Prolactin-secreting pituitary adenomas compromise more than 50% of all hypophyseal
adenomas. The typical clinical manifestations in women are amenorrhea with lactorrhea.
Men suffer most often from decreased libido, gynecomastia, and obesity. The treatment
is still challenging due to the need of reproductive function return in addition to
tumor growth control.
It has been more than a century since prolactin-secreting pituitary adenomas are treated
surgically. Overall, surgery was the only effective method of treatment during this
period of time. Radiotherapy did not show enough efficacy as the main method of treatment
and was abandoned consequently.
The introduction of dopamine agonists was revolutionary, and the era of conservative
treatment of prolactin-secreting adenomas (PSA) started in the 1970s. The thoughts
about exclusively conservative treatment began to spread. However, the analysis of
clinical data did not meet those expectations, and even cabergoline showed efficacy
rate up to 70%.[1] In addition, approximately 15% of patients experienced dopamine agonists’ intolerance,
making its application not universal. The next issue is the recurrence following dopamine
agonists’ withdrawal.[2] This creates the tendency for lifelong drug taking. Hyperprolactinemia restoration
is reported in 55% of cases after pharmacy abolishment. It is worth mentioning the
side effects that are well seen during the follow-up period and even better described
in “internet forums” created by patients themselves.
Also, the misdiagnosis of truly secreting prolactinomas and adenomas, which create
secondary hyperprolactinemia cause obstacles for their effective treatment: last mentioned
are not sensitive for conservative treatment.
In recent decades, a technique of transsphenoidal microsurgical as well as endoscopic
removal of pituitary adenomas has developed rapidly. The level of surgical complications
decreased to 0.1%. In relation to noninvasive forms of tumors, the efficacy exceeded
the conservative method, and the result is reached almost immediately after surgery.[3]
From the financial point of view, expenses for time-consuming cabergoline are higher
than surgical treatment.
According to recent data, less than 10% of prolactinomas are treated surgically. These
are patients who are intolerant to cabergoline, did not gain significant effect by
conservative treatment, or choose surgery by themselves. We claim that endocrinological
remission could be reached in 50% of all patients and in more than 70% of noninvasive
purely endosellar cases. A marked tendency for worse outcome of pituitary adenomas’
excision is seen in patients who were previously treated with dopamine agonists.[4]
According to gained clinical data and notable controversies, treatment algorithm should
be reviewed, and surgical indications should be extended. Atleast patients, must be
better informed about all treatment options for prolactinoma and their related efficiency
potential.
