literature published up to November 2021 and searches of the PubMed, Google Scholar, and Web of Science databases. Results and Conclusions: The exact mechanisms underlying dopamine agonists’ resistance in lactotroph tumours are not fully understood, yet refractory prolactinomas pose a great challenge in everyday clinical practice. Several predictive factors that contribute to poor response to medical treatment have been identified, among them the elevated Ki-67 index. Recently, various alternative medical treatments have been considered, but their usefulness remains to be evaluated. A return of menses can serve as a first clinical indication of successful medical treatment.
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Fiala L, Lenz J, Havelka P, Vetvicka V. Delayed ejaculation in men with depressive disorders. Andrologia 2022; 54:e14412. [PMID: 35243671 DOI: 10.1111/and.14412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/16/2022] [Accepted: 02/25/2022] [Indexed: 11/30/2022] Open
Abstract
Delayed ejaculation belongs to the group of sexual disorders in men. The causes of delayed ejaculation or anejaculation are not exactly known. It is assumed that it can be caused by psychogenic or organic influences or their combinations. One of the causes of delayed ejaculation may be elevated prolactin levels, which may be increased by psychosocial stress, pituitary disorders or also treatment with selective serotonin reuptake inhibitors in the treatment of depression. We tested a selected group of 50 men who were diagnosed with a depressive disorder and whose antidepressant treatment lasted for at least 24 weeks. These patients reported long-term delayed ejaculation or, in some cases, anejaculation as comorbidity. The results showed significant Spearman's correlation between elevated prolactin levels and intravaginal ejaculation latency values (R = 0.45), as well as between Beck's Depression-II inventory and intravaginal ejaculation latency and latency values (R = 0.48).
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Affiliation(s)
- Ludek Fiala
- Department of Sexology, Psychiatric Clinic, Faculty of Medicine, Charles University, Pilsen, Czech Republic.,First Faculty of Medicine, Institute of Sexology, Charles University, Prague, Czech Republic
| | - Jiri Lenz
- Department of Pathology, Znojmo Hospital, Znojmo, Czech Republic.,Department of Anatomy, Histology and Embryology, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Pavel Havelka
- Department of Gynecology and Sexology, Bata Hospital, Zlin, Czech Republic
| | - Vaclav Vetvicka
- Department of Pathology, University of Louisville, Louisville, Kentucky, USA
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Cozzi R, Ambrosio MR, Attanasio R, Battista C, Bozzao A, Caputo M, Ciccarelli E, De Marinis L, De Menis E, Faustini Fustini M, Grimaldi F, Lania A, Lasio G, Logoluso F, Losa M, Maffei P, Milani D, Poggi M, Zini M, Katznelson L, Luger A, Poiana C. Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors. Eur J Endocrinol 2022; 186:P1-P33. [PMID: 35000899 PMCID: PMC8859924 DOI: 10.1530/eje-21-0977] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022]
Abstract
Prolactinomas are the most frequent pituitary adenomas. Prolactinoma may occur in different clinical settings and always require an individually tailored approach. This is the reason why a panel of Italian neuroendocrine experts was charged with the task to provide indications for the diagnostic and therapeutic approaches that can be easily applied in different contexts. The document provides 15 recommendations for diagnosis and 54 recommendations for treatment, issued according to the GRADE system. The level of agreement among panel members was formally evaluated by RAND-UCLA methodology. In the last century, prolactinomas represented the paradigm of pituitary tumors for which the development of highly effective drugs obtained the best results, allowing to avoid neurosurgery in most cases. The impressive improvement of neurosurgical endoscopic techniques allows a far better definition of the tumoral tissue during surgery and the remission of endocrine symptoms in many patients with pituitary tumors. Consequently, this refinement of neurosurgery is changing the therapeutic strategy in prolactinomas, allowing the definitive cure of some patients with permanent discontinuation of medical therapy.
