2025 Proffered Presentations
S168: MEDICATION VERSUS EARLY SURGERY IN PROLACTINOMAS WITH VISUAL INVOLVEMENT: TIME FOR RANDOMIZED CONTROLLED TRIALS
Adam Z Levitan, BSc1; Megan Laing2; Hannah Liu1; Zummana Ahsan1; Janissardhar Skulsampaopol, MD3; Jeannette Goguen, MD, MEd1; John Lee, MD, FRCSC, MSc1; Jennifer Anderson, MD, FRCSC, MSc1; Irene Vanek, MD, FRCPC4; Michael D Cusimano, MD, MHPE, PhD, FRCS, DABNS, FACS1; 1University of Toronto; 2McMaster University; 3Mahidol University; 4St. Michael's Hospital
Background: Visual morbidity due to optic compressive neuropathy is common in patients with large prolactinomas. Although medical therapy has been the mainstay of treatment for these patients, some researchers have argued that early surgery leads to better visual outcomes by more rapidly decompressing the optic system than medicines. We performed a systematic review to compare the visual outcomes of patients with macroprolactinomas treated medically versus surgically to better understand if there is equipoise to support a randomized controlled trial in the field.
Methods: A systematic review was performed using PRISMA Guidelines. Pubmed, EMBASE, and MEDLINE were searched from inception to September 2, 2024, for primary articles that reported visual outcomes in adult patients with macroprolactinoma treated with either medication, surgery, or both. A quantitative and qualitative analysis was used to compare visual outcomes between treatment methods.
Results: Of 15 eligible studies in the final analysis, all were case series and of moderate or high risk of bias. 3 investigated surgery (TSS), 3 oral bromocriptine (BRC), 3 injectable bromocriptine (BRC-LAR), 4 cabergoline (CAB) and 2 quinagolide (CV). Visual defect (VD) resolution was highest in and comparable between surgery (25/30, 83%), CAB (134/163, 82%) and BRC-LAR (13/15, 87%). VDs resolved at lower rates in patients treated with oral BRC (15/31, 48%) and CV (4/7, 57%). There were no direct controlled comparisons of surgery and medical therapy and considerations of risk benefit ratios or long term economic implications was limited.
Discussion: Reported visual outcomes are similar between surgery and the best medical therapies; however, direct controlled comparisons are lacking. Given the similarity in outcomes and rapidly improving surgical approaches, randomized controlled trials assessing visual outcomes between surgery and medical therapy in patients with large prolactinomas are justified to better delineate the role of each modality of treatment for these patients.