Medical treatment of prolactinomas

The open sella technique for surgical treatment of pituitary macroadenomas: Safety and efficacy in a large clinical series

PURPOSE

To analyse the efficacy and safety of the transsphenoidal microsurgical approach with open sella technique (OST) for the treatment of pituitary adenoma (PA) with suprasellar extension.

METHODS

We retrospectively reviewed 2305 consecutive patients with PA who underwent their first surgery through the transsphenoidal microsurgical approach at our department between 1990 and 2018. Focusing on tumours with suprasellar extension, in particular, grade B, C and D adenomas according to Wilson-Hardy's classification, 376 patients who received the OST surgery were identified. Outcomes and complications were evaluated and compared with those obtained in patients who underwent a standard transsphenoidal approach (TSM).

RESULTS

Two-hundred and sixty-four of 376 patients (70.2%) were found to be suffering from a non-functioning pituitary adenoma, whereas 112 of 376 patients (29.8%) from a hormone-secreting PA. The mean craniocaudal diameter of the tumor was 30.6 ± 0.3 mm (range, 21-75 mm) and 151 patients (40.1%) had a cavernous sinus invasion too. An overall surgical remission rate of 50.3% was achieved in the OST group, whereas the recurrence rate was 10.5%. Patients were followed for a mean period of 68 ± 1.4 months (range, 6-96 months). Less postoperative intrasellar haemorrhages have been recorded in the OST group than the TSM one (1.1% vs. 4.6%, p = 0.02).

CONCLUSIONS

In experienced hands, OST represents an effective and safe treatment strategy for PA with suprasellar extension.

Gender Differences in Patients with Prolactinoma: Single-center Ukrainian Experience

INTRODUCTION

Prolactinomas are the most common type of pituitary gland tumors that secrete overly prolactin. They account for approximately 60% of all hormone-secreting hypophysis tumors.

AIM

This study aims to analyze gender differences in patients with prolactinomas who were operated on transsphenoidal surgery and conduct a single-center retrospective analysis of patient data.

MATERIAL AND METHODS

This study evaluated the medical records of 109 patients (61 females and 48 males) from 2009 to 2019 at Feofaniya Clinical Hospital of the State Administration of Affairs in Kyiv, Ukraine. The primary criterion for including patients was a Serum Prolactin (PRL) level of over 100 ng/ml and the presence of a pituitary adenoma (PA) as observed on MRI. Additionally, the histological examination needed to confirm the presence of Prolactin-Secreting Pituitary Adenomas (PSPAs) without plurihormonal activity through both microscopy and immunohistochemical (IHC) staining.

RESULTS

Significant differences in preoperative PRL levels were not observed. However, males had significantly larger tumor sizes and prevalence of macroadenomas. In male patients, the preoperative PLR levels showed a weak negative correlation with age (r=-0.304, p < 0.036) and a positive correlation with tumor size (r=0.555, p < 0.001) and cavernous sinus invasion (r=0.339, p < 0.018). In females, preoperative PRL was significantly associated only with tumor size and Knosp grade.

CONCLUSION

Prolactin-Secreting Pituitary Adenomas (PSPAs) are more common in women than men and are characterized by larger and more invasive tumors with high PRL levels at diagnosis. The PRL level and tumor size before surgery can predict early biochemical remission in both males and females with an accuracy of 58.3% and 68.8%, respectively.

Case report: Bilateral simple Syndactyly in a toddler with maternal exposure to cabergoline

Cabergoline is routinely prescribed in the management of prolactin excreting adenomas and is associated with low risk of congenital malformations and teratogenicity. Here, we reported the case of a bilateral simple syndactyly in a toddler with maternal exposure to cabergoline during the pregnancy. This association has not been previously described before.

Drug-induced Hyperprolactinemia Results in Atypical Atypical Fracture

We report a case of bilateral femur fracture which may have resulted in part from long-term administration of antipsychotic agents. A 43-year-old female patient with pain in both thighs visited our clinic. We conducted X-ray and magnetic resonance imaging (MRI) examinations which revealed bilateral femur fractures. The right proximal femur had a complete fracture, and the left proximal femur had an incomplete fracture, both of which were in the subtrochanteric area. The patient was treated by intramedullary nailing in the right femur. Laboratory analysis showed hyperprolactinemia and hypogonadism. Bone mineral density analysis showed osteoporosis. Antipsychotic drug-induced hyperprolactinemia is a well-known phenomenon. Despite concerns about hyperprolactinemia induced osteoporotic fracture in patients treated with only prolactin-elevating medications, the issue has not been extensively studied. If hyperprolactinemia patients suffer from uncontrolled pain, we recommend MRI examination as surgeons should be aware of the possibility of osteoporotic fracture induced by hyperprolactinemia.

Long-term Outcome of Microscopic Transsphenoidal Surgery for Prolactinomas as an Alternative to Dopamine Agonists

BACKGROUND

Although long-term dopamine agonist (DA) therapy is recommended as a first-line treatment for prolactinoma, some patients may prefer surgical treatment because of the potential adverse effects of long-term medication, or the desire to become pregnant. This study aimed to determine whether surgical treatment of prolactinomas could be an alternative to DA therapy.

METHODS

In this retrospective study, 96 consecutive patients (74 female, 22 male) underwent primary pituitary surgery without long-term DA treatment for prolactinomas at a single institution from 1990 to 2010. All patients underwent primary surgical treatment in the microscopic transsphenoidal approach (TSA).

RESULTS

The median age and median follow-up period were 31 (16-73) years and 139.1 (12.2-319.6) months, respectively. An initial overall remission was accomplished in 47.9% (46 of 96 patients, 33 macroadenomas, and 13 microadenomas) of patients. DA dose reduction was achieved in all patients after TSA. A better remission rate was independently predicted by lower diagnostic prolactin levels and by a greater extent of surgical resection. Overall remission at the last follow-up was 33.3%, and the overall recurrence rate was 30.4%. The permanent complication rate was 3.1%, and there was no mortality.

CONCLUSION

TSA can be considered a safe and potentially curative treatment for selective microprolactinomas as an alternative to treatment with a long-term DA.

Diagnosis and Management of pituitary disease with focus on the role of Magnetic Resonance Imaging

Magnetic resonance (MR) imaging is an essential tool in the diagnosis and management of pituitary diseases, indispensable for making correct treatment decisions. Successful management and follow-up of pituitary pathology requires an understanding of the MR appearance of normal and abnormal structures in the sellar region. This review will describe the MR appearance of the normal and abnormal pituitary gland and proposes an algorithm for the management strategy of some of the most common abnormalities in or around the sella.

Magnetic resonance imaging in the management of prolactinomas; a review of the evidence

PURPOSE

This review aimed to evaluate data on the use of magnetic resonance imaging in the management of prolactinomas.

METHODS

Recent literature about prolactinoma behavior and magnetic resonance imaging in the management of prolactinomas is reviewed.

RESULTS

A review of evidence regarding prolactinoma pituitary MRI follow-up; techniques and sequences, recent data on possible gadolinium retention, the role and a review of T2-weighted images in the identification of prolactinomas and frequently encountered clinical scenarios, as well as MRI correlation with prolactin secretion, tumor growth and prediction of response to medical therapy are presented.

