Prolactinoma1 PDF
Prolactinoma1 PDF
Prolactinoma1 PDF
Prolactin
Is a polypeptide hormone containing 198 amino acids and having a molecular weight of 22,000 daltons
It circulates in different molecular sizesa (small) form (mol wt 22,000), a (big) form (mol wt 50,000), and an even larger (big-big) form (mol wt >100,000) The small form is biologically active, and about 80% of the hormone secreted is in this form
Prolactin
Discovered by Sticker 1928 (Veterinarian) It is one of the stress hormones It has a short half-life (20 min) Sleep-related circadian rhythm , highest in the
early morning & lower in the afternoon
Prolactin
PIF:
Dopamine Gonadotropin-associated peptide (GAP) Gamma aminobutyric acid (GABA)
PRF
TRH VIP Peptide histidine methionine (PHM)
Etiology of Hyperprolactinemia
Pituitary disease
Hypothalamic disease
Craniopharyngiomas Meningiomas Dysgerminomas Non-secretory pituitary adenomas Other tumors Sarcoidosis Eosinophilic graniuloma Neuraxis irradiation Vascular Pituitary stalk section
Medications
Tricyclic antidepressants
Neurogenic
Other
Idiopathic hyperprolactinemia
One third, prolactin levels return to normal 10-15% of patients, rise in prolactin levels to more than 50% over baseline Over 2-6 yr follow up, evidence of microadenomas developed in 10% of patients
Clonal proliferation of a single mutated cell Pituitary tumor transforming gene (PTTG), localized to chromosome 5q33 Correlate with tumor invasiveness in hormone-secreting adenomas Prolactinomas occur in 20% of patients with MEN type 1 More aggressive than sporadic prolactinomas Risk of progression from microadenoma to macroadenoma is only 7% One third return to normal levels
Manifestation of hyperprolactinemia
In Females :
Galactorrhea (Non-puerperal lactation) Unilateral or bilateral Free floating or expressive Continuous or intermittent Ovulatory dysfunction Oligo-ovulation LPD Anovulation Menstrual troubles Oligomenorrhea Hypomenorrhea Amenorrhea
Osteoporosis Nervous manifestations ( headache ) Visual field defects ( Bitemporal Hemianopia ) Hirsutism
Osteoporosis Nervous manifestations ( headache ) Visual field defects ( Bitemporal Hemianopia ) Hirsutism In men: Impotence Oligospermia Gynecomastia Headache Osteoporosis Visual field defects
Diagnosis of Prolactinomas
Prolactin is secreted episodically Nonsecreting tumor causing modest prolactin elevations (usually < 150 ng/ml) Prolactin-secreting macroadenoma (prolactin levels usually > 250 ng/ml) Although modern high-speed helical CT scanners produce very detailed images
MRI is the imaging study of choice
A "giant" prolactinoma
Treatment of Prolactinomas
Observation
Effects of tumor size or effects of hyperprolactinemia 93% microprolaactinomas do not enlarge over 4-6 yr period of observation If prolactin levels rise significantly, repeat scanning 7% will grow to be a macroadenoma Other indications for therapy: decreased libido, sexual dysfunction, menstrual dysfunction, galactorrhea, infertility, hirsutism, premature osteoporosis Without therapy, prolactin levels may return to normal in about one third of patients
Management
Remember that there are four main known causes of hyperprolactinemia
1. 2. 3. 4. Pregnancy Drug use Hypothyroidism Pituitary tumors
Remember that it is not essential to treat asymptomatic hyperprolactinemic women but followup is a must
Dr. Mohammed R. Zughbur
2. 3.
Medical Therapy
Dopamine agonists
Agonist Bromocriptine (Parlodel) Lisuride (Dopergine) Quinagolide (Norprolac) Cabergoline (Dostinex)
Dr. Mohammed R. Zughbur
Ergot
Ergot
25-300 g/day
0.25-1 mg/TWW
75 g/day
1 mg/week
Most common side effects: nausea and vomiting 3-5% Usually transient but may recur with each dose increase Orthostatic hypotension Digital vasospasm, nasal congestion and depression Minimized by starting with 1.25 mg/d with snack at bedtime Gradually increased to 2.5 mg bid with meals over 7-10 days Higher than 7.5 mg/d usually does not necessary Psychotic reaction 8 of 600 patients, resolve within 72 h of discontinuing the medication
Pituitary Surgery
Transsphenoidal approach:
used for 95% of pituitary tumors
Surgery
Transpheoidal surgery mainly, craniotomy rarely Recurreeence of hyperprolactinemia often occurs within first yr Recurrence rates for microadenomas (21%) and macroadenomas (20%) Long-term surgical cure rate is about 50-60% for microadenomas and 25% for macroadenomas
Radiation Therapy
Reserved for patients with larger tumors and/or persistent hormonal hyperfunction despite surgical intervention
Conventional radiotherapy Gamma knife radiosurgery