Giant prolactinomas: clinical management and long-term follow up

Restricted access

Object. Giant prolactinomas are rare tumors whose treatment and outcome has only been addressed in isolated case reports. The authors document the long-term follow-up findings and clinical outcome in a group of patients with giant prolactinomas.

Methods. This study is a retrospective chart and clinical review of more than 2000 cases of pituitary tumors treated at the authors' institution, of which 10 met the criteria for inclusion (prolactin level > 1000 ng/ml, diameter > 4 cm on neuroimaging studies, and clinical signs of hyperprolactinemia/mass effect). The average follow-up duration was 6.7 years after initial treatment with either bromocriptine or transsphenoidal resection. In more than 90% of the patients in this series the disease was controlled by medical treatment with bromocriptine alone; the other 10% required early surgery via transsphenoidal resection. All patients had improvement in visual symptoms. All tumors had extrasellar components, five of which exhibited frank invasion of the cavernous sinus. Tumor volume on magnetic resonance imaging was decreased on average by 69%; this occurred at a faster rate and in larger amounts when treated with bromocriptine than has been reported in the literature for macroprolactinomas.

Conclusions. According to long-term follow-up findings, giant prolactinomas are exquisitely responsive to dopamine agonist therapy. In giant prolactinomas the prolactin level does not correlate with size. The main indication for early surgery is intratumoral hematoma, whereas our main indications for late surgery are cerebrospinal fluid leakage caused by medical treatment, or an increasing prolactin level despite medical therapy. Checking prolactin levels in suspicious sellar and/or suprasellar lesions may be diagnostic and prevent unnecessary surgery.

Article Information

Address reprint requests to: Raj K. Shrivastava, M.D., Department of Neurosurgery, Mount Sinai Medical Center, New York, New York 10029. email: rkshrivastava@aol.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Schematic representations of formal Goldmann perimetry studies showing pre- and posttreatment visual fields in all patients. OD = oculus dexter; OS = oculus sinister.

  • View in gallery

    Case 7. Upper Left: Pretreatment sagittal T1-weighted MR image with gadolinium enhancement, demonstrating a giant sellar tumor with suprasellar extension. Upper Center: Coronal T1-weighted MR image with gadolinium enhancement, demonstrating the same giant sellar tumor; the pretreatment volume was 252 cm3. Upper Right: Sagittal T1-weighted MR image with gadolinium enhancement obtained 4 months after initiation of bromocriptine treatment, demonstrating significant chiasmal decompression. Lower Left: Coronal T1-weighted MR image with gadolinium enhancement obtained 4 months after initiation of bromocriptine treatment, demonstrating an 81% reduction in tumor volume with decreased suprasellar extension. Lower Right: Coronal T1-weighted MR image with gadolinium enhancement obtained 1 year after initiation of bromocriptine treatment, demonstrating an 81% reduction in tumor volume.

  • View in gallery

    Case 9. Left: Pretreatment coronal T1-weighted MR image with gadolinium enhancement, demonstrating a giant sellar tumor extending into the left sylvian fissure with a cystic component. Center: Sagittal T1-weighted MR image with gadolinium enhancement; the pretreatment volume was 378 cm3. Right: Coronal T1-weighted MR image with gadolinium enhancement obtained 1 year after initiation of bromocriptine treatment, demonstrating a 63% reduction in tumor volume.

  • View in gallery

    Case 8. Coronal T1-weighted MR image with gadolinium enhancement, demonstrating pretreatment intratumoral hematoma.

  • View in gallery

    Case 4. Pretreatment CT scan bone window through the skull base, demonstrating extensive erosion.

References

1.

Al-Mefty OWoodhouse N: Microprolactinoma and large prolactinoma: are they two different diseases. Neurosurgery 17:3791985Al-Mefty O Woodhouse N: Microprolactinoma and large prolactinoma: are they two different diseases. Neurosurgery 17:379 1985

2.

Amar APHinton DRKrieger MDet al: Invasive pituitary adenomas: significance of proliferation parameters. Pituitary 2:1171221999Amar AP Hinton DR Krieger MD et al: Invasive pituitary adenomas: significance of proliferation parameters. Pituitary 2:117–122 1999

3.