CONCLUSION

The underlying decision to perform serial imaging in prolactinoma patients should be individualized on a case-by-case basis. Future studies should focus on alternative imaging methods and/or contract agents.

Clinical and epidemiological characteristics of pituitary tumours in a single centre in Saudi Arabia

PURPOSE

Pituitary tumours are slowly progressing tumours, mostly benign, with a reported global prevalence of 16.7% (22.5% in radiologic studies and 14.4% in autopsy studies). Clinical and epidemiological data on pituitary adenomas in Saudi Arabia are lacking. We aimed to utilise our database variables to determine clinical and epidemiological characteristics as well as treatment outcomes of pituitary tumours among Saudi patients.

METHODS

This retrospective study was conducted in King Fahad Medical City, Riyadh, Saudi Arabia, in patients with pituitary tumours. Data were collected between 2006 and 2017.

RESULTS

Overall, 284 patients (females: 38.1 ± 13.9 years; males: 44.1 ± 15.4 years) with pituitary tumours were included. Common pituitary tumours were prolactin-secreting adenomas (45%), non-functioning pituitary adenomas (NFPAs: 35.6%), growth hormone (GH)-secreting adenomas (10.6%), craniopharyngiomas (7%), and adrenocorticotropic hormone (ACTH)-secreting adenomas (1.8%). Prolactin-secreting adenomas were more frequently microadenomas and were common among females. Headaches and visual symptoms occurred commonly in NFPA patients (62.4 and 45.5%, respectively) than in those with prolactin-secreting adenomas (56.3 and 32.8%, respectively) or GH-secreting adenomas (40 and 16.6%, respectively). Medical treatment was the mainstay for prolactin-secreting adenoma patients (69%). Pituitary surgery was the primary therapy in NFPA patients (43.6%) and GH-secreting adenomas (86.7%).

CONCLUSION

This study identified the pattern of pituitary tumours in Saudi patients and management strategies. Further, the study highlights the need for a nationwide registry to improve surveillance and physicians' knowledge in Saudi Arabia.

[Cerebrospinal fluid rhinorrhea in primary treatment of large and giant prolactinomas with dopamine agonists]

At present, pharmacological therapy of prolactinomas with dopamine agonists (DAs) is considered the treatment of choice. In most cases, giant prolactinomas respond to treatment with dopamine agonists and decrease in size during the first months of the treatment. One of the rare but dangerous complications of conservative treatment of prolactinomas with invasive growth is cerebrospinal fluid rhinorrhea.

MATERIAL AND METHODS

We present a retrospective analysis of 15 patients with macropropactinomas who underwent surgery for cerebrospinal fluid rhinorrhea developed due to primary therapy with dopamine agonists at the Burdenko Neurosurgical Institute (BNI) in the period between 2005 and 2015. All patients had large and giant tumors (according to the classification adopted at the BNI). When cerebrospinal fluid rhinorrhea was detected, patients were hospitalized to the BNI for examination, detection of a CSF fistula, reconstruction of a defect, and resection (if possible) of the tumor.

RESULTS

In the period between 2005 and 2015, 15 patients (8 males and 7 females) with prolactinomas of a large and giant size at the onset of conservative therapy underwent surgery for cerebrospinal fluid rhinorrhea at the BNI. All patients underwent transnasal reconstruction of a skull base defect, with 13 out of 15 patients undergoing simultaneous resection of the tumor. After tumor resection, reconstruction was performed using auto-fat, fascia, and glue (in 8 cases). In the remaining cases, apart from auto-fat, fascia, and glue, a mucoperiosteal flap and auto-bone were used. Fourteen patients were followe-up. In 13 cases, there was no relapse of cerebrospinal fluid rhinorrhea after skull base reconstruction. In 1 case, there was a relapse of cerebrospinal fluid rhinorrhea.

CONCLUSION

Conservative treatment of patients with giant prolactinomas should be performed under regular control of ENT doctors and neurosurgeons for timely detection and surgical treatment of cerebrospinal fluid rhinorrhea.

Optimal timing of dopamine agonist withdrawal in patients with hyperprolactinemia: a systematic review and meta-analysis

PURPOSE

Dopamine agonists (DAs) are recommended as first-line treatment for patients with hyperprolactinemia. Generally, it is accepted that patients with hyperprolactinemia do not need lifelong medication, but the optimal timing for DA withdrawal has not been determined. The aim of this systematic review and meta-analysis is to assess the impact of DA withdrawal on the clinical outcomes of patients with hyperprolactinemia, and to explore possible factors affecting successful DA withdrawal.

METHODS

The databases of PubMed, Cochrane and EMBASE were searched up to May 2016.

RESULTS

The proportion of patients with persisting normoprolactinemia after DA withdrawal reached 36.6% in a random effects model (95% CI, 29.4-44.2%; I-squared: 82.5%). Data of stratified analysis showed that the success rate of drug withdrawal was high in patients using cabergoline (CAB) as the only treatment (41.2%; 95% CI 32.3-50.4%) and those using CAB over 24 months (48.7%; 95% CI 38.9-58.5%), especially in patients with idiopathic hyperprolactinemia (73.2%; 95% CI 55.6-87.7%). In addition, patients who received a low maintenance dose of CAB, and had a significant reduction in tumor size (over 50%) before withdrawal, were more likely to achieve success (51.5 and 49.4%, respectively).

CONCLUSION

The success rate of DA withdrawal has increased in recent years. Further, the success rate of CAB withdrawal was higher than that of bromocriptine, especially in patients with a duration of treatment longer than 24 months. Conclusively, the probability of success was higher in patients who received low-dose CAB maintenance treatment and those who achieved a significant reduction in tumor size before withdrawal.

Prolactinoma in a Dog

A 12-year-old male Yorkshire Terrier was presented because of decreased appetite. Physical examination revealed mammary gland swelling and galactorrhea. Contrast-enhanced computed tomographic scanning of the skull indicated an enlarged pituitary gland, compatible with a pituitary tumor. The serum prolactin concentration was markedly elevated. One week after the start of treatment with the dopamine agonist cabergoline, the serum prolactin concentration normalized and the galactorrhea resolved. Cabergoline was administered for approximately 4 months and then discontinued. Subsequently, serum prolactin concentration increased again, and mammary gland swelling and galactorrhea reappeared. The dog was euthanized 10 months after the first detection of the galactorrhea because of problems not directly related to pituitary disease. Postmortem examination revealed an infiltrative adenoma of the pituitary gland with immunolabeling for prolactin. The clinical and histopathologic findings indicated the diagnosis of a functional prolactinoma in a male dog.

[Indications for surgical treatment of prolactin-secreting pituitary adenomas]

Prolactinomas account for about 40% of all pituitary adenomas. The main treatment for prolactinomas is undoubtedly therapy with dopamine agonists (DAs). However, prolonged conservative treatment (for many years or even throughout life) that is necessary for permanent control of the disease makes some patients refuse pharmacological treatment for various reasons. In addition, not all prolactinomas respond to DAs therapy. Sometimes, the patient is not able to continue treatment because of the severity of side effects. Along with tumor resistance to therapy and patient intolerance of DAs, complications (liquorrhea, hemorrhage in the tumor) may occur during conservative treatment. In these cases, surgery is necessary. The paper analyzes the modern literature on various treatment options for prolactin-secreting pituitary adenomas and defines the indications for surgical treatment.

