Male prolactinomas presenting with normal testosterone levels

A Dermatological Intervention of Gynecomastia in Young Asian Man with a History of Soy Product Consumption: A Case Report

Gynecomastia is an enlargement of the breasts in men, which is usually benign but can also manifest as a result of malignancies, and can be either unilateral or bilateral. Pseudogynecomastia is male breast enlargement due to excessive fat, while true gynecomastia is a proliferation of glandular tissue. Gynecomastia is common in infants, adolescents, and elderly men, with the most common cause is related to hormonal changes associated with aging. Medical intervention is usually required for true gynecomastia that has lasted more than a year. Here, we report a case of a 33-year-old Chinese-Indonesian decent with enlarged breasts. The patient reported frequent consumption of homemade soybean milk (1/2 to 1 liter daily) accompanied by bland chicken during his body-building regimen. The patient had discontinued the regimen and the diet for 2 years prior to the initial visit. During physical examination, both breasts were enlarged and had firm nodule, mobile, and attached at the sub-central areola mammae with a diameter of 8 cm. The patient was then diagnosed with true gynecomastia Simon degree 2A and Geschikter and Copeland type 3. As the gynecomastia had persisted longer than a year, a dermatological intervention was planned. Ultrasound-assisted liposuction was performed with a solid probe and glandular excision. Fat tissue was obtained, 130 mL from the right breast and 120 mL from the left breast. A dense 2.5 cm × 2.5 cm × 2 cm glandular tissue was obtained from both breasts. The patient was satisfied with the surgery outcome.

Overview of Hyperprolactinemia: General Approach and Reproductive Health Implications

Prolactin (PRL) is a polypeptide hormone produced by the lactotrope cells of the anterior pituitary gland. Among its myriads of biological functions, PRL is the main regulator of mammary gland growth and development, as well as of the production and secretion of milk. Hyperprolactinemia represents a frequent consultation cause in medical practice. Nevertheless, elevations in serum PRL are not always pathological. Drug induced hyperprolactinemia is the most common cause, mainly by antipsychotics, followed by other causes such as pituitary neuroendocrine tumors, physiologic conditions, and systemic diseases such as chronic kidney disease and hypothyroidism. When evaluating a patient with hyperprolactinemia it is of utmost importance to consider the diverse etiologies of this condition in order to avoid unnecessary diagnostic workup and treatment. Regarding reproductive health, hyperprolactinemia is a well-documented cause of infertility, as approximately 15-20% of women undergoing infertility evaluation have hyperprolactinemia, which causes secondary amenorrhea, and other menstrual irregularities. Similarly, in men it is a cause of hypogonadism.

Recovery from hypogonadism in men with prolactinoma treated with dopamine agonists

PURPOSE

In men with prolactinoma treated with dopamine agonists (DA), the extent, timeline, and predictive factors of gonadotropic axis recovery are still unclear.

METHODS

We analyzed data of 97 men with a prolactinoma treated with DA (77/97 macroprolactinomas). We excluded patients with primary hypogonadism, surgery < 12 months after DA initiation, and patients with tumors < 5 mm or prolactin < 45 µg/l at diagnosis.

RESULTS

Among the 97 patients, 12 had normal total testosterone (NT group) and 85 had low testosterone at diagnosis (LT group). In the NT group, testosterone rose from a mean of 13.5 nmol/l to 17.1nmol/l at 6 months (n = 11; p < 0.05) then remained stable at 12 months (n = 8). In the LT group, testosterone rose from a mean of 5.2 nmol/l to 9.6 nmol/l at 6 months (n = 66; p < 0.001) and further to 13.1nmol/l at 12 months (n = 40; p < 0.001) then remained stable. Recovery from hypogonadism occurred in 43%, 50%, and 54% of patients at 6, 12 and 24 months, respectively (61%, 69 and 69% if prolactin was normal). Factors independently associated with persistent hypogonadism at 12 months were at baseline the presence of visual field deficit and lower testosterone levels, while the most significant independent predictor of persistent hypogonadism at one year was a testosterone level < 7.4 nmol/l at 6 months, with 91% sensitivity and 94% specificity.

