Macroadenoma of the pituitary gland with moderate hyperprolactinaemia

HISTORY AND CLINICAL FINDINGS: A 46-year-old woman was referred to the neurosurgery department for treatment of a macroadenoma of the pituitary. She had complained of recurrent galactorrhoea for 7 years; a hysterectomy was performed 4 years ago. The clinical investigation was unremarkable, except for a slight galactorrheoa on both sides. INVESTIGATIONS: The endocrinological work-up revealed a moderately elevated prolactin level of 3133 mU/l (147 ng/ml) with intact pituitary functions. She had no visual impairment and the MRI depicted a pituitary tumor with a maximal diameter of 1.9 cm and both intra- and suprasellar extension. DIAGNOSIS, TREATMENT AND CLINICAL COURSE: The diagnosis of a nonfunctioning macrodenoma with functional hyperprolactinemia was made and a selective transsphenoidal adenomectomy was performed. The primary histology showed a chromophobe adenoma. However, additional immunohistological investigations revealed distinct staining for prolactin. In the meantime, because of persistent galactorrhea and elevated prolactin levels, treatment with cabergolin 0.5 mg/week was started. This stopped galactorrhea and normalized the prolactin levels. A follow-up MRI after 3 months of treatment showed a significant shrinkage of the residual tumor. CONCLUSION: This case demonstrates that the differential diagnosis of macroprolactinoma with low secretory activity and functional hyperprolactinemia is very difficult preoperatively in individual cases. This is relevant because macroprolactinomas with low secretory activity can also be treated successfully with dopamine agonists. We therefore suggest a drug treatment trial with dopamine agonists in all macroadenoms with hyperprolactinemia, particularly in those with prolactin levels above 2000 mU/l (100 ng/ml).