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Affiliation(s)
- Renato Cozzi
- Division of Endocrinology, Niguarda Hospital, Milan, Italy
- Correspondence should be addressed to R Cozzi;
| | - Maria Rosaria Ambrosio
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Claudia Battista
- Endocrinology Unit, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo (FG), Italy
| | - Alessandro Bozzao
- Neuroradiology, S. Andrea Hospital, NESMOS Department (Neuroscience, Mental Health, Sensorial Organs), Sapienza University of Rome, Rome, Italy
| | - Marco Caputo
- Laboratorio Analisi Cliniche e Microbiologia, Synlab SRL, Calenzano, Florence, Italy
| | | | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | | | | | - Franco Grimaldi
- AME President, Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Udine, Italy
| | - Andrea Lania
- Department of Biomedical Sciences, Endocrinology Unit, Rozzano, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | | | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Maffei
- Department of Medicine (DIMED), 3rd Medical Clinic, Padua University Hospital, Padua, Italy
| | - Davide Milani
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Maurizio Poggi
- Endocrinology, Department of Clinical and Molecular Medicine, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Michele Zini
- Endocrinology Unit, Azienda Ospedaliera S. Maria Nuova IRCCS, Reggio Emilia, Italy
| | | | - Anton Luger
- Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - Catalina Poiana
- ‘Carol Davila’ University of Medicine and Pharmacy – Endocrinology, “C.I. Parhon” National Institute of Endocrinology – Pituitary and Neuroendocrine Disorders, Bucharest, Romania
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15
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Wildemberg LE, Fialho C, Gadelha MR. Prolactinomas. Presse Med 2021; 50:104080. [PMID: 34687915 DOI: 10.1016/j.lpm.2021.104080] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 08/31/2021] [Accepted: 10/12/2021] [Indexed: 12/28/2022] Open
Abstract
Hyperprolactinemia, defined by a level of serum prolactin above the standard upper limit of normal range, is a common finding in clinical practice and prolactinomas are the main pathological cause. Prolactinomas lead to signs and symptoms of hormone oversecretion, such as galactorrhea and hypogonadism, as well as symptoms of mass effect, including visual impairment, headaches and intracranial hypertension. Diagnosis involves prolactin measurement and sellar imaging, but several pitfalls are involved in this evaluation, which may difficult the proper management. Treatment is medical in the majority of cases, consisting of dopamine agonists, which present high response rates, with a very favorable safety profile. Major adverse effects that should be monitored consist of cardiac valvulopathy and impulse control disorders. Other treatment options include surgery and radiotherapy. Temozolomide may be used for aggressive or malignant carcinomas. Finally, pregnancy outcomes are similar to general population even when dopamine agonist treatment is maintained.
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Affiliation(s)
- Luiz Eduardo Wildemberg
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil
| | - Christhiane Fialho
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Monica R Gadelha
- Endocrine Unit and Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil; Neuroendocrine Unit - Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil; Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde, Rio de Janeiro, Brazil.
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Rudman Y, Duskin-Bitan H, Manisterski Y, Pertzov B, Akirov A, Masri-Iraqi H, Shimon I. Long-term response to cabergoline and multi-modal treatment in men with macroprolactinoma: Does size really matter? Clin Endocrinol (Oxf) 2021; 95:606-617. [PMID: 34160838 DOI: 10.1111/cen.14541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study the outcome of men with macroprolactinoma following cabergoline treatment based on tumour size. DESIGN Retrospective cohort study. METHODS The study included 94 men, divided into three groups according to adenoma diameter: 10-19 mm (Group A, n = 36); 20-39 mm (Group B, n = 41); or ≥40 mm (Group C, giant prolactinomas, n = 17). Patients were followed for a mean of 7.5 years with sellar magnetic resonance imaging, visual fields and hormone measurements. RESULTS Mean baseline prolactin was 767, 2090 and 24,806 ng/ml in Groups A, B and C, respectively (p < .01). Prolactin suppression below three times the upper limit of normal (ULN) was achieved in 34 (94%; mean weekly cabergoline dose of 1.2 mg), 37 (90%; cabergoline dose, 2.1 mg) and 15 (88%; cabergoline dose, 2.8 mg) men (p = .31) in each group. After excluding patients who underwent surgery and radiotherapy, cabergoline suppressed prolactin below three times ULN in 32/35 (91%), 29/37 (78%) and 11/14 (79%) men in Groups A, B and C, respectively (p = .27). Visual deficits were observed in 5 (14%), 12 (29%) and 10 (59%) patients (p < .01); improvement was achieved in 5/5 (100%), 11/12 (92%) and 10/10 (100%) of men in Groups A, B and C. Low baseline testosterone was measured in 26 (72%), 39 (95%) and 17 (100%) patients in the three groups (p < .01). Following multi-modal treatment, hypogonadism persisted in 3 (8%), 5 (12%) and 2 (12%) men, respectively (p = .85). CONCLUSION Macroprolactinomas in men were controlled with cabergoline in 84% of cases, independent of tumour size. Pituitary surgery and adjuvant radiotherapy further improved long-term response to 91%.
