Endocrine Abstracts

Introduction: Prolactin secreting pituitary adenoma represents the most common functioning pituitary neoplasm with a clinical picture that includes amenorrhea, galactorrhea and infertility. Tumor size may vary from microadenomas amendable to medical therapy with dopamine agonists to macroadenomas with difficult management. Complications are usually related to tumor size and most frequently include hypogonadism alone or associated with other pituitary deficiencies, visual field defects, headache and cranial neuropathies. Cerebrospinal fluid fistula represents a rare but severe finding that can complicate the evolution of prolactinomas.

Materials and methods: We report three cases of prolactinomas complicated with cerebrospinal fluid leak either spontaneously or during the course of treatment. The patients were all males, with age between 22 and 66 years and high tumor volume and prolactin values at diagnosis. The first patient presented with bitemporal hemianopia with an 86/77/64 mm sellar mass invasive into the suprasellar region and both sphenoid sinuses and a prolactin value at diagnosis of 11 432 ng/ml. He developed cerebrospinal fluid fistula after 9 months of treatment with cabergoline, at the attempt of increasing the dose from 3 mg/week to 4.5 mg/week. The second patient was diagnosed with pituitary macroadenoma on cerebral CT starting from clinical features that included headache, visual field defects and hypogonadism and performed transfrontal adenomectomy as first line therapy. His postoperative course was complicated by transient diabetes insipidus, hypopituitarism and cerebrospinal fluid leak that required surgical repair. Diagnosis of prolactinoma was established at the postoperative evaluation due to high levels of prolactin of 10 635 ng/ml and received treatment with dopamine agonists. The third patient presented with spontaneous rhinoliquorrhea and an invasive pituitary tumor of 67/45/44 mm. He performed transsphenoidal debulking of pituitary adenoma and surgical repair of the sellar floor. Postoperative, diagnosis of prolactinoma was made, with a prolactin value of 18 638 ng/ml and treatment with cabergoline was initiated.

Discussion: Cerebrospinal fluid fistula is a life-threatening condition associated with a high risk of developing meningitis, intracranial abscess and pneumocephalus. Postulated mechanisms are invasive pituitary macroadenomas with bone destruction in the sellar floor. Tumor shrinkage induced by medical or surgical treatment uncovers the bone defects leading to cerebrospinal fluid rhinoliquorrhea. Surgical repair via a transphenoidal approach is mandatory and long term follow-up is usually needed.