From the Guidelines
The goal that is not a part of prolactinoma surgery is preventing malignant transformation. Prolactinomas are benign pituitary tumors that secrete prolactin, and they very rarely undergo malignant transformation 1. Surgery for prolactinomas is primarily aimed at:
- Restoring normal hormone levels by removing the tumor tissue that is overproducing prolactin
- Improving visual defects caused by compression of the optic chiasm
- Relieving symptoms of increased intracranial pressure such as headaches The first-line treatment for prolactinomas is actually medical therapy with dopamine agonists like cabergoline or bromocriptine, which can normalize prolactin levels and reduce tumor size in most patients 1. Surgery is typically reserved for cases where medical therapy fails, patients cannot tolerate medication side effects, or there is significant compression of surrounding structures causing neurological symptoms 1. The risk of malignant transformation in prolactinomas is extremely low, making this an unnecessary goal for surgical intervention.
According to the consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence, surgery is considered if vision deteriorates or does not improve on medical therapy or if dopamine agonist resistance, escape or intolerance occurs 1. Transsphenoidal surgery induced remission in 30–50% of adults with prolactinomas and any residual post-operative hyperprolactinaemia was subsequently more responsive to dopamine agonists than pre-operatively 1. However, the primary goal of surgery is not to prevent malignant transformation, but rather to alleviate symptoms and improve quality of life by restoring normal hormone levels and relieving compression of surrounding structures.
In terms of treatment outcomes, the guideline recommends careful multidisciplinary discussion if the patient expresses a preference for surgery rather than long-term medication or is non-adherent to the latter 1. Radiotherapy should be reserved for exceptional patients with a growing prolactinoma and where other treatment modalities are not available or have been exhausted 1. Overall, the goal of preventing malignant transformation is not a primary objective of prolactinoma surgery, and treatment decisions should be based on individual patient needs and circumstances.
From the Research
Goals of Surgery for Prolactinoma
The goals of surgery for prolactinoma include:
- Restoring normal hormone levels 2, 3, 4, 5, 6
- Improving visual defects 3, 6
- Preventing signs and symptoms of increased intracranial pressure 3, 6
Non-Goals of Surgery for Prolactinoma
- Preventing malignant transformation is not a primary goal of surgery for prolactinoma, as prolactinomas are typically benign tumors 2, 3, 4, 5, 6
Key Considerations
- Surgery can be an effective treatment option for prolactinomas, particularly for non-invasive tumors 4, 5
- The decision to undergo surgery should be made on an individual basis, taking into account the patient's specific circumstances and the availability of skilled and experienced pituitary surgeons 4, 5, 6
- Dopamine agonists remain a reliable mode of therapy for most prolactinomas, but surgery can be a viable alternative for some patients 3, 4, 5, 6