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Raverot V, Perrin P, Chanson P, Jouanneau E, Brue T, Raverot G. Prolactin immunoassay: does the high-dose hook effect still exist? Pituitary 2022; 25:653-657. [PMID: 35793045 DOI: 10.1007/s11102-022-01246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Measurement of prolactin in clinical laboratories is an important component in the management of patients with pituitary adenoma. Prolactin measurement is known to be sensitive to the high-dose hook effect, in the presence of extremely high prolactin concentrations. This interference is referred to in most recent articles discussing prolactin assays and the management of prolactin-secreting pituitary adenomas. The objective of our study was to evaluate if the high-dose hook effect remains relevant in current practice, when using currently available assays. METHODS Serum from a patient with a giant macroprolactinoma was assayed using all of the available prolactin assays in France in 2020, using native serum and after dilution. Technical inserts from assays were reviewed to assess the information on analytical principles, numbers of steps, and any reference to high dose hook effect. RESULTS Fourteen assay kits were studied by 16 laboratories; all were two-site immunometric assays, mostly using one step (11/14). Results obtained after dilution varied from 17,900 µg/L to 86,900 µg/L depending on the assay used. One tested assay was sensitive to the high-dose hook effect leading to a falsely lower prolactin concentration when measuring native serum (150 µg/L compared to 17,900 µg/L after dilution). CONCLUSION The high-dose hook effect still exists in a very small minority of prolactin assays. The evolution of assay methods may lead to new assays that remain sensitive to this effect in the future. We therefore advise that the hook effect should still be mentioned in prolactin assay recommendations.
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Affiliation(s)
- Véronique Raverot
- Service de Biochimie et biologie moléculaire, Hospices Civils de Lyon, LBMMS, F-69677, Hormonologie, Bron cedex, France.
- Neuroscience Research Center (CRNL), Inserm UMRS 1028, Université de Lyon, Waking team, 69500, Bron, France.
| | - Pauline Perrin
- Service de Biochimie et biologie moléculaire, Hospices Civils de Lyon, LBMMS, F-69677, Hormonologie, Bron cedex, France
- Neuroscience Research Center (CRNL), Inserm UMRS 1028, Université de Lyon, Waking team, 69500, Bron, France
| | - Philippe Chanson
- Physiologie et Physiopathologie Endocriniennes, Hôpital Bicêtre, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Service d'Endocrinologie et des Maladies de la Reproduction, Université Paris-Saclay, Inserm, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Emmanuel Jouanneau
- Service de neurochirurgie, Hospices Civils de Lyon, Groupement Hospitalier Est, F-69677, Bron cedex, France
| | - Thierry Brue
- Department of Endocrinology, Hôpital de la Conception, Assistance Publique-Hôpitaux de Marseille (AP-HM), Centre de Référence des Maladies Rares de l'hypophyse HYPO, 13005, Marseille, France
- Aix-Marseille Université, Marseille Medical Genetics (MMG), Faculté des Sciences médicales et paramédicales, Institut National de la Santé et de la Recherche Médicale (INSERM), U1251, Institut Marseille Maladies Rares (MarMaRa), Marseille, France
| | - Gérald Raverot
- Fédération d'endocrinologie, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Faculté de Médecine Lyon Est, Hospices Civils de Lyon, Groupement Hospitalier Est, Université Claude Bernard Lyon1, F-69677, Bron cedex, France
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Untreated Giant Macroprolactinoma with Chronic Cerebrospinal Fluid Leakage: An Unusual Complication. Case Rep Endocrinol 2019; 2019:4825357. [PMID: 30766735 PMCID: PMC6350591 DOI: 10.1155/2019/4825357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/25/2018] [Accepted: 12/31/2018] [Indexed: 12/04/2022] Open
Abstract
Macroprolactinoma has the potential to cause base of skull erosion and often extends into the sphenoid sinus. Rapid shrinkage of this invasive tumor following dopamine agonist therapy has been postulated to cause unplugging of the eroded area, leading to cerebrospinal fluid leakage. To the best of our knowledge, the occurrence of spontaneous cerebrospinal fluid leak in treatment-naive prolactinomas is very rare, the majority of which involve undiagnosed macroprolactinomas. We describe here a lady presented late with giant macroprolactinoma, complicated by cerebrospinal fluid leakage. This case raised the dilemma in the management pertaining to the role of either pharmacotherapy or surgical intervention, or combination of both. As she strictly refused surgery, she was treated with bromocriptine which was later changed to cabergoline. On follow-up, there was cessation of cerebrospinal fluid leak, marked reduction of serum prolactin level, and imaging evidence of tumor shrinkage. The majority of patients with medically induced cerebrospinal fluid leakage will require surgical procedures to overcome this complication; however, there are isolated cases of leakage resolution on continuing dopamine agonist therapy while awaiting surgery. The use of dopamine agonist does not necessarily cause worsening of cerebrospinal fluid leakage and instead may produce spontaneous resolution as in this case.
