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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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Kumar S, Memon SS, Lila AR, Sarathi V, Sehemby M, Karlekar M, Sankhe S, Thakkar H, Patil VA, Shah N, Bandgar T. Giant prolactinoma in Asian-Indians: A single-center experience from Western India. ANNALES D'ENDOCRINOLOGIE 2023; 84:711-718. [PMID: 37866429 DOI: 10.1016/j.ando.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE Giant prolactinomas (GP) are rare tumors accounting for 4.3% of prolactinomas, with paucity of literature from India. We aim to describe clinical, biochemical, radiological, and treatment outcomes in a large series of Asian-Indian patients with GP. METHODS A single-center retrospective analysis of GPs (n=84), age-based (adults: 66 versus pediatric: 18) and gender-based (males: 64 versus females: 20) comparison was done. RESULTS The mean age at presentation was 34.1±13years, and 64 (76.2%) were males. Males were younger at presentation (32.1±12.2 versus 40.1±13.8years, P: 0.01). The majority presented with mass-effect-related manifestations (visual disturbances: 91.6%, headache: 84.5%) and/or hypogonadism (98.7%). At baseline, largest tumor dimension was 5.3±1.0cm, and serum prolactin was 8343 (3865.5-12,306) ng/mL; most (94.6%) had gonadal axis involvement. Dopamine-agonist (DA) as first-line therapy (45/67, 67.2%) achieved normoprolactinemia (maximum cabergoline dose: 2.0±1.2mg/week) in 36/45 (80%) and tumor response (≥50% reduction) in 36/37 (97.3%) patients at the last follow-up (median duration: 33 [14.5-53.5]months). Notably, gonadal axis recovery was poor (6/30, 20%) despite normoprolactinemia post-DA monotherapy. At latest follow-up, secondary hypothyroidism (32.5% versus 82.6%, P: 0.001) and central hypocortisolism (5.6% versus 42.9%, P: 0.007) were less frequent in DA monotherapy (n=43) than in multimodal therapy group (n=23). The proportion of males (94.4% versus 71.2%, P: 0.04) was higher in the pediatric age group, with DA-induced (first-line) normoprolactinemia observed in 66.7% of them. CONCLUSION GP has male predominance, DA as first-line therapy normalized prolactin in four-fifths of patients with better preservation of HPT and HPA axes in patients with DA monotherapy.
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Affiliation(s)
- Sandeep Kumar
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences, Research Centre, Bangalore, India
| | - Manjeetkaur Sehemby
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Shilpa Sankhe
- Department of Radiology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Hemangini Thakkar
- Department of Radiology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Virendra A Patil
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Nalini Shah
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G.S. Medical College & King Edward Memorial Hospital, Mumbai, India.
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Shimon I. Prolactinomas Resistant to Dopamine Agonists: Pathophysiology and Treatment. Arch Med Res 2023; 54:102883. [PMID: 37689507 DOI: 10.1016/j.arcmed.2023.102883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Abstract
Prolactinomas are the most common functional pituitary tumors, accounting for 40% of all pituitary adenomas. Medical treatment with dopamine agonists (DA), mainly cabergoline, is considered the primary therapy for these patients. Prolactin normalization is achieved in 80-90% of prolactinomas treated with cabergoline. Patients resistant to the standard dose can escalate the dose of cabergoline up to the maximum tolerated dose. The expression of dopamine (D2) receptors and dopamine affinity is decreased in aggressive and resistant prolactinomas. Patients with aggressive and DA-resistant adenomas or with rare PRL-secreting carcinomas can be treated off-label with temozolomide (TMZ), a DNA alkylating agent. TMZ is effective in 40-50% of treated lactotroph tumors showing at least a partial response. However, patients tend to escape from the effect of TMZ after a limited time of response. Other therapeutic options include aromatase inhibitors, the somatostatin receptor ligand pasireotide, peptide receptor radionuclide therapy (PRRT), immune-checkpoint inhibitors, tyrosine-kinase inhibitors, or everolimus, the mammalian target of rapamycin inhibitor. These experimental treatments were effective in some patients carrying refractory prolactinomas showing usually partial tumor control. However, the number of treated patients with any of these new therapeutic options is very limited and treatment results are inconsistent, thus additional experience with more patients is required.
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Affiliation(s)
- Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Petach-Tikva, and Sackler School of Medicine, Tel Aviv University, Israel.
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Sosa-Eroza E, Espinosa-Cárdenas E. Long-term Discontinuation of Dopamine Agonist Treatment in Patients with Prolactinomas Revisited. Arch Med Res 2023; 54:102893. [PMID: 37806785 DOI: 10.1016/j.arcmed.2023.102893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Abstract
The most common type of functioning pituitary adenomas is prolactinomas; unlike other types, they are treated medically with dopamine agonists (DA). This treatment aims to normalize PRL levels and decrease tumor size by 50% or more. These objectives are typically achieved by 90% of patients with microprolactinoma, two-thirds of those with macroprolactinomas, and about half of those with giant prolactinomas. Life-long pharmacological treatment implies costs, discomfort, and the possibility of side effects, therefore, it has been suggested that DA discontinuation could be attempted in some patients. Long-term remission seems more likely in who, after 2 years of therapy achieve clinical, biochemical, and imaging remission criteria: no evidence of hypogonadism, a normal PRL level (preferably <5 ng/mL), and a >50% of tumor size reduction. Long-term remission seems to be more likely if the patient has been treated with cabergoline (CBG) for a minimum of 2 years, the PRL levels have normalized, tumor size has decreased by at least 50%, and the DA dose can gradually be tapered down to 0.25-0.5 mg per week. After treatment withdrawal, about 65% of patients experience a recurrence of hyperprolactinemia within the first 12 months of DA discontinuation. Although in most patients in whom DA discontinuation has been attempted, the hyperprolactinemia will recur, not all of them will require re-initiation of treatment. A good clinical judgement is crucial to identify those patients who need life-long treatment.
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Affiliation(s)
- Ernesto Sosa-Eroza
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Etual Espinosa-Cárdenas
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Himonakos C, Burman P, Borg H, Dahlqvist P, Engström BE, Ekman B, Emilsson L, Olsson DS, Ragnarsson O, Wahlberg J, Åkerman AK, Höybye C, Berinder K. Long-term Follow-up of 84 Patients With Giant Prolactinomas-A Swedish Nationwide Study. J Clin Endocrinol Metab 2023; 108:e1506-e1514. [PMID: 37403202 PMCID: PMC10655522 DOI: 10.1210/clinem/dgad393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/22/2023] [Accepted: 06/30/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE To describe the clinical presentation and treatment outcomes in a nationwide cohort of patients with giant prolactinomas. METHODS Register-based study of patients with giant prolactinomas [serum prolactin (PRL) > 1000 µg/L, tumor diameter ≥40 mm] identified in the Swedish Pituitary Register 1991-2018. RESULTS Eighty-four patients [mean age 47 (SD ±16) years, 89% men] were included in the study. At diagnosis, the median PRL was 6305 µg/L (range 1450-253 000), the median tumor diameter was 47 mm (range 40-85), 84% of the patients had hypogonadotropic hypogonadism, and 71% visual field defects. All patients were treated with a dopamine agonist (DA) at some point. Twenty-three (27%) received 1 or more additional therapies, including surgery (n = 19), radiotherapy (n = 6), other medical treatments (n = 4), and chemotherapy (n = 2). Ki-67 was ≥10% in 4/14 tumors. At the last follow-up [median 9 years (interquartile range (IQR) 4-15)], the median PRL was 12 µg/L (IQR 4-126), and the median tumor diameter was 22 mm (IQR 3-40). Normalized PRL was achieved in 55%, significant tumor reduction in 69%, and combined response (normalized PRL and significant tumor reduction) in 43%. In the primary DA-treated patients (n = 79), the reduction in PRL or tumor size after the first year predicted the combined response at the last follow-up (P < .001 and P = .012, respectively). CONCLUSION DAs effectively reduced PRL and tumor size, but approximately 1 patient out of 4 needed multimodal treatment. Our results suggest that the response to DA after 1 year is useful for identifying patients who need more careful monitoring and, in some cases, additional treatment.
