Surgical outcomes of medically failed prolactinomas: a systematic review and meta-analysis

Yagnik, Karan J.; Erickson, Dana; Bancos, Irina; Atkinson, John L.D.; Choby, Garret; Peris-Celda, María; Gompel, Jamie J. Van

doi:10.1007/s11102-021-01188-7

Cited by 14 publications

(19 citation statements)

References 40 publications

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“…Additionally, complications such as diabetes insipidus are more frequent as a postoperative complication in patients pre-treated pharmacologically [ 7 ]. However, surgical debulking of lactotroph adenoma may improve hormonal control with normalisation of PRL levels with lower postoperative doses of DAs [ 16 , 26 ]. In a retrospective study on 94 patients with DA-resistant prolactinomas who underwent transsphenoidal surgery, 21% of the patients achieved dosage reduction after surgery for macroprolactinomas and 19% for microprolactinomas [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

Dopamine Agonist-Resistant Microprolactinoma—Mechanisms, Predictors and Management: A Case Report and Literature Review

Szmygin

Szydełko

Matyjaszek‐Matuszek

2022

JCM

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Objective: Prolactinomas are the most common type of functional, hormone-secreting pituitary adenomas that account for about 40% of total pituitary adenomas. Typical clinical presentations include loss of menstrual periods (amenorrhea) and galactorrhoea in women and sexual dysfunction in men. Prolactinomas are preferentially treated with dopamine agonists and respond to such therapy with hormonal normalisation and tumour shrinkage. However, about 10–20% of prolactinomas are resistant to dopamine agonists. The management of dopamine agonist-resistant prolactinomas poses a therapeutic challenge and includes several possible approaches. Design and Methods: In this study, we present a case report of a woman diagnosed with microprolactinoma at the age of 27 who did not fully respond either to treatment with dopamine agonists nor to transsphenoidal surgery. This was followed by a review of literature on the current state of knowledge about the mechanisms, predictors, and management of dopamine agonist-resistant prolactinomas on the basis of recent scientific literature published up to November 2021 and searches of the PubMed, Google Scholar, and Web of Science databases. Results and Conclusions: The exact mechanisms underlying dopamine agonists’ resistance in lactotroph tumours are not fully understood, yet refractory prolactinomas pose a great challenge in everyday clinical practice. Several predictive factors that contribute to poor response to medical treatment have been identified, among them the elevated Ki-67 index. Recently, various alternative medical treatments have been considered, but their usefulness remains to be evaluated. A return of menses can serve as a first clinical indication of successful medical treatment.

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Section: Discussionmentioning

confidence: 99%

Dopamine Agonist-Resistant Microprolactinoma—Mechanisms, Predictors and Management: A Case Report and Literature Review

Szmygin

Szydełko

Matyjaszek‐Matuszek

2022

JCM

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“…These findings have been endorsed in several systematic reviews and meta-analyses, which have reported TSS to deliver superior clinical outcomes compared to dopamine agonist therapy [ 19 , 20 , 63 ], with superior cost-effectiveness, although the absence of any randomised trials remains a major limitation [ 19 ]. Interestingly, one systematic review specifically investigated prolactinoma patients undergoing surgery because of resistance or intolerance to dopamine agonists, or patient preference, and reported that 38% achieved sustained remission without further treatment (66% of microprolactinomas, 22% of macroprolactinomas), while 62% achieved remission with adjunctive dopamine agonist therapy [ 64 ].…”

