Diagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement

Abstract

This Consensus Statement from an international, multidisciplinary workshop sponsored by the Pituitary Society offers evidence-based graded consensus recommendations and key summary points for clinical practice on the diagnosis and management of prolactinomas. Epidemiology and pathogenesis, clinical presentation of disordered pituitary hormone secretion, assessment of hyperprolactinaemia and biochemical evaluation, optimal use of imaging strategies and disease-related complications are addressed. In-depth discussions present the latest evidence on treatment of prolactinoma, including efficacy, adverse effects and options for withdrawal of dopamine agonist therapy, as well as indications for surgery, preoperative medical therapy and radiation therapy. Management of prolactinoma in special situations is discussed, including cystic lesions, mixed growth hormone-secreting and prolactin-secreting adenomas and giant and aggressive prolactinomas. Furthermore, considerations for pregnancy and fertility are outlined, as well as management of prolactinomas in children and adolescents, patients with an underlying psychiatric disorder, postmenopausal women, transgender individuals and patients with chronic kidney disease. The workshop concluded that, although treatment resistance is rare, there is a need for additional therapeutic options to address clinical challenges in treating these patients and a need to facilitate international registries to enable risk stratification and optimization of therapeutic strategies. Sections Clinical presentation Hyperprolactinaemia and hypogonadism• The presence of a sellar mass on imaging requires evaluation for hyperprolactinaemia (strong). • Galactorrhoea should trigger investigation for hyperprolactinaemia, except for known physiological reasons (for example, pregnant or lactating women) (strong). Importantly, absence of galactorrhoea does not exclude hyperprolactinaemia (strong).

Medically responsive amyloidogenic giant sellar-parasellar prolactinoma

“…According to the Pituitary Society International Consensus Statement (2023), medical therapy with dopamine agonists is a first-line treatment for giant prolactinomas with recommendations of debulking surgery in resistant cases to improve the medical treatment responsiveness. [ 9 ] However, the available literature suggests that medical therapy does not cause a decrease but rather an increase in tumor size in amyloidogenic prolactinomas, making surgery the treatment of choice. [ 4 ]…”

Neuregulin 4 (Nrg4) cooperates with melatonin to regulate the PRL expression via ErbB4/Erk signaling pathway as a potential prolactin (PRL) regulator

“…5 Nevertheless, the therapeutic efficacy of dopamine agonists is constrained in patients with prolactinoma owing to their pronounced drug resistance. 6,7 Currently, other studies are still exploring other factors implicated in the regulation of PRL. Further information and research are indeed necessary in the field of PRL regulation to better contextualize the missing information of PRL regulation.…”

The Effect of Preoperative Cabergoline on Prolactinoma Fibrosis: A Case Series

“…Such tumors, referred to as prolactinomas, account for approximately 50% of all PitNETs with an incidence of three to five cases/100,000/year. 1 2 Without treatment, prolactinomas can result in amenorrhea, diminished libido, galactorrhea, erectile dysfunction, infertility, gynecomastia, and decreased bone mass. 3 4 Additionally, patients may develop symptoms of hypopituitarism, visual field deficits, cranial nerve dysfunction, and seizures as a result of the mass effect that large tumors may impose on nearby intracranial structures.…”