Surgery for prolactinoma

Prolactinomas (lactotroph pituitary neuroendocrine tumours) account for almost half of all pituitary tumours and significantly affect quality of life. Dopamine agonists (DA) are effective in achieving biochemical control in prolactinoma, but rates of long-term biochemical remission off therapy are low, and there is an increasing recognition of a broad range of adverse drug reactions, particularly psychiatric. Surgery is a safe and effective treatment for microadenomas and non-invasive macroadenomas, achieving significantly higher rates of biochemical remission compared to DA. Moreover, surgical remission mitigates the significant side effects, costs, quality of life detriment, and treatment-related anxiety associated with sustained DA therapy. With advances in surgical technique and experience, even cases with invasion of the medial wall of the cavernous sinus or cavernous sinus compartment may be candidates for curative resection. Giant and invasive tumours still present a challenge to the surgeon, and DA is preferred upfront. Surgery in these tumours is required when DA fail to achieve biochemical control or adequate tumour shrinkage. Current research aims to delineate which patients may benefit most from upfront surgery and if preoperative DA hinder optimal surgical outcomes. In all patients with prolactinoma, the endocrine and oncological benefits of resection must be weighed against the risks of surgery, requiring multidisciplinary discussion and individualised decision making. Early referral to a pituitary tumour centre of excellence facilitates balanced decision making and optimal treatment for patients with prolactinoma.