The aim of treatment of any Pituitary macroadenoma is to achieve cure, since this could be achieved by medical therapy alone in macroprolactinomas, it is worthwhile to treat with dopamine agonists first. This is in contrast to other pituitary macroadenomas. Also, initiating medical treatment in macroprolactinomas with pressure symptom concerns allows reduction in the size of the mass, allowing a better chance for resection of the tumor in cases where surgical intervention is necessary.

Bromocriptine, lisuride and cabergoline in increasing doses to obtain the normalization of prolactin levels and reducing the volume of the adenoma. Also surgery for resection of the adenoma may be indicated (the nasal region) .

the pituitary macroadenoma warrats treatment with a dopamine agonist specially the more potent ones like cabergoline and only few indications warrant durgery -only if mri shows near cavernous sinus and levels of prolectin -sometimes a macroprolactinoma may be secreting prolactin but it maY NOT BE TYPICAL prolactin secreting macroprolactinoma which secrete prolactin in thousands and when impinging on a vessel and levels of prolactin much higher their are very rare indications except if sudden visual loss or MRI shows affect on optic tracts and visual fields affected

dependind onb cavernous sinus involvement or not and ensuring that actually it is a mactoprolactinoma in case of macroprolactinoma the treatment of choice remains dopamine agonistr -earlier with less experience with cabergoline bromocriptine was preferred due to risk of teratogenicitry in women of reproductive age but now caberline has shown to be sdafe and one needs to monitor these prolactinomas very carefully dfuring pregnancy and sudden visual loss is only one of few indications when pregnancy may need to be terminated otherwise pregnancy goes uneventfully.without any neurodurgery ever being required .

i disagree on the point as most microadenomas go unnoticed and are the ones which can be ignored and by the aiythority bon ptolactinomas MOLITCH me only dopamine agoniusts is required for women where prolactin levewls are over 100ng/ml since it interferes with fertility otherwise one can just ignore them and on post,ortem one finds silent micrprolactinomas in so many case so neurosyrgery is an invasive technique why go for it when not required.

Dopamine agonists(specially cabergoline) in increasing doses are usually successful in reducing tumor size and PRL secreting in majority cases.Neurosurgery is the second line therapy

I'm not an MD, rather a pituitary tumor researcher, but have worked closely with neurosurgeons and happen to know patients with prolactinomas. From what I am able to understand, both the neurosurgeons and patients prefer first treating with bromocriptine or either drug treatment, so long as the macro-prolactinoma isn't compressing the optic nerve or causing pain some other way. The surgeries for pituitary tumors have their risk, and even if the neurosurgeon is highly trained, patients tend to avoid this surgery type for fear of losing sight because of unexpected errors in the surgery that could affect the optic chiasm. As other mentioned (like Aldona), surgery is second line therapy, and I feel that taking the patients' preference with this is also very important.

Even a visual loss might have a good chance to improve on dopamine agonists therapy. Therefore, surgery should be reserved for refractory courses of the disease despite adequate escalation of medical treatment. Admittedly, the matrix of the prolactinoma turns tenaciously during therapy with dopamine agonists, making any resection challenging especially if the tumor is invading the cavernous sinus. interestingly, we found in some pituitary apoplexes an underlying prolactinoma in the immunohistochemical analysis. Yet, we could not find any correlations which prolactinomas would be prone to hemorrhage and which would not.

There is a vast body of evidence to favor dopamine agonist treatment in prolactinomas, cabergoline being the drug of first choice (except maybe in pregnant women, however, there is a growing body of evidence for cabergoline in pregnancy, see Maiter and Primeau). Treatment is especially well shown in the "Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas" which presents a simple treatment algorithm as a flow chart (fig. 2). I can also highly recommend the review article by Colao and Savastano published in Nature Reviews Endocrinology (that always features high-quality reviews).

Surgical cure is seldomly needed as first-line therapy. In experienced hands (see publication by Kreutzer et al.) it is a viable option with comparable results to medical treatment. However, overall success of neurosurgical cure of prolactinoma is inferior to medical treatment and recurrence rate is high; only the most experienced neurosurgeons can match medical treatment of prolactinomas. Interestingly, over the course of time, the indication for neurosurgical intervention of prolactinomas has shifted with lesser "classically indicated" operations towards a higher amount of surgeries performed due to patient's preference.

In essence, to answer your question:

Start with medical treatment in almost all cases. Consider first-line surgical intervention if there is apoplexy with neurological signs (emergency!) or a cystic macroprolactinoma with neurological signs (medical treatment response may be limited).

