Chinese Consensus on the Diagnosis and Treatment of Prolactinomas (2025 Edition)

Issuer: China Pituitary Adenoma Specialist Council (CPASC) Journal: Chinese Neurosurgical Journal, published online in 2026; developed using GRADE framework, total 36 recommendations. Core principle: Dopamine receptor agonist (DRA) remains first-line therapy; endoscopic surgery is an alternative for well-selected patients; multidisciplinary team (MDT) management for refractory cases, pregnancy and male prolactinomas

1. Background & Epidemiology

Prolactinoma is the most common functional pituitary neuroendocrine tumor. This consensus revises the 2014 Chinese guideline, incorporating new domestic and international evidence. It covers screening, diagnosis, differential diagnosis, medical/surgical/radiotherapy, and long-term follow-up, with special management for pregnant patients, males, macroprolactinemia and refractory prolactinomas. MDT including neurosurgery, endocrinology, neuroradiology, radiation oncology, pathology, ophthalmology and obstetrics & gynecology is strongly recommended for complex cases.

2. Diagnosis

2.1 Biochemical testing

1. Serum prolactin (PRL) test for suggestive symptoms: amenorrhea, galactorrhea, infertility, erectile dysfunction, headache, visual field defect.
2. Exclude physiological, drug-induced and other pathological hyperprolactinemia before diagnosing prolactinoma.
3. Watch for hook effect in large macroadenomas: serial dilution of PRL is required for giant adenoma.
4. Screen for macroprolactinemia when PRL is moderately elevated with no typical tumor manifestation.

2.2 Imaging

• Pituitary dynamic contrast-enhanced MRI is the preferred imaging modality.
• CT is only used for emergency bone assessment or patients contraindicated for MRI.
• New recommendation: Aneurysm screening for pituitary macroadenoma / giant adenoma before invasive surgery.
• Knosp grading for cavernous sinus invasion assessment.

2.3 Ophthalmologic evaluation

Formal visual acuity and perimetry for tumors compressing the optic chiasm.

2.4 Differential diagnosis

Rule out non-functioning pituitary adenoma, other sellar masses, primary hypothyroidism, drug-induced hyperprolactinemia, macroprolactinemia.

3. Treatment Strategy

3.1 Medical therapy (first-line)

1. Bromocriptine: traditional first-line oral DRA in mainland China; start low dose and titrate gradually. Monitor adverse effects: nausea, orthostatic hypotension, psychiatric symptoms.
2. Cabergoline: long-acting D2 agonist; recommended for bromocriptine-resistant patients if accessible. Regular echocardiography for long-term high-dose cabergoline to screen valvular heart disease. Monitor impulse control disorders.
3. Treatment target: normalize serum PRL, restore gonadal function, tumor shrinkage, relieve mass effect.
4. Tapering/discontinuation: after sustained remission (normal PRL + tumor disappearance or residual small lesion for ≥2–5 years), slow withdrawal can be attempted with close follow-up.

3.2 Surgical treatment

Indications for transsphenoidal neuroendoscopic surgery:

• Intolerance or severe adverse reaction to DRA
• DRA resistance / failed medical therapy
• Tumor hemorrhage (pituitary apoplexy) with progressive visual deterioration
• Cystic prolactinoma with mass effect
• Patient refuses long-term medication
• New highlight: Knosp 0–1 grade, well-circumscribed adenoma; surgery achieves high remission rate.

Surgery is NOT first-line for invasive macroprolactinoma.

3.3 Radiotherapy (stereotactic radiosurgery / fractionated radiotherapy)

Reserved for refractory, residual or recurrent tumors after medicine and surgery. Not for routine first-line use. Slow onset of action; risk of hypopituitarism.

4. Special Populations

4.1 Pregnancy

• Microprolactinoma: DRA may be stopped once pregnancy is confirmed, close clinical follow-up.
• Macroprolactinoma: individual risk-benefit assessment; continue DRA during pregnancy for high-risk mass effect.
• Visual monitoring; avoid routine PRL testing in uncomplicated pregnancy.

4.2 Male prolactinoma

Often diagnosed as macroadenoma at presentation; hypogonadism, mass symptoms common. Medical therapy remains first-line; monitor testosterone and pituitary function after PRL normalization.

4.3 Refractory prolactinoma

Defined as failure to normalize PRL despite adequate maximal tolerated DRA dose. MDT discussion: re-evaluate diagnosis, consider surgery, radiotherapy or clinical trial.

5. Long-term follow-up

1. Microadenoma on DRA: PRL every 3–6 months; MRI every 1–2 years once stable.
2. Macroadenoma: PRL + pituitary MRI at baseline, 3 months, then individualized interval.
3. Monitor pituitary axis function, visual fields, adverse effects of DRA.
4. After withdrawal of DRA: periodic surveillance for relapse.

6. Core Recommendations (abridged English version)

1. DRA is first-line therapy for most prolactinomas; transsphenoidal endoscopic surgery is an alternative for selected Knosp 0–1 grade well-defined adenomas.
2. Exclude non-tumoral hyperprolactinemia; recognize hook effect and macroprolactinemia pitfalls in PRL assay.
3. Dynamic contrast pituitary MRI is preferred imaging; perform aneurysm screening preoperatively for large/giant adenoma.
4. Cabergoline for bromocriptine-resistant cases; long-term high-dose cabergoline requires periodic echocardiography.
5. MDT assessment mandatory for refractory prolactinoma, giant adenoma, pregnancy and male patients.
6. Radiosurgery is a salvage option, not routine primary treatment.
7. Attempt drug tapering only after sustained long-term remission, with close surveillance for recurrence.
8. Pituitary apoplexy with progressive visual loss requires urgent MDT and possible surgical decompression.

Disclaimer: This is a condensed English summary of the 2025 Chinese Consensus on Prolactinoma, for academic reference only. It cannot replace individualized clinical decisions. Clinical implementation requires reading the full original paper, combined with local drug availability and patient conditions.