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| CASE REPORT |
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| Year : 2022 | Volume
: 28
| Issue : 2 | Page : 202-203 |
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Macroprolactinoma presenting as galactorrhoea in a male
Abdul Basith Ambalamcheri1, Rojan Kuruvilla1, MV Vimal2, Ashbina3
1 Department of General Surgery, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
2 Department of Endocrinology, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
3 Department of Radiology, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| Date of Submission | 15-Aug-2022 |
| Date of Decision | 15-Nov-2022 |
| Date of Acceptance | 03-Dec-2022 |
| Date of Web Publication | 30-Jan-2023 |
Correspondence Address:
Dr. Abdul Basith Ambalamcheri
Department of General Surgery, Aster Malabar Institute of Medical Sciences, Govindapuram, Kozhikode - 673 016, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ksj.ksj_31_22
Macroprolactinomas account for more than 50% of all functional pituitary tumours. These are equally prevalent in males and females, although they are diagnosed earlier in females. In females, the usual presentations include oligomenorrhoea, amenorrhoea, galactorrhoea and infertility, whereas males usually present with headache, sexual dysfunction and visual field defects. The following is a case of a 30-year-old male who presented with unilateral nipple discharge, sexual hypoactivity and grossly elevated serum prolactin levels. His magnetic resonance imaging revealed a macroprolactinoma. He responded well to cabergoline.
Keywords: Galactorrhoea in males, macroprolactinoma, pituitary tumour
How to cite this article:
Ambalamcheri AB, Kuruvilla R, Vimal M V, Ashbina. Macroprolactinoma presenting as galactorrhoea in a male. Kerala Surg J 2022;28:202-3 |
| Introduction | |  |
Pituitary adenomas are the most common amongst benign intracranial tumours and the incidence has been on the rise in recent years. Around 50% of functional hypophysis adenomas are prolactinomas.[1] Recent epidemiological studies estimate the incidence of prolactinoma to be 35–50 in the 100,000 population. Most prolactinomas are found in women aged 20–50 years,[1] and its unique clinical manifestations and tumour characteristics are less commonly seen in males. Dopamine agonists have been the first-line treatment for prolactinoma since the 1970s.[1] Transsphenoidal surgery is accepted as the second-line treatment for patients intolerant to dopamine agonists or patients with severe symptoms, such as rapid vision loss. Here, we are reporting a case of a young male patient with pituitary macroadenoma who presented with galactorrhoea and sexual dysfunction.
| Case Report | | |
A 30-year-old man, with no known comorbidities, presented with complaints of occasional milky discharge from the right nipple of 8 months duration; without any pain or swelling of the breast. There was no discharge from the left nipple. He also gave a history of progressive weight gain. No headache or visual disturbances. He was married and had one child who was 4 years old. For the past 2 years, he complains of decreased libido and also, in spite of trying for a second child during this period, was not successful. Physical examination revealed that the patient was overweight (105 kg); and had bilateral fatty breasts, without any tenderness or palpable lump in the breasts. His laboratory investigations revealed normal TSH and free T4 levels. His serum prolactin levels were very high – 2333 ng/ml (range: 4.04–15.2). USG breast showed normal fibroglandular parenchyma in bilateral breasts with no obvious focal lesions. He was referred to the endocrinologist. Magnetic resonance imaging (MRI) brain revealed a well-defined homogeneously enhancing T1, T2 isointense sellar lesion with suprasellar extension measuring 2.5 cm × 1.8 cm × 2 cm (images below) [Figure 1] – diagnosed as pituitary macroadenoma. His cortisol was 13 mcg/dL (range: 10–20 mcg/dL). He was started on tablet cabergoline 0.5 mg once weekly. After 1 month of treatment, the patient was symptomatically better and prolactin levels came down to 233 ng/ml. Repeat MRI after 4 months showed decrease in size of sellar lesion to 1.7 cm × 1 cm × 1.9 cm, with no significant suprasellar component. After 1 year of treatment with cabergoline, his Prolactin level was 17.5 ng/ml. | Figure 1: MRI showing sellar lesion (yellow arrow) with suprasellar extension; (a) Sagittal section, (b) Coronal section. MRI: Magnetic resonance imaging
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| Discussion | | |
Prolactinomas account for about 50% of functioning pituitary tumours and are the most frequent cause of chronic hyperprolactinemia. Sometimes, raised prolactin levels are caused by pituitary adenomas that secrete prolactin and other anterior pituitary hormones. Hyperprolactinemia with diffuse enlargement of the pituitary, without a tumour, is found in primary hypothyroidism.[2] Hypothalamic dysfunction causing hyperprolactinemia is frequently associated with drugs (e.g. Phenothiazines especially Chlorpromazine causes moderate levels of hyperprolactinemia, antidepressants and antihypertensives), hormones (e.g. oestrogen, testosterone and lack of T4) or a tumour (which usually also affects sleep and food regulation or causes diabetes insipidus).[3]
Prolactinoma usually manifests as oligomenorrhoea and galactorrhoea in females, whereas most male patients present with headache, sexual dysfunction and visual field defects. The clinical manifestations in males usually result from mass effects and pituitary apoplexy. According to different studies, men presented with larger tumours. Invasive tumours were exclusively observed in men and they showed more prevalence of visual defects. Higher testosterone levels in men could have a stimulating effect on prolactin secretion through oestrogen aromatisation at the pituitary. Our patient had galactorrhoea and sexual hypoactivity.