Arguello CBlevins LS: Prolactinomas: diagnosis and management. Contemp Neurosurg 17:161995Arguello C Blevins LS: Prolactinomas: diagnosis and management. Contemp Neurosurg 17:1–6 1995

4.

Bakay L: The results of 300 pituitary adenoma operations (Prof. Herbert Olivecrona's series). J Neurosurg 7:2402551950Bakay L: The results of 300 pituitary adenoma operations (Prof. Herbert Olivecrona's series). J Neurosurg 7:240–255 1950

5.

Barkan ALChandler WF: Giant pituitary prolactinoma with falsely low serum prolactin: the pitfall of the “high-dose hook effect”: case report. Neurosurgery 42:9139161998Barkan AL Chandler WF: Giant pituitary prolactinoma with falsely low serum prolactin: the pitfall of the “high-dose hook effect”: case report. Neurosurgery 42:913–916 1998

6.

Barrow DLMizuno JTindall GT: Management of prolactinomas associated with very high serum prolactin levels. J Neurosurg 68:5545581988Barrow DL Mizuno J Tindall GT: Management of prolactinomas associated with very high serum prolactin levels. J Neurosurg 68:554–558 1988

7.

Beckers APetrossians PAbs Ret al: Treatment of macroprolactinomas with the long-acting and repeatable form of bromocriptine: a report of 29 cases. J Clin Endocrinol Metab 75:2752801992Beckers A Petrossians P Abs R et al: Treatment of macroprolactinomas with the long-acting and repeatable form of bromocriptine: a report of 29 cases. J Clin Endocrinol Metab 75:275–280 1992

8.

Brisman MHKatz GPost KD: Symptoms of pituitary apoplexy rapidly reversed with bromocriptine. Case report. J Neurosurg 85:115311551996Brisman MH Katz G Post KD: Symptoms of pituitary apoplexy rapidly reversed with bromocriptine. Case report. J Neurosurg 85:1153–1155 1996

9.

Chiodini PLiuzzi ACozzi Ret al: Size reduction of macroprolactinomas by bromocriptine or lisuride treatment. J Clin Endocrinol Metab 53:7377431981Chiodini P Liuzzi A Cozzi R et al: Size reduction of macroprolactinomas by bromocriptine or lisuride treatment. J Clin Endocrinol Metab 53:737–743 1981

10.

Colao AAnnunziato LLombardi G: Treatment of prolactinomas. Ann Med 30:4524591998Colao A Annunziato L Lombardi G: Treatment of prolactinomas. Ann Med 30:452–459 1998

11.

Cook RJUttley DWilkins PRet al: Prolactinomas in men masquerading as invasive skull base tumours. Br J Neurosurg 8:51551994Cook RJ Uttley D Wilkins PR et al: Prolactinomas in men masquerading as invasive skull base tumours. Br J Neurosurg 8:51–55 1994

12.

Delgrange ETrouillas JMaiter Det al: Sex-related difference in the growth of prolactinomas: a clinical and proliferation marker study. J Clin Endocrinol Metab 82:210221071997Delgrange E Trouillas J Maiter D et al: Sex-related difference in the growth of prolactinomas: a clinical and proliferation marker study. J Clin Endocrinol Metab 82:2102–2107 1997

13.

Dolenc VV: Transcranial epidural approach to pituitary tumors extending beyond the sella. Neurosurgery 41:5425521997Dolenc VV: Transcranial epidural approach to pituitary tumors extending beyond the sella. Neurosurgery 41:542–552 1997

14.

Fahlbusch RBuchfelder M: Present status of neurosurgery in the treatment of prolactinomas. Neurosurg Rev 8:1952051985Fahlbusch R Buchfelder M: Present status of neurosurgery in the treatment of prolactinomas. Neurosurg Rev 8:195–205 1985

15.

Freda PUAndreadis CIKhandji AGet al: Long-term treatment of prolactin-secreting macroadenomas with pergolide. J Clin Endocrinol Metab 85:8132000Freda PU Andreadis CI Khandji AG et al: Long-term treatment of prolactin-secreting macroadenomas with pergolide. J Clin Endocrinol Metab 85:8–13 2000

16.

