Published online: 2019-12-20 Review Updates in the Medical Treatment of Pituitary Adenomas Authors Monica Livia Gheorghiu1, Francesca Negreanu2, Maria Fleseriu2 Affiliations ABSTRACT 1 CI Parhon National Institute of Endocrinology, Carol Davila Pituitary adenomas represent approximately 15 % of brain tu- University of Medicine and Pharmacy, Bucharest, Romania mors; incidence is significantly on the increase due to wides- 2 Northwest Pituitary Center, and Departments of Medicine pread use of magnetic resonance imaging. Surgery remains (Endocrinology) and Neurological Surgery, Oregon Health the first-line treatment for most tumors overall. The role of & Science University, Portland, United States dopaminergic agonists (DAs) and somatostatin receptor ligan- ds (SRLs) in the treatment of pituitary adenomas is quite well Key words established for prolactinomas and growth hormone (GH) ex- prolactinoma, somatostatin receptor ligands, non functio- cess. However, over the last decade new multi-receptor binding ning pituitary adenomas, glucocorticoid receptor blockade, SRLs are increasingly used for treatment of acromegaly and adrenal steroidogenesis inhibitors, Cushing’s disease, Cushing’s disease. SRLs/DA chimeric compounds seem to have acromegaly, pituitary adenoma enhanced potency and efficacy when compared to that of in- dividual SRLs or DA receptor agonists according to preclinical received 03.10.2019 data. However, following negative results, more research is accepted 13.11.2019 needed to determine if this interesting mechanism will trans- late into positive clinical effects for acromegaly patients. Fur- Bibliography thermore, new agents that block adrenal steroidogenesis have DOI https://doi.org/10.1055/a-1066-4592 been developed in phase III clinical trials for Cushing’s disease Published online: 20.12.2019 and several new compounds working at the pituitary level and/ Horm Metab Res 2020; 52: 8–24 or blocking the glucocorticoid receptor are also in develop- © Georg Thieme Verlag KG Stuttgart · New York ment. Combination therapy of drugs with similar or different ISSN 0018-5043 mechanisms (possibly synergistic) are also on the increase. A growing awareness regarding all mechanisms involved in both Correspondence control of pituitary secretion and cellular proliferation might Dr. Maria Fleseriu allow for sole medical treatment of pituitary adenomas, espe- Departments of Medicine and Neurological Surgery cially macroadenomas, rather than surgery and/or radiation Oregon Health & Science University therapy, in the future. Moreover, the underlying decision on 3303 SW Bond Ave how to treat patients with pituitary adenomas should be indi- Portland, Oregon 97239 vidualized on a case-by-case basis with not only a goal of tumor United States shrinkage and biochemical control, but also of improving pa- Tel.: +1 5034944314, Fax: +1 5033466810 tients’ quality of life. [email protected] This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Introduction Discussion We have conducted a review of evidence regarding medical treat- ment of prolactinomas (lactotroph adenomas), acromegaly, Prolactinomas Cushing’s disease, and “non-secretory” pituitary adenomas. Up- Prolactinomas, hormone-secreting pituitary adenomas that sec- dated information regarding efficacy and limitations of current rete prolactin (PRL) [1, 2] represent approximately 40–45 % of pi- treatments and recent developments (new drugs or combination tuitary tumors [3, 4]. Prevalence varies with both sex and age, oc- treatments) are presented. curring more frequently in women at a ratio of 10:1, and in those Medical treatment for aggressive pituitary adenomas will be dis- aged 20–50 years [5–8]. However, after the fifth decade of life, the cussed elsewhere in this special issue. female-to-male ratio radically changes to 1:1 [9]. Most prolactino- mas are microadenomas (80 %), while macroadenomas are more rare and more commonly observed in males [7]. Hyperprolactine- mia causes symptoms of amenorrhea/oligomenorrhea, galactor- 8 Gheorghiu M et al. Medical Treatments for Pituitary Tumors … Horm Metab Res 2020; 52: 8–24 rhea and infertility in premenopausal females and erectile dysfunc- calating the CAB weekly dosage, transsphenoidal surgery, radio- tion, infertility and gynecomastia in males [7]. Headaches are also therapy, or a combination of all lines of treatment optimization frequently noted in these patients, ranging from migraines (most [24, 26]. The CAB titration scheme is variable; usually starting with common) to cluster headaches and other related headache subty- 0.25 mg twice a week and increasing to 0.5 mg twice a week after pes [10]. Less common symptoms of prolactinomas can include vi- 4–6 weeks; further increases are based on patient tolerance to DA sual field disturbances, due to large tumor size, which can compress and PRL prolactin values. the optic chiasm or other cranial nerve [1, 2, 7]. Although there is Of note, long-term CAB high dose may cause clinical valvular di- a clear prevalence of prolactinomas in women, men