Introduction: Aggressive prolactinomas that are refractory to medical management pose a significant challenge. These tumors often require multiple treatment modalities. When these measures fail to prevent disease progression, novel strategies for tumor control must be considered. Temozolomide, an oral alkylating agent, has shown efficacy in the treatment of aggressive pituitary adenomas.
Methods: All three patients had their tumors managed by the multi-disciplinary team at UT Southwestern Medical Center. A 34-year-old woman with MEN1 syndrome demonstrated tumor progression despite high-dose cabergoline, tamoxifen, multiple surgeries, and radiotherapy. A 67-year-old female patient had tumor progression despite receiving a similar treatment regimen with her prolactin level reaching a peak of 8,300. The third patient is a 74-year-old man who also underwent multiple surgical resections and radiation therapy, but was unable to tolerate high-dose dopamine agonists due to comorbid schizophrenia.
Results: All three patients responded to temozolomide therapy. The first patient completed 18 cycles at a dose of 200 mg/m2. Her visual deficits improved, and her prolactin level dropped to 20. She remains stable four months into a temozolomide holiday. The second patient has completed 8 of 12 scheduled cycles at a dose of 200 mg/m2. Her pituitary mass has reduced in size and her prolactin level has decreased from 1373 to 376, a six-year low. The third patient completed 1 cycle at a dose of 200 mg/m2, which was subsequently reduced to 100 mg/m2 for an additional 8 cycles due to neutropenia and thrombocytopenia. At the completion of 9 cycles, his tumor had decreased in size and his prolactin level was less than 1. He remains clinically and radiographically stable 10 months out from his last temozolomide cycle.
Conclusions: These three cases demonstrate that temozolomide may be a safe and effective treatment in patients with aggressive prolactinoma.
Patient Care: Provide a potential alternative therapy for the management of aggressive prolactinomas
Learning Objectives: To understand the role temozolomide may play in the management of aggressive prolactinomas