Determinants of Surgical Remission in Prolactinomas: A Systematic Review and Meta-Analysis

Wright, Kyla; Chaker, Layal; Pacione, Donato; Sam, Keren; Feelders, Richard A; Xia, Yuhe; Agrawal, Nidhi

doi:10.1016/j.wneu.2021.07.035

Cited by 19 publications

(27 citation statements)

References 62 publications

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“…However, there has since been conflicting data as to whether surgical outcomes are worse for prolactinomas that have been pretreated with DAs ( Gillam et al 2006 ). A recent systematic review and meta-analysis of the determinants of surgical remission in prolactinomas found that DA pretreatment was associated with lower rates of postoperative remission ( Wright et al 2021 ). This could reflect DA-induced tumour fibrosis making surgical resection more difficult, although cabergoline is preferentially used over bromocriptine in current practice and cabergoline has not been associated with tumour fibrosis in recent data ( Baussart et al 2021 ).…”

Section: Risks Of Dopamine Agonist Therapymentioning

confidence: 99%

“…This could reflect DA-induced tumour fibrosis making surgical resection more difficult, although cabergoline is preferentially used over bromocriptine in current practice and cabergoline has not been associated with tumour fibrosis in recent data ( Baussart et al 2021 ). Alternatively, the need for DA treatment followed by surgery may reflect a greater proportion of DA-resistant, and hence more aggressive, prolactinomas ( Wright et al 2021 ).…”

Section: Risks Of Dopamine Agonist Therapymentioning

confidence: 99%

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Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

Sousa

2022

Endocrine Oncology

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The current treatment paradigm for prolactinomas involves dopamine agonist (DA) therapy as the first-line treatment, with surgical resection reserved for cases where there is DA failure due to resistance or intolerance. This review highlights how DA therapy can be optimised to overcome its increasingly recognised pitfalls, whilst also addressing the potential for expanding the use of surgery in the management of prolactinomas. The first part of the review discusses the limitations of DA therapy, namely: DA resistance; common DA side effects; and the rare but serious DA-induced risks of cardiac valvulopathy, impulse control disorders, psychosis, CSF rhinorrhoea and tumour fibrosis. The second part of the review explores the role of surgery in prolactinoma management with reference to its current second-line position and recent calls for surgery to be considered as an alternative first-line treatment alongside DA therapy. Randomised trials comparing medical versus surgical therapy for prolactinomas are currently underway. Pending these results, a low surgical threshold approach is herein proposed, whereby DA therapy remains the default treatment for prolactinomas unless there are specific triggers to consider surgery, including concern regarding DA side effects or risks in vulnerable patients, persistent and bothersome DA side effects, emergence of any serious risks of DA therapy, expected need for long-term DA therapy, as well as the traditional indications for surgery. This approach should optimise the use of DA therapy for those who will most benefit from it, whilst instituting surgery early in others in order to minimise the cumulative burden of prolonged DA therapy.

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Section: Risks Of Dopamine Agonist Therapymentioning

confidence: 99%

Section: Risks Of Dopamine Agonist Therapymentioning

confidence: 99%

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

Sousa

2022

Endocrine Oncology

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“…In a meta-analysis of 30 observational studies that followed 3152 patients with prolactinoma for a mean of 4.9 years, TSS was associated with normalization of prolactin levels in 69% of patients, while subsequent recurrence occurred in 18% after TSS . In another meta-analysis of 35 observational studies that included 3335 patients who underwent TSS for prolactinoma, normalization of prolactin levels was lower among patients with macroadenomas compared with those with microadenomas (pooled remission rate, 47.1% vs 76.4%; odds ratio, 0.20; 95% CI, 0.16-0.24) early postoperatively as well as at 1 year of follow-up (odds ratio, 0.11; 95% CI, 0.053-0.22) (absolute rates not available) . When an experienced neurosurgeon is available and the tumor location makes complete resection likely, TSS Is an alternative first-line option to medical therapy in patients with microprolactinomas.…”

Section: Treatmentmentioning

confidence: 99%

“…39 In another metaanalysis of 35 observational studies that included 3335 patients who underwent TSS for prolactinoma, normalization of prolactin levels was lower among patients with macroadenomas compared with those with microadenomas (pooled remission rate, 47.1% vs 76.4%; odds ratio, 0.20; 95% CI, 0.16-0.24) early postoperatively as well as at 1 year of follow-up (odds ratio, 0.11; 95% CI, 0.053-0.22) (absolute rates not available). 40 When an experienced neurosurgeon is available and the tumor location makes complete resection likely, TSS Is an alternative first-line option to medical therapy in patients with microprolactinomas. Pituitary surgery is first-line therapy in patients with acromegaly.…”

Section: Prolactinomamentioning

confidence: 99%

Diagnosis and Management of Pituitary Adenomas

Tritos

Miller

2023

JAMA

107

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ImportancePituitary 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.ObservationsPituitary adenomas are classified as either macroadenomas (≥10 mm) (48% of tumors) or microadenomas (&lt;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 RelevanceClinically 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.

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“…The overall postoperative and follow-up remission rates, having a median, mean follow-up period of 2.8 years using the random-effects model, were 0.62 and 0.61, respectively. The recurrence rate was 0.16 as assessed at a median follow-up period of 3.8 years [ 48 ]. The recurrence rate after surgery increased as the follow-up period increased [ 49 ].…”

Section: Surgical Treatmentmentioning

confidence: 99%

Update in Pathogenesis, Diagnosis, and Therapy of Prolactinoma

Fukuhara

Nishiyama

Iwasaki

2022

Cancers

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Prolactinomas comprise 30–50% of all pituitary neuroendocrine tumors, frequently occur in females aged 20 to 50, and cause hypogonadism and infertility. In typical cases, female patients exhibit galactorrhea and amenorrhea due to serum prolactin (PRL) elevation, and patients during pregnancy should be carefully treated. During diagnosis, other causes of hyperprolactinemia must be excluded, and an MRI is useful for detecting pituitary neuroendocrine tumors. For treating prolactinoma, dopamine agonists (DAs) are effective for decreasing PRL levels and shrinking tumor size in most patients. Some DA-resistant cases and the molecular mechanisms of resistance to a DA are partially clarified. The side effects of a DA include cardiac valve alterations and impulse control disorders. Although surgical therapies are invasive, recent analysis shows that long-term remission rates are higher than from medical therapies. The treatments for giant or malignant prolactinomas are challenging, and the combination of medication, surgery, and radiation therapy should be considered. Regarding pathogenesis, somatic SF3B1 mutations were recently identified even though molecular mechanisms in most cases of prolactinoma have not been elucidated. To understand the pathogenesis of prolactinomas, the development of new therapeutic approaches for treatment-resistant patients is expected. This review updates the recent advances in understanding the pathogenesis, diagnosis, and therapy of prolactinoma.

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Determinants of Surgical Remission in Prolactinomas: A Systematic Review and Meta-Analysis

Cited by 19 publications

References 62 publications

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

Diagnosis and Management of Pituitary Adenomas

Update in Pathogenesis, Diagnosis, and Therapy of Prolactinoma

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