Clinical, Hormonal, and Neuroradiological Characteristics and Therapeutic Outcomes of Prolactinomas in Children and Adolescents at a Single Center

Background/Purpose: A prolactinoma is the most common pituitary adenoma, but it is relatively rare in childhood and adolescence. There is only limited research about the clinical spectrum, treatment, and outcomes of prolactinomas in childhood and adolescence. In this single-center cohort study, we assessed the clinical, hormonal, and neuroradiological characteristics and therapeutic outcomes of children and adolescents with prolactinomas. Methods: This retrospective cohort study included 25 patients with prolactinomas diagnosed before 19 years of age, who presented at Samsung Medical Center during a 15-year period (March 2005 to August 2019). Results: The median age at diagnosis was 16.9 (range 10.1-18.5) years, and 80% of the patients were female. The common clinical manifestations at diagnosis were galactorrhea (10/20, 50%) and amenorrhea (9/20, 45%) among females and visual field defects (3/5, 60%) and headaches (2/5, 40%) among males. In our cohort, macroadenomas accounted for 56% of cases, and the rate of overall responsiveness to dopamine agonists (DAs) was 56% (10/18). Male gender, the prolactin (PRL) level at diagnosis, and the presence of panhypopituitarism were positively correlated with maximum tumor diameter (r = 0.443, P = 0.026; r = 0.710, P < 0.001; and r = 0.623, P = 0.001, respectively). After the trans-sphenoidal approach (TSA), 53% (8/15) of patients showed normalization of the PRL level. Three patients, who underwent gamma knife surgery (GKS) owing to either resistance or intolerance to DAs or recurrence after the TSA, achieved a normal PRL level accompanied with marked tumor reduction and symptom remission. Conclusions: A macroprolactinoma is more prevalent than a microprolactinoma in children and adolescents than in adults. Male gender, increased PRL levels, and the presence of panhypopituitarism at diagnosis are closely related to macroprolactinomas in children and adolescents.

Galactorrhoea of the neck following pectoralis major reconstruction of a pharyngeal defect

We describe a case of postoperative galactorrhea following the use of a pedicled pectoralis major myocutaneous flap for reconstruction of a pharyngolaryngeal defect in a woman with squamous cell carcinoma. We believe this to be unique in the literature, and an important complication to be reported, due to the similarities in appearance of galactorrhoea and postoperative aerodigestive tract/cutaneous fistula.

[Digital mammography: experiences in its clinical application]

TARGET

In 1989 in the Cantonal Hospital of Lucerne conventional film-screen mammography was replaced by digital mammography. With the support of a retrospective study, it was checked whether or not digital mammography represents an equally valid diagnostic procedure in daily routine.

METHODS

1204 patients were examined using digital mammography. A reevaluation of these patients was carried out using clinical and radiological routine controls. Additionally a radiological and histological examination was performed in 127 cases in which excisional biopsies had been done, paying particular attention to detail perception.

RESULTS

The sensitivity of digital mammography achieved a total of 85%, whereas the accuracy was 81%. With additional use of ultrasound and galactography the sensitivity attained 91%. By reevaluation the sensitivity amounted to 87%, the accuracy remaining at 81%. The positive predictive value was especially high with 76% and 77%.

CONCLUSION

Digital mammography offers satisfactory diagnostic performance.

Radioiodine breast uptake in nonbreastfeeding women: clinical and scintigraphic characteristics

We studied the scintigraphic and associated clinical characteristics of radioiodine breast uptake in nonbreastfeeding thyroid cancer patients undergoing routine whole-body radioiodine scanning.

METHODS

We performed a retrospective review of the radioiodine scans and medical records of 30 prospectively collected cases.

RESULTS

Twenty-three nonpregnant patients had discontinued breastfeeding for a mean of 11.4 mo. Three postmenopausal and four single nulliparous patients had radioiodine breast uptake on one or more occasions. This represented about 6% of all female patients who had radioiodine scans over a 3-yr period. Four patterns of uptake, full, focal, crescentic and irregular, were observed. Breast uptake mimicked lung metastasis in nine patients. Expressible galactorrhea and moderately elevated prolactin levels were present in 48% and 24%, respectively, of patients examined. In 14 patients followed for an average of 11.4 mo, there were no consistent changes in the pattern or intensity of breast uptake. In 18 patients who had both 123I diagnostic and 131I postablation scans within a few days, breast uptake was present on both scans in 75%. In four patients, breast uptake was present, despite the 4%-9% radioiodine uptake by the thyroid; in one patient, iodinated contrast material blocked the uptake of the thyroid gland but not of the breast.