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Affiliation(s)
- Yaron Rudman
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Duskin-Bitan
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Barak Pertzov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pulmonary Division, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Amit Akirov
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hiba Masri-Iraqi
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cander S, Oz Gul O, Eylemer E, Gullulu Boz E, Gunes E, Hakyemez B, Yilmazlar S, Ersoy C. Comparison of the effects of medical and surgical treatments in giant prolactinoma: a single-center experience. Hormones (Athens) 2021; 20:491-498. [PMID: 34236607 DOI: 10.1007/s42000-021-00307-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/25/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Giant prolactinomas, which have extremely large sizes and high prolactin (PRL) values, are rarely seen. Although medical therapy is effective, surgical treatment is more frequently applied due to slightly lower response rates and compression symptoms. This study aimed to compare the medical and surgical treatment results in giant prolactinomas. METHODS Thirty-nine patients who were followed up in our center for giant prolactinoma were included in the study, and the response rates of the patients were evaluated after the medical and surgical treatments. The treatment responses were compared in terms of tumor volume, PRL level, visual field, and pituitary function. RESULTS The outcomes of the 66 treatment periods (medical n = 42; surgical n = 24) in 39 patients (mean age, 47.2 years; men, 89.7%) were evaluated. The most common presentations were hypogonadism and visual defects. The mean longest tumor diameter at diagnosis was 52.2 ± 11.8 mm, and the median PRL levels were 5000 ng/mL. PRL level normalization was achieved in 69% with medical therapy, and a curative response was obtained in only two patients with surgery. Tumor volume reduction was 67% (no cure) in the medical and 75% (13% cure) in the surgical groups (p = 0.39). Improvement of visual field was 70.8% in the medical and 84.2% in the surgical group (p = 0.12). CONCLUSION In our study, it was observed that medical therapy was effective and safe in patients with giant prolactinomas. The use of surgical treatment should be limited to prolactinomas with compression or post-resistance to medical treatment in serious cases.
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Affiliation(s)
- Soner Cander
- Endocrinology and Metabolism, Bursa Uludag University Medical School, Bursa, Turkey.
