Indications for Therapy and for Neurosurgery in Patients with Prolactinomas

In contrast to macroadenomas, for which therapy is routinely indicated, microadenomas do not always require treatment. For patients with microadenomas who do not have these indications, symptoms and prolactin levels can be monitored, and MRI can be used to follow the size of the tumor.
Indications for Therapy in Patients with Prolactinomas

• Macroadenoma
• Enlarging microadenoma
• Infertility
• Bothersome galactorrhea
• Gynecomastia
• Testosterone deficiency
• Oligomenorrhea or amenorrhea
• Acne and hirsutism

Given the efficacy of medical therapy, only a small minority of patients with prolactinomas require transsphenoidal surgery or radiation therapy. Surgical cure rates, which are highly dependent on surgical skill and tumor anatomy, approach 80 to 90% for microadenomas but are less than 50% for macroadenomas.
Indications for Neurosurgery in Patients with Prolactinomas

• Increasing tumor size despite optimal medical therapy
• Pituitary apoplexy
• Inability to tolerate dopamine agonist therapy
• Dopamine agonist–resistant macroadenoma
• Dopamine agonist–resistant microadenoma in a woman seeking fertility, if ovulation induction is not appropriate
• Persistent chiasmal compression despite optimal medical therapy
• Medically unresponsive cystic prolactinoma
• In women seeking fertility, macroadenoma in close proximity to optic chiasm despite optimal medical therapy (prepregnancy debulking recommended)
• Cerebrospinal fluid leak during administration of dopamine agonist
• Macroadenoma in a patient with a psychiatric condition for which dopamine agonists are contraindicated

References:

1. Klibanski A. Clinical practice. Prolactinomas. N Engl J Med. 2010 Apr 1;362(13):1219-26. [Medline]
2. Molitch ME. Medical management of prolactin-secreting pituitary adenomas. Pituitary. 2002;5(2):55-65.[Medline]