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Affiliation(s)
- Christos Himonakos
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Internal Medicine, Center for Endocrinology and Diabetes, Karlstad Central Hospital, 651 85, Karlstad, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, Lund University, 214 28, Malmö, Sweden
| | - Henrik Borg
- Department of Endocrinology, Skåne University Hospital, Lund University, 222 42, Lund, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, 901 87, Umeå, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University and Uppsala University Hospital, 751 85, Uppsala, Sweden
| | - Bertil Ekman
- Department of Endocrinology and Department of Health, Medicine and Caring Sciences, Linköping University, 581 83, Linköping, Sweden
| | - Louise Emilsson
- Department of General Practice, Institute of Health and Society, University of Oslo, 0318, Oslo, Norway
- Nysäter Health Care Center and Center for Clinical Research, County Council of Värmland, 651 85, Karlstad, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, 171 77, Stockholm, Sweden
| | - Daniel S Olsson
- Department of Endocrinology at Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
- Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, 430 51, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology at Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
| | - Jeanette Wahlberg
- Department of Medicine, Örebro University Hospital, 701 85, Örebro, Sweden
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 701 82, Örebro, Sweden
| | - Anna-Karin Åkerman
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Medicine, Örebro University Hospital, 701 85, Örebro, Sweden
| | - Charlotte Höybye
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Katarina Berinder
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, 171 76, Stockholm, Sweden
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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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Tykhonova T, Barabash N, Kanishcheva O. Current and Perspective Approaches to the Treatment of Prolactinomas. Acta Med Litu 2023; 30:96-107. [PMID: 38516518 PMCID: PMC10952428 DOI: 10.15388/amed.2023.30.2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/18/2023] [Accepted: 04/17/2023] [Indexed: 03/23/2024] Open
Abstract
Background Along with the presence of the 2011 Endocrine Society Clinical Practice Guidelines and numerous large-scale studies on the treatment of hyperprolactinemia of different origin, there are some unresolved questions, ambiguous and sometimes contradictory points of view regarding the management of patients with prolactinomas. This overview is devoted to the analysis of the results of modern clinical studies and the approaches towards the management of hyperprolactinemia caused by prolactinoma. Materials and methods A systematic research of the literature for the appropriate keywords published mainly for the last 10 years was done; also, a reference list of each selected article was analysed. We included to our review the articles reporting controversial issues or new data on the treatment of hyperprolactinemia. Results The review describes various problems arising during the treatment of prolactinoma. The presence of primary and secondary dopamine agonist resistance in each case requires an individual approach, and sometimes may include the use of the antineoplastic agent t emozolomide. The side effects of dopamine agonists are discussed, with quite rare ones, including valvulopathy, pathological psychological conditions and cerebrospinal rhinorrhea. The controversial issue of the duration and doses of the drug used to achieve a lasting effect in the treatment of prolactinomas is considered. There are some points connected with the frequency of relapses. Thus, recurrence is correlated to the duration of treatment with dopamine agonists, prolactin levels at diagnosis, and the initial tumor size. Metformin, somatostatin analogues, selective estrogen receptor modulators, tyrosine kinase inhibitors, inhibitors of the mammalian target of rapamycin, epidermal growth factor receptor antagonists are investigated nowadays as potential alternative methods of drug treatment of prolactinomas. Conclusion Drug therapy with dopamine agonists makes it possible to achieve the desired results in the vast majority of patients. However, despite the proven safety of this group of medicines, the risk of side effects should still be taken into account. The therapy regimen should be determined by the clinical course of prolactinoma and the patient's response to treatment. Other options of treatment should be considered in patients intolerant to medical therapy, with contraindication or resistance to dopamine agonists, in the case of a malignant tumor. The presence of refractory to any of the applied methods of treatment and aggressive prolactinomas leads to the search for new drugs.
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Belhadj Slimane C, Oueslati I, Yazidi M, Kamoun E, Chihaoui M. De Novo Psychiatric Disorders in a Woman With Giant Prolactinoma Treated With Cabergoline. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231186062. [PMID: 37457316 PMCID: PMC10338660 DOI: 10.1177/11795476231186062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/17/2023] [Indexed: 07/18/2023]
Abstract
Dopamine agonists are the first-line treatment of prolactinomas. The risk of developing de novo psychiatric symptoms during dopamine agonist therapy is low. Herein, we report the case of a 42-year-old woman with a giant prolactinoma who developed a psychiatric disorder after 1 day of cabergoline therapy initiation. She presented with amenorrhea, galactorrhea, headaches, and disturbed vision. Biological investigations revealed hyperprolactinemia (2975 ng/ml) with gonadotropin deficiency. Pituitary MRI showed a giant pituitary adenoma. The patient was treated with cabergoline at the dose of 1 mg twice weekly. One day after the treatment initiation, she developed acute delirium with temporospatial disorientation and compulsive medication use. These symptoms disappeared 1 week after the reduction of the dose of cabergoline. Patients with hyperprolactinemia receiving an initial high dose of cabergoline may develop changes in mood and behavior regardless of prior psychiatric history.
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Affiliation(s)
| | - Ibtissem Oueslati
- Ibtissem Oueslati, La Rabta University Hospital Center, Rue JbelLakhdar, La RabtaJebbari, Tunis 1007, Tunisia.