| | - Ozen Oz Gul
- Endocrinology and Metabolism, Bursa Uludag University Medical School, Bursa, Turkey
| | - Eda Eylemer
- Internal Medicine, Bursa Uludag University Medical School, Bursa, Turkey
| | - Elif Gullulu Boz
- Internal Medicine, Bursa Uludag University Medical School, Bursa, Turkey
| | - Elif Gunes
- Endocrinology and Metabolism, Bursa City Hospital, Bursa, Turkey
| | | | | | - Canan Ersoy
- Endocrinology and Metabolism, Bursa Uludag University Medical School, Bursa, Turkey
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Mechanisms of Central Hypogonadism. Int J Mol Sci 2021; 22:ijms22158217. [PMID: 34360982 PMCID: PMC8348115 DOI: 10.3390/ijms22158217] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 02/01/2023] Open
Abstract
Reproductive function depends upon an operational hypothalamo–pituitary–gonadal (HPG) axis. Due to its role in determining survival versus reproductive strategies, the HPG axis is vulnerable to a diverse plethora of signals that ultimately manifest with Central Hypogonadism (CH) in all its many guises. Acquired CH can result from any pituitary or hypothalamic lesion, including its treatment (such as surgical resection and/or radiotherapy). The HPG axis is particularly sensitive to the suppressive effects of hyperprolactinaemia that can occur for many reasons, including prolactinomas, and as a side effect of certain drug therapies. Physiologically, prolactin (combined with the suppressive effects of autonomic neural signals from suckling) plays a key role in suppressing the gonadal axis and establishing temporary CH during lactation. Leptin is a further key endocrine regulator of the HPG axis. During starvation, hypoleptinaemia (from diminished fat stores) results in activation of hypothalamic agouti-related peptide neurons that have a dual purpose to enhance appetite (important for survival) and concomitantly suppresses GnRH neurons via effects on neural kisspeptin release. Obesity is associated with hyperleptinaemia and leptin resistance that may also suppress the HPG axis. The suppressibility of the HPG axis also leaves it vulnerable to the effects of external signals that include morphine, anabolic-androgenic steroids, physical trauma and stress, all of which are relatively common causes of CH. Finally, the HPG axis is susceptible to congenital malformations, with reports of mutations within >50 genes that manifest with congenital CH, including Kallmann Syndrome associated with hyposmia or anosmia (reduction or loss of the sense of smell due to the closely associated migration of GnRH with olfactory neurons during embryogenesis). Analogous to the HPG axis itself, patients with CH are often vulnerable, and their clinical management requires both sensitivity and empathy.
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19
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Determinants of Surgical Remission in Prolactinomas: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 154:e349-e369. [PMID: 34325023 DOI: 10.1016/j.wneu.2021.07.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Prolactin-secreting tumors respond well to medical management, with a few patients requiring surgery. We conducted a systematic review and meta-analysis to study the determinants of surgical remission in these tumors. METHODS We searched PubMed to identify eligible studies reporting postoperative remission in patients treated with transsphenoidal surgery for prolactinoma. Primary outcomes included postoperative remission, follow-up remission, and recurrence. Postoperative and follow-up remission were defined as normoprolactinemia at <1 year and >1 year after operation, respectively. Recurrence was defined as hyperprolactinemia after initial normalization of prolactin levels. Odds ratios (ORs) were calculated, stratified by radiologic size, tumor extension, and tumor invasion, and analyzed using a random-effects model meta-analysis. RESULTS Thirty-five studies were included. Macroadenomas were associated with lower rates of postoperative remission (OR, 0.20; 95% confidence interval [CI], 0.16-0.24) and lower rates of remission at follow-up (OR, 0.11; 95% CI, 0.053-0.22). Postoperative remission was less likely in tumors with extrasellar or suprasellar extension (OR, 0.16; 95% CI, 0.06-0.43) and tumors with cavernous sinus invasion (OR, 0.03; 95% CI, 0.01-0.13). Female gender and absence of preoperative dopamine agonist treatment were also associated with higher remission rates. Across the included studies, there was considerable heterogeneity in each primary outcome (postoperative remission, I2 = 94%; follow-up remission, I2 = 86%; recurrence, I2 = 68%). CONCLUSIONS Transsphenoidal surgery for prolactinomas may be particularly effective in small, noninvasive, treatment-naive tumors and may provide a viable first-line alternative to dopamine agonist therapy in such patients.
