Cortet-Rudelli C, Sapin R, Bonneville J-F, Brue T
Clinique Linquette, CHRU de Lille, 6, rue du Professeur-Laguesse, 59037 Lille cedex, France.
Ann Endocrinol (Paris). 2007 Jun;68(2-3):98-105. doi: 10.1016/j.ando.2007.03.013. Epub 2007 May 23.
There are numerous etiologies of hyperprolactinemia, a common reason for consultation. Diagnostic measures must be capable of identifying the tumors, the most frequent of which are prolactin adenomas. Hypothalamic-pituitary MRI is the reference morphological examination. In clinical practice, it is usually performed very early, following the discovery of increased plasma concentrations of PRL. This approach is warranted for marked increase in PRL in the absence of drugs with hyperprolactinemic effects (>10 x upper limit of normal) since a diagnosis of PRL adenoma is extremely likely under such circumstances. When hyperprolactinemia is moderate, which is the most common finding in practice, all etiologies are possible in theory and it is important to follow a rational diagnostic plan (history-taking to identify use of any drugs with hyperprolactinemic effects paying attention to renal and hepatic history, investigation for endocrine diseases occasionally associated with hyperprolactinemia such as hypothyroidism or polycystic ovary syndrome (PCOS), confirmation of hyperprolactinemia by a second assay when the initial level is less than five times the upper normal limit, pregnancy testing for women of childbearing age) in order to rule out all non-tumoral causes of hyperprolactinemia before proceeding with imaging. Absence of any consequences of hyperprolactinemia on gonadic function or the existence of a concomitant disease that could account for the clinical signs, demonstration of wide variations in PRL from one assay to another in a single patient could prompt screening for macroprolactinemia before MRI is ordered. Macroprolactinoma could also occur in the case of normal or doubtful MRI or discrepancy in response to medical or surgical treatment. T1- and T2-weighted coronal sections (with or without T1 after gadolinium injection) are generally sufficient for diagnosis of microprolactinoma. Dynamic tests may be useful if MRI is normal or unclear. Gadolinium injection with sagittal and axial sections is essential for examination of large lesions. In this case, when the increase of PRL is moderate (<150 mg/ml), a non-lactotropic lesion may be suspected without misdiagnosing a hook effect. Careful analysis of the images allows differentiation between tumoral lesions and pituitary hyperplasia.
高催乳素血症病因众多，是常见的就诊原因。诊断措施必须能够识别肿瘤，其中最常见的是催乳素腺瘤。下丘脑 - 垂体磁共振成像（MRI）是参考的形态学检查方法。在临床实践中，通常在发现血浆催乳素（PRL）浓度升高后很早便进行该项检查。对于在没有具有高催乳素血症作用的药物情况下PRL显著升高（>正常上限10倍）的情况，这种做法是合理的，因为在这种情况下PRL腺瘤的诊断极有可能。当高催乳素血症为中度时，这是实际中最常见的发现，理论上所有病因都有可能，因此在进行影像学检查之前，遵循合理的诊断计划（通过病史询问来确定是否使用了任何具有高催乳素血症作用的药物，同时注意肾脏和肝脏病史，排查偶尔与高催乳素血症相关的内分泌疾病，如甲状腺功能减退或多囊卵巢综合征（PCOS），当初始水平低于正常上限五倍时通过第二次检测确认高催乳素血症，对育龄女性进行妊娠检测）以排除高催乳素血症所有非肿瘤性病因很重要。高催乳素血症对性腺功能无任何影响，或者存在可解释临床症状的伴随疾病，或者在同一患者中一次检测到的PRL与另一次检测结果差异很大，这些情况都可能提示在进行MRI检查之前筛查巨催乳素血症。在MRI正常或存疑，或者对药物或手术治疗反应存在差异的情况下，也可能发生大催乳素瘤。T1加权和T2加权冠状位切片（注射钆剂后有无T1加权）通常足以诊断微催乳素瘤。如果MRI正常或不清晰，动态试验可能有用。注射钆剂后的矢状位和轴位切片对于检查大的病变至关重要。在这种情况下，当PRL升高为中度（<150μg/ml）时，可能怀疑为非催乳素瘤病变，同时避免误诊为钩效应。仔细分析图像可区分肿瘤性病变和垂体增生。