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Pekić S, Medic Stojanoska M, Popovic V. Hyperprolactinemia/Prolactinomas in the Postmenopausal Period: Challenges in Diagnosis and Management. Neuroendocrinology 2019; 109:28-33. [PMID: 30347396 DOI: 10.1159/000494725] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/22/2018] [Indexed: 11/19/2022]
Abstract
Hyperprolactinemia is not a common finding in postmenopausal women. Prolactinomas detected after menopause are usually macroadenomas. Due to atypical clinical features they may remain unrecognized for a long period of time. Interestingly the growth potential of prolactinomas remains after menopause. Most tumors are invasive and present with high prolactin levels. They respond to medical treatment with dopamine agonists in terms of prolactin normalization, tumor shrinkage, and improvement in pituitary function. Treatment with dopamine agonists is usually long term. Reducing doses of cabergoline to the lowest that keeps prolactin levels normal prior to withdrawal is proposed to patients with macroprolactinomas who normalize prolactin after > 5 years of treatment and who do not have cavernous sinus invasion. Cabergoline can achieve a high percentage of remission maintenance in the first years after withdrawal. However, the percentage of relapse-free patients 5 years after withdrawal is significantly lower. Besides recurrent hyper-prolactinemia in a subgroup of macroprolactinomas after a long-interval tumor regrowth may be detected. Menopause cannot ensure remission of the tumor so long-term surveillance is suggested. In patients with microadenomas data on long-term remission rates (normalization of prolactin and disappearance of the tumor) after suspension of treatment with dopamine agonists are highly variable. The current strategy for microprolactinomas is not to treat hyperprolactinemia in menopause if it recurrs after discontinuation of dopamine agonists. This is based on: (1) reports that elevated prolactin levels may normalize in some women after menopause, (2) the fact that the association between prolactin levels and breast cancer is inconsistent in postmenopausal women, (3) the lack of clinical evidence that normalization of prolactin levels in postmenopausal women improves bone mineral density or reduces the risk of fracture, and (4) the fact that, concerning the metabolic syndrome, no data are available on metabolic parameters after suspension of treatment with dopamine agonists. For a change in strategy, i.e., for the potential benefits from treatment of hyperprolactinemia in the postmenopausal period with dopamine agonists concerning weight loss, improved insulin sensitivity, decreased fracture risk, and improved sexuality, more evidence is needed.
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Affiliation(s)
- Sandra Pekić
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, University Clinical Center, Belgrade, Serbia
| | - Milica Medic Stojanoska
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Vera Popovic
- School of Medicine, University of Belgrade, Belgrade, Serbia,
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Briet C, Bernard F, Rodien P. Lesson to be remembered from a skull base tumor. Neurochirurgie 2017; 63:334-335. [PMID: 28882600 DOI: 10.1016/j.neuchi.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 04/05/2017] [Accepted: 04/21/2017] [Indexed: 11/17/2022]
Abstract
The natural history of giant prolactinomas is not known. While it is commonly accepted that the enlargement of microadenoma is rare and more limited than macroadenoma, it is so far uncommon that macroadenoma progress to giant adenoma. Thus, spontaneous enlargement of adenomas is poorly documented. We report the unusual history of undiagnosed microprolactinoma, revealed 12years later at the stage of a giant adenoma presenting as a skull base tumor. This unique observation provides information on the natural history of giant adenomas and arguments for particular attention to microadenomas with signs of invasion. Moreover, this clinical case highlights the need for a prolactin dosage for all midline skull base tumors.
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Affiliation(s)
- C Briet
- Institut Mitovasc, unité CNRS 6214/Inserm1083, université d'Angers, 49100 Angers, France; Service d'endocrinologie diabétologie nutrition, centre de référence des maladies rares de la réceptivité hormonale, CHU d'Angers, Angers, France
| | - F Bernard
- Service de neurochirurgie, CHU d'Angers, 49100 Angers, France
| | - P Rodien
- Institut Mitovasc, unité CNRS 6214/Inserm1083, université d'Angers, 49100 Angers, France; Service d'endocrinologie diabétologie nutrition, centre de référence des maladies rares de la réceptivité hormonale, CHU d'Angers, Angers, France.
