Challenges in the Management of Silent Lactotroph Pituitary Adenoma

Silent lactotroph pituitary adenomas are rare tumors that clinically resemble nonfunctioning macroadenomas but are identified histologically by prolactin immunoreactivity. We report a 29-year-old woman with progressive visual loss caused by a large sella-suprasellar mass compressing the optic chiasm and invading the cavernous sinus. Initial endocrine evaluation was unremarkable, and magnetic resonance imaging (MRI) suggested a nonfunctioning adenoma. She underwent urgent surgical decompression, and histology confirmed a sparsely granulated lactotroph adenoma. Despite significant residual tumor on postoperative MRI, dopamine agonist therapy was not initiated due to absent dopamine receptor type 2 staining and patient-specific factors. Retrospective imaging review revealed atypical features, including heterogeneous T2-weighted signal, mixed cystic-solid morphology, and fluid-attenuated inversion recovery-T2 mismatch. This is potentially indicative of a silent subtype. This case underscores the diagnostic challenges posed by silent lactotroph adenomas and highlights the role of detailed imaging interpretation, histopathological analysis, and multidisciplinary evaluation in guiding management, especially in the absence of standardized treatment protocols for residual or recurrent disease.