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Table of Contents
LETTERS TO THE EDITOR
Year : 2020  |  Volume : 24  |  Issue : 2  |  Page : 217-219

An interesting case of cystic prolactinomas


Senior consultant, Endodiab Clinic, Kozhikode, Kerala, India

Date of Submission18-Feb-2020
Date of Decision19-Feb-2020
Date of Acceptance19-Feb-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Raju A Gopal
Senior consultant Endocrinologist , Endodiab Clinic, 3rd Floor, Sheikh Square, Parayencheri, Kozhikode - 673 016, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijem.IJEM_86_20

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How to cite this article:
Gopal RA, George J. An interesting case of cystic prolactinomas. Indian J Endocr Metab 2020;24:217-9

How to cite this URL:
Gopal RA, George J. An interesting case of cystic prolactinomas. Indian J Endocr Metab [serial online] 2020 [cited 2020 Jun 2];24:217-9. Available from: http://www.ijem.in/text.asp?2020/24/2/217/283569



Sir,

Herein, we are describing a 52-year-old lady presented with blurring of vision for past 3 weeks presented to an ophthalmologist. Her evaluation showed optic atrophy in the left eye and hemianopia on the right side. MRI brain was ordered and it showed a pituitary macroadenoma along with suprasellar extension with a cystic area in the upper portion of macroadenoma [Figure 1]. She was referred to a neurosurgeon and he further referred her for endocrinology consultation. She was advised transsphenoidal surgery. However, due to financial constraints, she did not undergo surgery.
Figure 1: MRI pituitary with contrast- Before treatment - Sagittal view

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She was referred for review endocrine opinion. On enquiring further, she reported having a recurrent headache but no vomiting. She was postmenopausal and her prolactin level was 4549 ng/mL. Her thyroid function test was T3 83 ng/mL, T4 6.4 mcg/Dl and TSH 1.41, cortisol 10.8 mcg/dL, FSH 1.57 mIU/mL, and LH 0.1 mIU/mL.

MRI showed a sellar mass of 3.5 × 2.5 × 2.9 cm, superiorly compressing optic chiasma and bilateral cavernous sinus invasion. In addition, the superior aspect of the tumor had a non-contrast enhancing area, probably cystic area [Figure 1] and [Figure 2].
Figure 2: MRI pituitary with contrast- Before treatment- Coronal view

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After cautioning her about the success rates with medical therapy and carefully keeping her under observation for further worsening of eye symptoms, cabergoline 0.5 mg daily for 4 days was started. After 4 days, her visual symptoms were slightly better and her serum prolactin was 58 ng/mL; hence, the same dose of cabergoline was continued for 10 more days. After 2 weeks of the start of treatment, her diplopia completely subsided and vision improved. Ophthalmology review revealed better vision in the right eye; however, the field of vision could not be mapped. Her prolactin levels were 3.1 ng/mL and cabergoline dose was reduced to 1 mg thrice a week.

After one month, her prolactin level was 14 ng/mL and ophthalmology review showed visual acuity of 6/6 and significant improvement in the field of vision.

After 2 months her prolactin level was 0.97 ng/mL and cabergoline was reduced to 0.5 mg weekly twice and MRI was repeated. It showed sellar lesion reduced in size to 2 × 2.2 × 2.2 cm and cystic lesion completely disappeared [Figure 3] and [Figure 4].
Figure 3: MRI pituitary with contrast- After treatment- Sagittal view

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Figure 4: MRI pituitary with contrast- After treatment- Coronal view

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Now after 6 months her eye symptoms and headache completely recovered and presently she is on cabergoline 0.5 mg weekly once.

Most of the prolactinomas are microadenomas which are more common in females; males, on the contrary, harbour more macroadenomas. Cystic prolactinomas are prolactinomas that harbor cystic regions, usually occupying ≥50% of the tumor volume. According to the pituitary society guidelines, surgery should be considered as a treatment for cystic macroadenomas causing neurological symptoms.[1] It is hypothesized that dopamine agonists are ineffective in reducing cystic tumor mass due to the absence of dopamine receptors in the cystic portion of the tumor.

In a recent review of cystic prolactinoma patients, 80% with compression of the optic chiasm evident on MRI (mostly without visual field defect) at presentation achieved resolution of chiasm compression with medical treatment.[2] In a large series of patients, the majority (80%) of the patients who presented chiasm compression and visual field impairment had undergone transsphenoidal surgical resection.[3]

Present guidelines recommend medical treatment of cystic prolactinoma and surgery is indicated only in case medical treatment fails or develops drug intolerance. However, patients with optic chiasma compression, surgery is the first-line of management.[2]

Here, we report a patient who had a macroprolactinoma with a cystic component on the superior aspect with optic chiasma compression and visual symptoms who were treated with cabergoline and had effective tumor reduction and resolution of visual symptoms. Interestingly, the cystic component of the tumor disappeared during repeat imaging done after 2 months.

Our patient demonstrates that even in patients with cystic prolactinomas with optic chiasm compression and visual impairment, a short trial with a dopamine agonist may be tried before proceeding with transsphenoidal surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Casanueva FF, Molitch ME, Schlechte JA, Abs R, Bonert V, Bronstein MD, et al. Guidelines of the pituitary society for the diagnosis and management of pro- lactinomas. Clin Endocrinol 2006;65:265-73.  Back to cited text no. 1
    
2.
Akhleh A, Shehadeh N, Hochberg I, Zloczower M, Zolotov S, Taher R, et al. Management of cystic prolactinomas: A review. Pituitary 2018;21:425-30.  Back to cited text no. 2
    
3.
Faje A, Chunharojrith P, Nency J, Biller BM, Swearingen B, Klibanski A, et al. Dopamine agonists can reduce cystic prolactinomas. J Clin Endocrinol Metab 2016;101:3709-15.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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