CONCLUSION

Testosterone levels recover in a small majority of men with prolactinoma mostly during the first year of DA treatment. However, testosterone replacement could be considered earlier in patients with large and compressive tumors, and in whom testosterone remains below 7.4 nmol/l after 6 months of DA treatment.

Increase in Testosterone Levels and Improvement of Clinical Symptoms in Eugonadic men With a Prolactin-secreting Adenoma

Objective

Testosterone concentrations, albeit rarely, may be in the normal range (>3.0 ng/mL) in men with a prolactin-secreting pituitary adenoma (PSPA-nt). The evolution of total, bioavailable testosterone, gonadotropin levels, and that of graded symptoms of testosterone deficiency (TD) are uncertain in these patients.

Design

Retrospective case-control longitudinal study at a tertiary referral center.

Methods

From 287 men, we selected 25 PSPA-nt men undergoing prolactin normalization (<20.0 ng/mL) during the follow-up. Graded symptoms of TD were investigated by structured interviews. Biochemical changes and TD symptoms were compared to those of a matched cohort of 61 men with pituitary neoplasms and normal testosterone levels (PA-nt).

Results

Baseline testosterone levels were similar between PSPA-nt and PA-nt subjects. The prevalence of specific and suggestive symptoms of TD was higher in PSPA-nt (20% and 68%) than in PAnt (3.3 and 29.5%; P = .02 and P = .0015, respectively). At the follow-up, total and bioavailable testosterone levels increased in PSPA-nt but not in PA-nt patients (Δ change: 1.28 ± 2.1 vs0.03 ± 1.5 ng/mL, + 0.33 ± 0.55 vs-0.26 ± 0.60 ng/mL; P = .0028 and P = .0088, respectively). LH and FSH levels also increased in PSPA-nt men (P < .05). Specific and suggestive, but not nonspecific symptoms of TD, improved only in PSPA-nt men (P < .05 for both). Baseline testosterone and LH were the strongest predictors of testosterone improvement in PSPA-nt patients.

Conclusion

Despite having normal testosterone levels at baseline, patients with PSPA-nt experience a relief of TD symptoms and an improvement of their pituitary-gonadal axis function following prolactin normalization, especially when baseline TT and LH levels are in the low-normal range.

Prolactin-secreting pituitary adenomas: male-specific differences in pathogenesis, clinical presentation and treatment

Prolactinomas (PRLomas) constitute approximately half of all pituitary adenomas and approximately one-fifth of them are diagnosed in males. The clinical presentation of PRLomas results from direct prolactin (PRL) action, duration and severity of hyperprolactinemia, and tumor mass effect. Male PRLomas, compared to females, tend to be larger and more invasive, are associated with higher PRL concentration at diagnosis, present higher proliferative potential, are more frequently resistant to standard pharmacotherapy, and thus may require multimodal approach, including surgical resection, radiotherapy, and alternative medical agents. Therefore, the management of PRLomas in men is challenging in many cases. Additionally, hyperprolactinemia is associated with a significant negative impact on men's health, including sexual function and fertility potential, bone health, cardiovascular and metabolic complications, leading to decreased quality of life. In this review, we highlight the differences in pathogenesis, clinical presentation and treatment of PRLomas concerning the male sex.

A giant invasive macroprolactinoma with recurrent nasal bleeding as the first clinical presentation: case report and review of literature

BACKGROUND

Giant prolactinoma (> 4 cm in dimension) is a rare disorder. Invasive macroprolactinoma has the potential to cause base of skull erosion and extend into the nasal cavity or even the sphenoid sinus. Nasal bleeding caused by intranasal tumor extension is a rare complication associated with invasive giant prolactinoma. We report a case of giant invasive macroprolactinoma with repeated nasal bleeding as the initial symptom.

CASE PRESENTATION

A 24-year-old man with an invasive giant prolactinoma in the nasal cavity and sellar region who presented with nasal bleeding as the initial symptom, misdiagnosed as olfactory neuroblastoma. However, markedly elevated serum prolactin levels (4700 ng/mL), and a 7.8-cm invasive sellar mass confirmed the diagnosis of invasive giant prolactinoma. He was treated with oral bromocriptine. Serum prolactin was reduced to near normal after 6 months of treatment. Follow-up magnetic resonance imaging showed that the sellar lesion had disappeared completely and the skull base lesions were reduced.