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Kumar S, Sarathi V, Lila AR, Sehemby M, Memon SS, Karlekar M, Sankhe S, Patil VA, Shah N, Bandgar T. Giant prolactinoma in children and adolescents: a single-center experience and systematic review. Pituitary 2022; 25:819-830. [PMID: 35851929 DOI: 10.1007/s11102-022-01250-y] [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: 06/28/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Giant prolactinoma (GP) in childhood and adolescence is a rare entity with scarce literature. We aimed to describe clinical features, biochemistry, radiology, genetics, management, and outcome in pediatric (≤ 20 years) GP. METHODS Retrospective record review of 18 pediatric GP patients from our center and systematic review including these and 77 from the literature (total cohort: 95). RESULTS GP constituted 20% of our pediatric prolactinoma cohort. In the total cohort (age: 15.4 ± 3.5 years), the majority (77, 82.8%) were males. Mass effect symptoms (88.6%), and pubertal delay/arrest in males (82.1%) were frequent. Median basal prolactin was 8649 (3246-17,532) ng/ml and the maximum tumor dimension was 5.5 ± 1.5 cm. MEN1 and AIP mutations were noted in 7 (21.9%) and 6 (18.8%) patients, respectively. Males with central hypogonadism had baseline bi-testicular volume of 20.2 ± 8.4 cc, lower LH than FSH (-2.04 ± 0.9 vs. -0.7 ± 1.6 SDS, p = 0.0075), and mostly, normal inhibin B. Majority (49/76, 64.5%) received dopamine agonist (DA) as first-line treatment with additional therapy in 35% (17/49). DA monotherapy arm had less frequent central hypothyroidism (42.9% vs 87.1%, p = 0.002) and central adrenal insufficiency (7.1% vs 66.7%, p = 0.0003) than multimodal therapy. A smaller tumor dimension (4.7 vs. 5.7 cm, p = 0.04) was associated with normoprolactinemia on DA monotherapy and AIP mutations (33.3% vs. nil, p = 0.02) with multimodal therapy. CONCLUSION GP is characterized by male predominance with frequent delay/arrest of puberty (82%), but relative sparing of the FSH-inhibin B axis in boys. DA monotherapy may be preferred as the first-line therapy in pediatric GP.
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Affiliation(s)
- Sandeep Kumar
- Department of Endocrinology and Metabolism, Seth G S Medical College & KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Anurag Ranjan Lila
- Department of Endocrinology and Metabolism, Seth G S Medical College & KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India.
| | - Manjeetkaur Sehemby
- Department of Endocrinology and Metabolism, Seth G S Medical College & KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India
| | - Saba Samad Memon
- Department of Endocrinology and Metabolism, Seth G S Medical College & KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India
| | - Manjiri Karlekar
- Department of Endocrinology and Metabolism, Seth G S Medical College & KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India
| | - Shilpa Sankhe
- Department of Radiology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Virendra A Patil
- Department of Endocrinology and Metabolism, Seth G S Medical College & KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India
| | - Nalini Shah
- Department of Endocrinology and Metabolism, Seth G S Medical College & KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India
| | - Tushar Bandgar
- Department of Endocrinology and Metabolism, Seth G S Medical College & KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India
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Rudman Y, Duskin-Bitan H, Masri-Iraqi H, Akirov A, Shimon I. Predicting hypogonadotropic hypogonadism persistence in male macroprolactinoma. Pituitary 2022; 25:882-890. [PMID: 36036309 DOI: 10.1007/s11102-022-01259-3] [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: 07/08/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE To study the baseline characteristics predicting hypogonadotropic hypogonadism (HH) persistence in men with macroprolactinoma that achieved prolactin normalization. DESIGN Retrospective cohort study. METHODS Male patients diagnosed with macroprolactinoma and HH that received cabergoline treatment with subsequent prolactin normalization were included: men that achieved eugonadism, and men that remained hypogonadal. Patient's demographic, clinical and biochemical parameters, sellar imaging, and visual fields tests were obtained. Univariate and multivariate models were used to identify predictors of HH persistence. RESULTS Fifty-eight male patients (age 49.2 ± 12.6 years) with a median baseline prolactin of 1154 ng/mL (IQR 478-2763 ng/mL) and adenoma (maximal) diameter of 25.9 ± 14.8 mm were followed for a median of 5.6 years (IQR 3.0-10.7). Twelve men (21%) suffered from HH persistence at the end of follow-up and 46 men achieved eugonadism. Forty-two out of 46 men (91%) accomplished eugonadism within the first year following prolactin normalization. In a multivariate logistic regression model, hypopituitarism (OR 10.1; 95% CI 1.10-101.94), visual field defect (OR 9.9; 95% CI 1.07-92.33), and low baseline testosterone levels (OR 0.5; 95% CI 0.29-0.93) were independent predictors of HH persistence. CONCLUSION In our cohort of men with macroprolactinoma that reached prolactin normalization with cabergoline treatment, 21% had HH persistence. Pituitary hormone deficiency, visual field defects, and low baseline testosterone levels were independently associated with HH persistence. 91% of men achieved eugonadism within the first year following prolactin normalization. These findings may support informed clinical decision-making regarding the initiation of testosterone replacement in men with macroprolactinomas.
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Affiliation(s)
- Yaron Rudman
- Rabin Medical Center, Institute of Endocrinology, Beilinson Hospital, 4941492, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Duskin-Bitan
- Rabin Medical Center, Institute of Endocrinology, Beilinson Hospital, 4941492, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hiba Masri-Iraqi
- Rabin Medical Center, Institute of Endocrinology, Beilinson Hospital, 4941492, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Akirov
- Rabin Medical Center, Institute of Endocrinology, Beilinson Hospital, 4941492, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Shimon
- Rabin Medical Center, Institute of Endocrinology, Beilinson Hospital, 4941492, Petah-Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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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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Cai X, Zhu J, Yang J, Tang C, Cong Z, Ma C. Are dopamine agonists still the first-choice treatment for prolactinoma in the era of endoscopy? A systematic review and meta-analysis. Chin Neurosurg J 2022; 8:9. [PMID: 35395837 PMCID: PMC8994364 DOI: 10.1186/s41016-022-00277-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 03/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background For prolactinoma patients, dopamine agonists (DAs) are indicated as the first-line treatment and surgery is an adjunctive choice. However, with the development of surgical technique and equipment, the effect of surgery has improved. The aim of this study was to assess the efficacy and safety of surgery versus DAs in patients with different types of prolactinomas. Methods A systematic search of literature using Web of Science, PubMed, Cochrane Library, and Clinical Trial databases was conducted until July 12, 2019. Prolactinoma patients treated with DAs (bromocriptine or cabergoline) or surgery (microscopic or endoscopic surgery) were included. Outcomes included the biochemical cure rate, recurrence rate, prolactin level, improvement rates of symptoms, and incidence rates of complications. A random-effects model was used to pool the extracted data. Qualitative comparisons were conducted instead of quantitative comparison. Results DAs were better than surgery in terms of the biochemical cure rate (0.78 versus 0.66), but surgery had a much lower recurrence rate (0.19 versus 0.57). Full advantages were not demonstrated in improvement rates of symptoms and incidence rates of complications with both treatment options. In microprolactinoma patients, the biochemical cure rate of endoscopic surgery was equal to the average cure rate of DAs (0.86 versus 0.86) and it surpassed the biochemical cure rate of bromocriptine (0.86 versus 0.76). In macroprolactinoma patients, endoscopic surgery was slightly higher than bromocriptine (0.66 versus 0.64) in terms of the biochemical cure rate. Conclusion For patients with clear indications or contraindications for surgery, choosing surgery or DAs accordingly is unequivocal. However, for patients with clinical equipoise, such as surgery, especially endoscopic surgery, in microprolactinoma and macroprolactinoma patients, we suggest that neurosurgeons and endocrinologists conduct high-quality clinical trials to address the clinical equipoise quantitatively. Supplementary Information The online version contains supplementary material available at 10.1186/s41016-022-00277-1.
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Affiliation(s)
- Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Jin Yang
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Tang
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Chiyuan Ma
- School of Medicine, Southeast University, Nanjing, China. .,School of Medicine, Nanjing Medical University, Nanjing, China. .,Department of Neurosurgery, Jinling Hospital, Nanjing, China. .,School of Medicine, Nanjing University, Nanjing, China.
