-
The Journal of Clinical Endocrinology... Aug 2023Prolactinomas are the most common pituitary tumor histotype, with microprolactinomas being prevalent in women and macroprolactinomas in men. Hyperprolactinemia is among... (Review)
Review
Prolactinomas are the most common pituitary tumor histotype, with microprolactinomas being prevalent in women and macroprolactinomas in men. Hyperprolactinemia is among the most common causes of hypogonadotropic hypogonadism in both sexes, prompting medical advice for hypogonadism (infertility, oligo-amenorrhea, impotence, osteoporosis/osteopenia) in both sexes, and for signs and symptoms of mass effects (hypopituitarism, visual loss, optic chiasm compression, cranial nerve deficits, headaches) predominantly in men. Diagnostic workup involves a single prolactin measurement and pituitary imaging, but some laboratory artifacts (ie, the "hook effect" and macroprolactin) can complicate or delay the diagnosis. The treatment of choice for prolactinomas is represented by dopamine agonists, mainly cabergoline, which are able to induce disease control, restore fertility in both sexes, and definitively cure one-third of patients, thus permitting treatment discontinuation. Pregnancy and menopause may promote spontaneous prolactin decline and anticipate cabergoline discontinuation in women. Surgery and/or radiotherapy are indicated in case of resistance to cabergoline not overcome by the increase in drug dose up to the maximally tolerated or the patient's personal choice of surgery. The evidence of resistance to cabergoline in invasive and proliferative tumors may indicate biological aggressiveness, thus requiring alternative therapeutic approaches mainly based on temozolomide use as monotherapy or combined with radiotherapy. In uncontrolled patients, new medical approaches (alternative hormonal treatments, cytotoxic drugs, peptide receptor radionuclide therapy, mTOR/Akt inhibitors, tyrosine kinase inhibitors, or immunotherapy) may be offered but the experience collected to date is still very scant. This article reviews different facets of prolactinomas and discusses approaches to the condition in more common clinical situations.
Topics: Male; Pregnancy; Humans; Female; Prolactinoma; Cabergoline; Prolactin; Ergolines; Pituitary Neoplasms; Dopamine Agonists; Hypogonadism
PubMed: 36974474
DOI: 10.1210/clinem/dgad174 -
Medicina (Kaunas, Lithuania) Aug 2022Prolactinomas are the commonest form of pituitary neuroendocrine tumor (PitNET), representing approximately half of such tumors. Dopamine agonists (DAs) have... (Review)
Review
Prolactinomas are the commonest form of pituitary neuroendocrine tumor (PitNET), representing approximately half of such tumors. Dopamine agonists (DAs) have traditionally been the primary treatment for the majority of prolactinomas, with surgery considered the second line. The aim of this review is to examine the historical and modern management of prolactinomas, including medical therapy with DAs, transsphenoidal surgery, and multimodality therapy for the treatment of aggressive prolactinomas and metastatic PitNETs, with an emphasis on the efficacy, safety, and future directions of current therapeutic modalities. DAs have been the mainstay of prolactinoma management since the 1970s, initially with bromocriptine and more recently with cabergoline. Cabergoline normalizes prolactin in up to 85% of patients and causes tumor shrinkage in up to 80%. Primary surgical resection of microprolactinomas and enclosed macroprolactinomas performed by experienced pituitary neurosurgeons have similar remission rates to cabergoline. Aggressive prolactinomas and metastatic PitNETS should receive multimodality therapy including high dose cabergoline, surgery, radiation therapy (preferably using stereotactic radiosurgery where suitable), and temozolomide. DAs remain a reliable mode of therapy for most prolactinomas but results from transsphenoidal surgery in expert hands have improved considerably over the last one to two decades. Surgery should be strongly considered as primary therapy, particularly in the setting of microprolactinomas, non-invasive macroprolactinomas, or prior to attempting pregnancy, and has an important role in the management of DA resistant and aggressive prolactinomas.