CONCLUSION

This case is notable in demonstrating the aggressive nature of untreated invasive giant prolactinomas which can cause a diagnostic difficulty with potential serious consequences. Early detection of hormonal levels can avoid unnecessary nasal biopsy. Early identification of pituitary adenoma with nasal bleeding as the first symptom is particularly important.

Hypogonadism in Male Patients with Pituitary Adenoma and Its Related Mechanism: A Review of Literature

Maintaining normal gonadal axis hormone levels is important for improving the condition of male patients with pituitary adenoma. The current literature is somewhat divided on the results of evaluations of gonadal axis function in male patients with pituitary adenoma before and after treatment, and the increasing demand for better quality of life has provided motivation for this research to continue. In this article, we summarize the feasibility of using testosterone as an indicator for assessing male function and discuss the changes reported in various studies for gonadal hormones before and after treatment in male patients with pituitary adenoma. It is important for clinicians to understand the advantages of each treatment option and the effectiveness of assessing gonadal function. The rationale behind the theory that pituitary adenomas affect gonadal function and the criteria for evaluating pituitary–gonadal axis hormones should be explored in more depth.

Mild hyperprolactinemia in a couple: what impact on fertility?

Mild-to-moderate hyperprolactinemia is a frequent finding in young women presenting with infertility. Prolactin (PRL) concentration should be determined accurately, whether or not the patient has other symptoms suggestive of excess PRL such as galactorrhea or menstrual cycle disorder. After confirmation of persistent hyperprolactinemia on a second blood sample (avoiding conditions known to raise prolactin) and exclusion of macroprolactinemia, prolactinoma and other identifiable non-tumoral causes of hyperprolactinemia must be ruled out. Mildly elevated PRL levels may cause luteal insufficiency in cycling women and are associated with recurrent miscarriage. Any confirmed hyperprolactinemia should be treated in a woman who wishes or fails to become pregnant. Preference is given to cabergoline at the lowest possible dose that normalizes PRL, restoring fertility in the vast majority of cases. Evidence is much less robust in men, in whom PRL concentrations are less prone to increase and the reproductive system is less sensitive to the negative effects of hyperprolactinemia. Nevertheless, chronic and significant hyperprolactinemia in men may impair fertility or cause infertility (with or without hypogonadism) and must be treated, as in women. However, more clinical studies are clearly needed concerning male reproductive function. The significance of mild but persistent hyperprolactinemia in either member of a couple incidentally discovered during assisted reproductive technology (ART) procedures is unclear, and future evidence-based studies are needed to determine whether normalizing prolactin can improve ART outcome.

Clomiphene Citrate for Men with Hypogonadism - A Systematic Review & Meta-analysis

BACKGROUND

Male hypogonadism is a clinical and biochemical androgen insufficiency syndrome, becoming more prevalent with age. Exogenous testosterone is first choice therapy, with several side-effects, including negative feedback of the hypothalamic-pituitary-gonadal axis, resulting in suppression of intratesticular testosterone production and spermatogenesis. To preserve these testicular functions while treating male hypogonadism clomiphene citrate (CC) is used as off-label therapy. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of CC therapy for men with hypogonadism.

METHODS

The EMBASE, PubMed, Cochrane databases were searched in May 2021, for effectiveness studies of men with hypogonadism treated with CC. Both intervention and observational studies were included. The Effective Public Health Practice Project Quality Assessment Tool, a validated instrument was used to assess methodological study quality. The primary outcome measure was the evaluation of serum hormone concentration. Secondary outcomes were symptoms of hypogonadism, metabolic- and lipid profile, side-effects, safety aspects.

