Issues and questions to be addressed in this approach to long-term management of prolactinomas include the frequency of radiographic monitoring, effect of pregnancy and menopause, safety of estrogen in women taking oral contraceptives, and the potential for discontinuation of dopamine agonist therapy 1).
Although transsphenoidal surgery (TSS) is an option for prolactinoma treatment, it is less effective than medical management, carries considerably more risk, and is more expensive. The benefit/risk ratio for DA therapy compared to TSS actually becomes increasingly more favorable as tumor size increases. Therefore DA should remain the clear treatment of choice for essentially all patients with prolactinomas, reserving TSS as a second-line option for the very small number of patients that do not tolerate or are completely resistant to DA therapy 2).
Surgery is typically necessary in patients refractory to DA or other medical therapies, or in emergency situations in patients presenting with pituitary apoplexy and rapidly progressing neurological symptoms due to mass effect.
Surgery provides the additional benefit of sampling the tumor pathology and a means to gauge the aggressiveness of the tumor, which may be evident on histopathology. It also allows for an immediate decrease in the mass effect and tumor burden. Increasingly, these tumors are being treated using the endoscopic endonasal technique. In the large cohort of 200 patients, Dehdashti et al. treated 25 prolactinomas with endoscopic endonasal surgery with a 92 % gross total resection rate and 88 % remission rate 3).
The underlying decision to perform serial imaging in prolactinoma patients should be individualized on a case-by-case basis. Future studies should focus on alternative imaging methods and/or contrast agents 4).