Long-term outcome of macroprolactinomas

OBJECTIVE

Management of macroprolactinomas has dramatically changed in recent decades, from surgical to medical treatment as first-line therapy, with the development of dopamine agonists (DA). But few data exist on the long-term outcome of these patients.

PATIENTS AND METHODS

Retrospective descriptive multicenter study of patients with macroprolactinoma followed for at least 5 years between 1973 and 2008 at the University Hospitals of Strasbourg and Marseille.

RESULTS

Forty-eight patients were included with 27 men, hypopituitarism in 33.3% of all patients and mean serum prolactin (PRL) level at diagnosis 2218.2±4154.7μg/L. Among the patients, 58.3% received medical treatment, 25% had additional surgery and 12.5% surgery and radiotherapy. The mean follow-up duration was 196±100 months. At the end of follow-up, 10 patients (20.8%) were cured (i.e. normal PRL level and normal imaging, no symptoms and withdrawal of DA≥1 year), 33 (68.8%) were controlled (i.e. normal PRL level, normal or abnormal imaging, no symptoms, DA in progress) and 5 (10.4%) were uncontrolled. Uncontrolled patients had significant higher baseline PRL level (P=0.0412) and cabergoline cumulative dose (P=0.0065) compared to the controlled group. There was no increase in frequency of hypopituitarism. Clinically significant valvular heart disease was found in 2 patients but screening was not systematic.

CONCLUSIONS

Macroprolactinoma is currently most often a chronic disease controlled with DA. However, uncertainty about the adverse effects associated with high cumulative doses and the lack of data on the prognosis at very long-term should incite to revisit current strategies, including the role of surgery combined to medical treatment.

Developmental and Functional Effects of Steroid Hormones on the Neuroendocrine Axis and Spinal Cord

This review highlights the principal effects of steroid hormones at central and peripheral levels in the neuroendocrine axis. The data discussed highlight the principal role of oestrogens and testosterone in hormonal programming in relation to sexual orientation, reproductive and metabolic programming, and the neuroendocrine mechanism involved in the development of polycystic ovary syndrome phenotype. Moreover, consistent with the wide range of processes in which steroid hormones take part, we discuss the protective effects of progesterone on neurodegenerative disease and the signalling mechanism involved in the genesis of oestrogen-induced pituitary prolactinomas.

Withdrawal of dopamine agonist therapy in prolactinomas: In which patients and when?

PURPOSE

The aim of the study was to assess the effect of dopamine agonist (DA) withdrawal, the current recurrence rate of hyperprolactinemia, and possible factors that predict recurrence in patients with prolactinoma.

METHODS

We evaluated DA withdrawal in 67 patients with prolactinoma (50 female/17 male) who received DA treatment for at least 2 years and showed normalization of prolactin (PRL) levels and tumor disappearance or ≥50 % tumor shrinkage, retrospectively. Accordingly, patients were divided into two groups as remission and recurrence groups, and factors that predict recurrence were evaluated.

RESULTS

The overall remission rate was 46 %; the remission ratios were 65 % in microprolactinomas and 36 % in macroprolactinomas. Remission rates were 39 % in the bromocriptine withdrawal group and 55 % in the cabergoline withdrawal group. The maximum tumor diameter and baseline PRL levels were significantly higher in the recurrence group (p = 0.001 and p = 0.003, respectively). The mean duration of DA therapy was significantly longer in the remission group (88.7 ± 48.1 and 66.7 ± 30.4 months, respectively, p = 0.026).The mean time to recurrence was 5.3 ± 3.2 months. The mean PRL levels at recurrence time were significantly lower than baseline PRL levels (p = 0.001).

CONCLUSION

The most important predictors of recurrence were maximum tumor diameter and baseline PRL levels in this study. The remission rate in our study group was higher, which was thought to be associated with the longer duration of DA treatment and that our patients were selected according to certain criteria. Despite these positive results, close monitoring is necessary for detection of early and late recurrence, especially within the first year after DA withdrawal.

Endocrinology in pregnancy: management of the pregnant patient with a prolactinoma

A woman with a prolactinoma is usually infertile. Dopamine agonists usually restore ovulation and fertility and such treatment generally is preferred over transsphenoidal surgery because of higher efficacy and safety. Cabergoline is usually preferred over bromocriptine because of its better efficacy with fewer adverse effects. Either drug increases the rates of spontaneous abortions, preterm deliveries, multiple births, or congenital malformations over what may be expected. However, the number of pregnancies reporting such experience is about sevenfold greater for bromocriptine. Tumor growth causing significant symptoms and requiring intervention has been reported to occur in 2.4% of those with microadenomas, 21% in those with macroadenomas without prior surgery or irradiation, and 4.7% of those with macroadenomas with prior surgery or irradiation. Visual fields should be assessed periodically during gestation in women with macroadenomas. If significant tumor growth occurs, most patients respond well to reinstitution of the dopamine agonist. Delivery of the baby and placenta can also be considered if the pregnancy is sufficiently advanced. Transsphenoidal debulking of the tumor is rarely necessary.

Retrospective comparison of cabergoline and bromocriptine effects in hyperprolactinemia: a single center experience

INTRODUCTION

Patients with hyperprolactinemia who require medical therapy are typically treated with dopamine agonists (DAs). In most cases, DAs normalize prolactin levels, control symptoms, and substantially decrease tumor size. Here, we aimed to compare the efficacy of cabergoline (CAB) and bromocriptine (BRC) in patients with hyperprolactinemia at a single center.

METHODS

Retrospective analysis of the clinical records of 498 patients with hyperprolactinemia [mean age 33.3 ± 10.8 years (range 16-66), 450 women, and 48 men] who had received either CAB (n = 450) or BRC (n = 48) was performed.

RESULTS

The mean age, gender distribution, and treatment duration were similar between the CAB and BRC groups (33.2 ± 11 vs. 34.1 ± 9.6 years, male/female 44/406 vs. 4/44, 18.7 ± 12.1 vs. 17.8 ± 6.0 months, respectively; p > 0.05 for all). Mean dosage was 1.5 ± 1.6 mg/week for CAB and 3.8 ± 2.7 mg/day for BRC. Baseline prolactin levels, frequency of galactorrhea, amenorrhea, oligomenorrhea, erectile dysfunction, infertility, and visual impairment were similar between the two groups, whereas the baseline tumor volume was higher in the CAB group. The prolactin normalization rate (87.4 vs. 41.4 %, p = 0.029) and tumor volume shrinkage (79.8 ± 39.1 vs. 54.1 ± 55.3 %, p = 0.015) were significantly higher in the CAB-treated patients than in the BRC-treated patients, while the tumor cure rates were similar. Symptom relief was higher in the CAB group than in the BRC group. More side effects were recorded in patients who took BRC (29.1 vs. 5.3 %, p < 0.001).

CONCLUSION

Our data revealed that CAB was more effective than BRC in controlling symptoms associated with hormone excess, normalizing serum prolactin levels, and shrinking prolactinomas.

