Bromocriptine treatment of invasive giant prolactinomas involving the cavernous sinus: results of a long-term follow up

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Object

The aim of this study was to observe long-term clinical outcomes in a group of patients treated with bromocriptine for invasive giant prolactinomas involving the cavernous sinus.

Methods

Data from 20 patients with invasive giant prolactinomas at the authors’ institutions between July 1997 and June 2004 were retrospectively reviewed. The criteria to qualify for study participation included: 1) tumor diameter greater than 4 cm, invading the cavernous sinus to an extent corresponding to Grade III or IV in the classification scheme of Knosp and colleagues; 2) serum prolactin (PRL) level greater than 200 ng/ml; and 3) clinical signs of hyperprolactinemia and mass effect. Among the 20 patients who met the criteria, six had undergone unsuccessful transcranial or transsphenoidal microsurgery prior to bromocriptine treatment and 14 patients received bromocriptine as the primary treatment. Eleven of the 20 patients underwent adjuvant radiotherapy.

After a mean follow-up period of 37.3 months, the clinical symptoms in all patients improved by different degrees. Tumor volume on magnetic resonance images was decreased by a mean of 93.3%. In 11 patients, the tumor had almost completely disappeared; in the other nine patients, residual tumor invaded the cavernous sinus. Visual symptoms improved in 13 of the patients who had presented with visual loss. Eight patients had normal PRL levels. The postoperative PRL level was more than 200 ng/ml in seven patients. During the course of drug administration, cerebrospinal fluid leakage occurred in one patient, who subsequently underwent transsphenoidal surgery. No case of apoplexy occurred during bromocriptine treatment.

Conclusions

Dopamine agonist medications are effective as a first-line therapy for invasive giant prolactinomas, because they can significantly shrink tumor volume and control the PRL level. Tumor mass vanishes in some patients after bromocriptine treatment; in other patients with localized residual tumor, stereotactic radiosurgery is a viable option so that unnecessary surgery can be avoided. The application of radiotherapy does not reliably shrink tumor volume.

Abbreviations used in this paper: CSF = cerebrospinal fluid; MR = magnetic resonance; PRL = prolactin.

Article Information

Address reprint requests to: Zhe Bao Wu, M.D., Department of Neurosurgery, First Affiliated Hospital of Wenzhou Medical College, Wenzhou 325000, People’s Republic of China. email: zhebaowu@yahoo.com.cn.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 2. Magnetic resonance images obtained in a 33- year-old man. A and B: The patient displayed a giant sellar tumor that extensively invaded the nasal cavity and skull base. He had undergone resection at another hospital to remove the nasal cavity tumor. Results of a postoperative pathological examination revealed an invasive pituitary tumor, and radiotherapy after patient discharge was suggested. One month later, after radiotherapy, the patient was admitted to our hospital. C and D: The tumor before bromocriptine treatment. E and F: Gadolinium-enhanced T1-weighted MR images obtained 16 months after initiating bromocriptine treatment. G and H: Gadolinium-enhanced T1-weighted MR images obtained 25 months after initiating bromocriptine treatment. The latter four images show a nearly total disappearance of the lesion, with only a residual tumor envelope. Recently, the PRL level in this patient was 205 ng/ml and he has continued to take 2.5 mg/day bromocriptine.

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    Case 18. A and B: Pretreatment T1-weighted MR images with Gd enhancement demonstrating a giant sellar tumor with suprasellar, sphenoidal sinus, clival, and parasellar extension. C and D: Gadolinium-enhanced T1-weighted MR images obtained 6 months after initiation of bromocriptine treatment, showing suprasellar and sphenoidal sinus lesion shrinkage, as well as residual tumor located in the bilateral cavernous sinus. E and F: Gadolinium- enhanced T1-weighted MR images obtained 13 months after initiation of bromocriptine treatment, demonstrating a near total disappearance of tumor despite a PRL level of 258 ng/ml.

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    Case 17. A–C: Pretreatment T1-weighted MR images with Gd enhancement demonstrating a giant sellar lesion with suprasellar, sphenoidal sinus, clival, and parasellar extension. D: A T1-weighted unenhanced MR image obtained 2 months after initiation of bromocriptine treatment together with adjuvant radiotherapy, demonstrating obvious shrinkage of a suprasellar tumor. E and F: Gadolinium-enhanced T1-weighted MR images obtained 11 months after initiation of bromocriptine treatment, showing a small residual tumor mainly located in the bilateral cavernous sinus.

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    Case 16. A: Pretreatment T1-weighted MR image with Gd enhancement showing a giant tumor with obvious right cavernous sinus extension. B–D: Three T1-weighted MR images obtained 12, 28, and 40 months after initiation of bromocriptine treatment, respectively, demonstrating obvious shrinkage (76%) of a giant tumor. Residual tumor existed mainly in the right cavernous sinus.

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