Goel ANadkarni T: Surgical management of giant pituitary tumours—a review of 30 cases. Acta Neurochir 138:104210491996Goel A Nadkarni T: Surgical management of giant pituitary tumours—a review of 30 cases. Acta Neurochir 138:1042–1049 1996

17.

Grote E: Characteristics of giant pituitary adenomas. Acta Neurochir 60:1411531982Grote E: Characteristics of giant pituitary adenomas. Acta Neurochir 60:141–153 1982

18.

Hardy J: Trans-sphenoidal microsurgical removal of pituitary micro-adenoma. Prog Neurol Surg 6:2002161975Hardy J: Trans-sphenoidal microsurgical removal of pituitary micro-adenoma. Prog Neurol Surg 6:200–216 1975

19.

Hashimoto NHanda HYamashita Jet al: Long-term follow-up of large or invasive pituitary adenomas. Surg Neurol 25:49541986Hashimoto N Handa H Yamashita J et al: Long-term follow-up of large or invasive pituitary adenomas. Surg Neurol 25:49–54 1986

20.

Hulting ALMuhr CLundberg POet al: Prolactinomas in men: clinical characteristics and the effect of bromocriptine treatment. Acta Med Scand 217:1011091985Hulting AL Muhr C Lundberg PO et al: Prolactinomas in men: clinical characteristics and the effect of bromocriptine treatment. Acta Med Scand 217:101–109 1985

21.

Iwai YHakuba AKhosla VKet al: Giant basal prolactinoma extending into the nasal cavity. Surg Neurol 37:2802831992Iwai Y Hakuba A Khosla VK et al: Giant basal prolactinoma extending into the nasal cavity. Surg Neurol 37:280–283 1992

22.

Jamrozik SIBennet APJames-Deidier Aet al: Treatment with long acting repeatable bromocriptine (Parlodel-LAR*) in patients with macroprolactinomas: long-term study in 29 patients. J Endocrinol Invest 19:4724791996Jamrozik SI Bennet AP James-Deidier A et al: Treatment with long acting repeatable bromocriptine (Parlodel-LAR*) in patients with macroprolactinomas: long-term study in 29 patients. J Endocrinol Invest 19:472–479 1996

23.

Jefferson A: Chromophobe pituitary adenomata the size of the suprasellar portion in relation to the safety of the operation. J Neurol Neurosurg Psychiatry 32:6331969 (Abstract)Jefferson A: Chromophobe pituitary adenomata the size of the suprasellar portion in relation to the safety of the operation. J Neurol Neurosurg Psychiatry 32:633 1969 (Abstract)

24.

Johnston DGPrescott RWKendall-Taylor Pet al: Hyperprolactinemia. Long-term effects of bromocriptine. Am J Med 75:8688741983Johnston DG Prescott RW Kendall-Taylor P et al: Hyperprolactinemia. Long-term effects of bromocriptine. Am J Med 75:868–874 1983

25.

Jones APKeogh AJ: A simple method of estimating the size of large pituitary adenomas. Acta Neurochir 107:61621990Jones AP Keogh AJ: A simple method of estimating the size of large pituitary adenomas. Acta Neurochir 107:61–62 1990

26.

King WARodts GE JrBecker DPet al: Microsurgical management of giant pituitary tumors. Skull Base Surg 6:17261996King WA Rodts GE Jr Becker DP et al: Microsurgical management of giant pituitary tumors. Skull Base Surg 6:17–26 1996

27.

Krisht AF: Giant invasive pituitary adenomas in Krisht AFTindall GT (eds): Pituitary Disorders: Comprehensive Management. Baltimore: Lippincott1999 pp 287294Krisht AF: Giant invasive pituitary adenomas in Krisht AF Tindall GT (eds): Pituitary Disorders: Comprehensive Management. Baltimore: Lippincott 1999 pp 287–294

28.

Krisht AF: Giant invasive pituitary adenomas: management plan. Contemp Neurosurg 21:161999 (Reference unverified)Krisht AF: Giant invasive pituitary adenomas: management plan. Contemp Neurosurg 21:1–6 1999 (Reference unverified)

29.

Landolt AMKeller PJFroesch ERet al: Bromocriptine: does it jeopardize the result of later surgery for prolactinomas? Lancet 2:6576581982Landolt AM Keller PJ Froesch ER et al: Bromocriptine: does it jeopardize the result of later surgery for prolactinomas? Lancet 2:657–658 1982

30.