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Shimon I, Rudman Y, Manisterski Y, Gorshtein A, Masri H, Duskin-Bitan H. True hyperprolactinemia in men without visible pituitary adenoma. Endocrine 2021; 72:809-813. [PMID: 33566310 DOI: 10.1007/s12020-021-02624-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Men with mild to moderate hyperprolactinemia rarely present with normal pituitary on MRI with no visible adenoma, a condition entitled also "idiopathic hyperprolactinemia" or "non-tumoral hyperprolactinemia". We have characterized a cohort of hyperprolactinemic men with normal pituitary imaging. DESIGN We have identified 13 men with true hyperprolactinemia and normal pituitary MRI. Baseline clinical and hormonal characteristics and response to medical treatment were retrospectively retrieved from medical records. RESULTS Mean age at diagnosis was 51 ± 16 years (range, 20-77); mean serum prolactin level at presentation was 91 ng/ml (range, 28-264), eight men presented with low baseline testosterone. Initial complaints leading to diagnosis included sexual dysfunction in ten men and gynecomastia in five. All patients were treated with cabergoline, except for one who was given bromocriptine; none required pituitary surgery. All patients normalized prolactin and testosterone with subsequent clinical improvement reported by most men. Currently, after a mean follow-up of 72 months, ten patients continue treatment with caborgoline (median weekly dose, 0.25 mg), whereas three men discontinued treatment. CONCLUSIONS Men with symptomatic hyperprolactinemia may rarely present with normal pituitary imaging. Medical treatment can lead to hormonal improvement with clinical benefit.
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Affiliation(s)
- Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel.
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Yaron Rudman
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | - Alex Gorshtein
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Hiba Masri
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Hadar Duskin-Bitan
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Andereggen L, Christ E. Commentary: "Prolactinomas: Prognostic Factors of Early Remission After Transsphenoidal Surgery". Front Endocrinol (Lausanne) 2021; 12:695498. [PMID: 34054739 PMCID: PMC8160469 DOI: 10.3389/fendo.2021.695498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
- *Correspondence: Lukas Andereggen, , orcid.org/0000-0003-1764-688X
| | - Emanuel Christ
- Department of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, Basel, Switzerland
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Araujo-Castro M, Pascual-Corrales E, Acitores Cancela A, García Duque S, Ley Urzaiz L, Rodríguez Berrocal V. Status and clinical and radiological predictive factors of presurgical anterior pituitary function in pituitary adenomas. Study of 232 patients. Endocrine 2020; 70:584-592. [PMID: 32785896 DOI: 10.1007/s12020-020-02455-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 08/03/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE To investigate the status of preoperative anterior pituitary function in patients undergoing pituitary adenoma (PA) resection and to identify factors associated with preoperative anterior pituitary dysfunction (APD). METHODS Patients with functioning and nonfunctioning PAs who underwent pituitary adenoma resection for first time, from January 2009 to December 2019 were analyzed. RESULTS Total sample included 232 patients; 123 (53.2%) females, mean age at diagnosis was 53.3 years. Sixty-three percent presented as nonfunctioning PAs and 37.1% as functioning PAs. Eighty-eight percent were macroadenomas and 34.9% had cavernous sinus invasion. APD was demonstrated in 36.2% (n = 84) of the patients. The FSH/LH deficit was the most frequent anterior pituitary deficit (31.9%); followed by ACTH (18.1%); TSH (16.4%) and GH (13.8%). We identified as independent risk factors of APD, male sex (OR = 6.1, 95% CI = 3.3-11.0); age (OR = 1.03 for each year, 95% CI = 1.01-1.04), diabetes mellitus (OR = 3.5, 95% CI = 1.63-7.69), pituitary apoplexy presentation (OR = 4.3, 95% CI = 1.3-14.5) and tumor size (OR = 1.06 for each mm, 95% CI = 1.04-1.09). Nonfunctioning PAs (NFPA) had higher risk of APD than functioning PAs (FPA) (OR = 2.8 (95% CI = 1.5-5.0), but these differences disappeared after adjusted by tumor size (OR adjusted by tumor size = 1.7, 95% CI = 0.9-3.3). The tumor size with the highest diagnostic accuracy to predict hypopituitarism was 22 mm (sensitivity of 61.9% and specificity of 70.1%). CONCLUSION More than one third of PAs candidates for surgery had APD. The male sex, diabetes, an older age, pituitary apoplexy, and larger PAs were risk factors of APD. Hence, in these patients, the hormonal study should be prioritized and the need for dynamic tests must be carefully assessed.