CONCLUSION

Although the mechanisms of radioiodine breast uptake remain unclear, breast uptake should be suspected in all female patients with radioiodine uptake in the chest area, even in the absence of a history of breastfeeding.

[Galactography]

Spontaneous single duct discharge is the main indication for galactography. This abnormality has in most cases a benign aetiology (> 90%). With a meticulous technique and sufficient experience, the ducts can be cannulated in 95% of the cases. A nipple adenoma with a blood stained discharge is seldom to pass for cannulation. Because cytology of the nipple discharge is not always positive in case of intraductal proliferations, microdochectomy must be used to obtain the differential diagnosis. Galactography shows multiple normal duct variations, depending on age, surrounding tissue, and a possible history of lactation. Pathologic images can be seen in dystrophic breasts, solitary papillomas, (juvenile) papillomas or (intraductal) carcinomas. In addition to high frequency ultrasonography (> or = 10 MHz), which is able to visualise the retro-areolar and superficial ducts, galactography can give a more detailed and better overview of the pathology.

[Localization of pathologically secreting lactiferous ducts]

During the investigation of ductographic findings in 200 patients with secretory disease of the breasts it was discovered that pathologically secreting lactiferous ducts were statistically predominantly localized in the retroareolar region and in the lower quadrates of the breasts. This prevalence does not correspond with the regions of the most voluminous portions of the mammary gland and with the most frequent localization of mammography manifestations of its fibroepithelial dysplasia.

[Xeroductogalactography. Case reports]

Xerogalactography represents the most important instrumental examination in the diagnosis of the secreting breast. The authors describe the radiological findings in the ductal ectasia, intraductal papillomas and papillomatosis and carcinomas in a personal experience concerning 52 patients with mammary secretion.

Breast disease in the male: galactographic evaluation

Seven men with unilateral nipple discharge underwent galactography. In two patients the diagnosis was carcinoma, two were benign papillomas, one was a breast abscess, and two were ductal ectasia. Galactography is useful in men and women with nipple discharge, especially when the discharge is bloody and there is no palpable tumor. The precise location of an intraductal lesion through the use of galactography guides the biopsy and makes conservative surgery easier.

Serum prolactin levels before and after galactography in patients with pathological nipple discharge

Serum prolactin levels were determined in 25 women who underwent galactography on account of pathological nipple discharge. The test samples were obtained immediately before galactography as well as 5, 10, 15 and 30 minutes after. There was no significant change in serum prolactin levels following galactography. In 2 cases out of 25, the basal level of prolactin was well above normal while in 1 case it was below normal. Those three were cases of galactorrhea. The clinical aspect of pathological nipple discharge did not correlate with serum prolactin levels, and galactorrhea would appear to be compatible with serum prolactin levels below normal.

[Radiological investigation of prolactin-producing pituitary microadenomas (author's transl)]

The CT scans and thin section sellar tomograms of 12 patients with amenorrhea, galactorrhea and hyperprolactinemia syndrome were analyzed. Three patients showed a remodeled sella on plain X-ray of the skull and a protrusion of the suprasellar cistern below the diaphragmatic line on pneumoencephalography (empty sella). CT scan confirmed the low absorption values within the sella and showed an intrasellar area of increased density after contrast infusion. In 9 patients, thin section tomograms showed an abnormal sellar configuration. 5 of these patients had an eccentric, high density area adjacent to the sellar floor on postcontrast CT scans. The remaining 4 patients did not show postcontrast enhancement.

Comparison of serum prolactin, plain radiography, and hypocycloidal tomography of the sella turcica in patients with galactorrhea

Hypocycloidal tomography of the sella turcica is being used with increasing frequency in patients with galactorrhea in order to establish the diagnosis of pituitary adenoma. In 201 patients with galactorrhea, serum prolactin (PRL) levels were correlated with anteroposterior (AP)--lateral plain radiographs and hypocycloidal tomography of the sella turcica. Plain films were normal in 167 and abnormal in 34 patients. Of the 167 patients with normal AP-lateral plain films, 80 had normal tomograms and normal serum prolactin levels while 80 patients had normal tomograms and elevated serum PRL levels (21 to 256 ng/ml). The remaining seven of the 167 patients had normal plain films with abnormal tomograms and elevated serum PRL levels (28 to 176 ng/ml). All patients with abnormal plain radiographs had abnormal tomograms and had either elevated or normal serum PRL levels. In view of these findings, sella tomography is only necessary in patients with normal plain radiographs and elevated serum PRL levels.