At present, the first-line treatment in the management of prolactinoma is a dopaminergic agonist, such as cabergoline or bromocriptine, which bind to dopamine 2 receptors on lactotroph cells and results in inhibition of prolactin secretion. This results in decrease in size of the tumour and the functional recovery of sexual glands.[4] In a trial, the prolactin levels in 59% of patients returned to normal after bromocriptine treatment,[5] whereas 12% of patients were unable to tolerate its side effects. Cabergoline is a long-acting dopaminergic agonist and its efficacy reaches up to 83%, and it also has fewer side effects than bromocriptine. However, in a study by Colao and Savastano., the 5-year recurrence rate of macroadenoma in patients after cabergoline treatment was found to be 33%.[6]
The second-line treatment for prolactinoma is neurosurgery; indications for which include resistance to medical management, intolerability to side effects, cerebrospinal fluid leakage due to the shrinking tumour, rapid diminution of vision and cranial nerve palsy due to tumour bleeding (pituitary apoplexy).
Our patient had unilateral galactorrhoea which is a rare manifestation of prolactinoma.[7] The manifestations of prolactinoma in a male may be subtle and non-specific. Early diagnosis may help in avoiding visual loss and development of hypopituitarism. Here, the presence of galactorrhoea helped us in reaching the diagnosis sufficiently early so that major complications could be avoided.
| Conclusion | | |
Prolactinomas in males are typically macroadenomas and are usually characterised by very high serum prolactin levels. The main clinical manifestations include sexual hypoactivity, headache and visual defects. Galactorrhoea as the predominant presenting complaint is rare. Prompt diagnosis by assessing serum prolactin levels and conservative treatment with dopamine agonists will result in symptomatic relief in the majority of patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Salazar-López-Ortiz CG, Hernández-Bueno JA, González-Bárcena D, López-Gamboa M, Ortiz-Plata A, Porias-Cuéllar HL, et al. Clinical practice guideline for the diagnosis and treatment of hyperprolactinemia. Ginecol Obstet Mex 2014;82:123-42.  |
| 2. | Yen SS. Chronic anovulation due to CNS-hypothalamic pituitary dysfunction. Reprod endocrinol 1986. p. 500-45. |
| 3. | Wallach E, Archer DF. Current concepts of prolactin physiology in normal and abnormal conditions. Fertil Steril 1977;28:125-34. |
| 4. | Song YJ, Chen MT, Lian W, Xing B, Yao Y, Feng M, et al. Surgical treatment for male prolactinoma: A retrospective study of 184 cases. Medicine (Baltimore) 2017;96:e5833. |
| 5. | Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF. A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. cabergoline comparative study group. N Engl J Med 1994;331:904-9. |
| 6. | Colao A, Savastano S. Medical treatment of prolactinomas. Nat Rev Endocrinol 2011;7:267-78. |
| 7. | Leggett CA. Galactorrhoea. Report of a case in a male patient. Aust N Z J Surg 1991;61:540-1. |
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