Diagnostic pitfalls of hyperprolactinemia: the importance of sequential pituitary imaging

BACKGROUND

The purpose of this study is to confirm whether the serum prolactin cut-off value is definitive to distinguish prolactinoma and non-functioning pituitary adenoma with hyperprolactinemia. We retrospectively reviewed patients with non-functioning pituitary adenoma, including gonadotroph cell adenoma, null cell adenoma and prolactinoma who were surgically treated at Kohnan hospital between June 2005 and March 2012. The patients without endocrinological/neurological symptom and with the tumor larger than 40 mm in diameter were excluded. According to previously reported cut-off value of serum prolactin, mild hyperprolactinemia, which is considered non-definitive (border zone) concentration between prolactinoma and non-functioning pituitary adenoma, were defined as 90 - 200 ng/ml. Ninety-five prolactinoma patients and 212 patients with non-functioning pituitary adenoma were analyzed. The serum prolactin concentration, tumor size, and clinical characteristics were statistically compared.

RESULTS

Receiver operating characteristic (ROC) curve analysis was performed, indicating that cut-off value of serum prolactin concentration to distinguish between non-functioning pituitary adenoma and prolactinoma was 38.6 ng/ml. Although it was statistically good accuracy (the area under the curve; 0.96, sensitivity; 0.99 and specificity; 0.81), the result did not fit the clinical situation as many false-positive cases (40 of 212, 18.9%) were included. Among them, mild hyperprolactinemia were shown in 9 (4.2%) and 53 (55.8%) non-functioning pituitary adenoma and prolactinoma, respectively. Four of 9 border zone patients with non-functioning pituitary adenoma were initially treated with dopamine agonists. Sequential head magnetic resonance imaging revealed no tumor shrinkage in all of them despite serum prolactin concentration was decreased. Surgery was chosen for them 24.6 months in average after the introduction of medication.

CONCLUSIONS

Non-negligible number of patients with non-functioning pituitary adenoma presented unexpectedly high concentration of prolactin, fraught with a potential risk of misdiagnosis. While this equivocal population is not the majority, the prolactin cut-off value is not safely applicable. Especially for the patients with border zone prolactin concentration, meticulous follow up with sequential pituitary imaging is important.

Macroprolactinoma: a diagnostic and therapeutic update

Prolactinomas are the most common type of pituitary adenomas. Macroprolactinomas are the name used for these tumors when their size is ≥ 1 cm. These tumors commonly cause symptoms due to the excessive production of prolactin as well as complaints caused by tumor mass and compression of neural adjacent structures. Clinical diagnosis and assessment of macroprolactinoma are based on the measurement of serum prolactin concentrations and the morphological evaluation of the pituitary gland by magnetic resonance imaging. Dopamine agonists are the first-line treatment modality, with cabergoline being preferred to bromocriptine, because of its better tolerance and feasibility of administration. Cabergoline therapy has been reported to achieve normalization of prolactin levels and gonadal function and reduction of tumor volume in >50% of patients with macroprolactinoma. Resistance or intolerance to dopamine agonists are the main indications for transsphenoidal adenomectomy in patients with macroprolactinoma. External radiation therapy has been used in patients with poor response to medical and surgical procedures. Clinically significant tumor growth may occur during pregnancy in women with macroprolactinomas, especially if they have not received prior surgical or radiation therapy. Visual fields should be assessed periodically during pregnancy and therapy with dopamine agonists is indicated if symptomatic tumor growth occurs. Cystic and giant prolactinomas as well as the rare cases of malignant prolactinomas have special peculiarities and entail a therapeutic challenge.

Vanishing tumor in pregnancy

A patient with microprolactinoma, who had two successful pregnancies, is described for management issues. First pregnancy was uneventful. During the second pregnancy, the tumor enlarged to macroprolactinoma with headache and blurring of vision which was managed successfully with bromocriptine. Post delivery, complete disappearance of the tumor was documented.

Prolactinomas in men: a multicentre and retrospective analysis of treatment outcome

AIMS

To assess treatment outcome in male patients with micro- and macroprolactinomas.

DESIGN

Multicentre and retrospective study.

PATIENTS

Eighty-eight male patients (15 micro- and 73 macroprolactinomas), aged 40·3 ± 14·7 years, were studied. Time of follow-up ranged from 3 to 244 months.

METHODS

Clinical, hormonal and radiological data were registered at diagnosis and follow-up. Treatment outcome was evaluated in relation to the modality of therapy (dopamine agonists, surgery and radiation therapy).

RESULTS

Dopamine agonists normalized prolactin levels in 73·3% and 65·2% of patients with micro- and macroprolactinomas, respectively. Disappearance of tumour was reached in 53·3% and 28·3% of subjects with micro- and macroprolactinomas, respectively. Tumour absence at last visit was achieved in 7 of 14 patients with macroprolactinoma and treated by means of dual therapy (dopamine agonists and neurosurgery) and in 9 of 13 patients with macroprolactinoma managed with triple therapy (dopamine agonists, neurosurgery and radiation therapy). Normalization of prolactin levels at last visit was present in 68·9%, 79·6% and 69·2% of patients treated by medical therapy, dual therapy and triple therapy, respectively (differences not significant). Multivariate logistic regression analysis showed that the time on therapy was the only significant variable related to tumour disappearance.

CONCLUSION

We conclude that medical therapy normalizes prolactin and reduces tumour size in the majority of men with prolactinomas. The addition of pituitary surgery with or without radiation therapy does not offer significant advantages over medical therapy with dopamine agonists in male patients with macroprolactinomas.

Prolactinoma in pregnancy

Prolactinomas commonly cause infertility and treatment usually restores ovulation and fertility. The dopamine agonists are the preferred mode of treatment, with cabergoline generally being preferred to bromocriptine because of its higher therapeutic ratio. Experience with both drugs shows no increase in spontaneous abortions, preterm deliveries, multiple births, or congenital malformations, compared to what is expected in the normal population but the experience with bromocriptine is approximately 10-fold greater than with cabergoline. Clinically significant tumor growth may occur in 2.7% of those with microadenomas, 22.9% in those with macroadenomas without prior ablative treatment and 4.8% of those with macroadenomas with prior ablative treatment. Patients with macroadenomas should have visual fields assessed periodically during gestation. Should symptomatic tumor growth occur, reinstitution of the dopamine agonist is usually successful in shrinking the tumor but delivery if the pregnancy is sufficiently advanced is also an option and transsphenoidal debulking is rarely necessary.

Pituitary surgery for small prolactinomas as an alternative to treatment with dopamine agonists

Despite the fact that consensus guidelines recommend long-term dopamine agonist (DA) therapy as a first-line approach to the treatment of small prolactinoma, some patients continue to prefer a primary surgical approach. Concerns over potential adverse effects of long-term medical therapy and/or the desire to become pregnant and avoid long-term medication are often mentioned as reasons to pursue surgical removal. In this retrospective study, 34 consecutive patients (30 female, 4 male) preferably underwent primary pituitary surgery without prior DA treatment for small prolactinomas (microprolactinoma 1-10 mm, macroprolactinoma 11-20 mm) at the Department of Neurosurgery, University of Bern, Switzerland. At the time of diagnosis, 31 of 34 patients (91%) presented with symptoms. Patients with microprolactinomas had significantly lower preoperative prolactin (PRL) levels compared to patients with macroprolactinomas (median 143 μg/l vs. 340 μg/l). Ninety percent of symptomatic patients experienced significant improvement of their signs and symptoms upon surgery. The postoperative PRL levels (median 3.45 μg/l) returned to normal in 94% of patients with small prolactinomas. There was no mortality and no major morbidities. One patient suffered from hypogonadotropic hypogonadism after surgery despite postoperative normal PRL levels. Long-term remission was achieved in 22 of 24 patients (91%) with microprolactinomas, and in 8 of 10 patients (80%) with macroprolactinomas after a median follow-up period of 33.5 months. Patients with small prolactinomas can safely consider pituitary surgery in a specialized centre with good chance of long-term remission as an alternative to long-term DA therapy.