RESULTS

We included 19 studies, comprising four randomized controlled trials and 15 observational studies, resulting in 1642 patients. Seventeen studies were included in the meta-analysis, with a total of 1279 patients. Therapy and follow-up duration varied between one and a half and 52 months. Total testosterone (TT) increased with 2.60 (95% CI 1.82 - 3.38) during CC treatment. An increase was also seen in free testosterone, luteinizing hormone, follicle stimulating hormone, sex hormone-binding globulin and estradiol. Different symptom scoring methods were used in the included studies. The most frequently used instrument was the Androgen Deficiency in Aging Males-questionnaire, which score improved during treatment. Reported side-effects were only prevalent in less than 10% of the study populations and no serious adverse events were reported.

CONCLUSION

CC is an effective therapy for improving both biochemical as well as clinical symptoms of males suffering from hypogonadism. CC has few reported side-effects and good safety aspects. This article is protected by copyright. All rights reserved.

Drug-Drug Interactions in Vestibular Diseases, Clinical Problems, and Medico-Legal Implications

Peripheral vestibular disease can be treated with several approaches (e.g., maneuvers, surgery, or medical approach). Comorbidity is common in elderly patients, so polytherapy is used, but it can generate the development of drug-drug interactions (DDIs) that play a role in both adverse drug reactions and reduced adherence. For this reason, they need a complex kind of approach, considering all their individual characteristics. Physicians must be able to prescribe and deprescribe drugs based on a solid knowledge of pharmacokinetics, pharmacodynamics, and clinical indications. Moreover, full information is required to reach a real therapeutic alliance, to improve the safety of care and reduce possible malpractice claims related to drug-drug interactions. In this review, using PubMed, Embase, and Cochrane library, we searched articles published until 30 August 2021, and described both pharmacokinetic and pharmacodynamic DDIs in patients with vestibular disorders, focusing the interest on their clinical implications and on risk management strategies.

Optimal testosterone level to improve symptoms of hypogonadism without causing dopa-testotoxicosis in male macroprolactinoma

BACKGROUND

Male prolactinoma treatment by dopamine agonists (DA) restores sexual function. However, excessive DA dose can lead to impulse control disorder.

OBJECTIVES

The aim of this retrospective study was to determine the level of testosterone that eliminates symptoms and provides fertility in male macroprolactinoma, without causing these adverse effects.

MATERIALS AND METHODS

Twenty-seven male patients with macroprolactinoma were included. There were 16 macro (≥1-2.8 cm), 7 large macro (≥2.9-3.9 cm) and 4 giant (≥4 cm) adenomas. Prolactin (PRL) and testosterone (T) levels were evaluated. A timeline was created to analyze improvement in symptoms of hypogonadism and infertility. Testosterone levels were compared with age-matched controls.

RESULTS

Mean PRL, basal tumor diameter and shrinkage were 2,846±3,415 ng/mL, 27.2±10.2 mm and 63.4%, respectively. Basal T levels were 1.6±1.0 ng/mL for patients and 4.4±1.5 ng/mL for controls (p<0.001). Mean T level in the asymptomatic period was significantly lower than in controls (3.2±0.4 ng/mL vs. 4.4±1.5 ng/mL, respectively; p=0.002), while mean PRL was 27.2 ng/ml. Fertility was achieved in 6 of the patients seeking fertility, and there was no difference in T level between these patients and controls (3.7±0.8 ng/mL and 4.4±1.5 ng/mL, respectively; p=0.14); when fertility was achieved, mean PRL was 26.9±23 ng/mL.

CONCLUSION

Patients should be carefully questioned regarding complaints at each consultation, and DA dose should not be increased unnecessarily, to avoid possible serious adverse effects.

Prolactinomas in males: any differences?

CONTEXT

Prolactinomas in men are usually large and invasive, presenting with signs and symptoms of hypogonadism and mass effects, including visual damage. Prolactin levels are high, associated with low testosterone, anemia, metabolic syndrome and if long-standing also osteoporosis.

RESULTS

Medical treatment with the dopamine agonist, cabergoline, became the preferred first-line treatment for male prolactinomas as well as for giant tumors, leading to prolactin normalization in ~ 80% of treated men, and tumor shrinkage, improved visual fields and recovery of hypogonadism in most patients. Multi-modal approach including surgery and occasionally radiotherapy together with a high-dose cabergoline is saved for resistant and invasive adenomas. Experimental treatments including temozolomide or pasireotide may improve clinical response in men harboring resistant prolactinomas.

