Abstract
Prolactin (PRL) secreting tumors are the most common functional neoplasms of the pituitary and are commonly subdivided into microprolactinomas (<10 mm) and macroprolactinomas (≥10 mm) according to their baseline diameter. Patients with prolactinoma present with symptoms evolving from hyperprolactinemia and with those caused by pressure of the expanding mass on surrounding tissues, including the optic chiasm and the cavernous sinuses. We hereby describe the possible complications of macroprolactinomas, including mass effects, hypopituitarism, CSF leak and apoplexy and discuss their relevant management.In general, all patients harboring macroprolactinomas should be treated, the objectives being to achieve normal or near normal PRL levels, to reduce or stabilize adenoma size and to recover altered pituitary axes. Medical therapy with dopamine agonists (DA) is the preferred initial treatment for the vast majority of patients harboring prolactinomas. Pituitary surgery is indicated in patients who cannot tolerate or are resistant to therapy with DAs, patients that seek fertility and harbor adenomas that impinge on the optic chiasm, psychiatric patients with contraindication to DA treatment and patients presenting with pituitary apoplexy or a cerebrospinal fluid (CSF) leak. In addition, in this review, several patient populations with unique clinical characteristics will be discussed separately namely postmenopausal women, the elderly, children and patients with pituitary carcinoma.
Highlights
Prolactin-secreting tumors are the most common functional neoplasms of the pituitary, accounting for 30-40 % of pituitary adenomas [1]
There are several indications for pituitary surgery that might be applicable for a selected group of patients, those who cannot tolerate, or are resistant to therapy with dopamine agonists (DA), patients that seek fertility and harbor adenomas that impinge on the optic chiasm, psychiatric patients with contraindication to DA treatment and patients presenting with pituitary apoplexy or cerebrospinal fluid (CSF) leak [6]
We found some recovery of the corticotrophs with no thyrotroph recovery [55], Colao et al [30], found similar patterns, Karavitaki et al [21] showed recovery of thyrotrophs in 25 % of affected patients but no recovery of Adrenocorticotropic hormone (ACTH) secretion and Sibal et al [35] demonstrated re-secretion of both ACTH and Thyroid stimulating hormone (TSH) in some patients in their cohort
Summary
Prolactin-secreting tumors are the most common functional neoplasms of the pituitary, accounting for 30-40 % of pituitary adenomas [1]. Dopamine agonists - adenoma shrinkage Apart from PRL normalization and hormone secretion recovery, tumor shrinkage to relieve tumor mass effects and prevent neurological complications is another treatment goal for patients harboring macroprolactinomas [6]. Dopamine agonists – resistance Resistance to DAs has several different definitions in the literature, including failure to achieve normal PRL levels or adenoma shrinkage of >50 % [13, 33], failure to reduce PRL by >50 %, or to induce ovulation in women [33], or failure to reduce symptoms or normalize PRL despite CAB dose ≥2 mg/week [34].
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