Paradigm Shift in the Management of Prolactinoma: Is Primary Surgery Better than Medical Management in Select Patients?

Abstract

Prolactinomas, benign hormone-secreting tumours of the anterior pituitary, are traditionally treated with dopamine agonists (DAs), such as cabergoline, due to their high efficacy in normalizing prolactin levels, alleviating symptoms, and reducing tumour size. However, DA therapy often necessitates long-term use, with potential adverse effects and variable remission rates after discontinuation. Surgical resection, primarily via endoscopic transsphenoidal approaches, offers an alternative and increasingly reconsidered option. This review explores the evolving paradigm in prolactinoma management, emphasizing primary surgery’s role in select cases. Surgery demonstrates high remission rates, especially for Macroprolactinoma and non-invasive macroprolactinomas, and presents the potential for a permanent cure. Expanding indications for surgery include DA resistance, intolerance, patient preference, and certain tumour characteristics. Advancements in surgical techniques and improved outcomes further support its use. The review underscores the importance of individualized treatment plans, considering tumour characteristics, patient factors, and the expertise available. Future clinical trials comparing surgical and medical approaches aim to refine evidence-based pathways in prolactinoma care.