Manejo de pacientes con diagnóstico de adenoma hipofisario productor de prolactina. Experiencia del Hospital San José

Introducción: El prolactinoma es el tumor hipofisiario funcionante más frecuente.
Objetivo: Describir la experiencia del servicio de endocrinología del Hospital San José de Bogotá en el manejo de pacientes con prolactinoma que consultaron entre enero de 2006 y diciembre de 2012.
Métodos: Serie de casos. Se describieron variables demográficas, clínicas, seguimiento radiológico anual, prolactina (PRL) basal, a los 6 y 24 meses. Ingresaron pacientes con adenoma hipofisario documentado por resonancia nuclear magnética (RNM) contrastada, PRL sérica mayor de 100 ng/ml, o diagnóstico extrainstitucional de prolactinoma.
Resultados: Se analizaron 95 pacientes; 71% con microprolactinomas y 28,4% con macroprolactinomas. La mediana de duración del tratamiento en pacientes con microprolactinomas fue 73,4 meses con una mediana de dosis acumulada de cabergolina (CAB) de 52 mg. En las personas con macroprolactinoma fue de 65 meses, con mediana de dosis acumulada de CAB de 156 mg. El 78,3% inició tratamiento con bromocriptina (BRC). Ocho pacientes cumplieron criterios de remisión.
Conclusión: La población atendida en el Hospital San José tiene características similares a las registradas en la literatura; sin embargo, el porcentaje de remisión es bajo, lo cual, posiblemente está asociado al uso de bajas dosis de agonistas de dopamina. Se requieren estudios prospectivos para aclarar si la dosis acumulada es un factor predictor para aumentar el porcentaje de pacientes con retiro exitoso y establecer la mejor estrategia para retiro de agonistas de dopamina en pacientes con prolactinomas.

Summary

Objective: To describe our experience in the Endocrinology Service of Hospital San José in the treatment of patients with prolactinoma who were seen between 2006 and 2012.
Methodology: Case series. Demographic and clinical variables were described, as well as radiological monitoring once yearly and basal prolactin (PRL) measurements at 6 and 24 months. The patients included suffered from pituitary adenoma documented by contrast magnetic resonance imaging (cMRI), with serum PRL 100 ?g/L or above, or who had been diagnosed with prolactinoma by another institution.
Results: 95 patients were analyzed. 71% presented with microprolactinomas and 28.9% with macroprolactinomas. The median treatment duration for patients with microprolactinomas was 73.4 months, with a median accumulated dosage of cabergoline (CAB) of 52 mg. For macroprolactinomas, the median treatment duration was 65 months and the median accumulated dose of cabergoline was 156 mg. 73.8% of patients received bromocriptine. Eight patients met remission criteria.
Conclusion: The patient population treated at Hospital San José has similar features to that described in the literature. However, the remission rate is low, possibly explained by the use of low doses of dopamine agonists. Prospective studies are required to clarify whether the cumulative dose is a predictive factor for increasing the rate of patients with successful with- drawal and to establish the best strategy to withdraw dopamine agonists in patients with prolactinomas.

1. Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA, et al. Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011;96(2):273-88.
2. Reyes Leal B. Prolactinoma: tratamiento médico. Acta Medica Colombiana [6], 217-223. 1981.
3. Klibanski A. Clinical practice. Prolactinomas. N Engl J Med 2010; ;362(13):1219-26.
4. Hamilton DK, Vance ML, Boulos PT, Laws ER. Surgical outcomes in hyporesponsive prolactinomas: analysis of patients with resistance or intolerance to dopamine agonists. Pituitary 2005;8(1):53-60.
5. Antagnostis P, Adamidou F, Polyzos SA, Efstathiadou Z, Karathanassi E, Kita M. Long term follow-up of patients with prolactinomas and outcome of dopamine agonist withdrawal: a single center experience. Pituitary 2012 Mar;15(1):25-9.
6. Vroonen L, Jaffrain-Rea ML, Petrossians P, Tamagno G, Chanson P, Vilar L, et al. Prolactinomas resistant to standard doses of cabergoline: a multicenter study of 92 patients. Eur J Endocrinol 2012;167(5):651-62.
7. Hamilton DK, Vance ML, Boulos PT, Laws ER. Surgical outcomes in hyporesponsive prolactinomas: analysis of patients with resistance or intolerance to dopamine agonists. Pituitary 2005;8(1):53-60.
8. Oh MC, Aghi MK. Dopamine agonist-resistant prolactinomas. J Neurosurg 2011 May;114(5):1369-79.
9. Colao A. Pituitary tumours: the prolactinoma. Best Pract Res Clin Endocrinol Metab 2009;23(5):575-96.
10. Fajardo-Montanana C, Daly AF, Riesgo-Suarez P, Gomez- Vela J, Tichomirowa MA, Camara-Gomez R, et al. [AIP mutations in familial and sporadic pituitary adenomas: local experience and review of the literature]. Endocrinol Nutr 2009;56(7):369-77.
11. Lancellotti P, Livadariu E, Markov M, Daly AF, Burlacu MC, Betea D, et al. Cabergoline and the risk of valvular lesions in endocrine disease. Eur J Endocrinol 2008;159(1):1-5.
12. Colao A, Di SA, Guerra E, Pivonello R, Cappabianca P, Caranci F, et al. Predictors of remission of hyperprolactinaemia after long-term withdrawal of cabergoline therapy. Clin Endocrinol (Oxf ) 2007;67(3):426-33.
13. Kars M, Delgado V, Holman ER, Feelders RA, Smit JW, Romijn JA, et al. Aortic valve calcification and mild tricuspid regurgitation but no clinical heart disease after 8 years of dopamine agonist therapy for prolactinoma. J Clin Endocrinol Metab 2008;93(9):3348-56.
14. Vallette S, Serri K, Rivera J, Santagata P, Delorme S, Garfield N, et al. Long-term cabergoline therapy is not associated with valvular heart disease in patients with prolactinomas. Pituitary 2009;12(3):153-7.
15. Bogazzi F, Buralli S, Manetti L, Raffaelli V, Cigni T, Lombardi M, et al. Treatment with low doses of cabergoline is not associated with increased prevalence of cardiac valve regurgitation in patients with hyperprolactinaemia. Int J Clin Pract 2008 Dec;62(12):1864-9.
16. Iglesias P, Diez JJ. Macroprolactinoma: a diagnostic and therapeutic update. QJM 2013 Jun;106(6):495-504.
17. Delgrange E, Sassolas G, Perrin G, Jan M, Trouillas J. Clinical and histological correlations in prolactinomas, with special reference to bromocriptine resistance. Acta Neurochir (Wien ) 2005;147(7):751-7.

Prolactinoma
Hiperprolactinemia
agonistas de dopamina
cabergolina
bromocriptina
Hyperprolactinemia
Dopamine agonists
Cabergoline
Bromocriptine