[Hormonal control of pituitary adenomas by transsphenoidal surgery: results of the first five years of experience]

OBJECTIVE

To evaluate the initial results of a surgical team in the hormonal control of secreting pituitary adenomas.

MATERIALS AND METHODS

In five years 51 functioning adenomas were operated (31 GH-secreting, 14 ACTH-secreting, 5 PRL-secreting and 1 TSH-secreting). Hormonal control was defined as GH < 2,5 ng/mL, normal free-urinary cortisol, lower prolactin and normal T3 and FT4.

RESULTS

Control rates were 36% in acromegaly, and 57% in Cushing's disease. Two prolactinomas normalized prolactin levels. Thyroid hormone levels were normalized in the TSH-secreting adenoma. Control of hypercortisolism was positively correlated with years of experience (p = 0.01).

CONCLUSION

Our results, although restricted to the beginning of our experience, lie below the reported range of other surgical series with much longer experience. During these years, there was a significant improvement in initial post surgery urinary cortisol levels in Cushing's disease as a function of surgical experience.

Effects of cabergoline on pregnancy and embryo-fetal development: retrospective study on 103 pregnancies and a review of the literature

The aim of the study is to assess the rate of any potential adverse effects on women who became pregnant under cabergoline (CAB) treatment and to evaluate any effects on the embryo-fetal development and on children who were born from mothers exposed to CAB in early weeks of gestation. Observational, retrospective and multicenter study on 103 pregnancies in 90 women with hyperprolactinemia. All patients were under CAB at conception. Serum prolactin at baseline was between 30 and 1921 ng/ml. Duration of therapy before pregnancy ranged from 1 to 120 months and doses ranged from 0.125 to 5 mg/week. Fetal exposure ranged from 3 to 25 weeks, 96.9% of patients received CAB during the first trimester of pregnancy and the rest until the second one. No significant complications during pregnancy were found. Seven women (7.2%) had spontaneous abortions. Preterm deliveries were recorded in eight (8.8%), only one with low weight for gestational age. Neonatal abnormalities were observed in 3 (3.6%): 1 major (Down syndrome) and 2 minor malformations (umbilical and inguinal hernia). We were able to asses the children's development in 61. Two had epilepsy and two had Pervasive Developmental Disorder (PDD). No significantly higher frequency of complications was found in pregnancies and/or offspring exposed to CAB than in the normal population. We registered 2 abnormalities in the development of the children: epilepsy and PDD. Larger series of patients are needed to assess the safety of this drug during pregnancy.

Effect of bromocriptine on antipsychotic drug-induced hyperprolactinemia: eight-week randomized, single-blind, placebo-controlled, multicenter study

AIM

The objective of the present study was to assess the efficacy and safety of bromocriptine treatment for patients with antipsychotic-drug-induced hyperprolactinemia in clinical practice.

METHODS

This was an 8-week randomized, single-blind, placebo-controlled, multicenter study. Sixty female schizophrenia patients were enrolled and were randomly assigned to one of four treatment groups: bromocriptine 2.5 mg/day, 5 mg/day, 10 mg/day, and placebo. Serum levels of prolactin, estradiol (E2), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were evaluated on three occasions (baseline, and 4 and 8 weeks after commencement of the treatment paradigm). Extrapyramidal symptoms (EPS) and clinical symptoms were assessed using the Simpson-Angus scale and the Positive and Negative Syndrome Scale (PANSS), respectively.

RESULTS

Of the 60 subjects who were enrolled, 48 completed the study (n = 14, 13, 11, and 10 in the bromocriptine 2.5 mg/day, 5 mg/day, and 10 mg/day, and placebo groups, respectively). Four patients in the 10-mg/day group, two in the 5-mg/day group, and one in the placebo group resumed menses during the study. The mean level of prolactin significantly decreased from baseline to week 4, and then plateaued, showing no significant change for the remaining 4 weeks of the study. No significant changes in LH, FSH, or E2 levels were observed throughout the 8-week study period, either within or between groups.

CONCLUSION

Administration of bromocriptine is a safe method for treating antipsychotic-drug-induced hyperprolactinemia without exacerbating either psychotic symptoms or EPS.

Contemporary issues in pituitary disease: case-based management update

Since 2005, the Cleveland Clinic Foundation has held an annual symposium addressing contemporary issues in pituitary disease. The faculty includes Cleveland Clinic Foundation staff, physicians and invited specialists, and the presentations are case-based with frequent audience response in order to be of real value in terms of the issues that may occur in day-to-day clinical practice relating to pituitary disease. This brief meeting report summarizes the key points arising from this interactive format. We feel it is worth pointing out that re-emphasizing 'old truths' is always an essential and valid aspect of any symposium addressing contemporary issues.

Prospective study of high-dose cabergoline treatment of prolactinomas in 150 patients

CONTEXT

Cabergoline fails to normalize hyperprolactinemia in a considerable proportion of prolactinomas, especially macroadenomas.

OBJECTIVE

We examined the effect of individualized high-dose cabergoline treatment on hyperprolactinemia in prolactinomas.

PATIENTS

The study included 122 women and 28 men (93 microadenomas and 57 macroadenomas). Forty-seven had undergone transsphenoidal surgery. According to the preceding medical treatment, the participants were separated into untreated (group U; n = 60), intolerant (group I; n = 64), and resistant (group R; n = 26) groups.

INTERVENTIONS

We promptly increased cabergoline dose on the basis of individual prolactin levels. Length of treatment was 1 yr.

RESULTS

Cabergoline normalized hyperprolactinemia in all patients except one. The proportion of prolactin normalization in both groups U and I was 83% at 3 months and 95% at 6 months. By contrast, that in group R was 35% at 3 months and 58% at 6 months. Mean cabergoline dose in milligrams per week at the time of prolactin normalization was 2.0 +/- 0.3 in group U, 0.9 +/- 0.1 in group I, and 5.2 +/- 0.6 in group R. Prolactin normalization rate at the 3 mg/wk dose was 84% overall but only 35% in group R. Serum progesterone or testosterone levels, diminished in 122 women or 16 men, respectively, were recovered in all except one resistant and four postmenopausal or panhypopituitary patients.

CONCLUSION

Individualized high-dose cabergoline treatment can normalize hyperprolactinemia and hypogonadism in nearly all prolactinomas irrespective of tumor size or preceding treatments. Hyperprolactinemia could be controlled in poor responders within 1 yr with doses higher than 3 mg/wk.

