Abstract
Objective Dopamine agonists (DAs) are recommended as the first-line treatment for prolactinomas; however, tumour recurrence after drug withdrawal remains a clinical problem. Recent studies have reported high remission rates via surgery in microprolactinomas. The aim of this systematic review and meta-analysis was to compare the clinical result of DA treatment with surgery as initial therapy in patients with treatment-naive microprolactinoma. Methods A comprehensive literature search for studies and reports regarding microprolactinoma patients treated with DAs and/or surgery published between January 1970 and November 2020 was conducted using four electronic databases (PubMed, Embase, Google Scholar, and the Cochrane Library). Clinical treatment outcome was evaluated by the biochemical remission of serum prolactin level to normal after treatment. The I2 statistic was used to quantify heterogeneity. Pooled data were analysed according to a random effect model. Results Eighteen studies with 661 patients were included for analysis. The DA treatment group achieved a higher remission rate at ≥12 months follow-up (96% vs. 86%; P=0.019). Surgery showed a higher remission rate than the DA treatment group after the treatment withdrawal (78% vs. 44%; P=0.003). Patients with preoperative prolactin level of ≤200 ng/mL had a higher remission rate than patients with preoperative prolactin level of >200 ng/mL (92% vs. 40%; P=0.029). Conclusion Surgery showed a high remission rate in treatment-naive microprolactinoma patients after treatment withdrawal and may be an alternative first-line treatment strategy in addition to DAs, particularly in patients with a preoperative prolactin level of ≤200 ng/mL.
Highlights
As the most common subtype of pituitary adenomas, prolactinomas account for approximately 32%–66% of all pituitary adenomas [1]
At final follow-up periods, namely, treatment withdrawal (DA withdrawal in the medical group; no other therapy was applied after surgery), the surgery group had an obvious higher remission rate than medical treatment (78% vs. 44%; P 0.003; Table 2; Figure 4(a))
Some studies have suggested that surgery could be offered as the initial therapeutic approach for microprolactinomas due to the high remission rate observed after surgery when performed by experienced neurosurgeons [15, 20]
Summary
As the most common subtype of pituitary adenomas, prolactinomas account for approximately 32%–66% of all pituitary adenomas [1]. Erapeutic options include pharmacotherapy, surgery, and radiation. Since the mid-1980s, surgery and radiotherapy have been progressively replaced by pharmacotherapy with dopamine agonists (DAs) [6]. Ese agents result in prolactin (PRL) normalisation in approximately 75%–90% of prolactinoma cases [7] and are recommended as first-line therapy [1, 8]. Tumour recurrence after withdrawal of DA therapy remains a clinical problem. Recurrence of hyperprolactinemia after DA withdrawal reportedly ranges from 33.9% to 100%, even if the PRL had normalised during DA treatment for >2 years [9, 10]
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