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Faje A, Jones P, Swearingen B, Tritos NA. The prolactin per unit tumor volume ratio accurately distinguishes prolactinomas from secondary hyperprolactinemia due to stalk effect. Endocr Pract 2022; 28:572-577. [PMID: 35339688 DOI: 10.1016/j.eprac.2022.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Prolactin levels alone are insufficient to distinguish between some cases of prolactinomas and stalk effect. We aimed to (i) formally characterize the relationship between serum prolactin and prolactinoma volume, (ii) determine a cutoff for prolactin/mm3 that accurately distinguishes prolactinomas from stalk effect, and (iii) validate this cutoff in a cohort selected to include ambiguous prolactin values ranging from 50-150 ng/ml. METHODS We utilized the Research Patient Database Registry and transsphenoidal surgery database in our institution to retrospectively identify adult patients with clinically nonfunctioning tumors (primary analysis n=279; validation cohort n=10) and prolactinomas (primary analysis n=94; validation cohort n=18). Solid tumor volumes were measured by Visage®7 software, and cystic foci within tumors were excluded. RESULTS Prolactin levels correlated strongly with prolactinoma volume (r2=0.801) but were not a relevant predictor of nonfunctioning tumor size (r2=0.015). Prolactin/mm3 values did not overlap between nonfunctioning tumors (median 0.016, interquartile range [IR] 0.009-0.028) and prolactinomas (median 0.551, IR 0.265-0.845), p<0.0001. A cutoff of 0.065 (ng/ml)/mm3 correctly discriminated between prolactinomas and nonfunctioning tumors in all 401 patients in the primary analysis and validation cohort. CONCLUSIONS The prolactin:volume ratio correctly distinguished all prolactinomas from stalk effect in this study, including a validation cohort specifically chosen for potential ambiguity. This study is the first formal volumetric analysis of prolactin secretion in pituitary adenomas, and our results suggest that measurement of prolactin/mm3 is a valuable tool to better characterize challenging cases of primary tumoral secretion versus secondary hyperprolactinemia due to stalk effect.
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Affiliation(s)
- Alexander Faje
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114; Harvard Medical School, Boston, MA 02115.
| | - Pamela Jones
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114; Harvard Medical School, Boston, MA 02115
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114; Harvard Medical School, Boston, MA 02115
| | - Nicholas A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114; Harvard Medical School, Boston, MA 02115
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CANDER S, ÖZ GÜL Ö. Comparison of Ki-67 index values between patients with operated giant prolactinomas and macroprolactinomas. TURKISH JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.46310/tjim.1070094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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15
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Caklili OT, Ok AM, Istemihan Z, Selcukbiricik O, Yarman S. Optimal testosterone level to improve symptoms of hypogonadism without causing dopa-testotoxicosis in male macroprolactinoma. ANNALES D'ENDOCRINOLOGIE 2021; 83:9-15. [PMID: 34871603 DOI: 10.1016/j.ando.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/26/2021] [Accepted: 11/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Male prolactinoma treatment by dopamine agonists (DA) restores sexual function. However, excessive DA dose can lead to impulse control disorder. OBJECTIVES The aim of this retrospective study was to determine the level of testosterone that eliminates symptoms and provides fertility in male macroprolactinoma, without causing these adverse effects. MATERIALS AND METHODS Twenty-seven male patients with macroprolactinoma were included. There were 16 macro (≥1-2.8 cm), 7 large macro (≥2.9-3.9 cm) and 4 giant (≥4 cm) adenomas. Prolactin (PRL) and testosterone (T) levels were evaluated. A timeline was created to analyze improvement in symptoms of hypogonadism and infertility. Testosterone levels were compared with age-matched controls. RESULTS Mean PRL, basal tumor diameter and shrinkage were 2,846±3,415 ng/mL, 27.2±10.2 mm and 63.4%, respectively. Basal T levels were 1.6±1.0 ng/mL for patients and 4.4±1.5 ng/mL for controls (p<0.001). Mean T level in the asymptomatic period was significantly lower than in controls (3.2±0.4 ng/mL vs. 4.4±1.5 ng/mL, respectively; p=0.002), while mean PRL was 27.2 ng/ml. Fertility was achieved in 6 of the patients seeking fertility, and there was no difference in T level between these patients and controls (3.7±0.8 ng/mL and 4.4±1.5 ng/mL, respectively; p=0.14); when fertility was achieved, mean PRL was 26.9±23 ng/mL. CONCLUSION Patients should be carefully questioned regarding complaints at each consultation, and DA dose should not be increased unnecessarily, to avoid possible serious adverse effects.
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Affiliation(s)
- Ozge Telci Caklili
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Turkey; Division of Endocrinology and Metabolic Disease, Istanbul, Turkey.
| | - Ayse Merve Ok
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Turkey; Division of Endocrinology and Metabolic Disease, Istanbul, Turkey
| | - Zulal Istemihan
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Turkey
| | - Ozlem Selcukbiricik
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Turkey; Division of Endocrinology and Metabolic Disease, Istanbul, Turkey
| | - Sema Yarman
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Turkey; Division of Endocrinology and Metabolic Disease, Istanbul, Turkey
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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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Remón-Ruiz P, Venegas-Moreno E, Dios Fuentes E, Matias Kaen A, Cardenas Ruiz-Valdepeñas E, Martin-Schrader I, Roldán F, Fajardo E, Cano D, Soto-Moreno A. Our experience in prolactinomas larger than 60mm. ACTA ACUST UNITED AC 2020; 68:3-10. [PMID: 32861621 DOI: 10.1016/j.endinu.2020.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/11/2020] [Accepted: 03/14/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Giant prolactinomas (tumor size larger than 40mm) are a rare entity of benign nature. Prolactinomas larger than 60mm are usually underrepresented in published studies and their clinical presentation, outcomes and management might be different from smaller giant prolactinomas. PATIENTS AND METHODS We retrospective collected data from patients with prolactinomas larger than 60mm in maximum diameter and prolactin (PRL) serum levels higher than 21,200μIU/mL in our series of prolactinomas (283). Data were collected from January 2012 to December 2017. We included three patients with prolactinomas larger than 60mm. RESULTS At diagnosis, two patients presented neurological symptoms and one nasal protrusion. All patients received medical treatment with dopamine agonists. No surgical procedure was performed. Median prolactin levels at diagnosis was 108,180 [52,594-514,984]μIU/mL. Medical treatment achieved a marked reduction (>99%) in prolactin levels in all cases. Tumor size reduction (higher than 33%) was observed in all cases. In one patient cerebrospinal fluid (CSF) leak was observed after tumor shrinkage. CONCLUSIONS Dopamine agonists appear to be an effective and safe first-line treatment in prolactinomas larger than 60mm even in life-threatening situations. More studies with a higher number of patients are necessary to obtain enough data to make major recommendations.
