Multidisciplinary Treatment of Giant Prolactinoma in Young Adult

https://doi.org/10.25143/rsu-bjcmr.2024.01.038-040

Abstract

Key words. giant prolactinoma, hyperprolactinemia, neurosurgery.

Introduction. Prolactinomas are characterized by their hormonal activity and size. Tumors above 4 cm are considered giant (they form less than 1% of all pituitary tumors), which are challenging to manage, because of extreme hyperprolactinemia and tumor tissue compressing optic chiasm and invading cavernous sinus [1].

Case Description. An 18-year-old male patient sought help from an ophthalmologist after two months of severe vision loss (VOS=0.01, VOD=0.1). In November 2021 performed exams, such as MRI and blood tests, showed further results: left optic nerve compression due to giant intrasellar lesion (61.5 cm³) with blood prolactin 358071.00 mU/I (norm – 89-365 mU/I), leading to diagnosis of giant prolactinoma.

Total tumor resection was technically impossible, so a combination of surgical and pharmacological therapy was chosen. First, the patient was treated with Cabergoline (2x/week) which decreased prolactin concentration to 107175.00 mU/I in two weeks, tumor shrank from 5.1x4.9x4.7 cm (61.5cm³) to 4.5x4.3x3.6 cm (36.5 cm³) and the patient regained his vision totally. Three weeks after diagnosis, routine microscopic transsphenoidal adenomectomy was performed to decompress optic chiasm and reduce hormone secreting mass. Surgeons removed tumor mass of 1.6 cm³. Histological findings confirmed the diagnosis of prolactinoma. Surgery led to a decreased prolactin concentration of 45977.97 mU/I. Due to still high levels of prolactin, Cabergoline treatment was continued, the dose increased from 0.25 micrograms to 0.25 milligrams two times a week. A year after, prolactin concentration gradually decreases, vision is normal and follow-up MRI shows only 3.3x2.1x1.8 (6.5 cm³) of tissue remnants. The patient continues the use of Cabergoline, now 1 milligram two times a week.

Summary. An 18-year-old male patient with giant prolactinoma showed a significant positive response to combined pharmacological and surgical therapy (decreased tumor size, prolactin secretion and optic nerve compression) in brief period.

Conclusion. Giant prolactinomas are known for their immense hormonal activity, which cannot be controlled with either only surgery or pharmacological treatment [2]. Despite general practice of conservative surgical prolactinoma treatment [3], this case displays the importance of combined surgical and pharmacological therapy.

Referances:

1. Subasinghe CJ, Somasundaram N, Sivatharshya P, Ranasinghe LD, Korbonits M. Giant Prolactinoma of Young Onset: A Clue to Diagnosis of MEN-1 Syndrome. Case Rep Endocrinol [Internet]. 2018 Aug 14 [cited 2023 May 3];2018:1–6. Available from: https://pubmed.ncbi.nlm.nih.gov/30186640/
2. Cho EH, Lee SA, Chung JY, Koh EH, Cho YH, Kim JH, et al. Efficacy and Safety of Cabergoline as First Line Treatment for Invasive Giant Prolactinoma. J Korean Med Sci [Internet]. 2009 Oct [cited 2023 May 3];24(5):874. Available from: /pmc/articles/PMC2752771/
3. Song YJ, Chen MT, Lian W, Xing B, Yao Y, Feng M, et al. Surgical treatment for male prolactinoma: A retrospective study of 184 cases. Medicine [Internet]. 2017 [cited 2023 May 3];96(2). Available from: https://pubmed.ncbi.nlm.nih.gov/28079813/