Prolactin elevation to 16,630 mU/l in a case of a large non-functioning pituitary adenoma
Bibliographic record
Abstract
An 18-year old male presented with galactorrhoaea and obesity. PRL measured 16,630 mU/l, FSH 6.0 U/l, LH 5.0 U/l, testosterone 8.6 nmol/l, SHBG 15.0 nmol/l, IGF-1 22.0 nmol/l and TSH 1.39 mU/l. Several 24-hour urinary free cortisol estimations excluded hypercortisolism. Short synacthen test confirmed an intact HPA axis. Visual fields were full. Pituitary-MRI revealed a large adenoma extending into the right cavernous sinus without suprasellar extension. PRL started declining upon commencing bromocriptine and at 3 months had fallen to 1,504 mU/l. This was associated with severe headaches and visual disturbance. The dose of bromocriptine was reduced to slow down the presumed rapid shrinkage of prolactinoma. Subsequent MRI failed to confirm significant tumour shrinkage or apoplexy. Over the next year bromocriptine was tolerated only in small doses on account of the headaches, and was replaced with cabergoline. Tumour-size diminished to a moderate degree while prolactin levels settled to < 800 mU/l over a further two years of follow-up with regular imaging. Trans-sphenoidal adenomectomy was undertaken to define the histopathology of the tumour in view of the atypical clinical course. Histology revealed chromophobe cells with negative staining for PRL, ACTH, FSH, LH, GH and TSH. Unfortunately, but not unexpectedly, the hyperprolactinaemia recurred within 12 months of surgery accompanied by tumour regrowth. Anterior pituitary function (ACTH and TSH reserve) remained intact. Cabergoline was reintroduced with satisfactory control of hyperprolactinaemia and sex steroid reserve. Further therapeutic options - medical vs. pituitary fossa clearance and/or radiotherapy - and possible complications were discussed with the patient; he opted for dopamine-agonist therapy. This is the first reported case of a significant prolactin elevation in the range pathognomonic of lactotroph macroadenoma associated with NFPA. Histological diagnosis is essential in the presence of an atypical clinical course as demonstrated in this case. Further management of our patient remains difficult.Severe hyperprolactinaemia (PRL > 8,000 mU/l) is almost always due to a prolactinoma, and biochemical response to dopamine-agonist therapy in the presence of radiographic evidence of an adenoma is often regarded as sufficient confirmation. Our case is the first report of an exception to this rule. Definitive treatment engenders jeopardising pituitary function which has survived intact pre- and post- surgery, limiting future therapeutic options.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.003 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.004 | 0.003 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".