Pituitary macroadenoma is a benign tumor with slow growth originating from cells pituitary gland cells, measuring ≥10 mm. Based on the presence or absence of hormone secretion by tumors, pituitary adenomas can be divided into tumors that secrete hormones (functional /endocrine active) and those that do not secrete hormones (non-functional / endocrine inactive). Pituitary adenoma, both microadenoma and macroadenoma, in the pediatric and adolescent population is very rare, with a prevalence of 1: 1000,000. In children and adolescents, most of the pituitary macroadenomas that occur are functional adenomas, especially prolactinomas, which are more common in the adolescent population.
Common clinical symptoms such as headaches and visual disturbances due to the binding effect of the cranial nerves by the tumor mass. Another clinical symptom that can arise is an increase in the level of the hormone prolactin in the blood (hyperprolactinemia). Hyperprolactinemia that occurs in pituitary macroadenoma can be caused by the binding effect of the tumor mass on the infundibulum or due to the secretion of prolactin by the tumor. Clinical symptoms that can arise in hyperprolactinemia are breast enlargement in men (gynecomastia), discharge of milk from the breasts (galactorrhea) in men or women who are not breastfeeding, and erectile dysfunction in men.
Therapeutic modalities for pituitary macroadenoma with hyperprolactinemia consist of pharmacologic therapy with dopamine agonists such as bromocriptine and cabergoline, EETA surgery, and radiotherapy. In clinical practice, dopamine agonists (AD) have been recommended as first-line therapy in prolactinoma cases to control tumor mass/volume, normalize prolactin secretion, relieve neurological symptoms, and restore normal pituitary function. Bromocriptine is one of AD which is commonly used for the treatment of hyperprolactinemia in pituitary macroadenoma. Bromocriptine administration is initiated at a dose of 1.25–2.5 mg per day, may be increased by 2.5 mg every 3–7 days until an optimal therapeutic effect is achieved. In the research of Cho et al. 2013 Among 23 patients with invasive prolactinoma, it was found that 69.5% of subjects achieved normal prolactin levels after six months of receiving bromocriptine therapy at a maximum dose of 15–22.5 mg per day without any significant side effects. Similar results were obtained in the study of Araujo et al., namely as many as 86.6% of the study subjects achieved normalization of prolactin. A total of 55.2% of residents achieved normalization of prolactin and reduction in tumor size at six months of initiation of bromocriptine therapy. In the case of a non-functional pituitary macroadenoma, the use of bromocriptine had a stabilizing effect on tumor growth in 90.47% of patients.
EETA is another therapeutic modality for pituitary macroadenoma, which is generally the treatment of choice in patients with visual impairments and chronic headaches. Hamilton et al. in a study of prolactinoma patients resistant to dopamine agonists reported that EETA surgery normalized prolactin levels in 36% of patients not being treated with dopamine agonists and 15% of patients being treated with postoperative dopamine agonists. Research by Gayatri and Hidayati found an improvement in clinical conditions and a total decrease in prolactin levels by 79.70% (pre-treatment 198.10 ng / mL, post-treatment 40.20 ng / mL) in patients with pituitary macroadenoma accompanied by hyperprolactinemia after administration. Bromocriptine 2.5 mg daily for 14 days of hospital stay and EETA surgery.
Authors: Ni Putu Ayu Deviana Gayatri, Hanik Badriyah Hidayati