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Dopamine agonists are currently the primary treatment for patients with prolactinomas and bromocriptine has been the dopamine agonist of choice for a long time. However, side effects such as nausea, vomiting or postural hypotension associated with a relatively short half-life, which required frequent daily administrations, made the compliance to bromocriptine difficult. For this reason cabergoline (CAB) gradually replaced bromocriptine as the drug of choice, because of its efficacy, safety and very simple modality of treatment. CAB was shown to be effective, probably due to its better tolerance, in several bromocriptine-resistant prolactinomas. In my opinion cabergoline (CAB) treatment is an effective, safe and well tolerated approach also for patients with macroprolactinoma and both serum prolactin decrease and tumor size reduction has been reported in a large number of cases, also in patients previously untreated with other hypoprolactinemic drugs, neurosurgery or radiotherapy. Moreover, the decrease of hyperprolactinemia and the shrinkage of the tumor size are followed by the return of menses or potency and by the amelioration of other clinical symptoms in most treated patients.

The decrease of serum PRL levels, the tumor shrinkage, the long-lasting inhibition of PRL values after drug withdrawal and the absence of risks for pregnancies suggest that CAB can be considered a first-choice treatment for patients with PRL-secreting pituitary adenoma.

i tend to agree more with what Lorenzo Curto HAS STATED THAN with Sylvere Stermans opinion and agree with bromocriptine postural hypotension is a big troublesome complication and since many trials say no teratogenicity and convenience and marked efficacy and personally treating so many cases i agree currently cabergoline is the drug of choice and occasionaklly surgery is required for vsome patients having very high levels which is only when cavernous sinus is being approached.

I agree that medical treatment - with the aforementioned exceptions - has a clear priority in the management of prolactinomas. But I would like to ask the group on another question: how long do you wait to decide if a patient is a responder or non-responder to medications? In patients with visual defects this might be very essential issue.

I SUPPOSE NOT MORE THAN 6 months if their is no shrinkage of thumour on MRI and compression of optic tracts remains same ,but if evidence of response one can podtpone.

I agree that cabergoline gives very good results in treating hyperprolactinemia. Increasing the dose gradually is very important. It also helps to reduce the tumor size before surgery.  

Medical treatment first line anyway. But not in cases of cystic tumours and apoplexy.

The main question for prolactinomas - to define resistant case as soon as possible.

That's why medical treatment of prolactinomas it is not so simple as it seems, and always must be under neurosurgical supervision.

If there is no sign of pituitary apoplexy or visual loss and if the tumor is not compressing or making a neurological sign Dopamine agonist therapy may be the first choice. A big percentage of patients respond very well to medical therapy. But I always tell my patients the side effects of the drug first and try to begin with low doses. If the tumor shrinkage is not achieved after six months surgery should be recommend even if the patient thus not want to go to surgery. The advantages of drug therapy and surgery should be spoken with the patient at each step.  

but very important to counsel the disadvantages of surgery along ewith the mwdical therapy since most og the actual macroprlactinomas respond not only to doipamine agonists but seem to undergo pregnancy also smoothly and patients should be warned of neyrosdurgeons who just for making money will operate in india and surgery has its own side effects and chances of damaging CNS tissue and only indicated if some complicatoion oir medical therapy not working and cvisusal compromise increasing /cavernous sinus involvement.

I think the drug cabergoline is easier to use and causes fewer side effects for the patient

There is à strong body of evidence for the use of DA in macroprolactinomas. Surgery should be reserved to patients intolerant or resistant

Heaving an experience more than 400 pituitary cases i can said that only Cabergolin! 

The size of tumor dosen't metter!

Beyiond intolerant or resistant DA patients we may consider surgery in a pregnant patient with increasing tumor size..

In my opinion the first choice is cabergoline (1-2 mg/week, or bromocriptine if cabergoline is not available or tolerated). In my experience cabergoline is high effective, even in macroadenoma closo to optic chiasm or with initial visual distubances.

I have treated maybe more than 200 patients with dopamine agonists, in the last years manly with cabergoline. Medical treatment is our clear first choice, even when visual field defects can be detected. We only consider surgery in the following cases:

- resistance to dopamin agonist therapy (meaning increasing prolactin levels or tumor size despite high doses of dopamine agonists

- increasing visual defects despite domain agonist therapy in large tumors

- severe sidefeffects of dopamine agonist therapy 

We feel that our approach is covered by most of the published guidelines. It should also be emphasized that macro adenomas often can't be removed completely even by experts so that dopamine agonist therapy has to be established anyway. 

Medical (e.g. cabergoline)

i agree that caberline is the choice and except for cavernous sinus invasion when levels of serum prolactin are in over 10,000 as compared to 1000s in usual cases of macropeolactinoma only one considers surgery otherwise if patient deveelops sevewre postural hypotension occasionally which is rare with caberlin and mostly used tpo occur witrh beomocriptine.