Pregnancy and delivery after surgical remission in women with prolactinomas desiring pregnancy: Refining surgical indications

TL;DR

Surgery for prolactinomas in women wanting pregnancy may lead to long-term remission and prevent recurrence if specific criteria are met.

Contribution

The study identifies refined surgical criteria and shows that pregnancy after surgery is linked to no recurrence in prolactinoma patients.

Findings

Surgical remission with postoperative prolactin <3 ng/mL was associated with a 4.3% recurrence rate, compared to 50% for 3–15 ng/mL.

Women who conceived and delivered after surgery had 0% recurrence, while 20% of those who did not conceive experienced recurrence.

Refined criteria led to remission in all 20 women who underwent surgery and met the selection criteria.

Abstract

Prolactinomas are usually managed with cabergoline, and surgery is reserved for strictly selected cases. Based on our surgical experience, we observed no recurrence in women who conceived and delivered after surgical remission. We therefore evaluated surgical outcomes and indications in pregnancy-seeking women.

We retrospectively reviewed 57 women who underwent surgery in 1998–2008 (median age 28.0 years) and identified predictors of remission and recurrence. Refined criteria (desiring pregnancy, enclosed-type tumor, and Knosp grade ≤ 2 with anticipated complete resection) were then applied to 135 women treated in 2009–2022 (median age 35.0 years).

In 1998–2008, remission was achieved in 73.8% of enclosed-type microadenomas and improved to 95.2% in the later period. Postoperative prolactin < 3 ng/mL predicted lower recurrence than 3–15 ng/mL (4.3% vs 50.0%, P = 0.0098). In 2009–2022, 25/135 (18.5%) underwent surgery. Of 32 women who met the refined criteria, 20 elected surgery, and all achieved remission without new deficits. Across both cohorts, 59 women of childbearing age achieved remission. Recurrence occurred in 6 of 30 women who did not conceive (20%) but in none of the 29 who conceived and delivered (0%, P = 0.0237).

Pregnancy and delivery following surgical remission were associated with no recurrence, suggesting a potential cure in this subgroup. When performed by experienced pituitary surgeons, transsphenoidal surgery may offer a curative pathway for carefully selected women desiring pregnancy. These findings support further refinement of surgical candidacy in pregnancy-seeking women and warrant validation in larger cohorts.

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