Resistant prolactinomas

Prolactinomas as the most common type of functional pituitary adenoma and most will respond to dopamine agonist (DA) therapy with normalization of prolactin levels, restoration of gonadal function and/or reduction in tumor volume. A minority of prolactinomas are refractory to conventional doses of DA and present a clinical challenge. Characteristics associated with DA resistance include male sex, certain radiologic features (large size, cavernous sinus invasion, other characteristics), histopathologic evidence of high cell proliferation, and in a small number of cases, inherited pathologic germline variants of genes associated with pituitary tumors, such as MEN1 and AIP. Clinical management often requires a multimodal approach including titration of DA to higher than usual doses, surgical resection or debulking, and targeted radiotherapy. Robust evidence is lacking for non-approved adjunct therapies, such as aromatase inhibitors and estrogen receptor modulators, although the somatostatin receptor ligand pasireotide may have potential in select patients.