Role of Surgery in Treating Prolactinoma

Background: Prolactin-secreting pituitary adenomas—prolactinomas account for approximately 30% of all pituitary adenomas and 50 to 60% of functional pituitary tumors. Clinical manifestations are infertility, gonadal and sexual dysfunction in both sexes. In clinical practice, macroprolactinomas are less common than microprolactinomas, and occur more often in men than in women. The objectives for treatment of hyperprolactinemia are to suppress excessive hormone secretion, preserve residual pituitary function, and prevent disease recurrence. Medical therapy with dopamine agonists (DA) is the primary treatment of choice in most cases. Medical therapy is effective in normalizing prolactin levels in more than 90% of patients. Classical surgical indications are intolerance or lack of efficiency of DA, marked visual affection or pituitary appoplexy. Objective: The aim of this study was to analyze outcomes of patients with a prolactinoma treated surgically, to identify factors associated with remission and relapse, and to evaluate if surgical debulking allows for better hormonal control in patients with preoperative resistance to dopamine agonists (DAs). Patients Methods: This is a retrospective study of thirty cases operated upon for prolactinomas, all their data were reviewed including clinical presentation, preoperative and postoperative prolactin levels, preoperative and postoperative magnetic resonance imaging (MRI), history of medical treatment if present, and indication of surgery in each patient. The outcome either clinical or laboratory was reviewed. Results: Surgery was indicated in patients with severe visual affection, those with apoplexy. In patients who received medical therapy intolerance to the medication was the leading cause then failure of medical therapy. Postoperative remission was obtained in 71.4% of microprolactinomas, 34% of noninvasive macroprolactinomas, and none of the invasive macroprolactinomas. Better remission rate was independently predicted by lower diagnostic prolactin (PRL) levels and by the lack of abnormal postoperative residual tissue,. In patients with preoperative DA resistance treated again after surgery, there was a significant reduction in prolactin levels and received a lower DA dose, and about half of the patients had prolactin normalization. Conclusion: Although the high success rates achieved with medical therapy in prolactinoma , surgery still plays role in those with marked visual affection , apoplexy or intolerance to medical therapy, normalization of prolactin can be achieved by surgery and in others who still have high prolactin medication can be used as adjuvant therapy but with lower doses tolerable for the patients..