Liuzzi ADallabonzana DOppizzi Get al: Low doses of dopamine agonists in the long-term treatment of macroprolactinomas. N Engl J Med 313:6566591985Liuzzi A Dallabonzana D Oppizzi G et al: Low doses of dopamine agonists in the long-term treatment of macroprolactinomas. N Engl J Med 313:656–659 1985

31.

Majos CColl SAguilera Cet al: Imaging of giant pituitary adenomas. Neuroradiology 40:6516551998Majos C Coll S Aguilera C et al: Imaging of giant pituitary adenomas. Neuroradiology 40:651–655 1998

32.

Mohr GHardy JComtois Ret al: Surgical management of giant pituitary adenomas. Can J Neurol Sci 17:62661990Mohr G Hardy J Comtois R et al: Surgical management of giant pituitary adenomas. Can J Neurol Sci 17:62–66 1990

33.

Molitch MEElton RLBlackwell REet al: Bromocriptine as primary therapy for prolactin-secreting macroadenomas: results of a prospective multicenter study. J Clin Endocrinol Metab 60:6987051985Molitch ME Elton RL Blackwell RE et al: Bromocriptine as primary therapy for prolactin-secreting macroadenomas: results of a prospective multicenter study. J Clin Endocrinol Metab 60:698–705 1985

34.

Murphy FYVesely DLJordan RMet al: Giant invasive prolactinomas. Am J Med 83:99510021987Murphy FY Vesely DL Jordan RM et al: Giant invasive prolactinomas. Am J Med 83:995–1002 1987

35.

Nelson PBGoodman MMaroon JCet al: Factors in predicting outcome from operation in patients with prolactin-secreting pituitary adenomas. Neurosurgery 13:6346411983Nelson PB Goodman M Maroon JC et al: Factors in predicting outcome from operation in patients with prolactin-secreting pituitary adenomas. Neurosurgery 13:634–641 1983

36.

Oruckaptan HHSenmevsim OOzcan OEet al: Pituitary adenomas: results of 684 surgically treated patients and review of the literature. Surg Neurol 53:2112192000Oruckaptan HH Senmevsim O Ozcan OE et al: Pituitary adenomas: results of 684 surgically treated patients and review of the literature. Surg Neurol 53:211–219 2000

37.

Perani DColombo NScotti Get al: Rapid size reduction of giant prolactinoma following medical treatment. J Comput Assist Tomogr 8:1311331984Perani D Colombo N Scotti G et al: Rapid size reduction of giant prolactinoma following medical treatment. J Comput Assist Tomogr 8:131–133 1984

38.

Pernicone PJScheithauer BWSebo TJet al: Pituitary carcinoma: a clinicopathologic study of 15 cases. Cancer 79:8048121997Pernicone PJ Scheithauer BW Sebo TJ et al: Pituitary carcinoma: a clinicopathologic study of 15 cases. Cancer 79:804–812 1997

39.

Pia HWGrote EHildebrandt G: Giant pituitary adenomas. Neurosurg Rev 8:2072201985Pia HW Grote E Hildebrandt G: Giant pituitary adenomas. Neurosurg Rev 8:207–220 1985

40.

Post KDBiller BJAdelman LSet al: Selective transsphenoidal adenomectomy in women with galactorrhea-amenorrhea. JAMA 242:1581621979Post KD Biller BJ Adelman LS et al: Selective transsphenoidal adenomectomy in women with galactorrhea-amenorrhea. JAMA 242:158–162 1979

41.

Rodman EFMolitch MEPost KDet al: Long-term follow-up of transsphenoidal selective adenomectomy for prolactinoma. JAMA 252:9219241984Rodman EF Molitch ME Post KD et al: Long-term follow-up of transsphenoidal selective adenomectomy for prolactinoma. JAMA 252:921–924 1984

42.

Schlechte JSherman BHalmi Net al: Prolactin-secreting pituitary tumors in amenorrheic women: a comprehensive study. Endocr Rev 1:2953081980Schlechte J Sherman B Halmi N et al: Prolactin-secreting pituitary tumors in amenorrheic women: a comprehensive study. Endocr Rev 1:295–308 1980

43.

