Prolactinomas in adolescent and elderly patients-A comparative long-term analysis

Predictors of favorable long-term outcomes in first-line surgery for microprolactinomas

PURPOSE

Opting for first-line surgery in carefully selected patients with microprolactinomas provides the advantage of avoiding long-term dopamine agonist (DA) medication and potential associated side effects. However, the lack of comprehensive long-term data poses a challenge in identifying those patients who would benefit the most from upfront surgery. To improve guidance in the selection process for microprolactinoma patients in clinical practice, we aimed to establish simple clinical and biochemical parameters predicting non-dependence on DAs.

METHODOLOGY

Retrospective analysis of a prospectively maintained database, focusing on patients with microprolactinomas who underwent upfront surgery. We assessed clinical and biochemical risk factors for the patients' reliance on DAs at their latest follow-up using regression analysis. We next proceeded to conduct Receiver Operating Characteristic (ROC) analysis to determine the optimal threshold cutoff prolactin (PRL) level for practical application in clinical settings that best differentiates between surgical long-term remission status and long-term dependence on DAs.

RESULTS

A microadenoma was observed in 46 patients, of whom 12 (26%) exhibited long-term dependence on DAs at a median follow-up of 78 months. Baseline PRL values were significantly higher in patients with long-term DA dependence compared to those without (p = 0.05). High baseline PRL values (HR 23.9, 95% CI 1.0-593.7, p = 0.05), but not the presence of headache or male gender, were identified as independent predictors of long-term dependence on DAs. PRL thresholds for discriminating long-term DA dependence were estimated to be 290 µg/L (AUROC = 0.73, 95% CI 0.55-0.92, p = 0.03; sensitivity = 90%, specificity = 80%).

CONCLUSIONS

In patients with microprolactinomas, first-line surgery presents a favorable prospect for reducing reliance on DAs. However, for those with high PRL levels ≥ 290 µg/L at diagnosis, first-line surgery is not recommended, as the majority of them require adjuvant DA therapy in the long term.

Gender differences in prolactin thresholds and their association with lactotroph adenoma invasiveness for potential treatment considerations

Recent trends in first-line transsphenoidal surgery (TSS) for prolactinoma patients aim to reduce long-term dependence on dopamine agonists (DA). Key factors linked to poor surgical outcomes include cavernous sinus invasiveness and high baseline serum prolactin (PRL) levels. Defining simple PRL threshold values to indicate invasiveness and inform treatment strategy is crucial. In this retrospective cohort study of 149 prolactinoma patients treated with first-line transsphenoidal surgery (TSS) or dopamine agonist (DA) therapy, we evaluated preoperative prolactin (PRL) levels and cavernous sinus invasion as factors associated with long-term remission. Bayesian modeling identified cohort-wide and gender-specific PRL thresholds associated with invasiveness. Preoperative PRL values strongly correlated with cavernous sinus invasion (AUROC = 0.95; 95% CI: 0.90-0.98). The cohort-wide PRL threshold was 431.9 µg/L (95% CI: 181.1-708.3 µg/L), with gender-specific thresholds of 280.8 µg/L (95% CI: 51.0-528.2 µg/L) for women and 1325.0 µg/L (95% CI: 667.2-2582.9 µg/L) for men. Female thresholds were lower and less affected by age and obesity, while male thresholds were influenced by these factors, particularly in young, obese men. These findings suggest that gender-specific PRL thresholds may be useful for improving specificity and sensitivity in identifying invasiveness, potentially aiding clinical decisions. Personalized treatment informed by preoperative biomarkers is essential for optimizing outcomes and reducing DA reliance, but it should be considered in conjunction with a comprehensive clinical evaluation.