Pituitary disorders: an overview for the general physician

The pituitary gland is responsible for the production of the trophic hormones that control normal homeostasis. The hyper- or hypofunction of one or more of these may result in a distinct pathological clinical presentation, particularly in the presence of macroadenoma. Most pituitary disorders, however, present with non-specific signs and symptoms. This review gives an overview of pituitary disorders, their causes, clinical presentation, diagnosis and management.

Hyperprolactinaemia

Hyperprolactinaemia is a frequent cause of reproductive problems encountered in clinical practice. A variety of pathophysiological conditions can lead to hyperprolactinaemia; therefore, pregnancy, drug effects, hypothyroidism and polycystic ovary syndrome should be excluded before investigating for prolactin-secreting pituitary tumours. Prolactinomas are mainly diagnosed in women aged 20-40 years. They present with clinical features of hyperprolactinaemia (galactorrhoea, gonadal dysfunction), and more rarely with large tumours, headache and visual field loss due to optic chiasm compression. Medical therapy with dopamine agonists is the treatment of choice for both micro- and macroprolactinomas. Tumour shrinkage and restoration of gonadal function are achieved in the majority of cases with dopamine agonists. A trial of withdrawal of medical therapy may be considered in many patients with close follow-up. Pituitary surgery and radiotherapy currently have very limited indications. Pregnancies in patients with prolactinomas need careful planning and close monitoring.

Hyperprolactinemia and prolactinomas

Any process interfering with dopamine synthesis, its transport to the pituitary gland, or its action at the level of lactotroph dopamine receptors can cause hyperprolactinemia. As described in this article, considering the complexity of prolactin regulation, many factors could cause hyperprolactinemia, and hyperprolactinemia can have clinical effects not only on the reproductive axis. Once any drug effects are excluded, prolactinomas are the most common cause of hyperprolactinemia. The most frequent symptom is hypogonadism in both genders. Medical and surgical therapies generally have excellent results, and most prolactinomas are well controlled or even cured in some cases.

Pituitary apoplexy during treatment of cystic macroprolactinomas with cabergoline

Pituitary apoplexy is a rare and life-threatening clinical condition caused by hemorrhage and/or infarction of the pituitary gland or adenoma. Although pituitary apoplexy is usually spontaneous, it has been associated with numerous precipitating factors, such as bromocriptine use. However, reports of pituitary apoplexy during cabergoline therapy are scarce. We report three patients with cystic macroprolactinomas who developed pituitary apoplexy during cabergoline treatment.

Parity, pregnancy and neonatal outcomes in women treated for hyperprolactinaemia compared with a control group

OBJECTIVE

Infertility is a common problem in women with hyperprolactinaemia. There are limited data on the fertility and pregnancy course among these women. The objective was to study parity, pregnancy and neonatal outcomes in women with hyperprolactinaemia as compared with a control group.

DESIGN

Register study.

PATIENTS

Two hundred and seventy-one female patients treated for primary hyperprolactinaemia were identified in the hospital record archives between 1974 and 2002. For each patient four comparison subjects, matched by sex, birth year and county of residence were identified in the Register of Population. Data were retrieved from the Swedish medical birth register and were analysed using logistic regression and analysis of variance. Measurements Parity, maternal age at first delivery, weeks of gestation, induction of labour, caesarean delivery, multiple birth, Apgar score, birth weight, length, sex, congenital malformations, neonatal care.

RESULTS

One hundred and sixty-two deliveries in the hyperprolactinaemia group and 1220 deliveries in the control group were analysed.

PATIENTS

with hyperprolactinaemia were significantly older at their first pregnancy than their controls: 29.0 (+/- 4.4) and 27.2 (+/- 4.8) years, respectively (P = 0.0002). Furthermore, parity was inversely associated with hyperprolactinaemia status (P for trend = 0.0009). The odds of having three or more children were threefold lower among the patients (OR 0.31 (95% CI 0.16, 0.60)). There were no differences between patients and controls with respect to pregnancy complications, delivery or neonatal outcome variables.

CONCLUSIONS

We found no evidence of increased risk of pregnancy complications or adverse pregnancy outcomes in women with treated hyperprolactinaemia. However, the patients were older at their first pregnancy and had a reduced overall parity.

Clinical presentation and response to therapy in patients with massive prolactin hypersecretion

Prolactin hypersecretion from a pituitary adenoma usually results in a serum prolactin level less than 1,000 ng/ml. During therapy with a dopamine agonist, prolactin levels usually normalize and the tumors shrink substantially. In the past few years, we have seen three men who presented with serum prolactin levels greater than 10,000 ng/ml. All presented with large tumors, visual field deficits, and hypogonadotropic hypogonadism. All other pituitary hormones were normal. In all three patients, significant tumor shrinkage was achieved with improvement or resolution of headaches and visual field deficits. None of our patients has been able to achieve a normal prolactin or testosterone. A literature review identified 32 patients with prolactin levels of more than 10,000 ng/ml. Twenty-six (81%) were males. Most had large tumors, headaches and visual field defects. Even with the addition of surgery and/or radiation therapy to medical therapy, normalization of serum prolactin occurred in only six patients (19%) and only one man achieved a normal testosterone. We conclude that in patients with massive prolactin hypersecretion, therapy with a dopamine agonist will lead to tumor shrinkage and improvement of mass effects, but usually does not normalize prolactin or testosterone. Rather than waiting for maximal prolactin reduction, we would recommend early institution of testosterone replacement therapy.

Advances in the treatment of prolactinomas

Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future.

Development of a macroprolactinoma in association with hormone replacement therapy in a perimenopausal woman with presumed idiopathic hyperprolactinemia

OBJECTIVE

To describe a 48-year-old woman with presumed idiopathic hyperprolactinemia, who was found to have a macroprolactinoma after receiving hormone replacement therapy for almost 3 years.

METHODS

We present a detailed case report, including a chronologic summary of clinical and laboratory findings as well as the drug history of our patient. The related literature is also reviewed.

RESULTS

Premenopausal women with idiopathic hyperprolactinemia or microprolactinomas (<1 cm) are treated with dopamine agonists if fertility is desired or galactorrhea is bothersome. Otherwise, estrogens and progestational agents may be prescribed to regularize menses and prevent osteoporosis. Several case reports of prolactinoma formation or enlargement after exposure to exogenous estrogens have been published. In our patient, a perimenopausal woman with presumably idiopathic long-standing hyperprolactinemia, a macroprolactinoma developed within 3 years after initiation of hormone replacement therapy for management of perimenopausal symptoms. The only clue for ordering a pituitary imaging study in this case was a substantial increase in the level of the serum prolactin. Treatment with cabergoline normalized the patient's serum prolactin level and considerably decreased the size of her pituitary adenoma.

CONCLUSION

It is postulated that exogenous estrogens could have an important role in tumor development or growth in some patients with idiopathic hyperprolactinemia. Therefore, it is recommended that women with idiopathic hyperprolactinemia or microprolactinomas treated with estrogens be considered for concomitant therapy with dopamine agonists. In all cases, serum prolactin levels should be diligently monitored.

The effect of MR contrast medium dose on pituitary gland enhancement, microlesion enhancement and pituitary gland-to-lesion contrast conspicuity

INTRODUCTION

The purpose of this study was to compare the differences in gland enhancement, microlesion enhancement and gland-lesion contrast ratio in patient groups in which half-dose (HD), standard-dose (SD) and double-dose (DD) contrast medium was used in pituitary MR imaging.