Selman WRLaws ER JrScheithauer BWet al: The occurrence of dural invasion in pituitary adenomas. J Neurosurg 64:4024071986Selman WR Laws ER Jr Scheithauer BW et al: The occurrence of dural invasion in pituitary adenomas. J Neurosurg 64:402–407 1986

44.

Serri ORasio EBeauregard Het al: Recurrence of hyperprolactinemia after selective transsphenoidal adenomectomy in women with prolactinoma. N Engl J Med 309:2802831983Serri O Rasio E Beauregard H et al: Recurrence of hyperprolactinemia after selective transsphenoidal adenomectomy in women with prolactinoma. N Engl J Med 309:280–283 1983

45.

Shimon IMelmed S: Management of pituitary tumors. Ann Intern Med 129:4724831998Shimon I Melmed S: Management of pituitary tumors. Ann Intern Med 129:472–483 1998

46.

Sieck JONiles NLJinkins JRet al: Extrasellar prolactinomas: successful management of 24 patients using bromocriptine. Horm Res 23:1671761986Sieck JO Niles NL Jinkins JR et al: Extrasellar prolactinomas: successful management of 24 patients using bromocriptine. Horm Res 23:167–176 1986

47.

Symon LJakubowski JKendall B: Surgical treatment of giant pituitary adenomas. J Neurol Neurosurg Psychiatry 42:9739821979Symon L Jakubowski J Kendall B: Surgical treatment of giant pituitary adenomas. J Neurol Neurosurg Psychiatry 42:973–982 1979

48.

Taxel PWaitzman DMHarrington JF Jret al: Chiasmal herniation as a complication of bromocriptine therapy. J Neuroophthalmol 16:2522571996Taxel P Waitzman DM Harrington JF Jr et al: Chiasmal herniation as a complication of bromocriptine therapy. J Neuroophthalmol 16:252–257 1996

49.

Tyrrell JBLamborn KRHannegan LTet al: Transsphenoidal microsurgical therapy of prolactinomas: initial outcomes and long-term results. Neurosurgery 44:2542631999Tyrrell JB Lamborn KR Hannegan LT et al: Transsphenoidal microsurgical therapy of prolactinomas: initial outcomes and long-term results. Neurosurgery 44:254–263 1999

50.

Vertosick FT Jr: Role of defective dopaminergic inhibition of prolactin secretion in the pathogenesis of prolactinoma. Neurosurgery 16:2612661985Vertosick FT Jr: Role of defective dopaminergic inhibition of prolactin secretion in the pathogenesis of prolactinoma. Neurosurgery 16:261–266 1985

51.

Wang CLam KSLMa JTCet al: Long-term treatment of hyperprolactinaemia with bromocriptine: effect of drug withdrawal. Clin Endocrinol 27:3633711987Wang C Lam KSL Ma JTC et al: Long-term treatment of hyperprolactinaemia with bromocriptine: effect of drug withdrawal. Clin Endocrinol 27:363–371 1987

52.

Wilson CB: A decade of pituitary microsurgery. The Herbert Olivecrona lecture. J Neurosurg 61:8148331984Wilson CB: A decade of pituitary microsurgery. The Herbert Olivecrona lecture. J Neurosurg 61:814–833 1984

53.

Wirth FPSchwartz HGSchwetschenau PR: Pituitary adenomas: factors in treatment. Clin Neurosurg 21:8251974Wirth FP Schwartz HG Schwetschenau PR: Pituitary adenomas: factors in treatment. Clin Neurosurg 21:8–25 1974

54.

Woodhouse NJKhouqueer FSieck JO: Prolactinomas and optic nerve compression: disappearance of suprasellar extension and visual recovery after two weeks bromocriptine treatment. Horm Res 14:1411471981Woodhouse NJ Khouqueer F Sieck JO: Prolactinomas and optic nerve compression: disappearance of suprasellar extension and visual recovery after two weeks bromocriptine treatment. Horm Res 14:141–147 1981

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 147 147 48
Full Text Views 183 183 5
PDF Downloads 114 114 4
EPUB Downloads 0 0 0

PubMed

Google Scholar