Aara Tabassum

[Aara Tabassum @aara_24]

Recurrence:
The following could be the possible reason for recurrence:
- Tumor may be multifocal in origin
- Recurrent hyperplasia

[Aara Tabassum @aara_24]

Prognosis:
Microprolactinomas have a good prognosis and prolactin levels normalize with treatment.
In macro prolactinoma, around 50% of patients are in remission after surgery.

[Aara Tabassum @aara_24]

Surgery/Radiation treatment:
Surgical treatment for prolactinomas are done when patients are resistant to medical therapy. Endoscopic endonasal transsphenoidal is the preferred method. Adjuvant radiation therapy should be considered for residual tumor.

[Aara Tabassum @aara_24]

Side effects of medications:
Nausea, vomiting, headache, constipation, dizziness, faintness, depression, postural hypotension, digital vasospasm and nasal stuffiness. All of the side effects, is mostly due to the lysergic acid part of the molecule.

[Aara Tabassum @aara_24]

Bromocriptine is preferred during pregnancy because of more favorable data than cabergoline.

[Aara Tabassum @aara_24]

Bromocriptine: This is a strong dopamine agonist which binds to dopamine receptor and directly inhibits PRL secretion. It acts by decreasing prolactin synthesis, DNA synthesis, cell multiplication and overall size of prolactinoma.

[Aara Tabassum @aara_24]

In stable patients who respond to therapy, prolactin level measurement at 6-12 monthly intervals is sufficient.

[Aara Tabassum @aara_24]

High doses of cabergoline (2600 to 6700 mg) in patients with Parkinson’s disease can have rare side effect of cardiac valve fibrosis.

[Aara Tabassum @aara_24]

Once PRL levels reach to the normal levels, then check PRL levels after every 3 to 6 months in the first year and then after every 6 to 12 months.
Patients with visual disturbances should assessed by regular vision evaluation and MRI.

[Aara Tabassum @aara_24]

Pituitary microadenoma: <10mm
Pituitary macroadenoma: >10mm
Adenomas can compress optic chiasma leading to bitemporal hemianopia.

[Aara Tabassum @aara_24]

Dosage of dopamine agonists:

- Cabergoline: 0.5-1mg/weekly, max. dosage: 4.5mg/week
- Bromocriptine: 2-15mg/day or 2.5-5mg/bd/daily

[Aara Tabassum @aara_24]

Radiological imaging can be repeated after 6-8 weeks of initiation of cabergoline therapy. On the other hand, in microprolactinoma, there is generally no need to repeat prolactin levels.

[Aara Tabassum @aara_24]

In macroprolactinoma: response to cabergoline therapy is generally relatively rapid (within weeks); normalisation (or drop) of prolactin levels provides a solid indication regarding therapeutic response.

[Aara Tabassum @aara_24]

In patients with a macroprolactinoma which shows growth during pregnancy, cabergoline can be initiated/continued. Cabergoline remains a safe option in pregnancy (especially from the 2nd trimester onwards) and should be tried even if the tumour shows signs of enlargement.

[Aara Tabassum @aara_24]

Cabergoline: Considered as the first line usually. This is more effective in suppressing prolactin and reducing tumor size.
Dose: 0.25mg twice per week, maximum dose of 1mg is given twice a week.

[Aara Tabassum @aara_24]

3. Hyperprolactinemia due to systemic disorders, drugs, pituitary hyper-secretion and hypothalamic-pituitary stalk damage: Treatment of underlying etiology

[Aara Tabassum @aara_24]

Management:
This can be divided into 3 groups:
1. Idiopathic or micro adenoma associated with hyperprolactinemia: Medical management is the mainstay.
2. Hyperprolactinemia with macroadenoma: Requires fertility management in combination of drugs and surgery/radiotherapy.

[Aara Tabassum @aara_24]

Serum prolactin levels are higher in the noon, so morning measurement is preferred. Hyperprolactinemia is defined as >20ng/mL in men and >25 ng/mL in women, measured at least 2 hours after waking. If levels not markedly raised, repeat testing is recommended before diagnosis.

[Aara Tabassum @aara_24]

it is important to recognize that the accuracy of MRI detection in microadenomas can vary based on several factors, as noted by Cano, A et al These include the magnetic field strength, the technique and time lapse between contrast administration and imaging data acquisition.

[Aara Tabassum @aara_24]

A pituitary microadenoma can be identified on MRI as:
T1 weighted images show microadenomas as isointense compared to surrounding normal pituitary. T2 weighted images may display a variable presentation.