Retroperitoneal fibrosis in a patient with macroprolactinoma treated with bromocriptine

The Effect of Preoperative Cabergoline on Prolactinoma Fibrosis: A Case Series

Introduction  Prolactinomas are a common intracranial neoplasm and constitute most pituitary tumors. Although patients can present with variable hormone dysregulation and symptom severity, the use of dopamine agonists remains a first-line treatment. While bromocriptine has been found to increase tumor fibrosis, the effect of cabergoline on collagen deposition has been disputed. The aim of this article is to understand the influence of cabergoline on tumor fibrosis prior to resection. Case Presentations  Four male patients who underwent prolactinoma resection were included in this report. The average age was 39.8 years (range: 26-52 years). Pre-treatment prolactin levels ranged from 957.8 to 16,487.4 ng/mL. Three patients received cabergoline for at least 1 month prior to surgery (treatment range: 1-6 months). One patient had surgery without prior cabergoline use. Pathology reports confirmed each tumor to be of lactotroph origin. For each sample, Masson's trichrome staining was performed and the percentage of sample fibrosis was quantified using an artificial intelligence imaging software. Among those who received preoperative cabergoline, the extent of tumor fibrosis was in the range of 50 to 70%. In contrast, specimen fibrosis was approximately 15% without cabergoline use. Conclusion  This report demonstrates that a short duration of preoperative cabergoline can cause significant prolactinoma fibrosis. Understanding the effect of cabergoline on tumor consistency prior to surgery is essential as increased fibrosis can lead to more difficult tumor removal, reduce the extent of resection, and increase surgical complications. Considering these effects, further studies regarding the use of surgery prior to cabergoline for prolactinoma management are warranted.

Surgical Treatment of Prolactinomas: Potential Role as a First-Line Treatment Modality

PURPOSE

Treatment with dopamine agonists (DAs) has been the first-line standard treatment for prolactinoma, and surgery has been reserved for drug intolerance and resistance for several decades. We evaluated whether surgery plays a primary role in prolactinoma management.

MATERIALS AND METHODS

We conducted a retrospective study of 210 prolactinoma patients who had received surgical treatment at our institution. We analyzed the treatment outcomes according to tumor extent, sex, and preoperative DA medication.

RESULTS

Overall hormonal remission was achieved in 164 patients (78.1%), and complete removal was achieved in 194 patients (92.4%). When the tumors were completely removed, the remission rate increased to 84.5%. Anterior pituitary function was normalized or improved in 94.6% of patients, whereas only 4.1% of patients showed worsening of hormone control. Hormonal remission was higher in patients who had not received DA preoperatively than in those who had received preoperative DA treatment. Smaller tumor size (<1 cm), no invasion into the cavernous sinus, and female sex were predictors of good surgical outcomes.

CONCLUSION

Although DAs remain the first-line standard treatment for prolactinomas, surgery can be an excellent option and should be considered as an alternative primary treatment modality when patients are predicted to achieve a good surgical outcome.

Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management?

The current treatment paradigm for prolactinomas involves dopamine agonist (DA) therapy as the first-line treatment, with surgical resection reserved for cases where there is DA failure due to resistance or intolerance. This review highlights how DA therapy can be optimised to overcome its increasingly recognised pitfalls, whilst also addressing the potential for expanding the use of surgery in the management of prolactinomas. The first part of the review discusses the limitations of DA therapy, namely: DA resistance; common DA side effects; and the rare but serious DA-induced risks of cardiac valvulopathy, impulse control disorders, psychosis, CSF rhinorrhoea and tumour fibrosis. The second part of the review explores the role of surgery in prolactinoma management with reference to its current second-line position and recent calls for surgery to be considered as an alternative first-line treatment alongside DA therapy. Randomised trials comparing medical vs surgical therapy for prolactinomas are currently underway. Pending these results, a low surgical threshold approach is herein proposed, whereby DA therapy remains the default treatment for prolactinomas unless there are specific triggers to consider surgery, including concern regarding DA side effects or risks in vulnerable patients, persistent and bothersome DA side effects, emergence of any serious risks of DA therapy, expected need for long-term DA therapy, as well as the traditional indications for surgery. This approach should optimise the use of DA therapy for those who will most benefit from it, whilst instituting surgery early in others in order to minimise the cumulative burden of prolonged DA therapy.

[Prolactinoma: from quest of pregnancy to delivery]

Prolactinoma is the most frequent hormone-secreting pituitary tumor (100 for million patients) and a major cause of both female and male reproductive function disorders. Physician, gynecologist, urologist and sexologist can face this situation during their career. As part of the fertility restoration, treatment gives very satisfactory results. With adequate management, most women are expected to achieve successful pregnancies. The natural history of these tumors during pregnancy depends on their size with a risk of a clinically relevant estimate between 5 to 30 %. Their management is complex, requiring finding balance between effects of pregnancy on tumor growth and potential risks of overtreatment on fetal development. The aim of this study is to discuss the management of prolactinoma on woman before, during and after pregnancy, and to evaluate the medical and surgical alternatives regarding the actual literature.

