Galactorrhea in a 12-year-old boy with a chromophobe adenoma

Transnasal surgery for prolactin-secreting pituitary adenomas in childhood and adolescence

BACKGROUND

Prolactin (PRL)-secreting pituitary adenomas (prolactinomas) are rare in childhood and adolescence; there are only a few published series of patients who were surgically treated. We discuss the gender-dependent differences, and the surgical indications and results for 14 patients with prolactinomas under 18 years of age at surgery.

METHODS

We reviewed the data for 14 patients (10 girls and 4 boys) treated surgically for prolactinomas between 1980 and 1996. Surgery was chosen because of intolerance and/or resistance to dopamine agonist (DA) in 9 patients, the patient's decision in 3, rhinorrhea in 1, and pituitary apoplexy in 1 during DA therapy. All patients underwent direct transnasal explorations. Since 1988, intraoperative PRL measurements were performed. The follow-up period was at least 6 years.

RESULTS

Nine of the 10 girls had primary or secondary amenorrhea, and 3 of the 4 boys had visual field defects. The boys and girls were the same age at the onset of symptoms and had the same preoperative duration of symptoms. Boys had larger, more invasive tumors and higher preoperative and postoperative plasma PRL levels than girls. Two boys demonstrated significant extrasellar extension at the time of diagnosis. Two patients required drilling of the incompletely pneumatized sphenoid sinus to reach the sella. Radical tumor resection was achieved in seven girls and in none of the four boys. In 12 of the 14 patients, normal pituitary function was preserved by transnasal surgery. There was no severe surgical morbidity or mortality. Endocrinological remission by surgery alone was achieved for seven girls, and was achieved in 4 of the 5 patients (80%) with microadenomas. In patients with preoperative mean PRL levels of less than 200 microg/L, the surgical cure rate was 75%.

CONCLUSIONS

Prolactinomas in childhood and adolescence differ in their biology in boys and girls. Transnasal surgery is as safe in childhood patients as it is in adult patients, and it may be an effective alternative to long-term medical therapy for selected patients with prolactinomas. Successful surgical outcomes were achieved in patients with microadenomas and preoperative serum PRL levels of less than 200 microg/L.

Macrotestes associated with hyperprolactinemia

Prolactin secreting pituitary adenomas are a rare finding in prepubertal children /1/. As in adults, their incidence is higher in girls than in boys; however, the macroadenomas are predominant in boys /20-16/. Two prepubertal boys who presented with short stature and linear growth deceleration were diagnosed to have prolactin secreting pituitary macroadenoma associated with growth hormone (GH) deficiency. They were treated with bromocryptine and exogenous recombinant hGH. They achieved a normal adult stature, full sexual maturation and tumor regression on the therapy. In addition, both boys developed macrotestes. Further evaluation ruled out other etiologies for macrotestes. We presume that the elevated prolactin caused local testicular growth factors to induce testicular cell division and/or hypertrophy resulting in an increased testicular volume.

Pituitary adenomas in childhood and adolescence. Results of transsphenoidal surgery