Topics: Bromocriptine; Cabergoline; Dopamine Agonists; Female; Humans; Pituitary Neoplasms; Pregnancy; Prolactinoma; Treatment Outcome
PubMed: 36013562
DOI: 10.3390/medicina58081095 -
Otolaryngologic Clinics of North America Apr 2022Prolactinomas are the most common secretory tumor of the pituitary gland. Clinical symptoms may be due to prolactin oversecretion, localized mass effect, or a... (Review)
Review
Prolactinomas are the most common secretory tumor of the pituitary gland. Clinical symptoms may be due to prolactin oversecretion, localized mass effect, or a combination of both. Although the mainstay of prolactinoma management is medical therapy with dopamine agonists, endoscopic endonasal or transcranial surgery, radiation therapy, or a combination of these is an important treatment option in select cases. This article discusses prolactinoma phenotypes, clinical presentations, and clinically pertinent medical and surgical considerations when managing these tumors.
Topics: Dopamine Agonists; Humans; Nose; Pituitary Neoplasms; Prolactin; Prolactinoma
PubMed: 35256169
DOI: 10.1016/j.otc.2021.12.005 -
Arquivos Brasileiros de Endocrinologia... Mar 2014Prolactinomas are the most common pituitary adenomas that affect young women at fertile age. Hyperprolactinemia causes hypogonadism, menstrual irregularities or... (Review)
Review
Prolactinomas are the most common pituitary adenomas that affect young women at fertile age. Hyperprolactinemia causes hypogonadism, menstrual irregularities or amenorrhea in women, low serum testosterone levels in men, and infertility and sexual dysfunction in both men and women. Macroprolactinomas may cause cephalea, visual disturbance, and hypopituitarism. Clinical treatment with dopamine agonists is the gold standard, with cabergoline as the first choice due to its greater efficiency and tolerability. In about 20% of the cases, treatment is partially or completely ineffective, a situation in which surgery, in general by transsphenoidal route, is indicated. Radiotherapy is indicated only in the control of tumor growth in invasive/aggressive cases. In invasive macroprolactinoma, the necessary approach, in general, is the combination of several therapeutic modalities, including debulking and recently-approved drugs, such as temozolamide. As for pregnancy, the drug of choice to induce ovulation still is bromocriptine. In the cases of microprolactinomas and intrasselar macroprolactinomas, the treatment with dopaminergic agonists may be suspended after pregnancy is confirmed. In macroprolactinomas, management should be individualized.
Topics: Dopamine Agonists; Female; Fertility; Humans; Hyperprolactinemia; Male; Pituitary Neoplasms; Pregnancy; Prolactin; Prolactinoma
PubMed: 24830588
DOI: 10.1590/0004-2730000002961 -
Best Practice & Research. Clinical... Dec 2011Prolactinomas commonly cause infertility and treatment usually restores ovulation and fertility. The dopamine agonists are the preferred mode of treatment, with... (Review)
Review
Prolactinomas commonly cause infertility and treatment usually restores ovulation and fertility. The dopamine agonists are the preferred mode of treatment, with cabergoline generally being preferred to bromocriptine because of its higher therapeutic ratio. Experience with both drugs shows no increase in spontaneous abortions, preterm deliveries, multiple births, or congenital malformations, compared to what is expected in the normal population but the experience with bromocriptine is approximately 10-fold greater than with cabergoline. Clinically significant tumor growth may occur in 2.7% of those with microadenomas, 22.9% in those with macroadenomas without prior ablative treatment and 4.8% of those with macroadenomas with prior ablative treatment. Patients with macroadenomas should have visual fields assessed periodically during gestation. Should symptomatic tumor growth occur, reinstitution of the dopamine agonist is usually successful in shrinking the tumor but delivery if the pregnancy is sufficiently advanced is also an option and transsphenoidal debulking is rarely necessary.
Topics: Bromocriptine; Cabergoline; Dopamine Agonists; Ergolines; Female; Fetus; Humans; Hyperprolactinemia; Infertility, Female; Pregnancy; Pregnancy Complications, Neoplastic; Prolactinoma
PubMed: 22115164
DOI: 10.1016/j.beem.2011.05.011 -
Handbook of Clinical Neurology 2014Prolactinomas are the most frequent pituitary adenomas. In patients with prolactinomas the primary cause of hyperprolactinemia is excessive and autonomic production of... (Review)
Review
Prolactinomas are the most frequent pituitary adenomas. In patients with prolactinomas the primary cause of hyperprolactinemia is excessive and autonomic production of prolactin by lactotroph cells. In other conditions, except in case of macroprolactinemia, hyperprolactinemia is secondary to circumstances that stimulate secretion of prolactin by intrinsically normal lactotroph cells, or, rarely, that are the result of decreased clearance of prolactin. In general, cabergoline is the preferred treatment for micro- and macroprolactinomas, because it is more effective with respect to normalization of prolactin levels and reduction of prolactinoma size and because it has fewer side-effects compared to bromocriptine. Recently, it has been suggested that a standardized, individualized, stepwise, dose-escalating regimen of cabergoline may normalize prolactin levels and reduce prolactinoma size in patients who were otherwise considered to be dopamine agonist resistant. In general, the cardiac adverse effects of dopamine agonists reported in Parkinson's disease are not of clinical concern in the treatment of prolactinomas, which are treated with much lower doses. Nonetheless, there is uncertainty with respect to the dose and duration of cabergoline treatment, which requires echocardiographic follow-up. Although withdrawal of dopamine agonists may be considered in patients with prolactinomas well controlled by dopamine agonists, especially in postmenopausal women, recurrence of signs and symptoms may occur in a considerable portion of patients.
