Original ArticleLong-Term Follow-Up of Primary Medical Versus Surgical Treatment of Prolactinomas in Men: Effects on Hyperprolactinemia, Hypogonadism, and Bone Health
Introduction
Prolactinoma is the most common hormone-secreting pituitary tumor; however, diagnosis in men is far less frequent than in women.1 Late diagnosis and, therefore, macroprolactinomas are more common in men probably because of the more subtle symptoms in comparison with women. Prevailing symptoms are usually related to hypogonadism, including decreased libido, azoospermia, and sometimes erectile dysfunction.2 Osteopenia or osteoporosis is considered to be the principle consequence of prolonged hyperprolactin-induced hypogonadism in men.3, 4 Gonadal steroid deprivation increases bone resorption leading to impaired bone mineral density.5 Data on the long-term control of hyperprolactinemia, hypogonadism, and bone health in men with prolactinomas treated either primarily surgically or primarily medically are limited because medical therapy with dopamine agonists (DAs) is considered the first-line approach in micro- and macroprolactinoma.6 In this study, we investigated the long-term control of hyperprolactinemia, hypogonadism, and bone health after either treatment.
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Materials and Methods
We retrospectively evaluated the medical records of 44 consecutive men managed with primary medical therapy or surgical therapy at our institution between 1997 and 2010. Patients who met the inclusion criteria had not been treated with DAs prior to study entry and had documented long-term follow-up data (more than 12 months). All patients fulfilled the diagnostic criteria of a prolactin (PRL)-secreting pituitary adenoma (i.e., PRL levels >200 μg/L for macroprolactinomas and >30μg/L for
Patient Characteristics at Baseline
Patient allocation to the surgical or medical cohort did not show a significant selection bias for age, chief complaints, affected pituitary axes, bone health status, BMI, or median follow-up time. The number of microprolactinomas, macroprolactinomas, and tumors infiltrating the cavernous sinus was not significantly different between the medical and surgical cohorts (Table 1).
At baseline, serum PRL levels in patients with a macroadenoma were significantly higher than patients with a
Discussion
The main findings of this study can be summarized as follows. (1) After a mean follow-up of more than 7 years, PRL levels were within normal range in 86% of all patients, with persistent need for DAs in 53% of the patients with a primarily surgical approach and 90% of patients with a primarily medical approach. (2) The rate of hypogonadism significantly decreased in all patients; however, long-term testosterone substitution was required in 25% of them. (3) A pathologic bone health status
Conclusions
These data indicate that despite control of hyperprolactinemia and hypogonadism in most men independent of the primary treatment strategy, the prevalence of an impaired bone mineral density remains high, and as a result, osteodensitometry can be recommended.
Acknowledgments
The authors thank Edward R. Laws Jr., MD, FACS, Director, Pituitary and Neuroendocrine Center, Brigham & Women's Hospital, Boston, Massachusetts, USA, for his insightful suggestions, and Dr. Kush Kapur, Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts, USA, for statistical advice.
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Conflict of interest statement: This study is supported by the Swiss National Science Foundation (PBBEB-146099 and PBBEB-155299 to L. Andereggen).