METHODS

Pituitary gland enhancement and microlesion enhancement were measured and gland-lesion contrast ratios were calculated in 18 patients receiving HD (0.05 mmol/kg), 9 receiving SD (0.1 mmol/kg) and 13 receiving DD (0.2 mmol/kg) contrast medium. Gland enhancement and microlesion enhancement over baseline were determined employing DICOM region of interest measurements and compared after normalization to temporal lobe white matter. Contrast ratios and differences were also calculated and compared.

RESULTS

Gland enhancement and lesion enhancement were greater with larger contrast medium doses (gland: HD 50%, SD 99%, DD 132%; microlesion: HD 19%, SD 54%, DD 86%). The gland-lesion contrast ratios were similar with the three doses (25.6%), reflecting expected similar fractional contrast medium distributions in spite of different doses. The signal difference between gland and microlesion, therefore, was a fixed percentage of gland enhancement (DeltaS approximately 26%) with greater signal differences with larger contrast medium doses.

CONCLUSION

Greater gland-to-lesion signal differences with larger contrast medium doses would likely improve pituitary microlesion visualization and margin characterization aiding in microlesion detection as well as preoperative planning.

Hyperprolactinaemia in 271 women: up to three decades of clinical follow-up

OBJECTIVE

To characterize women with hyperprolactinaemia at diagnosis and to assess the effect of treatment after long duration of the disease.

DESIGN

Retrospective chart review.

PATIENTS AND MEASUREMENTS

Two hundred and seventy-one women with hyperprolactinaemia at the Karolinska University Hospital, Stockholm, Sweden between 1974 and 2002 were evaluated retrospectively. Criterion for inclusion was elevated S-PRL (> or = 20 microg/l) found on at least two occasions. Secondary hyperprolactinaemia was excluded. The patients were followed for a median time period of 111 (6-348) months. Two hundred and forty patients were treated with dopamine agonists, 17 underwent surgery, seven received radiotherapy and seven were followed without treatment.

RESULTS

Mean age at diagnosis was 31 (+/- 9.5) years and median PRL level was 72 (25-3500) microg/l. Menstrual disturbances were present in 87% of the women of reproductive age and 47% had galactorrhoea. Microadenomas were found in 63%, macroadenomas in 8% and idiopathic hyperprolactinaemia in 29%. Patients with menstrual disturbances had higher PRL levels than women with normal menstrual function (P < 0.001). We found no differences in PRL levels between patients with or without galactorrhoea (P = 0.578). At the end of clinical follow-up, menstrual cycle was normalized in 94% and galactorrhoea disappeared in 94%. In the medically treated patients, median PRL levels decreased from 70 (25-3100) to 13 (0-89) microg/l, (P < 0.0001). Normalization of PRL level was achieved in 71% of the patients and 80% showed a total or partial degree of tumour shrinkage. In the surgically treated patients, 53% had normal PRL levels without medication at follow-up.

CONCLUSION

Medical treatment was effective in correcting hypogonadism, normalizing PRL levels and reducing tumour size in the majority of the patients after short-term treatment and also in the long run. However, the possibility of transsphenoidal surgery in specific cases must be considered.

Obstructive Hydrocephalus and Intracranial Hypertension Caused by a Giant Macroprolactinoma. Prompt Response to Medical Treatment

Patients with large prolactin (PRL)-secreting pituitary adenoma often have symptoms due to varying degree of hypopituitarism and/or mass effect on visual structures, while presentation with hydrocephalus is extremely uncommon. Even more exceptional is the development of the syndrome of intracranial hypertension as a consequence of tumor obstruction of the cerebrospinal fluid circulation. In this report, we describe a 26-year-old man who was referred to the emergency department of our hospital because of headache, nausea, and vomiting. Clinical and radiological assessment led to the diagnosis of obstructive hydrocephalus caused by a giant macroprolactinoma. The patient received a temporary external ventricular drainage to relieve the symptoms of intracranial hypertension. The same day, after we received the result of the basal PRL level, medical treatment with cabergoline was initiated. A prompt response to the drug ensued with resolution of the obstructive hydrocephalus, which allowed removal of the external ventricular drainage. Initial shrinkage of the mass was already noted on a magnetic resonance imaging performed 12 days thereafter. Subsequent medical treatment led to progressive and marked shrinkage of the tumor. Eighteen months after presentation the patient was well while on cabergoline treatment and showed no symptom attributable to compression of the surrounding nervous structures. Our report confirms that, even in cases of giant sellar mass with neurological symptoms, a rapid hormonal evaluation is mandatory. If a macroprolactinoma is diagnosed, treatment with dopamine agonists can lead to prompt clinical amelioration and shrinkage of the tumor, with eventual resolution of neurological symptoms.

Transcranial Surgery for Pituitary Adenomas

Although The Transsphenoidal approach is the preferred approach to the vast majority of pituitary tumors with or without suprasellar extension, the transcranial approach remains a vital part of the neurosurgical armamentarium for 1 to 4% of these tumors. The transcranial approach is effective when resection becomes necessary for a portion of a pituitary macroadenoma that is judged to be inaccessible from the transsphenoidal route because of isolation by a narrow waist at the diaphragma sellae, containment within the cavernous sinus lateral to the carotid artery, projection anteriorly onto the planum sphenoidale, or projection laterally into the middle fossa. The application of a transcranial approach in these circumstances may still be mitigated by response to prolactin inhibition of prolactinomas, the frequent lack of necessity to remove asymptomatic nonsecretory adenomas from the cavernous sinus, and the lack of evidence that sustained chemical cures can be reliably achieved by removal of secretory adenomas (adrenocorticotropic hormone, growth hormone) from the cavernous sinus. Cranial base surgical techniques have refined the surgical approach to pituitary adenomas but have had less effect on actual surgical indications than anticipated. Because application of the transcranial approach to pituitary adenomas is and should be rare in clinical practice, it is useful to standardize the technique to a default mode with which the surgical team is most experienced and, therefore, most comfortable. Our default mode for transcranial pituitary surgery is the frontotemporal-orbitozygomatic approach.

Results of Transsphenoidal Surgery in a Large Series of Patients with Pituitary Adenoma

OBJECTIVE:

To report the efficacy and safety of microsurgical transsphenoidal surgery in a series of previously untreated patients with pituitary adenoma.

METHODS:

One thousand one hundred forty consecutive patients undergoing transsphenoidal resection of a pituitary adenoma at our department from January 1990 through December 2002 were included in our study. Postoperative results were classified uniformly during the period of the study. Patients were considered in remission of disease when strict hormonal and radiological criteria of cure were met.

RESULTS:

The most frequent tumor type was clinically nonfunctioning adenoma (NFPA) (33.2%), followed by growth hormone-secreting adenoma (28.1%), adrenocorticotropin-secreting adenoma (23.0%), prolactin-secreting adenoma (13.2%), and last, thyrotropin-secreting adenoma (2.5%). The patient population was 59.7% female and 40.3% male. Mean age was 43.0 ± 0.4 years. There were 788 macroadenomas (69.1%), and in 233 patients (20.4%), the tumor invaded one or both cavernous sinuses. The overall rate of early surgical success was achieved in 504 (66.1%) of the 762 patients with a hormone-active adenoma. Surgical outcome was better in patients with microadenomas than in patients with macroadenomas (78.9% and 55.5%, respectively), whereas tumors invading the cavernous sinus had a poorer outcome (7.4%). In patients with NFPA, no residual adenoma was present in 234 patients (64.8%). Normalization of visual defects occurred in 117 (40.5%) of the 289 patients with visual disturbances and improved in another 148 patients (51.2%). Three patients (0.3%) died as a consequence of surgery.