Topics: Animals; Dopamine Agonists; Female; Humans; Hyperprolactinemia; Pituitary Neoplasms; Prolactin; Prolactinoma
PubMed: 25248588
DOI: 10.1016/B978-0-444-59602-4.00013-7 -
JAMA Apr 2023Pituitary adenomas are neoplasms of the pituitary adenohypophyseal cell lineage and include functioning tumors, characterized by the secretion of pituitary hormones, and... (Review)
Review
IMPORTANCE
Pituitary adenomas are neoplasms of the pituitary adenohypophyseal cell lineage and include functioning tumors, characterized by the secretion of pituitary hormones, and nonfunctioning tumors. Clinically evident pituitary adenomas occur in approximately 1 in 1100 persons.
OBSERVATIONS
Pituitary adenomas are classified as either macroadenomas (≥10 mm) (48% of tumors) or microadenomas (<10 mm). Macroadenomas may cause mass effect, such as visual field defects, headache, and/or hypopituitarism, which occur in about 18% to 78%, 17% to 75%, and 34% to 89% of patients, respectively. Thirty percent of pituitary adenomas are nonfunctioning adenomas, which do not produce hormones. Functioning tumors are those that produce an excess of normally produced hormones and include prolactinomas, somatotropinomas, corticotropinomas, and thyrotropinomas, which produce prolactin, growth hormone, corticotropin, and thyrotropin, respectively. Approximately 53% of pituitary adenomas are prolactinomas, which can cause hypogonadism, infertility, and/or galactorrhea. Twelve percent are somatotropinomas, which cause acromegaly in adults and gigantism in children, and 4% are corticotropinomas, which secrete corticotropin autonomously, resulting in hypercortisolemia and Cushing disease. All patients with pituitary tumors require endocrine evaluation for hormone hypersecretion. Patients with macroadenomas additionally require evaluation for hypopituitarism, and patients with tumors compressing the optic chiasm should be referred to an ophthalmologist for formal visual field testing. For those requiring treatment, first-line therapy is usually transsphenoidal pituitary surgery, except for prolactinomas, for which medical therapy, either bromocriptine or cabergoline, is usually first line.
CONCLUSIONS AND RELEVANCE
Clinically manifest pituitary adenomas affect approximately 1 in 1100 people and can be complicated by syndromes of hormone excess as well as visual field defects and hypopituitarism from mass effect in larger tumors. First-line therapy for prolactinomas consists of bromocriptine or cabergoline, and transsphenoidal pituitary surgery is first-line therapy for other pituitary adenomas requiring treatment.
Topics: Adult; Child; Female; Humans; Pregnancy; Adenoma; Adrenocorticotropic Hormone; Bromocriptine; Cabergoline; Human Growth Hormone; Hypopituitarism; Pituitary Neoplasms; Prolactinoma
PubMed: 37097352
DOI: 10.1001/jama.2023.5444 -
British Journal of Neurosurgery Oct 2023Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with... (Review)
Review
BACKGROUND
Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with dopamine agonists. Locally invasive prolactinomas may create CSF fistulae through formation of dural and osseous skull base defects. Tumor shrinkage secondary to dopamine agonist therapy unmasks skull base defects, thus inducing CSF rhinorrhea. In these cases, repair of the leak may be achieved through collaborative surgical intervention by rhinologists and neurosurgeons. Multiple variables have been investigated as potential contributors to the risk of CSF rhinorrhea development in medically treated prolactinoma patients, with little consensus.
