prolactinoma

Question 1

definition of prolactinoma

Answer 1

Prolactinomas are benign lactotroph adenomas expressing and secreting prolactin.

Question 2

classification of prolactinoma

Answer 2

micro:

• small intrasellar tumours, less than 10mm in diameter
• more common in women
• rarely increase in size

macro:

• more common in men and post menopausal women
• more than 10mm in diameter
• locally invasive into the suprasellar and parasellar regions
• usually benign

Question 3

signs and symptoms

Answer 3

• oligomenorrhea / amenorrhea
• galactorrhea
• gynaecomastia
• infertility
• reduced libido
• erectile dysfunction
• bitemporal hemianopia (in macro adenomas with suprasellar extension)
• osteoporosis (due to low testosterone/oestradiol levels)
• opthalmoplegia (due to cranial nerve palsy because of compression)
• headache (related to pituitary apoplexy)

Question 4

risk factors

Answer 4

female, 20-50 y/o

genetic predisposition (MEN1, familial isolated pituitary adenoma FIPA)
ostrogen therapy
male 30-60 y/o

Question 5

investigations

Answer 5

serum prolactin
MRI pituitary
computerised visual fields assessment

Question 6

treatment

Answer 6

men:

1. dopamine agonist (CABERGOLINE or BROMOCRIPTINE)
2. trans sphenoidal surgery
3. sellar radiotherapy

pre menopausal women, asymptomatic /post menopausal :

1. observe
2. dopamine agonist
3. trans sphenoidal surgery
4. sellar radiotherapy

symptomatic microprolactinomas who do not desire pregnancy

1. dopamine agonist
2. combined oral contraceptive
3. trans sphenoidal surgery
4. sellar radiotherapy

microprolactinomas who desire pregnancy, or macroprolactinomas

1. dopamine agonist
2. trans sphenoidal surgery
3. sellar radiotherapy

Question 7

complications

Answer 7

of prolactinoma:

• visual field impairment
• pituitary apoplexy
• CSF leakage (can also be due to treatment with high-dose dopamine)

of treatment:

• anterior pituitary failure and/or diabetes insipidus (due to trans sphenoidal surgery)
• hypopituitarism due to radiotherapy
• cabergoline associated valvular insufficiency

Question 8

prognosis

Answer 8

basically very good!

This benign disease follows a progressive improving course while medically treated. Since the introduction of bromocriptine in the 1970s into the treatment of prolactinomas, the course of this condition has changed and the prognosis improved. Today, even when large invasive macro-adenomas or giant prolactinomas are diagnosed with chiasmal compression and bilateral temporal hemianopia, continuous treatment with relatively large doses of dopamine agonists will result in prolactin normalisation, tumour shrinkage or disappearance, and rapid visual improvement.[31] In some patients, dopamine agonist treatment may be withdrawn after several years without tumour recurrence