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Table of Contents
LETTER TO THE EDITOR
Year : 2012  |  Volume : 16  |  Issue : 6  |  Page : 1052-1053

Rapid improvement in visual field with cabergoline in suprasellar tumor in a young adult: Clinical dilemma solved and surgery averted


Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantonment, India

Date of Web Publication31-Oct-2012

Correspondence Address:
M K Garg
Department of Medicine, Command Hospital (Southern Command), Pune 411040
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-8210.103043

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How to cite this article:
Kharb S, Pandit A, Garg M K, Brar KS. Rapid improvement in visual field with cabergoline in suprasellar tumor in a young adult: Clinical dilemma solved and surgery averted. Indian J Endocr Metab 2012;16:1052-3

How to cite this URL:
Kharb S, Pandit A, Garg M K, Brar KS. Rapid improvement in visual field with cabergoline in suprasellar tumor in a young adult: Clinical dilemma solved and surgery averted. Indian J Endocr Metab [serial online] 2012 [cited 2019 Dec 12];16:1052-3. Available from: http://www.ijem.in/text.asp?2012/16/6/1052/103043

Sir,

We report a case of suprasellar mass with visual compromise, hypogonadism and hyperprolactinemia, where weekly visual perimetry after dopamine agonist (cabergoline) therapy helped to differentiate between pituitary adenoma (macroprolactinoma) and craniopharyngioma with stalk compression syndrome. This case highlights the use of simple clinical test of visual perimetry to help in quick and reliable decision making, regarding surgery.

A 24-year-old male was presented to the neurosurgery department with a history of headache, diminution of vision of 4 months' duration. His MRI of the brain revealed 20 × 21 × 19 mm sized, well-defined, smoothly marginated ovoid lesion in suprasellar region diagnosed as craniopharyngioma [Figure 1]a and b. The lesion was compressing and displacing the optic chiasm and circle of Willis superiorly, pituitary gland and stalk inferiorly and supraclinoid internal carotid artery laterally. He was then referred to the endocrinology department for hormonal evaluation in view of suprasellar mass before transcranial removal of tumor. He also gave a history of decreased libido, decreased frequency of shaving and postural giddiness. His general and systemic examination was unremarkable except decreased bilateral lateral visual field. Sexual maturity score was of a normal adult (P5G5) and bilateral testicular volume was 20 ml. His hormonal profile revealed hypogonadotropic hypogonadism (LH/FSH - 3.02/2.43; S. testosterone - 0.5 ng/ml), secondary hypothyroidism (FT4 - 0.96 ng/ml; TSH - 0.01 μIU/ml), secondary adrenal insufficiency (basal and post-ACTH cortisol-2.29 / 12.3 μg/dl), and hyperprolactinemia (178 ng/ml; normal<25). His visual perimetry revealed bitemporal hemianopia with additional restriction of field of vision in left inferior quadrant [[Figure 2], baseline]. He was diagnosed as a case of macroprolactinoma with remote possibility of craniopharyngioma with pituitary stalk compression. We advised him to defer the surgery for 4 weeks and started on cabergoline with rapid increase to 0.5 mg twice-weekly alongwith thyroxin and hydrocortisone. After 2 weeks, there was subjective and objective improvement of vision. His visual perimetry showed bitemporal superior quadrantanopia with minimal involvement of inferior lateral quadrants [Figure 2]. In view of the dramatic response to dopamine agonists, we decided to hold the surgery and patient was continued on tab cabergoline and planned for follow-up after 4 weeks. After 6 weeks of exhibition of cabergoline, his repeat visual perimetry was near normal [Figure 2] and repeat MRI brain showed reduction in size of lesion (16 × 16 × 19 mm 3), with stalk [Figure 1]c and optic chiasma [Figure 1]d clearly visible to be separated from the tumor. His prolactin had normalized to 3.48 ng/ml and hypopituitarism completely recovered with hormonal parameters of LH/FSH/testosterone -8.44/4.95/4.9 ng/ ml; serum cortisol basal/post-ACTH -8.7 / 26.4 μg/dl and FT4 -2.33 ng/ ml (0.8-1.7), TSH -4.4 μIU/ml without any replacement.
Figure 1: Coronal and sagittal section in post-gadolinium T2W MRI before (a, b) and after 6 weeks (c, d) of cabergoline therapy. Pituitary stalk and optic chiasma are clearly visible and separated from tumor in image c and d, respectively

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Figure 2: Visual field by perimetry at baseline, after 2 and 6 weeks of cabergoline therapy

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Both neoplastic and non-neoplastic sellar masses may arise from regions within and adjacent to the hypothalamus and pituitary. Prolactin>100 ng/ml can be caused by prolactinoma, sellar masses with stalk compression and use of drugs. Prolactin levels above 250 ng/ml are almost exclusively caused by prolactinomas. [1] In our patient, possible causes of hyperprolactinemia were restricted to either a prolactinoma or suprasellar mass (? craniopharyngioma) with stalk compression.

Prolactinomas are the most common secretary pituitary adenomas. [2] Males usually present with macroadenomas, often with headache, visual symptoms, or both, in addition to hypogonadism. Non-functioning sellar masses also present with similar symptoms. In view of the diagnostic dilemma, we decided to expose our patient to dopamine agonist therapy (cabergoline). As the patient was quite apprehensive about finding of a tumor in the brain, and persistent headache and visual loss, he was explained about rationale of therapy to allay his anxiety. Though he had a diagnosis of craniopharyngioma with stalk compression, we decided to give a trial of dopamine agonist therapy to avoid unnecessary surgery with a view that it was prolactinoma. Classical differentiation between prolactinoma and suprasellar mass with raised prolactin levels is done by assessing decrease in the size of adenoma after dopamine agonist therapy as assessed by MRI of the brain after 1-3 months or visual perimetry after 2-3 months. [3],[4] We here, report this case where we followed-up our patient with visual perimetry to assess response to therapy very early during the course of the disease, thus the decreased time lag before taking the final decision. Visual perimetry is cheap, easily accessible, and has clinical correlate in form of visual confrontation test.This case also highlights rapid reversibility of hypopituitarism due to stalk compression which was confirmed on imaging.

 
   References Top

1.Karavitaki N, Thanabalasingham G, Shore HC, Trifanescu R, Ansorge O, Meston N, et al. Do the limits of serum prolactin in disconnection hyperprolactinaemia need re-definition? A study of 226 patients with histologically verified non-functioning pituitary macroadenoma. Clin Endocrinol (Oxf) 2006;65:524-9.  Back to cited text no. 1
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2.Klibanski A. Clinical practice. Prolactinomas. N Engl J Med 2010;362:1219-26.  Back to cited text no. 2
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3.Colao A, Vitale G, Cappabianca P, Briganti F, Ciccarelli A, De Rosa M, et al. Outcome of cabergoline treatment in men with prolactinoma: Effects of a 24-month treatment on prolactin levels, tumor mass, recovery of pituitary function, and semen analysis. J Clin Endocrinol Metab 2004;89:1704-11.  Back to cited text no. 3
[PUBMED]    
4.Acharya SV, Gopal RA, Menon PS, Bandgar TR, Shah NS. Giantprolactinomaand effectiveness of medical management. Endocr Pract 2010;16:42-6.  Back to cited text no. 4
[PUBMED]    


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