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Affiliation(s)
- Marta Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain.
| | - Eider Pascual-Corrales
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Alberto Acitores Cancela
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Sara García Duque
- Endoscopic Skull Base Unit, Department of Neurosurgery, Hospital Universitario HM Puerta del Sur, Madrid, Spain
| | - Luis Ley Urzaiz
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Víctor Rodríguez Berrocal
- Pituitary Surgery Unit, Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Endoscopic Skull Base Unit, Department of Neurosurgery, Hospital Universitario HM Puerta del Sur, Madrid, Spain
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Sehemby M, Lila AR, Sarathi V, Shah R, Sankhe S, Jaiswal SK, Ramteke-Jadhav S, Patil V, Shah N, Bandgar T. Predictors of Chronic LH-Testosterone Axis Suppression in Male Macroprolactinomas With Normoprolactinemia on Cabergoline. J Clin Endocrinol Metab 2020; 105:5907987. [PMID: 32942295 DOI: 10.1210/clinem/dgaa650] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/16/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Data are limited regarding prevalence, predictors, and mechanisms of persistent hypogonadotropic hypogonadism (HH) in males with a macroprolactinoma who achieve normoprolactinemia on dopamine-agonist therapy. None of the previous studies provide cutoffs to predict the achievement of eugonadism. OBJECTIVE The objective of this work is to evaluate the prevalence of persistent HH and its determinants in men with a macroprolactinoma who achieve normoprolactinemia on cabergoline monotherapy. DESIGN AND SETTING This retrospective study with prospective cross-sectional evaluation took place at a tertiary health care center. PATIENTS Study participants included men with a macroprolactinoma and baseline HH who achieved normoprolactinemia on cabergoline monotherapy. MAIN OUTCOME MEASURES Outcome measures of this study included the prevalence of persistent HH and its predictors. RESULTS Thirty participants (age, 38.3 ± 10.1 years) with baseline tumor size of 4.08 ± 1.48 cm and median (interquartile range) prolactin of 2871 ng/mL (range, 1665-8425 ng/mL) were included. Eight of 30 participants achieved eugonadism after a median follow-up of 3 years. Patients with persistent HH had suppression of the luteinizing hormone (LH)-testosterone axis with sparing of other anterior pituitary hormonal axes, including follicle-stimulating hormone-inhibin B. Baseline prolactin (1674 vs 4120 ng/mL; P = .008) and maximal tumor diameter (2.55 ± 0.36 vs 4.64 ± 1.32 cm; P = .003) were lower in patients who achieved eugonadism. Baseline maximal tumor diameter less than or equal to 3.2 cm (sensitivity: 75%, specificity: 63.6%) and serum prolactin less than or equal to 2098 ng/mL (sensitivity: 87.5%, specificity: 77.3%) best predicted reversal of HH. CONCLUSION Recovery of the LH-testosterone axis occurred in 26.7% of men with a macroprolactinoma who achieved normoprolactinemia on cabergoline monotherapy. Higher baseline tumor size and serum prolactin predict persistent HH. Our data favor chronic functional modification of the hypothalamic-pituitary-gonadal axis over gonadotroph damage as the cause of persistent HH.
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Affiliation(s)
- Manjeetkaur Sehemby
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Center, Bangalore, Karnataka, India
| | - Ravikumar Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Shilpa Sankhe
- Department of Radiology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Sanjeet Kumar Jaiswal
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Swati Ramteke-Jadhav
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Erik-Blumenfeld-Platz 27a, 22587, Hamburg, Germany.
| | - Andrea Giustina
- Endocrinology Unit, Ospedale San Raffaele and Università Vita-Salute San Raffaele, Milan, Italy
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