Giant Prolactinomas: Outcomes of Multimodal Treatments for 42 Cases with Long-Term Follow-Up

Abstract

Giant prolactinomas represent a rare entity of pituitary tumors so that the management of these patients is still a prevalent challenge at present. Paying special attention to the treatment strategy and outcomes, we presented a large series of 42 cases looking forward to share our understanding and experience in management of these patients. Male patients accounted for 71.4% of this series and were relatively younger (35.70±2.42 vs. 52.00±3.55 years, p=0.0011) and harbored bigger tumors (14.57 vs. 7.74 cm, p=0.0179) compared to females. Almost all of these tumors showed suprasellar extension (97.6%) and cavernous sinus invasion (92.9%). Dopamine agonist represented an efficient method to control PRL concentrations (98.8%) and reduce tumor burdens (81.2 %). PRL normalization was detected in 13 out of the 27 patients initially treated with bromocriptine (BRC) whereas none of the 14 patients with first-line operation gained a normalization of PRL concentration after surgery. Although there was no reliable predictor of tumor response, First PRL reduction was a predictive criterion for the nadir PRL level during the long-time period of follow-up for first-line bromocriptine treatment. In conclusion, patients with giant prolactinomas did not gain more benefits from initial surgery. Dopamine agonist (BRC) should be first-line treatment for giant prolactinomas whereas operation merely served as a remedy for acute compression symptoms and dopamine agonist resistance. Consecutive monitoring of serum PRL levels in the early stage of initial BRC treatment is useful for evaluation of therapeutic effect and further therapeutic decision.

Giant Prolactinoma Presenting With Facial Nerve Palsy and Hemiparesis

“…Giant prolactinoma can present with very high PRL level [ 6 , 7 , 9 ]. However, no consistent correlation has been reported between PRL level and tumor size [ 5 , 6 , 9 , 11 , 12 ].…”

“…Giant prolactinoma can present with very high PRL level [ 6 , 7 , 9 ]. However, no consistent correlation has been reported between PRL level and tumor size [ 5 , 6 , 9 , 11 , 12 ]. Dopamine agonists, including bromocriptine and CAB, are effective first-line therapy and generally well tolerated.…”

Could hormonal remission in prolactinomas be achieved with surgery? Our experience

“…It is known that DA affects the pituitary D2 receptors that inhibit the activity of adenylyl cyclase and, as a result, suppress gene transcription and prolactin secretion. However, DAs have a significant effect on other dopamine, serotonin androgenic receptors, which leads to severe neurological disorders such as postural hypotension or dyskinesia, psychosis, or mania, which provoke compulsive states [25][26][27]. Patients with pituitary microadenomas were offered for medication therapy for several years with a possible biochemical remission of 40-100 % [17], or EET surgery over the micro and macroprolactinomas (tumor should be removed in capsule).…”

Are dopamine agonists still the first-choice treatment for prolactinoma in the era of endoscopy? A systematic review and meta-analysis

“…The eligibility criteria consisted of the following items: (1) only studies that included patients who had been diagnosed with prolactinoma. Prolactinomas are classified by the size of the tumor as microprolactinoma (< 10 mm), macroprolactinoma (≥ 10 mm), and giant prolactinoma (> 40 mm) [ 13 ]; (2) required treatments included surgery (microscopic surgery or endoscopic surgery) or DAs (bromocriptine or cabergoline). Patients in the DAs group only received DAs, but patients in the surgery group may have received DAs before surgery; (3) included studies reported the data of at least one available outcome that was assessed in this study.…”