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Affiliation(s)
- Pablo Remón-Ruiz
- Unidad de Gestión de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, Spain.
| | - Eva Venegas-Moreno
- Unidad de Gestión de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, Spain
| | - Elena Dios Fuentes
- Unidad de Gestión de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, Spain
| | - Ariel Matias Kaen
- Neurosurgery Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | | | | | - Florinda Roldán
- Unidad de Gestión de Radiodiagnóstico, Virgen del Rocio University Hospital, Spain
| | - Elena Fajardo
- Unidad de Gestión de Radiodiagnóstico, Virgen del Rocio University Hospital, Spain
| | - David Cano
- Unidad de Gestión de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, Spain
| | - Alfonso Soto-Moreno
- Unidad de Gestión de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBiS), Virgen del Rocio University Hospital/CSIC/University of Seville, Spain
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Lim J, Talsania M, Azar M. SPONTANEOUS CEREBROSPINAL FLUID LEAK AFTER INITIATION OF DOPAMINE AGONIST THERAPY IN MACROPROLACTINOMAS: TWO CASE REPORTS AND A LITERATURE REVIEW. AACE Clin Case Rep 2020; 6:e90-e93. [PMID: 32524018 DOI: 10.4158/aacr-2019-0372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/01/2020] [Indexed: 11/15/2022] Open
Abstract
Objective To describe 2 spontaneous cerebrospinal fluid (CSF) leaks complicating treatment of macroprolactinoma (MPRL) with dopamine agonist (DA) therapy. Methods We present the 2 cases of spontaneous, DA-related CSF leaks. Prolactin levels were used to assess hyperprolactinemia. Beta-2 transferrin was tested in rhinorrhea fluid, and magnetic resonance imaging was used to assess the sella. Results Case 1 was a 45-year-old woman with a history of MPRL, recently started on bromocriptine at 15 mg/day, presented with clear rhinorrhea, headache, and nuchal rigidity. Magnetic resonance imaging showed a large sellar lesion extending into the cavernous sinuses, posterior sphenoid sinuses, and suprasellar cistern. Computed tomography revealed areas concerning for bony erosion, likely representing leak sites, and the rhinorrhea fluid was positive for beta-2 transferrin, confirming the CSF source. Empiric antibiotics for meningitis were given and she underwent urgent neuroendoscopic, transsphenoidal CSF leak repair and debulking of the pituitary mass. Case 2 was a 55-year-old man with a 10-year history of untreated MPRL who was started on bromocriptine at 5 mg/day 2 weeks prior to admission. He presented with clear rhinorrhea and a metallic taste in his mouth, worse with the Valsalva maneuver. Imaging confirmed clinical suspicion and he was taken for surgery. A high-flow CSF leak was encountered once the tumor was debulked. This was repaired with an abdominal fat pad graft. Both patients developed diabetes insipidus and required postoperative adjuvant DA therapy. Conclusion Spontaneous CSF leaks can complicate medical therapy of large MPRL with underlying skull defects, typically within weeks of initiation of DA. This should prompt clinicians to educate patients about the symptoms of potential CSF rhinorrhea and encourage them to promptly report them.
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Abstract
The management of aggressive pituitary adenomas represents a special clinical challenge, and usually involves a combination of surgery, radiotherapy and pharmacological agents to control tumor growth and hormone abnormalities. Fertility is commonly affected in these patients due to compressive effects of the tumor, pituitary hormone dysfunction or as a result of the multiple therapies. The initial approach to restore fertility involves the reduction of tumor volume by the use of dopamine agonists in prolactinomas and by surgery in other pituitary adenomas. Somatostatin analogues are alternative options for GH, ACTH and TSH-secreting tumors. When present, pituitary deficiencies should be appropriately treated, particularly GH deficiency that has been associated with poor pregnancy rates in hypopituitary patients. Other therapies for aggressive pituitary tumors, such as invasive surgery, radiotherapy and temozolamide, may lead to infertility. In such cases, fertility preservation strategies might be considered and discussed with the patient desiring conception before or during treatment. In men and women with hypogonadotropic hypogonadism, administration of gonadotropins or pulse GnRH has resulted in satisfactory pregnancy rates. If spontaneous gestation is not achieved, assisted reproduction techniques can be employed as the last line of treatment. In any context, pre-conception counseling and care are essential as pregnancies in women with aggressive pituitary tumors should always be considered high risk.
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Affiliation(s)
- Júlia Vieira Oberger Marques
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Agostinho Leão Junior 285, Curitiba, PR, 80030-110, Brazil
| | - Cesar Luiz Boguszewski
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Agostinho Leão Junior 285, Curitiba, PR, 80030-110, Brazil.
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Abstract
CONTEXT Prolactinomas in men are usually large and invasive, presenting with signs and symptoms of hypogonadism and mass effects, including visual damage. Prolactin levels are high, associated with low testosterone, anemia, metabolic syndrome and if long-standing also osteoporosis. RESULTS Medical treatment with the dopamine agonist, cabergoline, became the preferred first-line treatment for male prolactinomas as well as for giant tumors, leading to prolactin normalization in ~ 80% of treated men, and tumor shrinkage, improved visual fields and recovery of hypogonadism in most patients. Multi-modal approach including surgery and occasionally radiotherapy together with a high-dose cabergoline is saved for resistant and invasive adenomas. Experimental treatments including temozolomide or pasireotide may improve clinical response in men harboring resistant prolactinomas. CONCLUSIONS Compared to other pituitary adenomas, secreting and non-secreting, where pituitary surgery is the recommended first-line treatment, men with prolactinomas will usually respond to medical treatment with no need for any additional treatment.
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Affiliation(s)
- Hadar Duskin-Bitan
- Institute of Endocrinology and Metabolism, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Shimon
- Institute of Endocrinology and Metabolism, Rabin Medical Center - Beilinson Hospital, 4941492, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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22
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Lin S, Zhang A, Zhang X, Wu ZB. Treatment of Pituitary and Other Tumours with Cabergoline: New Mechanisms and Potential Broader Applications. Neuroendocrinology 2020; 110:477-488. [PMID: 31597135 DOI: 10.1159/000504000] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022]
Abstract
Cabergoline is a dopamine agonist that has been used as the first-line treatment option for prolactin-secreting pituitary adenomas for several decades. It not only suppresses hormone production from these prolactinomas, but also causes tumour shrinkage. Recent studies revealed some novel mechanisms by which cabergoline suppresses tumour cell proliferation and induces cell death. In this article, we review the most recent findings in cabergoline studies, focusing on its anti-tumour function. These studies suggest the potential broader clinical use of cabergoline in the treatment of other tumours such as breast cancer, pancreatic neuroendocrine tumours, and lung cancer.
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Affiliation(s)
- Shaojian Lin
- Center of Pituitary Tumour, Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Anke Zhang
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xun Zhang
- Neuroendocrine Research Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Zhe Bao Wu
- Center of Pituitary Tumour, Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,
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23
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Sahakian N, Castinetti F, Dufour H, Graillon T, Romanet P, Barlier A, Brue T, Cuny T. Clinical management of difficult to treat macroprolactinomas. Expert Rev Endocrinol Metab 2019; 14:179-192. [PMID: 30913932 DOI: 10.1080/17446651.2019.1596024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/13/2019] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Prolactinomas represent the most common pituitary adenomas encountered in the clinic. While a majority of these tumors will be successfully treated by dopamine agonist (DA) such as cabergoline, their management becomes problematic since a resistance to DA can occur and/or if the tumor displays features of aggressiveness, two conditions that are closely related. AREAS COVERED Epidemiology and medical treatment of prolactinomas; resistance to DA and molecular basis of DA-resistance; therapeutical alternatives in case of DA-resistant Prolactinomas and therapies in development; summarizing conclusions. EXPERT OPINION The management of DA-resistant prolactinomas requires a multidisciplinary approach by an expert team. Along with discussions about surgery with or without gamma knife radiosurgery, genetic screening for multiple endocrine neoplasia type 1 (MEN1) syndrome is actively discussed in a case-by-case approach. In case of surgery, a careful analysis of the tumor sample can provide information about its aggressivity potential according to recent criteria. Ultimately, temozolomide can be indicated if the tumor is rapidly growing and/or threatening for the patient.
