Prolactinomas are the most common functional pituitary adenomas, comprising 40% of all pituitary adenomas. There are consensus guidelines and several common management pathways. This article discusses the role of surgery for these patients. Following diagnosis, the goals of treatment are to prevent neurologic morbidity and to restore endocrine function. Medical management with a dopamine agonist (DA) is the optimal first line treatment for many patients. The authors describe several subsets of patients that may require surgical management. Surgery as a first-line therapy is recommended prior to a trial of DA in patients presenting with apoplexy or acute onset of neurologic deficits including visual loss, patients who are more likely to have possible stalk effect but with whom diagnostic uncertainty exists, or patients who have a cystic prolactinoma. However, it is of note that recent studies have questioned whether cystic prolactinoma patients undergo DA therapy first when they are without chiasmatic compression or neurologic deficit. Surgery as a second-line therapy for patients previously treated with DAs fall under the broad categories of DA therapy intolerance, DA therapy treatment failure or surgery for recurrent and aggressive prolactinomas. Side-effects of cabergoline (DA) include headache and rarely adverse events such as intratumoural haemorrhage and CSF leak. The authors’ experience of surgical resection indicates that most surgery is performed following DA trial, with the commonest indications of DA intolerance, DA failure or both. Aggressive prolactinomas are uncommon, they rarely progress to pituitary carcinomas. Multimodal treatment is often considered in these cases including radiotherapy, chemotherapy and metastases en bloc resection.
To summarise, prolactinomas represent a common, but complex neuroendocrine challenge requiring specialist multidisciplinary teams.
The majority can be managed medically but there is a clear role for surgery in select patients.