THERAPY OF ENDOCRINE DISEASE: Surgery in microprolactinomas: effectiveness and risks based on contemporary literature

Abstract

Microprolactinomas are the most common pituitary adenomas. In symptomatic patients, dopamine agonists are the first-line treatment of choice; when cabergoline is used, biochemical control rates between 85 and 93% have been reported. Long-term treatment is needed in most of the cases with compliance, patient convenience, and potential adverse effects representing areas requiring attention. Based on the literature published in the past 15 years, transsphenoidal surgery can lead to normal prolactin in the postoperative period in usually 71 -100% of the cases with very low postoperative complication rates. Surgical expertise is the major determinant of the outcomes, and it may be a cost-effective option in young patients with life expectancy greater than 10 years (provided it is performed by experienced surgeons at high volume centers with confirmed optimal outcomes). Larger series of patients with adequate follow-up could further validate the place of transsphenoidal surgery (particularly through the endoscopic approach for which long-term results are currently limited) in the management algorithm of patients with microprolactinoma. 175:3R89-R96 M Tampourlou and others Surgery for microprolactinomas

Hyperprolactinaemia

“…Surgery could be considered for prolactinomas where maximum doses of DA are not effective or tolerated, for those presenting with pituitary apoplexy with visual deterioration, when there are cystic tumour components compressing the visual pathway, or if cerebrospinal fluid leak develops [25,43,110,111,113]. Surgery may also be an option for young patients with microprolactinoma, as this may be a more cost-effective approach compared with lifelong DA therapy [114]. Rates of post-operative remission are widely variable across the literature, and are reported 38 to 100% for microprolactinomas and 7 to 80 % for macroprolactinomas [115]; lower rates of remission are described in tumours with cavernous sinus invasion [111,116].…”

“…Rates of post-operative remission are widely variable across the literature, and are reported 38 to 100% for microprolactinomas and 7 to 80 % for macroprolactinomas [115]; lower rates of remission are described in tumours with cavernous sinus invasion [111,116]. Higher success rates are seen in the hands of experienced pituitary surgeons [114]. DA resistant prolactinomas may show improved responsiveness to these agents following debulking surgery [110,111].…”

Males with prolactinoma are at increased risk of incident cardiovascular disease

“…First‐line treatment is dopamine agonists, with cabergoline achieving normal PRL in approximately 90% of microadenomas and 60%‐90% of macroadenomas. In cases of resistance or intolerance to medical treatment, surgery combined or not with radiotherapy are further options, with various success rates and complications …”

Comparison of Male and Female Prolactinoma Patients Requiring Surgical Intervention

“…Prolactinomas are the most common of all pituitary adenomas, accounting for 51 to 66% of these tumors. 1 Common presenting symptoms include headache, visual impairment, galactorrhea, and effects of hypogonadism including ame-norrhea, infertility, and erectile dysfunction. 2 Dopamineagonist therapy including cabergoline and bromocriptine are the first-line treatments for prolactinomas.…”

“…[4][5][6] Previous analyses have reported that up to 93% patients with prolactinomas achieve remission with surgery, with variability due to the extent of invasion and size of the tumor. 1,[7][8][9] Studies have noted some gender differences in prolactinomas. Hyperprolactinemia has been shown to be more common among women with the incidence varying with age.…”