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Abstract
Giant prolactinomas are rare tumours, representing only 2-3% of all prolactin (PRL)-secreting tumours and raising special diagnostic and therapeutic challenges. Based on several considerations developed in this review, their definition should be restricted to pituitary adenomas with a diameter of 40 mm or more, significant extrasellar extension, very high PRL concentrations (usually above 1000 μg/l) and no concomitant GH or ACTH secretion. Giant prolactinomas are much more frequent in young to middle-aged men than in women, with a male to female ratio of about 9:1. Endocrine symptoms are often present but overlooked for a long period of time, and diagnosis is eventually made when neurologic complications arise from massive extension into the surrounding structures, leading to cranial nerve palsies, hydrocephalus, temporal epilepsy or exophthalmos. PRL concentrations are usually in the range of 1000-100,000 μg/l, but may be underestimated by the so-called 'high-dose hook effect'. As in every prolactinoma, dopamine agonists are the first-line treatment allowing rapid alleviation of neurologic symptoms in the majority of the cases, a significant reduction in tumour size in three-fourths of the patients and PRL normalization in 60-70%. These extensive tumours are usually not completely resectable and neurosurgery has significant morbidity and mortality. It should therefore be restricted to acute complications such as apoplexy or leakage of cerebrospinal fluid (often induced by medical treatment) or to patients with insufficient tumoural response or progression. Irradiation and temozolomide are useful adjuvant therapies in a subset of patients with aggressive/invasive tumours, which are not controlled despite combined medical and surgical treatments. Because of these various challenges, we advocate a multidisciplinary management of these giant tumours in expert centres.
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Affiliation(s)
- Dominique Maiter
- Department of EndocrinologyCliniques Universitaires Saint-LucCentre Hospitalier Universitaire de Mont-GodinneMont-sur-Meuse, Université catholique de Louvain, Avenue Hippocrate 54.74, 1200 Brussels, Belgium
| | - Etienne Delgrange
- Department of EndocrinologyCliniques Universitaires Saint-LucCentre Hospitalier Universitaire de Mont-GodinneMont-sur-Meuse, Université catholique de Louvain, Avenue Hippocrate 54.74, 1200 Brussels, Belgium
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Delgrange E, Raverot G, Bex M, Burman P, Decoudier B, Devuyst F, Feldt-Rasmussen U, Andersen M, Maiter D. Giant prolactinomas in women. Eur J Endocrinol 2014; 170:31-8. [PMID: 24088550 DOI: 10.1530/eje-13-0503] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To characterise distinctive clinical features of giant prolactinomas in women. DESIGN A multicentre, retrospective case series and literature review. METHODS We collected data from 15 female patients with a pituitary tumour larger than 4 cm and prolactin levels above 1000 μg/l and identified 19 similar cases from the literature; a gender-based comparison of the frequency and age distribution was obtained from a literature review. RESULTS The initial PubMed search using the term 'giant prolactinomas' identified 125 patients (13 women) responding to the inclusion criteria. The female:male ratio was 1:9. Another six female patients were found by extending the literature search, while our own series added 15 patients. The median age at diagnosis was 44 years in women compared with 35 years in men (P<0.05). All cases diagnosed before the age of 15 years were boys. In women (n=34), we observed a minor peak incidence during the third decade of life and a major peak during the fifth decade. Amenorrhoea was a constant feature with seven cases of primary amenorrhoea. In eight women with onset of secondary amenorrhoea before the age of 40 years, the diagnosis was made 2-31 years later (median 9 years) and in all but one because of tumour pressure symptoms. The prolactin levels were above 10,000 μg/l in 15/34 and misdiagnosis due to 'hook effect' occurred in two of them. Eighteen patients were treated with cabergoline; standard doses (<2.0 mg/week) were able to normalise prolactin in only 4/18 patients, and 7/18 patients were resistant to weekly doses ranging from 3.0 to 7.0 mg. CONCLUSION Giant prolactinomas are rare in women, often resistant to dopamine agonists and seem to be distributed in two age groups, with a larger late-onset peak.
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Affiliation(s)
- Etienne Delgrange
- Service d'Endocrinologie, Centre Hospitalier Universitaire de Mont-Godinne, Université Catholique de Louvain, B-5530 Mont-sur-Meuse, Belgium
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Agarwal M, Das A, Singh AS. High-dose hook effect in prolactin macroadenomas: A diagnostic concern. J Hum Reprod Sci 2011; 3:160-1. [PMID: 21234181 PMCID: PMC3017337 DOI: 10.4103/0974-1208.74164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Manika Agarwal
- Department of Obstetrics & Gynaecology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGRIHMS), Mawdiangdiang, Shillong, Meghalaya, India
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