Clinical Study Non-surgical management of cystic prolactinomas Biji Bahuleyan, Girish Menon * , Suresh Nair, B.R.M. Rao, H.V. Easwer, Kumar Krishna Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram 695 011, Kerala, India article info Article history: Received 1 February 2009 Accepted 18 March 2009 Keywords: Cystic Dopamine agonist Prolactinomas Treatment abstract Cystic prolactinomas are considered not amenable to dopamine agonist therapy. We present the results of dopamine agonist therapy in six patients with cystic prolactinomas. The inclusion criteria of patients were: (i) cystic macroadenomas with the cyst occupying more than 50% of the tumour volume; (ii) a serum prolactin value more than 150 ng/mL. All patients were males with a mean age of 35 years. The clinical presentations were erectile dysfunction in 66.6%, visual deficits in 50% and headache in 50% of patients. All patients were treated with bromocriptine only except one who was treated with both bro- mocriptine and cabergoline. The mean duration of follow up was 57.1 months. At the final follow-up 50% of patients had hormonal cure, 50% had radiological cure and 50% had reduction in the size of the tumour. Hence, it is appropriate to consider dopamine agonist therapy in patients with cystic prolactinomas before considering surgery. Ó 2009 Elsevier Ltd. All rights reserved. 1. Introduction Prolactinomas respond well to medical management and in re- cent years dopamine agonists (DA) have replaced surgery as the gold standard for the treatment of prolactinomas. 1 Unlike solid prolactinomas, their cystic counterparts are considered to respond less favorably to medical treatment and are managed surgically. 1–3 In the absence of large series of cystic prolactinomas (CP), ideal management protocols are yet to develop. We share our experi- ence with DA therapy in six patients with CP and discuss the man- agement issues. 2. Methods and materials Retrospective (January1995–December 2006) and prospective (January 2007 till date) analysis of patients with prolactinomas treated with DA who satisfied the following inclusion criteria were included in the study: (i) cystic macroadenomas with the cyst occupying more than 50% of the whole volume of the tumour; (ii) a serum prolactin concentration of more than 150 ng/mL. The case records, radiological images and laboratory reports were re- viewed. The patients were reassessed in the outpatient department and when possible, data were collected during a telephone conver- sation. The outcome was analysed by combining the various crite- ria proposed by Kreutzer et al., 1 Shrivastava et al. 4 and Serri et al. 5 Cure was defined as those patients with prolactinomas who, after DA therapy had been stopped for 3 months were: (i) symptom free (clinical cure); (ii) had a serum prolactin concentration of <23.6 ng/ mL (hormonal cure); and (iii) neuroimaging showed a total disap- pearance of the tumour (radiological cure). A total cure was de- fined as those patients who had attained a clinical, radiological and hormonal cure. 3. Results There were six males from 24 to 45 years old (mean 35.2 years) (Table 1). The commonest clinical presentation was erectile dys- function, seen in four (66.6%) patients. Three patients (50%) pre- sented with visual deficits and three (50%) had headache. There were four patients with Hardy’s stage C (patients 1–4), one with stage B (patient 5) and one with stage C/E (patient 6) in whom the lesion was extending to the right cavernous sinus. The location of the cystic component was either at the center of the lesion (Fig. 1A) with a rim of solid tumour in the periphery as seen in pa- tients 4 and 5, or at the superior aspect of the tumour (Fig. 1B) with the solid component inferiorly. In patient 5, the lesion mimicked a suprasellar aneurysm and an angiogram was done to rule out an aneurysm. The serum prolactin concentration of patients at first visit ranged from 347 ng/mL to 9780 ng/mL. At presentation, ser- um cortisol was low in three patients and serum thyroid functions were low in two. Serum testosterone level was conducted in two patients, both of whom were low or very low. A sperm count was done in three patients of whom one had azoospermia and the other two had oligozoospermia. All patients except patient 4 were treated with bromocriptine only at doses ranging from 7.5 mg/day to 10 mg/day. Patient 4 had undergone an aborted transcranial surgery at another centre followed by radiation 0967-5868/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2009.03.024 * Corresponding author. Tel.: +91 471 2524262; fax: +91 471 2559274. E-mail address: gmr@sctimst.ac.in (G. Menon). Journal of Clinical Neuroscience 16 (2009) 1421–1424 Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn