Cabergoline and quinagolide therapy for prolactinomas

Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm

Background  Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives  The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods  The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results  Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3-581), nine remained with recurrent/persistent disease (23%). Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0-240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion  Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.

Pituitary tumours: the prolactinoma

This review focus on the epidemiology, diagnosis and treatment of prolactinomas. In particular, attention was given to recent data showing a high prevalence of these tumours in the general population, 3-5 times higher than previously reported. The diagnosis of hyperprolactinaemia has been simplified in recent years, and only prolactin (PRL) assay and magnetic resonance imaging of the sella are required. Nonetheless, macroprolactinaemia should be assessed in patients with hyperprolactinaemia in the absence of clinical symptoms of elevated PRL levels. The recent evidence that medical therapy with dopamine agonists should be continued lifelong has been confirmed by several studied. The patients achieving disappearance of the tumours and suppression of PRL levels during treatment are those showing the highest likelihood to have persistent remission of hyperprolactinaemia after treatment withdrawal.

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.

Ovulation induction--optimizing results and minimizing risks

The aim of ovulation induction therapy should be, wherever possible, to correct the underlying disturbance and achieve safe, repeated unifollicular ovulation to achieve the live birth of singleton babies. This article outlines the main causes of anovulatory infertility but deals mostly with the management of anovulatory polycystic ovary syndrome (PCOS), which is the most common problem to confront specialists in reproductive medicine. PCOS is associated with insulin resistance, particularly in those who are overweight. Thus, strategies to achieve weight loss and improve insulin sensitivity, including the use of drugs such as metformin, enhance reproductive function. Therapies to induce ovulation involve first the use of the anti-oestrogen clomiphene citrate. For those who fail to ovulate in response to clomiphene citrate, the principal options include parenteral gonadotrophin therapy or laparoscopic ovarian diathermy.

Current management of prolactinomas

Prolactinomas constitute the largest group of pituitary adenomas in autopsy series. However, their relative incidence in recent surgical series is much less impressive since medical treatment with dopamine agonists is routinely employed, which in many cases leads to tumor shrinkage and normalization of prolactin levels. The clinical symptoms of hyperprolactinemia are menstrual dysfunction and galactorrhea in women and loss of libido and potency in men. Prolactinomas may present also as space occupying sellar mass lesions impinging on the adjacent structures like the pituitary gland, cavernous sinus and optic nerves. The standard primary treatment is medical by dopamine agonists. Prolactinomas are the prototype of tumors, the growth of which can be reliably and safely inhibited by specific drugs other than cytostatic chemotherapy. These unfortunately have side effects, like orthostatic hypotension, nausea and vomiting. The effects induced by dopamine agonists are suppressive but not tumoricidal. Thus, the therapeutic effect is only maintained as long as the drug is administered. Consequently. in most cases, treatment has to be continued life-long with a few exceptions, in whom normoprolactinemia persists even after discontinuation of dopamine agonists. Main indications of surgery in prolactinomas are intolerance of the medication, and tumors not responding to dopamine agonists. Occasionally, these may ultimately require radiation therapy. Remission rates in large series of surgically treated prolactinomas vary between 54% and 86%. In our consecutive series of 540 surgically treated prolactinomas, the normalization rate after transsphenoidal surgery basically depended on the preoperative prolactin levels, tumor size and extension. The remission rate of 82% in microprolactinomas with initial prolactin levels <200 ng/ml would even in small adenomas make one consider surgical treatment as an interesting alternative to long-term medical treatment.