Intrasellar subarachnoid herniation or empty sella associated with galactorrhea

Eight of 115 patients with empty sella had concurrent galactorrhea. All 8 patients had abnormal sellae, and the diagnosis of empty sella was made by polytome pneumoencephalography. There were no obvious endocrine dysfunctions, but 2 patients had elevated prolactin levels. One mechanism for production of galactorrhea may involve compression of the hypothalamus and/or pituitary stalk; this was suggested by most of our observations. There may be a coincidental association of empty sella with galactorrhea, and this association is probably more common than previously noted. Evaluation of patients with galactorrhea and abnormal sellae by polytome pneumoencephalography is emphasized.

The borderline pituitary fossa in patients with amenorrhoea and/or galactorrhoea

A retrospective clinicoradiological study of 80 patients with amenorrhoea and/or galactorrhoea showed: 1. Of 60 patients, in whom prolactin levels were estimated, 28 (47%) had hyperprolactinaemia (serum prolactin levels greater than 20 ng/ml). 2. Hyperprolactinaemia was present in 85% of patients with amenorrhoea and galactorrhoea, 35% of those with galactorrhoea only, and 12.5% of those with only amenorrhoea. 3. Pituitary adenomas were surgically removed from six patients; all but one had prolactin levels over 100 ng/ml. The level was 53 ng/ml in the sixth patient. 4. There is a considerable degree of observer variation in the interpretation of borderline sellar changes. 5. Minor abnormalities of the pituitary fossa were noted in 64% of patients with hyperprolactinaemia and 36% of those with normal prolactin levels. 6. The highest incidence of perfectly normal sellae was among patients with either amenorrhoea or galactorrhoea and normal serum prolactin.

Pluridirectional tomography in the evaluation of pituitary tumors

A series of 110 patients with suspected pituitary tumors was recently evaluated by endocrinologic and neuroradiologic studies. Of the 77 patients in this series who underwent surgery, 74 had confirmed pituitary adenomas, two had suprasella tumors of the influndibulum, and one had an empty sella not previously diagnosed at pneumoencephalography. All 17 patients with normal plain skull films but abnormal thin section tomography who underwent surgery had documented pituitary tumors. This includes six patients who presented with amenorrhea and/or galactorrhea and normal baseline serum prolactin levels; the only abnormality was found on tomography of the sella. In the preoperative evaluation of these patients, pluridirectional tomography of the sella was the most sensitive indicator of intrasellar pathology.

Prolactin-secreting pituitary microadenomas

Prolactin-secreting pituitary microadenomas have been surgically selectively removed in 20 patients presenting an amenorrhea-galactorrhea syndrome, hyperprolactinemia and radiological modifications of the sella turcica. In these patients, the sella was of normal size but hypocyloidal tomography evidenced subtle changes characterizing pituitary microadenomas. The surgical intervention has been based on the twin criteria of hyperprolactinemia and sellar findings.

[Case studies of galactography]

A brief account of radiological examination in diseases of the breast is followed by a discussion on galactography. Its technique is not difficult, but requires diligence, attention and experience. Its indications essentially concern cases in which there is secretion from the nipple. Contraindications are mainly known or strongly suspected malignant tumours. Disorders affecting the milk ducts are described with reference to their radiological picture as observed in 91 cases, 40 of which were followed operatively and histologically and 18 with cytological examination of the secretion. The examination is seen as an alternative of choice in cases of mammary lesion with secreting nipple, particularly in the exact localisation of damage.

[Microadenomas and hypersecreting pituitary adenomas]

The early radiographic changes of the sella turcica in the cases of hypersecreting pituitary adenomas (Cushing disease, acromegaly, amenorrhea-galactorrhea) are reported and discussed. The finding of the double contour of the sellar floor and the small crescentic bulging of its antero-inferior wall, with the aid of the tomographic cuts of the sella, has permited the diagnosis of the microadenoma'a localization. With this it si possible the achievement of a selective excision of the lesion in the initial stage, when the tumor has not caused yet irreversible damage to the inside normal pituitary tissue. This surgery is performed in the precocious stage with the primary goal to preserve the normal gland, without hurt it to avoid postoperative hipopituitarism. A anatomo-radiologic classification of the alterations sella turcica in 4 grades is made, which is of great utility for the surgical prognostic, since we have observed clinical and biological cure over 90% in the grade 1, 75% in the grade 2, 50% in the grade 3 and up to 10% in the grade 4 in the first surgery.