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Affiliation(s)
- Nicolas Sahakian
- a Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Service d'Endocrinologie , Aix Marseille Univ, APHM , Marseille , France
| | - Frederic Castinetti
- a Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Service d'Endocrinologie , Aix Marseille Univ, APHM , Marseille , France
| | - Henry Dufour
- b Marseille Medical Genetics, Inserm U1251, Hôpital de la Timone, Service de Neurochirurgie , Aix Marseille Univ, APHM , Marseille , France
| | - Thomas Graillon
- b Marseille Medical Genetics, Inserm U1251, Hôpital de la Timone, Service de Neurochirurgie , Aix Marseille Univ, APHM , Marseille , France
| | - Pauline Romanet
- c Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Laboratoire de Biologie Moléculaire et Biochimie , Aix Marseille Univ, APHM , Marseille , France
| | - Anne Barlier
- c Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Laboratoire de Biologie Moléculaire et Biochimie , Aix Marseille Univ, APHM , Marseille , France
| | - Thierry Brue
- a Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Service d'Endocrinologie , Aix Marseille Univ, APHM , Marseille , France
| | - Thomas Cuny
- a Marseille Medical Genetics, Inserm U1251, Hôpital de la Conception, Service d'Endocrinologie , Aix Marseille Univ, APHM , Marseille , France
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Dai C, Liu X, Ma W, Wang R. The Treatment of Refractory Pituitary Adenomas. Front Endocrinol (Lausanne) 2019; 10:334. [PMID: 31191457 PMCID: PMC6548863 DOI: 10.3389/fendo.2019.00334] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/09/2019] [Indexed: 12/22/2022] Open
Abstract
Refractory pituitary adenomas (PAs) are defined as aggressive-invasive PAs characterized by a high Ki-67 index, rapid growth, frequent recurrence, and resistance to conventional treatments. It is notoriously difficult to manage refractory PAs because the efficacy of current therapeutic options is limited. The purpose of this review is to address currently employed and promising therapeutic strategies for the treatment of refractory PAs. Except for prolactinomas, neurosurgery is the first-line option, but most refractory PAs often recur or re-grow after initial surgery and require further treatments. Medical therapy, radiotherapy and re-operation are explored when surgery has failed to completely resect tumors; however, refractory PAs are usually resistant to these treatments. As a salvage treatment, temozolomide (TMZ) has shown promising results and is currently used for all types of refractory PAs. However, not all refractory PAs are responsive to TMZ treatment, and some of these PAs are resistant to TMZ. Although targeted therapies such as vascular endothelial growth factor, epidermal growth factor and mTOR inhibitors have also been used to treat refractory PAs, the effectiveness of these targeted therapies is still not known due to a lack of data from randomized prospective trials. As a novel therapeutic method, cancer immunotherapy is a promising strategy for the treatment of refractory PAs, but further preclinical research and clinical trials are needed to assess the efficacy of this new approach. In summary, early identification and a multidisciplinary approach are required to treat refractory PAs.
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25
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Abstract
Prolactin-secreting adenomas (prolactinomas) are the most common secreting adenomas of the pituitary. Microprolactinomas (diameter <10 mm) are frequently diagnosed in women, whereas macroprolactinomas (maximum diameter ≥10 mm) are generally seen in men. Most macroprolactinomas measure between 10 and 40 mm. Giant prolactinomas, measuring >40 mm, are rare, accounting for only 1-5% of all prolactinomas. Although generally benign, giant prolactinomas are aggressive and invasive, extending into the suprasellar region and also involving the cavernous sinuses. The optic chiasm is frequently involved, which leads to visual damage, and patients occasionally suffer from ophthalmoplegia. Long-term (usually lifetime) therapy with high-dose dopamine agonists (cabergoline or bromocriptine), together with pituitary surgery in some cases and radiotherapy if required, can achieve biochemical remission, tumor control, and clinical improvement in most patients.
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Affiliation(s)
- Ilan Shimon
- Institute of Endocrinology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
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26
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Giant Prolactinoma of Young Onset: A Clue to Diagnosis of MEN-1 Syndrome. Case Rep Endocrinol 2018; 2018:2875074. [PMID: 30186640 PMCID: PMC6112072 DOI: 10.1155/2018/2875074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 08/01/2018] [Indexed: 11/18/2022] Open
Abstract
Multiple endocrine neoplasia (MEN) type 1 syndrome is an autosomal dominant disorder caused by germline mutations in MEN1 gene, characterized by tumours in endocrine and nonendocrine organs. Giant prolactinoma is defined as tumours larger than 40mm with very high prolactin secretion. We report two unrelated Sri Lankan patients (8-year-old boy and a 20-year-old female) who presented with giant prolactinomas with mass effects of the tumours. The female patient showed complete response to medical therapy, while the boy developed recurrent resistant prolactinoma needing surgery and radiotherapy. During follow-up, both developed pancreatic neuroendocrine tumours. Genetic analysis revealed that one was heterozygous for a nonsense mutation and other for missense mutation in MEN1 gene. Screening confirmed familial MEN-1 syndrome in their families. High clinical suspicion upon unusual clinical presentation prompted genetic evaluation in these patients and detection of MEN1 gene mutation. Pituitary adenomas in children with MEN-1 syndrome are larger tumours with higher rates of treatment resistance. This report emphasizes importance of screening young patients with giant prolactinoma for MEN-1 syndrome and arranging long-term follow-up for them expecting variable treatment outcomes. Sri Lanka requires further studies to describe the genotypic-phenotypic variability of MEN-1 syndrome in this population.
