Debate: Surgery as Initial Therapy for Microprolactinoma

Prolactinomas are the most frequent subtype of hormone-secreting pituitary adenomas, comprising about 50%, of which more than 70% are microprolactinomas. Treatment with oral dopamine agonists (DAs) has been the mainstay of treatment for macroprolactinoma for many decades, with cabergoline being the drug of choice in most instances. DAs are highly effective; prolactin normalization and tumor shrinkage are observed in close to 90% of patients. Twenty-five percent of patients can be withdrawn from cabergoline after 2 years of treatment. However, medication side effects, the need for longer-term therapy in most patients, dopamine resistance, or poor compliance affect overall utility. Endoscopic transsphenoidal surgery (TSS) using modern methods has a similarly high success rate in treating microprolactinomas, with surgical remission rates of 80% to 95% or more reported in many series. Long-term remission rates of 75% are generally observed. In the hands of experienced pituitary surgeons, TSS is very safe, with morbidities at less than 1% and mortality rates of 0%. Cost-wise, cabergoline therapy is less expensive, although the long-term differences in cost are not substantial. The goal of this editorial is to debate the pros and cons of surgery as a first-line option for the treatment of macroprolactinoma, presenting the views of an expert endocrinologist and pituitary surgeon both against and in favor of surgery.