have shown to sease (as shown in patients with Parkinson’s disease), and the risk have more aggressive macroadenomas, which are more likely to should be taken into consideration for some patients [9, 21, 26]. be resistant to dopamine agonists (DAs) [11]. A retrospective study Although occurrence of a clinically significant valvular disease was by Liu, et al., in 2018, analyzed outcomes of prolactinomas in men reassuringly low in large series of patients with prolactinomas tre- in comparison to a control group and found overall that men who ated with DAs [4, 9, 27], some groups recommend periodical fol- required surgery had larger and more invasive tumors, as well as low-up of high risk patients, notably those taking high doses higher rates of DA resistance, similar to silent corticotroph adeno- (e. g., > 3 mg/week) or high cumulative doses, with annual cardio- mas, tumors that are known to be more clinically aggressive [12]. vascular exam and, if necessary, echocardiogram (e. g., when a new The primary treatment goal for prolactinomas is to normalize cardiac murmur, edema, dyspnea, or cardiac failure occur) [28, 29]. serum PRL levels [4]. First-line treatment for most patients is a DA Over the last decade, increased impulse control disorders (ICD) [9, 13]. Dopamine typically regulates pituitary hormone secreted in patients treated with DAs has been reported, initially in patients through the dopamine subtype 2 receptor, which is generally ex- with Parkinson’s disease (PD) [18]. ICD symptoms manifest as hy- pressed in lactotrophs. After dopamine binds to D2R, on lactotroph persexuality, compulsive shopping, eating and gambling, and pun- cells, is inhibiting PRL secretion. Dopamine agonists non-selectively ding [14, 30]. Most recently, retrospective studies and case reports target and bind to the dopamine receptors, resulting in a decrease have also described patients with prolactinomas developing ICDs. in PRL levels [1]. Bromocriptine (BRC) and cabergoline (CAB) are the Prevalence varies between studies; Noronha, et al., reported an oc- two DAs that have been approved in the US as medical treatments. currence of 5 % [31], while a later cross-sectional observational Quinagolide is also used outside the US [14, 15]. In most cases, treat- study showed a higher prevalence, at 24.6 % in prolactinoma pati- ment is long-term [16], although some studies have tried to predict, ents [32]. The rate of significant ICD in prolactinoma patients in cli- which patients will be able to withdraw from long-term treatment. nical practice remains to be clarified by further studies. Impulse While non-selective, it has been shown that BRC tends to bind to D2 disorders can be detrimental to a person’s personal and professio- receptors in the pituitary and also the D1 receptors in the gut. CAB nal life [30]. Interestingly, there are no linked relationships between is more specific to D2 receptors in the pituitary, which makes it more ICDs and DA type, duration of treatment, or dosing regime, so far effective [1, 17]. Both BRC and CAB have been shown to bind to D3 [14, 32]. Although mechanisms are less clear, one hypothesis is that receptors in the limbic system [14, 18]. The side effects of BRC can this ties into the D3 receptor signaling cascade. Since both CAB and include: nausea, dizziness, which can make it less tolerated than CAB BRC can bind to the D3 receptors in the limbic system, this can have [19]. BRC has been shown to normalize PRL levels and reduce tumor an effect on impulsivity due to D3 receptor stimulation, with a hig- size in 80–90 % of microprolactinoma and 70 % of macroprolactino- her prevalence of BRC binding to D3 than CAB [14, 20]. In a recent ma cases [20]. CAB has better efficacy, normalizing PRL in up to 95 % case-controlled study, males with prolactinomas who were treated of patients, is able to reduce tumor size in 50-90 % of patients, and with either DA were 9.9 times more likely than females to develop controls the majority of symptoms [1, 21]. Typical dosing for BRC is an ICD [32]. It is unclear whether there is a correlation between in- approximately 2.5–15 mg/day, given the relatively short half-life dividuals with predisposing psychological traits or certain psychi- [20]. CAB dosing ranges from 0.5–3.5 mg/week due to the longer atry disorders [14]. The exact treatment for DA-related ICD is not half-life, which may indicate why CAB has higher patient adherence known, though stopping DAs seems to be the most effective ap- [20–22] (▶Table 1). A recent study collected data from 3 tertiary proach in managing ICDs; reducing DA dosage can also improve or care institutions looking at PRL secretion and tumor volume shrin- lead to symptoms eradication [14]. Other less common possible This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. kage following DA therapy. The study found evidence of plateaus in psychological effects of DAs can include mania, anxiety, depressi- both the size regression of prolactinoma tumors, as well as the PRL on, insomnia, psychosis, and paranoia [30].