Problems in the management of large prolactin-secreting pituitary adenomas

Objective: To determine current problems in the management of large prolactin-secreting pituitary adenomas. Design: Retrospective study of consecutive patients with prolactin-secreting adenomas over a 10-year period. Setting: Neurosurgical Division of King Khalid University Hospital, Riyadh, Saudi Arabia. Subjects: Thirty-one patients, four with microadenomas and 27 with macroprolactinomas. Interventions: Tumour resection was performed in 22 patients: transsphenoidal in 16 and transcranial in six. Six patients were treated conservatively (dopamine agonist alone in five cases, and combined with radiotherapy in one). Three patients refused surgery and were excluded. Main outcome measures: Surgical morbidity and mortality, postoperative basal prolactin level. Results: Six patients (27%) became normoprolactinaemic directly after surgery; 14 patients required additional postoperative treatment. The overall rate of return of serum prolactin level to normal at last follow-up was 71%. Hyperprolactinaemia was significantly reduced in a further 21% of the patients while the remaining 8% were unchanged. One patient died 40 days after transcranial surgery. Two patients developed tumour recurrences and hyperprolactinaemia relapsed in a third patient with no evidence of tumour regrowth. Conclusion: The failure rate of monotherapy in large prolactin-secreting adenomas is high. At present, the combination of transsphenoidal surgery and dopamine agonist therapy provides the highest control rates of the tumour and the associated hyperprolactinaemia.