Feasibility of Early Surgical Treatment for Adolescent Patients with Prolactinoma: A Case Report and Literature Review

Background and Objectives: Prolactinomas are the most common pituitary adenomas, comprising 30-50% of such tumors. These adenomas cause hyperprolactinemia, leading to decreased fertility, reduced energy and libido, and galactorrhea. Diagnosing and treating prolactinomas in adolescents present unique challenges, as symptoms may be confused with age-related developmental variations. This case report explores the outcomes of early surgical intervention in an adolescent with a prolactinoma. Materials and Methods: A 14-year-old female presented delayed menarche and absent pubertal development. Initial evaluation revealed hyperprolactinemia (228.37 ng/mL) with normal estradiol levels. Initial management through observation was adopted, but persistent amenorrhea and severe headaches prompted further investigation. Magnetic resonance imaging revealed a cystic pituitary mass with apoplexy. Due to concerns regarding delayed puberty and the need for rapid normalization of prolactin levels, the patient underwent transsphenoidal surgery. Results: After operation, prolactin levels normalized, menarche occurred within three months, and secondary sexual characteristics developed within eight months. Pathology confirmed a pituitary adenoma with a high Ki-67 index (15%). Conclusions: Early surgical intervention for prolactinomas in adolescents can achieve successful biochemical remission and resolution of endocrine symptoms. Adolescents, particularly those with a high Ki-67 index and potential resistance to dopamine agonists, may benefit from prompt surgical management, resulting in improved clinical outcomes and complete tumor resection.

Characteristics and outcomes of men with erectile dysfunction as the presenting symptom due to a lactotroph adenoma

PURPOSE

Erectile dysfunction (ED) is frequently underreported in men suffering from prolactinomas and can be challenging to manage. Both dopamine agonists (DAs) and transsphenoidal surgery (TSS) correct hyperprolactinemia and restore gonadal function. However, there is scarce data regarding their effectiveness in correcting ED over the long term.

METHODS

This study is a retrospective single-center comparative cohort study analyzing men diagnosed with prolactinomas, both with and without confirmed erectile dysfunction (ED) at diagnosis. Independent risk factors for persistent ED over the long term were examined using multivariate logistic regression.

RESULTS

Among the 39 men with lactotroph adenomas, ED was one of the presenting symptoms in 22 (56%). The mean age at diagnosis was 45 ± 12 years. Surgery was the primary treatment in 6 (27%) ED patients and 8 (47%) non-ED patients. After a mean follow-up of 74 ± 48 months, remission from hyperprolactinemia was achieved in the majority (76%) of men: 71% in the non-ED cohort and 81% in the ED group (p = 0.70), regardless of the primary treatment strategy (surgical 84% versus medical 72%, p = 0.46). Long-term remission of ED was noted in 16 (73%) patients. Interestingly, high baseline BMI levels emerged as potential risk factors for persistent ED over the long term (OR 1.4, 95%CI 1.0-1.9; p = 0.04), while neither the initial adenoma size nor the primary treatment strategy (i.e., TSS vs. DAs) reached statistical significance.

CONCLUSIONS

Correcting hyperprolactinemia and its associated hypogonadism significantly improves ED in the majority of men with prolactinomas over the long term, regardless of the primary treatment strategy employed. In addition to addressing endocrine deficiencies, the early initiation of weight control programs may be considered for men with lactotroph adenomas and ED. Although our study suggests an association between BMI and the risk of persistent ED, further research is needed to establish any causal relationships.

The diagnostic yield of inferior petrosal sinus sampling in Cushing syndrome in the era of ovine CRH shortage

PURPOSE

The ovine corticotropin-releasing hormone (oCRH) stimulation test has been routinely used in the diagnostic work-up of ACTH-dependent Cushing syndrome (CS). With oCRH currently being out-of-stock in Europe, we aimed at evaluating the diagnostic performance of inferior petrosal sinus sampling (IPSS) without oCRH stimulation.

METHODS

We compared the values of 40 patients with ACTH-dependent CS and negative MRI findings in whom ACTH was measured before and after oCRH stimulation.

RESULTS

The ratio of central-to-peripheral ACTH measurement (IPS:P) before the combined 3, 5, and 10 min of oCRH stimulation yielded diminished sensitivity (85% vs. 97%), alongside markedly decreased specificity (57% vs. 71%), as well as reduced positive and negative predictive values (90% vs. 94% and 44% vs. 83%), respectively.

CONCLUSIONS

With the current drug shortages in Europe, ACTH measurements without oCRH stimulation in IPSS cannot be recommended. Thus, we call for desmopressin or the commercially available human CRH as a potential alternative in the confirmation of ACTH excess by IPSS in equivocal MRI findings.