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27
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Iglesias P, Rodríguez Berrocal V, Díez JJ. Giant pituitary adenoma: histological types, clinical features and therapeutic approaches. Endocrine 2018; 61:407-421. [PMID: 29909598 DOI: 10.1007/s12020-018-1645-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 05/29/2018] [Indexed: 12/23/2022]
Abstract
Giant pituitary adenomas comprise about 6-10% of all pituitary tumors. They are mostly clinically non-functioning adenomas and occur predominantly in males. The presenting symptoms are usually secondary to compression of neighboring structures, but also due to partial or total hypopituitarism. Functioning adenomas give rise to specific symptoms of hormonal hypersecretion. The use of dopamine agonists is considered a first-line treatment in patients with giant macroprolactinomas. Somatostatin analogs can also be used as primary treatment in cases of growth hormone and thyrotropin producing giant adenomas, although remission of the disease is not achieved in the vast majority of these patients. Neurosurgical treatment, either through transsphenoidal or transcranial surgery, continues to be the treatment of choice in the majority of patients with giant pituitary adenomas. The intrinsic complexity of these tumors requires the use of different therapies in a combined or sequential way. A multimodal approach and a therapeutic strategy involving a multidisciplinary team of expert professionals form the basis of the therapeutic success in these patients.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology. Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.
| | | | - Juan José Díez
- Department of Endocrinology. Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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28
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Sosa-Eroza E, Espinosa E, Ramírez-Rentería C, Mendoza V, Arreola R, Mercado M. Treatment of multiresistant prolactinomas with a combination of cabergoline and octreotide LAR. Endocrine 2018; 61:343-348. [PMID: 29948930 DOI: 10.1007/s12020-018-1638-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 05/15/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Dopamine agonist (DA)-resistant prolactinomas are rare but they constitute a real challenge, since there are few therapeutic alternatives left for these patients. DESIGN AND SETTING Proof-of-concept study at a tertiary care, referral center. PATIENTS AND METHODS The studied population consisted of five patients (one female and four males, mean age at diagnosis 23.5 ± 19) with macroprolactinomas with persistent hyperprolactinemia and/or tumor mass despite high doses of cabergoline (CBG) and pituitary surgery, to whom 20 mg monthly of octreotide LAR was added for 6-13 months. Response was evaluated by measuring prolactin (PRL) levels and by magnetic resonance imaging. Immunohistochemistry (IHC) for pituitary hormones, Ki-67, and somatostatin receptor subtypes 2 and 5 was (SSTR2 and 5) was available in two of the subjects. RESULTS The addition of octreotide LAR to ongoing CBG treatment had no effect on either PRL levels or tumor size in three patients. In two of the five patients, combination treatment resulted in a significant reduction in PRL concentrations (from 7643 to 200 ng/mL and from 2587 to 470 ng/mL) as well as in adenoma size (93% reduction). IHC evaluation of tumor samples from two patients (a responder and a non-responder) revealed positive immunostaining for PRL and SSTR5 but not for other pituitary hormones or for SSTR2. CONCLUSIONS The addition of a somatostatin analog to ongoing CBG treatment may be effective in some patients with DA-resistant macroprolactinomas, independently of the adenoma's SSTR expression profile.
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Affiliation(s)
- Ernesto Sosa-Eroza
- Endocrinology Service and the Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, MX, USA
| | - Etual Espinosa
- Endocrinology Service and the Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, MX, USA
| | - Claudia Ramírez-Rentería
- Endocrinology Service and the Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, MX, USA
| | - Victoria Mendoza
- Endocrinology Service and the Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, MX, USA
| | - Rocío Arreola
- Pathology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, MX, USA
| | - Moises Mercado
- Endocrinology Service and the Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, MX, USA.
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29
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Vilar L, Abucham J, Albuquerque JL, Araujo LA, Azevedo MF, Boguszewski CL, Casulari LA, Cunha Neto MBC, Czepielewski MA, Duarte FHG, Faria MDS, Gadelha MR, Garmes HM, Glezer A, Gurgel MH, Jallad RS, Martins M, Miranda PAC, Montenegro RM, Musolino NRC, Naves LA, Ribeiro-Oliveira Júnior A, Silva CMS, Viecceli C, Bronstein MD. Controversial issues in the management of hyperprolactinemia and prolactinomas - An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:236-263. [PMID: 29768629 PMCID: PMC10118988 DOI: 10.20945/2359-3997000000032] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 08/09/2017] [Indexed: 11/23/2022]
Abstract
Prolactinomas are the most common pituitary adenomas (approximately 40% of cases), and they represent an important cause of hypogonadism and infertility in both sexes. The magnitude of prolactin (PRL) elevation can be useful in determining the etiology of hyperprolactinemia. Indeed, PRL levels > 250 ng/mL are highly suggestive of the presence of a prolactinoma. In contrast, most patients with stalk dysfunction, drug-induced hyperprolactinemia or systemic diseases present with PRL levels < 100 ng/mL. However, exceptions to these rules are not rare. On the other hand, among patients with macroprolactinomas (MACs), artificially low PRL levels may result from the so-called "hook effect". Patients harboring cystic MACs may also present with a mild PRL elevation. The screening for macroprolactin is mostly indicated for asymptomatic patients and those with apparent idiopathic hyperprolactinemia. Dopamine agonists (DAs) are the treatment of choice for prolactinomas, particularly cabergoline, which is more effective and better tolerated than bromocriptine. After 2 years of successful treatment, DA withdrawal should be considered in all cases of microprolactinomas and in selected cases of MACs. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) is to provide a review of the diagnosis and treatment of hyperprolactinemia and prolactinomas, emphasizing controversial issues regarding these topics. This review is based on data published in the literature and the authors' experience.
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Affiliation(s)
- Lucio Vilar
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Julio Abucham
- Unidade de Neuroendócrino, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp/EPM), São Paulo, SP, Brasil
| | - José Luciano Albuquerque
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Luiz Antônio Araujo
- Centro de Endocrinologia e Diabetes de Joinville (Endoville), Joinville, SC, Brasil
| | - Monalisa F Azevedo
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Cesar Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia, Hospital de Clínicas, Universidade Federal do Paraná (SEMPR), Curitiba, PR, Brasil
| | - Luiz Augusto Casulari
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Malebranche B C Cunha Neto
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Felipe H G Duarte
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manuel Dos S Faria
- Serviço de Endocrinologia, Hospital Universitário Presidente Dutra, Universidade Federal do Maranhão (UFMA), São Luís, MA, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brasil
| | - Heraldo M Garmes
- Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (FCM/Unicamp), Campinas, SP, Brasil
| | - Andrea Glezer
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Maria Helane Gurgel
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Raquel S Jallad
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manoel Martins
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Paulo A C Miranda
- Serviço de Endocrinologia e Metabologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
| | - Renan M Montenegro
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Nina R C Musolino
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | | | - Cíntia M S Silva
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil
| | - Camila Viecceli
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Marcello D Bronstein
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
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30
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Lundgren JA, Oldfield EH, Marshall JC. The longest stalk: preserved pituitary function after regression of a giant prolactinoma. Pituitary 2017; 20:485-487. [PMID: 28210909 PMCID: PMC5844470 DOI: 10.1007/s11102-017-0796-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Edward H Oldfield
- University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - John C Marshall
- University of Virginia Health System, Charlottesville, VA, 22908, USA
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31
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Shimon I. Giant prolactinomas: Multi-modal approach to achieve tumor control. Endocrine 2017; 56:227-228. [PMID: 28050685 DOI: 10.1007/s12020-016-1225-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 12/28/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, Petah-Tiqva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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32
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Andujar-Plata P, Villar-Taibo R, Ballesteros-Pomar MD, Vidal-Casariego A, Pérez-Corral B, Cabezas-Agrícola JM, Álvarez-Vázquez P, Serramito R, Bernabeu I. Long-term outcome of multimodal therapy for giant prolactinomas. Endocrine 2017; 55:231-238. [PMID: 27704480 DOI: 10.1007/s12020-016-1129-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
Abstract
Giant prolactinomas are rare tumors characterized by their large size, compressive symptoms, and extremely high prolactin secretion. The aim of this study is to describe our experience with a series of 16 giant prolactinomas cases in terms of clinical presentation, therapeutic decisions, and final outcomes. Retrospective analysis of adult patients diagnosed with giant prolactinomas at the endocrine departments of three university tertiary hospitals. We included 16 patients (43.7 % women); mean age at diagnosis: 42.1 ± 21 years. The most frequent presentation was compressive symptoms. The delay in diagnosis was higher in women (median of 150 months vs. 12 in men; p = 0.09). The mean maximum tumor diameter at diagnosis was 56.9 ± 15.5 mm, and mean prolactin levels were 10,995.9 ± 12,157.8 ng/mL. Dopamine agonists were the first-line treatment in 11 patients (mean maximum dose: 3.9 ± 3.2 mg/week). Surgery was the initial treatment in five patients and the second-line treatment in six. Radiotherapy was used in four cases. All patients but one, are still with dopamine agonists. After a mean follow-up of 9 years, prolactin normalized in 7/16 patients (43.7 %) and 13 patients (81 %) reached prolactin levels lower than twice the upper limit of normal. Mean prolactin level at last visit: 79.5 ± 143 ng/mL. Tumor volume was decreased by 93.8 ± 11.3 %, and final maximum tumor diameter was 18.4 ± 18.8 mm. Three patients are actually tumor free. Giant prolactinomas are characterized by a large tumor volume and extreme prolactin hypersecretion. Multimodal treatment is frequently required to obtain biochemical and tumor control.