Pituitary adenomas are uncommon in childhood. Between 1975 and 1988, 36 patients underwent transsphenoidal resection at the Mayo Clinic before their 17th birthday. Fifteen (41.7%) had prolactin (PRL)-secreting tumors, 16 (44.4%) had adrenocorticotropic hormone (ACTH)-secreting tumors (including two patients with Nelson-Salassa syndrome), and three (8.3%) had tumors secreting growth hormone (GH); two patients (5.6%) had clinically nonfunctioning tumors. Of the 36 patients, 21 (58.3%) were girls, and girls predominated in every group except that with ACTH-secreting tumors, where they accounted for only 37.5% of the patients. The average age at the time of surgery was 14.7 +/- 2.2 years, the youngest patient being 7.3 years old. The ACTH-secreting tumors were associated with an earlier onset of symptoms than the other tumor types: six (37.5%) of 16 patients became symptomatic before 10 years of age, compared with two (10.0%) of the 20 other patients. Presenting symptoms primarily reflected endocrine dysfunction, with neurological presentation (visual field deficits) occurring in only two patients. There were no deaths in this patient group. Significant operative morbidity included steroid-induced psychosis in one patient and diabetes insipidus in three, which resolved in two. Plurihormonal tumors, broadly defined as tumors producing more than one hormone, were common, comprising five (36%) of 14 PRL-secreting tumors, all three GH-secreting tumors, and one of two clinically nonfunctioning tumors, or 25.7% overall. Macroadenomas accounted for 89% of plurihormonal tumors. Long-term follow-up review (median > 5 years) revealed good control of PRL-secreting tumors (although five of 15 patients had received postoperative radiotherapy), contrasted with a 25% late recurrence rate for ACTH-secreting tumors, which had an 80% initial remission rate. The majority of patients had good endocrine function, including reproductive function. It is concluded that: 1) although pediatric pituitary adenomas occur primarily in adolescence, Cushing's disease is found at any age; 2) transsphenoidal surgery is feasible and safe in this age group; 3) plurihormonal tumors occur more frequently in the pediatric age group than in adults; and 4) long-term control rates in PRL- and ACTH-secreting tumors are probably similar to those seen in adults.

Adolescent gynecomastia. Differential diagnosis and management

Gynecomastia signifies a transient or permanent disturbance in steroid hormone physiology and occurs when the male breast is exposed to a decreased ratio of androgen to estrogen. This article discusses pubertal and pathologic gynecomastia, diagnostic approach, and treatment.

Pharmacology of new hormonal therapies in the treatment of pediatric endocrine disorders

Advances in genetic engineering will make possible treatment of many pediatric endocrine disorders with replacement therapy. Some of these conditions include short stature, precocious puberty, and diabetes mellitus. Although the availability of such hormonal replacement offers new treatment modalities, an understanding of their mechanism of action and pharmacologic characteristics is crucial to maximize their effectiveness while minimizing possible untoward effects. The clinician must evaluate potential risks and benefits as these substances come to market without definitive answers being available as to their long-term effects.

Massive prolactinoma with galactorrhoea in a prepubertal boy

An 8 year old prepubertal boy presented with raised intracranial pressure, left proptosis and was noted to have galactorrhoea. Cranial computerized tomography revealed a large pituitary tumour infiltrating the cavernous sinus and left orbit. The serum prolactin was 180,600 mU/l (normal value less than 360 mU/l). Prolactinomas are rare in children and galactorrhoea has not previously been reported in a prepubertal child. The management of massive prolactinomas is difficult, but the child presented has made an impressive response to a combination of treatment with surgery, dopamine agonist therapy and radiotherapy.

Prolactinomas presenting as primary amenorrhoea and delayed or arrested puberty: response to medical therapy

Fourteen patients presented with arrested pubertal development associated with prolactin-secreting pituitary tumours; serum prolactin ranged from 4000-104,300 mU/l in the ten females and 920-68,000 in four males. Skull X-ray showed a markedly expanded pituitary fossa in eight patients. CT scan and/or air encephalography showed macroadenomas in nine, of whom seven had large suprasellar extensions to their tumours, yet only five had complained of headache and only two had visual field defects. All were treated with bromocriptine (7.5-60 mg/day) which lowered prolactin substantially in all and into the normal range in 11 (range less than 60-3090, median 105 mU/l). Puberty thereafter progressed spontaneously in 13, but in one patient, whose prolactin did not suppress completely, menarche could be induced only with clomiphene. Anterior pituitary function improved on bromocriptine. In seven patients with macroadenomas, tumour shrinkage into the pituitary fossa was complete and in two others incomplete shrinkage was followed by transsphenoidal hypophysectomy. Seven patients received pituitary irradiation, six after bromocriptine-induced shrinkage and one after transsphenoidal surgery. At follow-up 6 months to 10 years (median 5 years) after presentation, ten remain on bromocriptine with a suppressed serum prolactin, one has a normal prolactin after surgery, and three are off bromocriptine with residual hyperprolactinaemia (418-4680 mU/l). To date, four females have become pregnant and one male has fathered two children. Prolactinomas are an important, albeit rare, cause of arrested puberty and should therefore be sought. Most patients respond well to bromocriptine, with or without pituitary irradiation.

