Abstract
Pituitary adenomas are associated with a variety of clinical manifestations resulting from excessive hormone secretion and tumor mass effects, and require a multidisciplinary management approach. This article discusses the treatment modalities for the management of patients with a prolactinoma, Cushing's disease and acromegaly, and summarizes the options for medical therapy in these patients.First-line treatment of prolactinomas is pharmacotherapy with dopamine agonists; recent reports of cardiac valve abnormalities associated with this class of medication in Parkinson's disease has prompted study in hyperprolactinemic populations. Patients with resistance to dopamine agonists may require other treatment.First-line treatment of Cushing's disease is pituitary surgery by a surgeon with experience in this condition. Current medical options for Cushing's disease block adrenal cortisol production, but do not treat the underlying disease. Pituitary-directed medical therapies are now being explored. In several small studies, the dopamine agonist cabergoline normalized urinary free cortisol in some patients. The multi-receptor targeted somatostatin analogue pasireotide (SOM230) shows promise as a pituitary-directed medical therapy in Cushing's disease; further studies will determine its efficacy and safety. Radiation therapy, with medical adrenal blockade while awaiting the effects of radiation, and bilateral adrenalectomy remain standard treatment options for patients not cured with pituitary surgery.In patients with acromegaly, surgery remains the first-line treatment option when the tumor is likely to be completely resected, or for debulking, especially when the tumor is compressing neurovisual structures. Primary therapy with somatostatin analogues has been used in some patients with large extrasellar tumors not amenable to surgical cure, patients at high surgical risk and patients who decline surgery. Pegvisomant is indicated in patients who have not responded to surgery and other medical therapy, although there are regional differences in when it is prescribed.In conclusion, the treatment of patients with pituitary adenomas requires a multidisciplinary approach. Dopamine agonists are an effective first-line medical therapy in most patients with a prolactinoma, and somatostatin analogues can be used as first-line therapy in selected patients with acromegaly. Current medical therapies for Cushing's disease primarily focus on adrenal blockade of cortisol production, although pasireotide and cabergoline show promise as pituitary-directed medical therapy for Cushing's disease; further long-term evaluation of efficacy and safety is important.
Highlights
Pituitary adenomas are associated with a variety of clinical manifestations resulting from excessive hormone secretion and tumor mass effects, and require a multidisciplinary management approach
In three separate studies in patients with macroprolactinomas who received 12-27 months of firstline therapy with dopamine agonists [7,8,9], tumor reduction of more than 50% was seen in 64%, 86% and 96% of patients treated with bromocriptine, pergolide and cabergoline, respectively (Table 1)
Cox regression analysis determined that tumor diameter on withdrawal of cabergoline is the major determinant of recurrent hyperprolactinemia [4]. These results show that cabergoline can be safely withdrawn in patients with normalized prolactin levels and no evidence of tumor, patients should be closely monitored upon withdrawal of therapy, those patients with macroprolactinomas in whom renewed growth of the tumor may compromise vision
Summary
Surgery remains the first-line treatment option in patients with GH-secreting tumors. Somatostatin analogues may be used as first-line therapy in selected patients with large extrasellar tumors not amenable to surgical cure, in patients at high surgical risk, and in patients who decline surgery. Somatostatin analogues may be used as first-line therapy for acromegaly in selected patients with large extrasellar tumors not amenable to surgical cure, frail patients, patients at high surgical risk, and patients who decline surgery. Authors' contributions BMKB, AC, SP, VSB and MB all participated in an independent CME symposium at the 89th Annual Meeting of the Endocrine Society. This manuscript was developed directly from those presentations, which each author prepared him/herself.
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
