10-year follow-up study comparing primary medical vs. surgical therapy in women with prolactinomas

Abstract

While dopamine-agonists are the first-line approach in treating prolactinomas, surgery can be considered in selected cases besides non-responders or patients with dopamine-agonist intolerance. The aim of the present study was to compare the long-term outcome in women with prolactinomas treated primarily either surgically or medically who had not had prior dopamine-agonist treatment. Retrospective case-note study of all consecutive women with prolactinomas primarily managed with medical therapy or surgery in a tertiary referral centre. The clinical, biochemical, and radiological responses to first-line treatment at early and long-term follow-up were analysed. The primary therapeutic strategy was dopamine-agonists for 36 (34 %) and surgery for 71 (66 %) of the women. Baseline clinical and biochemical characteristics were not significantly different between the primary surgical and medical cohort. Median follow-up time was 90 months (range 13-408). Following primary treatment, prolactin level significantly decreased in both cohorts, on average to 13.5 µg/L (IQR 7-21; p < 0.001), and was within the normal range in 82 % of all patients. No women in the surgical cohort demonstrated permanent sequelae and morbidity was low. At final follow-up, control of hyperprolactinaemia required dopamine-agonist therapy in 64 % of women who had undergone primary medical therapy vs. 32 % of those who had primary surgical therapy (p = 0.003). Logistic regression revealed that the primary therapeutic strategy, but not adenoma size, was an independent risk factor for long-term dependence on dopamine-agonists. The present data indicate that in a dedicated tertiary referral centre, long-term control of hyperprolactinaemia in women with prolactinomas is high. In selected cases, a primary neurosurgical approach might at least be interdisciplinarily discussed with the primary goal of minimizing long-term dependence on dopamine-agonists.

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

“…Surgery is considered as a second line treatment, in case of resistance to the medical treatment or intolerance or in cases of pituitary apoplexy. In the surgical series, the remission rate was 55% (all cases were macroprolactinomas), which is aligned with data from the literature, where remission rates vary from 34% to 79% 30,31 . Also for prolactinomas, the remission rates are significantly superior for microadenomas (88%) than macroadenomas 30,31 .…”

“…In the surgical series, the remission rate was 55% (all cases were macroprolactinomas), which is aligned with data from the literature, where remission rates vary from 34% to 79% 30,31 . Also for prolactinomas, the remission rates are significantly superior for microadenomas (88%) than macroadenomas 30,31 . Surgery for PRL adenomas also allows the reduction or discontinuance of medical therapy in 30% of patients, as has been verified by several groups 30,31. TSH-secreting adenomas are very rare tumors and represent between 0.5% and 3% of pituitary tumors in surgical series 32 .…”

Epidemiology and Management Challenges in Prolactinomas

“…Before the widespread use of primary dopamine agonist therapy, surgery was the main treatment for micro and macroprolactinomas [53]. Primary dopamine agonist and surgical treatment of prolactinomas are both associated with good efficacy and safety profiles [54]. Follow-up of surgically managed prolactinomas has shown that initial postoperative control rates can be as high as 60-63%, but that the risk of recurrent hyperprolactinemia can occur in up to a third of cases [55].…”

Management of prolactinoma: a survey of endocrinologists in China

“…Transshpenoidal surgery might be an alternative method to achieve long-term remission and avoid the side effects of medical therapy in prolactinoma patients. Patient preference and surgeon’s experience should be considered as indications for surgery in patients with prolactinoma ( 19 , 21 , 22 ). It seemed that most endocrinologists were conservative on surgery of prolactinoma.…”