OBJECTIVE
The primary aim of our study was the characterization of risk factors for CSF rhinorrhea development following dopamine agonist treatment.
METHODS
A systematic review of the literature was conducted to identify cases of CSF rhinorrhea following dopamine agonist treatment of prolactinoma. The clinical history, radiographic findings and treatment outcomes are discussed.
RESULTS
Fifty-four patients with dopamine agonist-induced CSF rhinorrhea were identified across 23 articles published from 1979 to 2019. Description of diagnostic imaging [computed tomography (CT)/magnetic resonance imaging (MRI)] was not provided for 18/54 subjects. For the 36 cases that described prolactinoma appearance on CT or MRI, invasion of the cavernous sinuses was reported in 13 (36.1%) and invasion of the sphenoid sinus was reported in 18 (50%).
CONCLUSION
Based on our systematic review, we propose that CT findings of osseous erosion of the sella or the anterior skull base may predict dopamine agonist-induced CSF rhinorrhea. We recommend obtaining a thin-slice CT of the sinuses in cases with MRI evidence of sphenoid involvement.
Topics: Humans; Prolactinoma; Dopamine Agonists; Cerebrospinal Fluid Rhinorrhea; Pituitary Neoplasms; Treatment Outcome
PubMed: 33783287
DOI: 10.1080/02688697.2021.1903389 -
Przeglad Lekarski 2009Prolactin-secreting tumours (prolactinomas) are benign neoplasms constituting about 40 percent of all pituitary tumours. The incidence of these tumours varies with age... (Review)
Review
Prolactin-secreting tumours (prolactinomas) are benign neoplasms constituting about 40 percent of all pituitary tumours. The incidence of these tumours varies with age and sex, occurring most frequently in females between 20 and 40-years-old. The clinical symptoms of prolactinomas are menstrual dysfunction and galactorrhea in women and loss of libido and potency in men. Differential diagnosis of the disease should include the intake of various drugs, hypothyroidism, renal failure, liver cirrhosis, compression of the pituitary stalk by other pathologies, idiopathic hyperprolactinemia and other types of pituitary adenomas. The aims of treatment are to restore or to achieve eugonadism through the normalisation of hyperprolactinemia and control of tumour mass. Because of the established effectiveness in the majority of cases and small number of acceptable adverse effects, dopamine agonists are considered the drugs of choice. Transsphenoidal surgery remains an option when medical therapy is neither effective nor well tolerated. The authors review the diagnosis and management of prolactinomas, including progress made in recent years.
Topics: Adult; Age Distribution; Causality; Dopamine Agonists; Female; Humans; Iatrogenic Disease; Male; Pituitary Neoplasms; Pregnancy; Pregnancy Complications, Neoplastic; Prevalence; Prolactinoma; Sex Distribution; Young Adult
PubMed: 19708510
DOI: No ID Found -
Presse Medicale (Paris, France : 1983) Dec 2021Hyperprolactinemia, defined by a level of serum prolactin above the standard upper limit of normal range, is a common finding in clinical practice and prolactinomas are... (Review)
Review
Hyperprolactinemia, defined by a level of serum prolactin above the standard upper limit of normal range, is a common finding in clinical practice and prolactinomas are the main pathological cause. Prolactinomas lead to signs and symptoms of hormone oversecretion, such as galactorrhea and hypogonadism, as well as symptoms of mass effect, including visual impairment, headaches and intracranial hypertension. Diagnosis involves prolactin measurement and sellar imaging, but several pitfalls are involved in this evaluation, which may difficult the proper management. Treatment is medical in the majority of cases, consisting of dopamine agonists, which present high response rates, with a very favorable safety profile. Major adverse effects that should be monitored consist of cardiac valvulopathy and impulse control disorders. Other treatment options include surgery and radiotherapy. Temozolomide may be used for aggressive or malignant carcinomas. Finally, pregnancy outcomes are similar to general population even when dopamine agonist treatment is maintained.
Topics: Antineoplastic Agents, Alkylating; Disruptive, Impulse Control, and Conduct Disorders; Dopamine Agonists; Female; Galactorrhea; Humans; Hyperprolactinemia; Hypogonadism; Pituitary Neoplasms; Pregnancy; Prolactin; Prolactinoma; Sella Turcica; Temozolomide
PubMed: 34687915
DOI: 10.1016/j.lpm.2021.104080