CONCLUSIONS

Compared to other pituitary adenomas, secreting and non-secreting, where pituitary surgery is the recommended first-line treatment, men with prolactinomas will usually respond to medical treatment with no need for any additional treatment.

The epidemiology, diagnosis and treatment of Prolactinomas: The old and the new

Prevalence and incidence of prolactinomas are approximately 50 per 100,000 and 3-5 new cases/100,000/year. The pathophysiological mechanism of hyperprolactinemia-induced gonadotropic failure involves kisspeptin neurons. Prolactinomas in males are larger, more invasive and less sensitive to dopamine agonists (DAs). Macroprolactin, responsible for pseudohyperprolactinemia is a frequent pitfall of prolactin assay. DAs still represent the primary therapy for most prolactinomas, but neurosurgery has regained interest, due to progress in surgical techniques and a high success rate in microprolactinoma, as well as to some underestimated side effects of long-term DA treatment, such as impulse control disorders or impaired quality of life. Recent data show that the suspected effects of DAs on cardiac valves in patients with prolactinomas are reassuring. Finally, temozolomide has emerged as a valuable treatment for rare cases of aggressive and malignant prolactinomas that do not respond to all other conventional treatments.

Long-Term Follow-Up of Primary Medical Versus Surgical Treatment of Prolactinomas in Men: Effects on Hyperprolactinemia, Hypogonadism, and Bone Health

OBJECTIVE

In men with prolactinomas, impaired bone density is the principle consequence of hyperprolactinemia-induced hypogonadism. Although dopamine agonists (DAs) are the first-line approach in prolactinomas, surgery can be considered in selected cases. In this study, we aimed to investigate the long-term control of hyperprolactinemia, hypogonadism, and bone health comparing primary medical and surgical therapy in men who had not had prior DA treatment.

METHODS

This is a retrospective case-note study of 44 consecutive men with prolactinomas and no prior DAs managed in a single tertiary referral center. Clinical, biochemical, and radiologic response to the first-line approach were analyzed in the 2 cohorts.

RESULTS

Mean age at diagnosis was 47 years (range, 22-78 years). The prevalence of hypogonadism was 86%, and 27% of patients had pathologic bone density at baseline. The primary therapeutic strategy was surgery for 34% and DAs for 66% of patients. Median long-term follow-up was 63 months (range, 17-238 months). Long-term control of hyperprolactinemia required DAs in 53% of patients with primary surgical therapy, versus 90% of patients with primary medical therapy (P = 0.02). Hypogonadism was controlled in 73% of patients. The prevalence of patients with pathologic bone density was 37% at last follow-up, with no differences between the 2 therapeutic cohorts (P = 0.48).

CONCLUSIONS

Despite control of hyperprolactinemia and hypogonadism in most patients independent of the primary treatment modality, the prevalence of impaired bone health status remains high, and osteodensitometry should be recommended.

Giant prolactinomas: are they really different from ordinary macroprolactinomas?

Giant prolactinomas (gPRLomas) are rare tumors of the lactotroph defined by an unusually large size (>4 cm) and serum PRL levels >1000 ng/mL. The purpose of this study is to characterize the clinical spectrum of gPRLomas comparing them with non-giant prolactinomas. This is a retrospective study at a large referral center. Data from patients harboring gPRLomas and macroprolactinomas were retrieved from medical records of the Prolactinoma Clinic. Analysis was focused on clinical, biochemical, and tumor volume characteristics, as well as on the response to treatment with dopamine agonists. Among 292 patients with prolactinomas followed between 2008 and 2015, 47 (16 %) met the diagnostic criteria for gPRLomas (42 males). The most common complaint was a visual field defect; headache was reported by 79 % and sexual dysfunction was present in over half of the patients. Median basal PRL level and tumor volume were 6667 ng/mL (3750-10,000) and 32 cm(3) (20-50), respectively; hypogonadotropic hypogonadism was documented in 87 %. Cabergoline treatment resulted in the normalization of PRL levels in 68 % and in the reduction of >50 % in tumor volume in 87 % of the gPRLoma patients. The composite goal of PRL normalization and >50 % tumor reduction was achieved by 55 % (n = 26) of patients with gPRL and by 66 % (n = 100) of patients with no giant macroprolactinomas (p = 0.19). Recovery of hypogonadism and improvement of visual fields defects occurred in 32 % and 68 % of the patients, respectively. Cabergoline treatment was equally effective in patients with gPRLoma and those with macroprolactinomas in regard of achieving treatment goals, although the median CBG dose was slightly higher in the gPRLoma group (2 vs. 1.5 mg/w). Six patients required surgery. Beyond their impressive dimensions and the huge amount of PRL they secrete, the clinical behavior of gPRLoma is not different from macroprolactinomas. These tumors are highly responsive to cabergoline treatment, and pituitary surgery is seldom required.

