Unraveling the 2023 Pituitary Society Consensus Statement on Prolactioma Management: An Endocrinologist’s Perspective

A vast number of guidelines and novel classifications are being published on a monthly basis, with more than 50 in the field of endocrinology, published only in the last 5 years on an international level, and more than five related to pituitary adenomas. In 2023 the Pituitary Society issued an international Consensus Statement, in which a long-standing concept for the conservative treatment of prolactionomas was being challenged and major step done towards a broader adoption of the surgical treatment of these, in most circumstances benign and particularly sensitive to dopamine receptor agonists pituitary tumors. A substantial part of the guidelines is focused on surgery being proposed as a first line therapeutic option in patients with microprolactinomas, as an equally effective alternative to conservative medical therapy, in the setting of a very experienced neurosurgeon being available on site. A PubMed search was conducted, which resulted in the inclusion of 20 systematic reviews. Out of the 20 systematic reviews, there was one recent paper suggesting a benefit to medical management over surgery in the treatment of patients with prolactinomas at primary diagnosis. No RCTs exploring the topic of surgery in prolactinoma patients were found. One RCT is ongoing, recruiting patients. Opting for surgery when diagnosing a microprolactinoma for the first time should be a rare clinical situation in the setting of a less experienced surgeon, as neurosurgical interventions are not without risk of postoperative hypopituitarism. The consensus statement of the Pituitary Society from 2023 does not provide unequivocal recommendation on how to interpret prolactine levels less than the given approximate threshold of 4255.31 mIU/L, when diagnosing a microprolactionoma. Moreover, studies relating microprolactinoma size to prolactin levels are lacking (i.e. defining a threshold of prolactine level for every adenoma size in the spectrum between 1 and 10 mm). With this novel concept, new challenges on prolactionoma care arose, with pre- and postoperative indications for surgical fitness and surgical remission need to be set. In practice it is essential to “first do no harm to patients” and rethinking the new approach to patients with prolactionomas before embracing the new consensus is what is called common clinical sense.