Surgery as a first-line option for prolactinomas

ABSTRACT

Introduction

Treatment of prolactinomas with dopamine agonists has been the established first-line treatment option for many years, with surgery reserved for refractory cases or medication intolerance. This approach may not be the best option in many cases.

Areas covered

Review of the epidemiology, biology, and treatment options available for prolactinomas, including best available data on outcomes, costs, and morbidities for each therapy. These data are then used to propose a ‘surgery-first’ treatment approach for a subset of prolactinomas as an alternative to primary medical management.

Expert opinion

Based on the available data, there is a strong rationale that transsphenoidal surgery should be considered a first-line treatment option for both micro- and macro-prolactinomas that do not demonstrate high grade cavernous sinus invasion on MRI imaging, with dopamine agonists administered as a secondary therapy for tumors not in remission following surgery, and for giant tumors. This ‘surgery-first’ approach assumes the availability of skilled and experienced pituitary surgeons to ensure optimal outcomes. This approach should result in high cure rates and reduced DA requirements for patients not cured from initial surgery. Further, it will reduce medical costs over a patient’s lifetime and the chronic morbidities associated with protracted dopamine agonist usage.

KEYWORDS:

• Prolactin
• prolactinoma
• transsphenoidal surgery
• dopamine agonist
• cabergoline
• bromocriptine
• side effects
• cost
• knosp grade
• cavernous sinus

Article highlights

• Dopamine agonists are established first-line therapy for the treatment of prolactinomas

• Prolactin levels are normalized in 73–96% of patients with treated with dopamine agonists, and tumor shrinkage is observed in 47–97%

• Long term dopamine agonist withdrawal after prolactin normalization is accomplished in only 16–21% of patients, often leading to protracted or even life-long use.

• Transsphenoidal surgical cure rates for microadenomas range from approximately 65–93% (up to 100% in some reports), and for macroadenomas approximately 45–60%, with patients in both groups who were not cured requiring less DA to achieve long-term remission.

• Transsphenoidal surgery for prolactinoma is very safe, with new hormonal deficiencies reported in less than 3% of patients, and major morbidity and mortality below 1%.

• Extent of cavernous sinus invasion, not tumor size, is the single most important independent primary predictor of surgical remission, with high rates of remission in tumors with low grade cavernous sinus invasion.

• Transsphenoidal surgery may be a more cost effective, easier, and equally effective treatment for prolactinomas without cavernous sinus invasion. It should be considered a first-line treatment in appropriate situations and when expert pituitary surgery is available.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.