Management of macroprolactinomas

Prolactin (PRL) secreting tumors are the most common functional neoplasms of the pituitary and are commonly subdivided into microprolactinomas (<10 mm) and macroprolactinomas (≥10 mm) according to their baseline diameter. Patients with prolactinoma present with symptoms evolving from hyperprolactinemia and with those caused by pressure of the expanding mass on surrounding tissues, including the optic chiasm and the cavernous sinuses. We hereby describe the possible complications of macroprolactinomas, including mass effects, hypopituitarism, CSF leak and apoplexy and discuss their relevant management.

In general, all patients harboring macroprolactinomas should be treated, the objectives being to achieve normal or near normal PRL levels, to reduce or stabilize adenoma size and to recover altered pituitary axes. Medical therapy with dopamine agonists (DA) is the preferred initial treatment for the vast majority of patients harboring prolactinomas. Pituitary surgery is indicated in patients who cannot tolerate or are resistant to therapy with DAs, patients that seek fertility and harbor adenomas that impinge on the optic chiasm, psychiatric patients with contraindication to DA treatment and patients presenting with pituitary apoplexy or a cerebrospinal fluid (CSF) leak. In addition, in this review, several patient populations with unique clinical characteristics will be discussed separately namely postmenopausal women, the elderly, children and patients with pituitary carcinoma.

Hypopituitarism patterns and prevalence among men with macroprolactinomas

PURPOSE

Men with prolactin-secreting tumors usually harbor macroadenomas. The degree of pituitary dysfunction may vary among different adenoma size subgroups, as is recovery after treatment. Our study purpose was to characterize hypopituitarism and recovery after treatment in men with macroprolactinomas.

METHODS

A retrospective study, including a consecutive group of 81 men with pituitary macroadenomas (≥10 mm) and hyperprolactinemia (>7×ULN). Patients were divided into three categories according to adenoma size at presentation: 10-19 mm (group A), 20-39 mm (group B), and ≥40 mm (group C). We compared total testosterone, gonadotropins, cortisol, thyroid hormones and hemoglobin levels at presentation and after treatment.

RESULTS

Eighty-one patients were included; 24, 31 and 26 patients in groups A, B and C, respectively. Pretreatment hypogonadism prevalence was 75.0, 93.5 and 90.9% (p = 0.046; A vs B and C), central hypocortisolism - 0, 6.9 and 33.3% (p = 0.005), and central hypothyroidism - 6.7, 17.9 and 26.1% (NS) in groups A, B and C, respectively. Only 26.7% of all patients presented with hypocortisolism and/or hypothyroidism (42.9% in group C). Anemia (Hb < 13.5 g%) was detected in 31.3, 57.1 and 80.0% in groups A, B and C, respectively (p = 0.04). Larger adenoma diameter correlated strongly with lower FT4 levels following treatment (r = -0.42, p = 0.043).

CONCLUSIONS

Macroprolactinomas in men caused partial hypopituitarism, affecting testosterone in all adenoma size groups and cortisol more in patients with larger adenomas. However, most of the men did not have pituitary hormones affected, beside testosterone. Most patients recovered central hypocortisolism but not hypothyroidism following treatment.