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Affiliation(s)
- Paula Andujar-Plata
- Endocrinology Division, Complejo Hospitalario Universitario de Ourense (CHUO)-SERGAS, Ourense, 32005, Spain
| | - Rocio Villar-Taibo
- Complejo Asistencial Universitario de León (CAULE)-SACYL, León, 24008, Spain
| | | | | | - Begoña Pérez-Corral
- Complejo Asistencial Universitario de León (CAULE)-SACYL, León, 24008, Spain
| | - Jose Manuel Cabezas-Agrícola
- Endocrinology Division, Complejo Hospitalario Universitario de Santiago de Compostela (CHUS)-SERGAS, Santiago de Compostela, 15706, Spain
| | - Paula Álvarez-Vázquez
- Endocrinology Division, Complejo Hospitalario Universitario de Ourense (CHUO)-SERGAS, Ourense, 32005, Spain
| | - Ramón Serramito
- Neurosurgery Division, Complejo Hospitalario Universitario de Santiago de Compostela (CHUS)-SERGAS, Santiago de Compostela, 15706, Spain
| | - Ignacio Bernabeu
- Endocrinology Division, Complejo Hospitalario Universitario de Santiago de Compostela (CHUS)-SERGAS, Santiago de Compostela, 15706, Spain.
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33
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Shimon I, Sosa E, Mendoza V, Greenman Y, Tirosh A, Espinosa E, Popovic V, Glezer A, Bronstein MD, Mercado M. Giant prolactinomas larger than 60 mm in size: a cohort of massive and aggressive prolactin-secreting pituitary adenomas. Pituitary 2016; 19:429-36. [PMID: 27138902 DOI: 10.1007/s11102-016-0723-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Prolactin (PRL)-secreting macroadenomas usually measure between 10 and 40 mm. Giant (adenoma size ≥40 mm) PRL-tumors are not common, and larger prolactinomas (maximal diameter ≥60 mm) are rare, and their management outcomes have not been well characterized. METHODS We have identified 18 subjects (16 men, 2 females) with giant PRL-adenomas (size ≥60 mm; PRL > 1000 ng/ml) and summarized their characteristics and response to treatment. RESULTS Mean age was 36.3 ± 13.5 years (range 12-59 years). Mean adenoma size was 71.8 ± 10.2 mm (60-92 mm). Complaints at presentation included headaches in 11 patients, visual deterioration in 9, sexual dysfunction in 9 males, and behavioral changes in two. Fourteen (78 %) had visual field defects. Mean PRL at presentation was 28,465 ng/ml (range 1300-270,000). All patients were treated with cabergoline (3.9 ± 2.0 mg/week), except for one who received bromocriptine. Treatment achieved PRL normalization in 11/18 patients within a median interval of 20 months. Visual improvement occurred in 12/14 patients with pre-treatment visual abnormalities. Nine patients underwent surgery (transsphenoidal, 7; transcranial, 2). None of the seven patients with elevated PRL before surgery achieved remission post-operatively. After a follow-up of 7.8 ± 5.1 years, 15/18 patients had significant adenoma shrinkage. Eleven patients are normoprolactinemic, 3 are partially controlled (PRL < 3 × ULN), and 4 remain with significantly elevated PRL. Most patients reported disappearance or improvement of their complaints. CONCLUSIONS These enormous PRL-adenomas are invasive but respond fairly well to medical treatment. Long-term therapy with high dose cabergoline together with a pituitary surgery in some patients was the key for their successful management, achieving biochemical and clinical remission in most patients.
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Affiliation(s)
- Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, 49100, Petah Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ernesto Sosa
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
| | - Victoria Mendoza
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
| | - Yona Greenman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Amit Tirosh
- Institute of Endocrinology, Beilinson Hospital, Rabin Medical Center, 49100, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Etual Espinosa
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
| | - Vera Popovic
- University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Andrea Glezer
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Moises Mercado
- Experimental Endocrinology Unit, Hospital de Especialidades, Centro Médico Nacional S.XXI, IMSS, Mexico City, Mexico
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Wu ZR, Zhang Y, Cai L, Lin SJ, Su ZP, Wei YX, Shang HB, Yang WL, Zhao WG, Wu ZB. Long-Term Clinical Outcomes of Invasive Giant Prolactinomas after a Mean Ten-Year Followup. Int J Endocrinol 2016; 2016:8580750. [PMID: 27999593 PMCID: PMC5141542 DOI: 10.1155/2016/8580750] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/24/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. The aim of this study is to observe clinical outcomes after more than ten years of followup in a group of patients with invasive giant prolactinomas (IGPs) treated with dopamine agonists (DAs). Methods. Twenty-five patients met the criteria of IGPs, among which 16 patients primarily received bromocriptine (BRC) and the other nine had undergone unsuccessful microsurgery prior to BRC treatment. Results. After a mean follow-up period of 135.5 ± 4.7 months, the clinical symptoms in all patients improved by different degrees. Tumor volume was decreased by a mean of 98.6%, and the tumors of 19 patients had almost completely disappeared. The mean duration of treatment at maximal doses of BRC was 48.5 months. At the last follow-up visit, nineteen patients had normal PRL levels, and 14 of these patients had received the low-dose BRC treatment (at an average of 2.9 ± 0.3 mg/d). Younger patients < 25 years had a significantly higher rate of persistent hyperprolactinemia after long-term BRC treatment (p = 0.043). Conclusion. DAs are a first-line therapy for IGPs because they can effectively achieve long-term control in both shrinking tumor volume and normalizing the PRL level, and majority of patients need low-dose DA maintenance. Younger patients are prone to persistent hyperprolactinemia despite long-term DA treatment.
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Affiliation(s)
- Ze Rui Wu
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yong Zhang
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Lin Cai
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Shao Jian Lin
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhi Peng Su
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yong Xu Wei
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Han Bing Shang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wen Lei Yang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wei Guo Zhao
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhe Bao Wu
- Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- *Zhe Bao Wu:
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