Lisuride, a dopamine receptor agonist with 5-HT2B receptor antagonist properties: absence of cardiac valvulopathy adverse drug reaction reports supports the concept of a crucial role for 5-HT2B receptor agonism in cardiac valvular fibrosis

OBJECTIVES

The high incidence of fibrotic cardiac valvulopathies reported in association with the 8beta-ergoline dopamine (DA) agonist, pergolide, and also case reports for cabergoline and bromocriptine have made it necessary to review the theoretical basis and actual findings in the case of another DA agonist, the 8alpha-ergoline lisuride (used since the 1970s for migraine prophylaxis as well as since the 1980s for its prolactin-lowering and anti-Parkinson activity).

METHODS

We have reviewed the pharmacology of lisuride in relation to other DA agonists, and we have performed a throughout literature search as well as a search of our own and other adverse drug reaction databases for a possible relationship of lisuride with cardiac valvulopathy or for any reports of fibrosis in other locations.

RESULTS

Our review of the pharmacology and the literature strongly suggests that drug-induced cardiac valvulopathies are always related to a stimulatory drug effect on trophic 5-HT(2B) receptors. As lisuride is devoid of such an effect, but on the contrary is an extremely potent 5-HT(2B) antagonist, an association of lisuride therapy with cardiac valvulopathies seems to be highly unlikely. In agreement with this hypothesis, not a single report of a cardiac valvulopathy associated with lisuride therapy has been identified in any database so far.Furthermore, against a background of an estimated 360,000 patient years, we have found only a very small number of cases of any other form of fibrosis (1x retroperitoneal, 2x pleural, 2x pulmonary, 1x interstitial pulmonary changes), in part combined with other risk factors and confounding variables. This closely matches 4 reports available from WHO (1x retroperitoneal, 3x pleural fibrosis). In addition, only 5 other possibly related conditions (3x pleural effusion, 1x pleuritis, 1x pericarditis) were identified in the lisuride adverse drug reaction database of Schering, Berlin.

CONCLUSIONS

No link has been found between lisuride use and fibrotic cardiac valvulopathy, in agreement with the 5-HT(2B) receptor antagonist effect of this drug. The very low incidence of spontaneous reports of any other fibrosis could be even compatible with an association by chance in the population exposed to lisuride. Although close monitoring for this kind of side effects is still to be recommended in the therapy with lisuride, our data do not support the concept of a class effect suggesting that all ergot-derived drugs and especially DA receptor agonists with some chemical similarity to the ergot structure will cause or facilitate cardiac valvulopathies as observed with pergolide.

[Severe pleuropericarditis induced by long-term bromocriptin therapy, report of a case and review of the literature]

INTRODUCTION

Bromocriptin, member of the class of ergolines, is commonly prescribed as treatment of Parkinson's disease. Apart from vascular, digestif, neurologic and psychic disorders, the authors report cases of retroperitoneal fibrosis and pleural effusion, as adverse reactions related to the bromocriptin.

SYNTHESIS

About 40 cases of skin, pleural, lung and retroperitoneal attacks were described after long term and high doses of bromocriptin. More ten years ago, the first case of constrictive pericarditis was cited in the medical literature, and the bromocriptin was incriminated as responsible. Since then, two other cases were cited. Our observation is a constrictive pericarditis, found in a 72 years old patient treated with bromocriptin for Parkinson's disease since five years (cumulative dose intake 73 grams). Investigations aimed to establish etiology were negative. Bromocriptin is suspected and the treatment is discontinued. As in the three other cases, cardiac and neurologic conditions markedly improved after bromocriptin's withdrawal. A pericardic thickening persists at the echography.

CONCLUSION

The responsibility of bromocriptin in the etiology of constrictive pericarditis is seldom discussed, because it remains an exclusion diagnosis. Periodic chest X-ray and echocardiography should be considered in patients with long-term bromocriptin treatment.

Treatment of Parkinson's disease with ropinirole after pergolide-induced retroperitoneal fibrosis

Pergolide is a dopaminergic agonist used to treat Parkinson's disease but is associated with the development of retroperitoneal fibrosis (RPF). Newer nonergot agents (pramipexole, ropinirole) may not carry this same risk. A patient with a history of pergolide-induced RPF was treated successfully with ropinirole for 1 year without complications.

Treatment of idiopathic retroperitoneal fibrosis by immunosuppression

Idiopathic retroperitoneal fibrosis is exceedingly uncommon in childhood and its etiology is uncertain. Support for an immunological basis for the disease is given by a report of a 14-year-old girl with severe retroperitoneal fibrosis causing progressive azotemia in whom azathioprine and prednisolone were used successfully. This case supports the efficacy of immunotherapy in the treatment of idiopathic retroperitoneal fibrosis.