CONCLUSION:

Transsphenoidal surgery is an effective and safe treatment for most patients with pituitary adenoma and could be considered the first-choice therapy in all cases except for prolactinomas responsive to dopamine agonists. Other treatment methods, such as radiotherapy, stereotactic radiosurgery, and medical therapy, play an important role in patients not cured by surgery.

A non-functioning pituitary adenoma initially mimicking a microprolactinoma: The case for long-term follow-up of patients with mild hyperprolactinemia?

OBJECTIVE

A correct differential diagnosis of patients with mild hyperprolactinemia is essential to select the most appropriate treatment modality.

CLINICAL PRESENTATION

A 50-yr-old woman presented to our Department for evaluation of an intra- and suprasellar mass causing progressive visual defect. Mild hyperprolactinemia causing menstrual irregularities was diagnosed in February 1989. In 1992, serum PRL levels ranged from 50 to 70 microg/l and magnetic resonance imaging (MRI) of the hypothalamic-pituitary region showed the presence of a 7 mm microadenoma. Bromocriptine therapy resulted in normalization of PRL levels and menstrual cycle, while a repeat MRI showed no change. Menses stopped in March 1998, when the patient was 46 yr old. Subsequently, the patient complained of worsening headaches and, starting from July 2001, visual disturbances. In March 2002, MRI showed a large pituitary tumor, measuring 40x37x28 mm. In May 2002, the patient was operated through the transsphenoidal approach with apparent total tumor removal. Histological examination confirmed a pituitary adenoma that stained negative for all pituitary hormones. Four months after surgery, the patient reported an improvement of visual function. MRI of the hypothalamic-pituitary region, performed 4, 13 and 25 months after surgery, showed a partially empty sella with no evidence of residual tumor.

CONCLUSIONS

This case suggests that, to exclude the alternative diagnosis of nonfunctioning pituitary adenoma or another mass lesion of the hypothalamic-pituitary region, repeat neuroimaging studies during long-term follow-up may be advisable in patients with presumed microprolactinoma who did not show reduction of the tumor during dopaminergic therapy.

Prolactinomas and pregnancy

Prolactinomas are the most frequent pituitary tumors. Treatment of infertility in such tumors usually is very successful. On the other hand, reports of pituitary tumor growth during pregnancy have been described since bromocriptine started to be used. Since then, dopamine agonists (DA) have been increasingly used as the first-choice treatment of prolactinomas, with surgery being reserved for resistance or persistent intolerance to DA or for special situations. More recently other DA, such as quinagolide and cabergoline have shown better tolerance than bromocriptine with similar or greater efficacy. Cabergoline is now the first choice drug but its use in pregnancy is still under evaluation. We followed 71 term pregnancies in women bearing microprolactinomas. Of the 22 patients with previous surgery, none presented symptoms of tumor growth. Of the 41 pregnant patients treated with bromocriptine alone, only one (2.4%) presented with headaches, which regressed with drug reintroduction. Fifty one term pregnancies in patients with macroprolactinomas were followed by us. Of those, 21 were in patients with previous surgery and none of them presented clinical evidence of tumor growth. On the other hand, of the 30 patients treated only with pre-gestational bromocriptine, 11 (37%) manifested complaints related to tumor growth. A non-hormonal contraceptive should be the use along with a DA drug until tumor shrinkage within sellar boundaries has been evidenced. After pregnancy has been confirmed, the DA can be withdrawn and the patient must be closely followed. If tumor expansion is suspected, confirmation can be made through MRI and by visual field testing. Reintroduction of bromocriptine in such cases can lead to tumor reduction and clinical improvement. Surgery can also be employed as treatment for symptomatic tumor growth in pregnancy.

Contemporary management of prolactinomas

Prolactin-secreting pituitary adenomas--prolactinomas--are the most common type of functional pituitary tumor. Treatment of hyperprolactinemia is indicated because of the consequences of infertility, gonadal dysfunction, and osteoporosis. Making the correct diagnosis is important because the first line of therapy is medical management with dopamine agonists. Medical therapy is effective in normalizing prolactin levels in more than 90% of patients, but longterm treatment may be required in some patients. Transsphenoidal surgery is usually indicated in those patients in whom medical therapy fails or cannot be tolerated, or in patients who harbor microprolactinomas. In experienced hands, a hormonal and oncological cure can be achieved in more than 90% of patients after transsphenoidal removal of microprolactinomas with minimal risks. Thus, surgery may be an option for microprolactinomas in a young patient who desires restoration of fertility and avoidance of long-term medical therapy. The authors review the diagnosis and management of prolactinomas, including medical therapy, surgical therapy, and stereotactic radiosurgery.

Withdrawal of long-term cabergoline therapy for tumoral and nontumoral hyperprolactinemia

BACKGROUND

Whether the withdrawal of treatment in patients with nontumoral hyperprolactinemia, microprolactinomas, or macroprolactinomas is safe and effective has been unclear. We performed an observational, prospective study of cabergoline (a dopamine-receptor agonist) withdrawal in such patients.

METHODS

The study population included 200 patients--25 patients with nontumoral hyperprolactinemia, 105 with microprolactinomas, and 70 with macroprolactinomas. Withdrawal of cabergoline was considered if prolactin levels were normal, magnetic resonance imaging (MRI) showed no tumor (or tumor reduction of 50 percent or more, with the tumor at a distance of more than 5 mm from the optic chiasm, and no invasion of the cavernous sinuses or other critical areas), and if follow-up after withdrawal could be continued for at least 24 months.

RESULTS

Recurrence rates two to five years after the withdrawal of cabergoline were 24 percent in patients with nontumoral hyperprolactinemia, 31 percent in patients with microprolactinomas, and 36 percent in patients; with macroprolactinomas. Renewed tumor growth did not occur in any patient; in 10 female patients (22 percent) and 7 male patients (39 percent) with recurrent hyperprolactinemia, gonadal dysfunction redeveloped. In all diagnostic groups, prolactin levels at the time of recurrence were significantly lower than at diagnosis (P<0.001). The Kaplan-Meier estimated rate of recurrence at five years was higher among patients with macroprolactinomas and those with microprolactinomas who had small remnant tumors visible on MRI at the time of treatment withdrawal than among patients whose MRI scans showed no evidence of tumor at the time of withdrawal (patients with macroprolactinomas, 78 percent vs. 33 percent, P=0.001; patients with microprolactinomas, 42 percent vs. 26 percent, P=0.02).

CONCLUSIONS

Cabergoline can be safely withdrawn in patients with normalized prolactin levels and no evidence of tumor. However, because the length of follow-up in our study was insufficient to rule out a delayed increase in the size of the tumor, we suggest that patients be closely monitored, particularly those with macroprolactinomas, in whom renewed growth of the tumor may compromise vision.