Computed tomographic appearances and clinical features of prolactin-secreting pituitary adenomas in young male patients

Prolactin-secreting adenomas, the commonest of the pituitary tumours, are being recognised with increasing frequency in men. Their appearance and behaviour differ from those occurring in women, being typically larger and more aggressive. We describe the clinical features and radiological findings of three prolactinomas in young males and review the literature.

Growth and puberty arrest due to prolactinoma

A 13-year-old male with prolactin secreting pituitary tumor is described. The unusual features were arrested puberty and growth. Previously reported pediatric patients with prolactinoma are reviewed. The importance of serum prolactin measurement and bromocriptine therapy is emphasized.

Galactorrhoea following hypophysectomy in a boy with a prolactinoma

An 18-year-old boy with delayed puberty was found to have a large prolactinoma. Hypophysectomy led to a fall in serum prolactin concentration, although it remained markedly elevated. The introduction of replacement therapy, including testosterone, resulted in painful swelling of the breasts and galactorrhoea. Bromocriptine therapy resulted in a cessation of galactorrhoea and normalization of serum prolactin concentrations. The absence of galactorrhoea in association with an astronomical concentration of prolactin, and its onset in association with diminished prolactin concentrations following hypophysectomy and the introduction of testosterone therapy, indicate that galactorrhoea requires the presence of high prolactin concentrations to act on mature breast tissue. This would account for the rarity of galactorrhoea in prepubertal children with prolactinomas.

Galactorrhea in the adolescent

Inappropriate lactation--that which occurs beyond the usual postpartum or breast-feeding period or in the male--has been of medical interest for centuries. There is a suggestion that the first recorded case occurred in the Bible in the Book of Esther wherein Mordecai may have breast-fed his niece Esther [1,2]. The Talmud describes a man who nursed his infant after his wife's death during childbirth [3]. Lactation in virgin women was noted by the early Greeks [4], and Aristotle observed lactation in men [5]. The phenomenon of "witch's milk," seen in the newborn, was described as early as 1684 by Bonetus [6]. The first alleged pediatric case of nonpuerperal lactation was of an 8-year-old girl who was able to suckle her baby brother as reported in the 18th Century by Baudelocque [7]. Subsequently, many other cases of abnormal lactation were described in the 19th and early 20th centuries [7-10]. In the past 15 years, there has been a vast proliferation of cases and studies concerning galactorrhea of both sexes [11]. The advent of the prolactin radioimmunoassay was the single most important factor behind the profusion of these investigations [11-14]. Most recently, attention has focused on the high incidence of pituitary tumors--specifically the prolactinoma--in women and to some degree in men [13,15]. The occurrence of such tumors in children and adolescents is also receiving more attention [16,17]. The purpose of this review is to update the reader on galactorrhea with a specific emphasis on: 1) outlining the various causes of galactorrhea that may be seen in adolescent patients; 2) describing the work-up and management of both the male and female adolescent patient with galactorrhea; and 3) describing what is known about the natural history of galactorrhea. A brief description of the physiology of the hypothalamic-pituitary-breast axis and lactation is also presented.

Transsphenoidal microsurgical removal of 250 pituitary adenomas

In a series of 250 pituitary adenomas, 72 (28.8%) were nonsecreting and 178 (71.2%) produced a hypersecretion syndrome: human growth hormone (83), prolactin (59), and adrenocorticotropic hormone (ACTH) (36). One-fifth had received prior treatment and one-fourth had visual impairment. The technical aspects of the transsphenoidal procedure are given with separate consideration of microadenomas and larger tumors. The results are provided in summary form with emphasis on the favorable outcome following removal of microadenomas. There was one postoperative death, and the complications observed after operation are presented.