Section: Discussionmentioning

confidence: 99%

11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy

et al. 2022

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Purpose To assess the potential for 11C-methionine PET (Met-PET) coregistered with volumetric magnetic resonance imaging (Met-PET/MRCR) to inform clinical decision making in patients with poorly visualized or occult microprolactinomas and dopamine agonist intolerance or resistance. Patients and methods Thirteen patients with pituitary microprolactinomas, and who were intolerant (n = 11) or resistant (n = 2) to dopamine agonist therapy, were referred to our specialist pituitary centre for Met-PET/MRCR between 2016 and 2020. All patients had persistent hyperprolactinemia and were being considered for surgical intervention, but standard clinical MRI had shown either no visible adenoma or equivocal appearances. Results In all 13 patients Met-PET/MRCR demonstrated a single focus of avid tracer uptake. This was localized either to the right or left side of the sella in 12 subjects. In one patient, who had previously undergone surgery for a left-sided adenoma, recurrent tumor was unexpectedly identified in the left cavernous sinus. Five patients underwent endoscopic transsphenoidal selective adenomectomy, with subsequent complete remission of hyperprolactinaemia and normalization of other pituitary function; three patients are awaiting surgery. In the patient with inoperable cavernous sinus disease PET-guided stereotactic radiosurgery (SRS) was performed with subsequent near-normalization of serum prolactin. Two patients elected for a further trial of medical therapy, while two declined surgery or radiotherapy and chose to remain off medical treatment. Conclusions In patients with dopamine agonist intolerance or resistance, and indeterminate pituitary MRI, molecular (functional) imaging with Met-PET/MRCR can allow precise localization of a microprolactinoma to facilitate selective surgical adenomectomy or SRS.

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“…These findings have been endorsed in several systematic reviews and meta-analyses, which have reported TSS to deliver superior clinical outcomes compared to dopamine agonist therapy [19,20,63], with superior costeffectiveness, although the absence of any randomised trials remains a major limitation [19]. Interestingly, one systematic review specifically investigated prolactinoma patients undergoing surgery because of resistance or intolerance to dopamine agonists, or patient preference, and reported that 38% achieved sustained remission without further treatment (66% of microprolactinomas, 22% of macroprolactinomas), while 62% achieved remission with adjunctive dopamine agonist therapy [64].…”

Section: Discussionmentioning

confidence: 99%

11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy

Bashari

Meulen

MacFarlane

et al. 2022

Preprint

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Purpose To assess the potential for 11C-methionine PET (Met-PET) coregistered with volumetric magnetic resonance imaging (Met-PET/MRCR) to inform clinical decision making in patients with poorly visualized or occult microprolactinomas and dopamine agonist intolerance or resistance. Patients and methods: Thirteen patients with pituitary microprolactinomas, and who were intolerant (n = 11) or resistant (n = 2) to dopamine agonist therapy, were referred to our specialist pituitary centre for Met-PET/MRCR between 2016 and 2020. All patients had persistent hyperprolactinaemia and were being considered for surgical intervention, but standard clinical MRI had shown either no visible adenoma or equivocal appearances. Results In all 13 patients Met-PET/MRCR demonstrated a single focus of avid tracer uptake. This was localized either to the right or left side of the sella in 12 subjects. In one patient, who had previously undergone surgery for a left-sided adenoma, recurrent tumor was unexpectedly identified in the left cavernous sinus. Five patients underwent endoscopic transsphenoidal selective adenomectomy, with subsequent complete remission of hyperprolactinaemia and normalization of other pituitary function; three patients are awaiting surgery. In the patient with inoperable cavernous sinus disease PET-guided stereotactic radiosurgery (SRS) was performed with subsequent near-normalization of serum prolactin. Two patients elected for a further trial of medical therapy, while two declined surgery or radiotherapy and chose to remain off medical treatment. Conclusions In patients with dopamine agonist intolerance or resistance, and indeterminate pituitary MRI, molecular (functional) imaging with Met-PET/MRCR can allow precise localization of a microprolactinoma to facilitate selective surgical adenomectomy or SRS.

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Surgical outcomes of medically failed prolactinomas: a systematic review and meta-analysis

Cited by 14 publications

References 40 publications

Dopamine Agonist-Resistant Microprolactinoma—Mechanisms, Predictors and Management: A Case Report and Literature Review

Dopamine Agonist-Resistant Microprolactinoma—Mechanisms, Predictors and Management: A Case Report and Literature Review

11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy

11C-methionine PET aids localization of microprolactinomas in patients with intolerance or resistance to dopamine agonist therapy

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