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Morbidity and Mortality Conference Ann Marie Lam, PGY-2 Emory University School of Medicine Family Medicine Residency Pr PowerPoint Presentation
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Morbidity and Mortality Conference Ann Marie Lam, PGY-2 Emory University School of Medicine Family Medicine Residency Program October 14 th , 2010. Pituitary Adenoma. Macroadenoma (>1 cm) Rarely malignant Hormone overproduction/deficiency Can become locally invasive Can lead to CN palsies

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Morbidity and Mortality ConferenceAnn Marie Lam, PGY-2Emory University School of MedicineFamily Medicine Residency ProgramOctober 14th, 2010

pituitary adenoma
Pituitary Adenoma
  • Macroadenoma (>1 cm)
  • Rarely malignant
  • Hormone overproduction/deficiency
  • Can become locally invasive
  • Can lead to CN palsies
  • Can lead to pituitary apoplexy
  • Can be associated with MEN I syndrome
  • Risk of recurrence
treatment
Treatment
  • Medical therapy: correction/replacement of hormone overproduction/deficiency
  • Surgical therapy: decompression, resection
  • Radiation an option for adjunctive therapy
types of pituitary adenoma
Types of Pituitary Adenoma
  • Prolactinoma (PRL) (35%)
  • Acromegaly (GH) (20%)
  • Cushing Disease (ACTH) (7%)
  • Gonadotropin-Producing Adenoma (LH, FSH) (<1%)
  • Non-secretory Adenoma (30%)
  • TSH-Secreting Adenoma (<1%)
  • Diabetes Insipidus (lack of VP)
prolactinoma
Prolactinoma
  • Presentation: amenorrhea, galactorrhea, infertility, (in men: impotence, dec libido)
  • Diagnosis: PRL level >200 ng/ml, R/O prolactinemia from mass effect
  • Treatment (large, sympt): Bromocriptine, cabergoline (dopamine analog, inhibits PRL)
acromegaly
Acromegaly
  • Presentation: coarse facial features, oily skin, carpal tunnel syndrome, OA, increased hat/glove/shoe size, DM
  • Diagnosis: elev ILGF-1, elev post-prandial GH on 100 g OGTT (failure to suppress GH to <2 ng/ml diagnostic)
  • Treatment: Octreotide SC (somatostatin analog), bromocriptine
cushing s disease
Cushing’s Disease
  • Presentation: truncal obesity, striae, round facies, hirsutism, HTN, DM, thin skin
  • Diagnosis: elev 24-hr urine cortisol, dexamethasone suppression test (1mg dex, night cortisol)
  • Treatment: ketoconazole (inhibits steroid synthesis)
tsh secreting adenoma
TSH-secreting adenoma
  • Presentation: goiter, thyrotoxicosis, visual impairment
  • Diagnosis: elev TSH, T3, T4
  • Treatment: surgery, octreotide
non secretory adenoma
Non-secretory adenoma
  • Usually large at time of presentation
  • Presentation: bitemporal hemianopsia, CN defects (cav sinus compression), hypopituitarism
  • Evaluation: assess pituitary function, VF testing
  • Treatment: surgery, +/-radiation
long term follow up
Long-term follow-up
  • Post-op 4-6 wks to confirm adenoma completely removed and hypersecretion resolved
  • Monitor yearly for recurrence, hypopituitarism
discussion
Discussion
  • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment
discussion12
Discussion
  • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment
  • Multi-disciplinary approach led by primary team leading
discussion13
Discussion
  • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment
  • Multi-disciplinary approach led by primary team leading
  • Consider transferring patient to primary care-providing team
discussion14
Discussion
  • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment
  • Multi-disciplinary approach led by primary team leading
  • Consider transferring patient to primary care-providing team
  • Patient-oriented care
discussion15
Discussion
  • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment
  • Multi-disciplinary approach led by primary team leading
  • Consider transferring patient to primary care-providing team
  • Patient-oriented care
  • Patient responsibility
references
References
  • Harrison’s Principles of Internal Medicine. 16th edition. Disorders of the anterior pituitary and hypothalamus, 2005.
  • Ferri’s Clinical Advisor. Pituitary adenoma, 2010.
  • Klibanski, A. Prolactinomas. NEJM 362: 1219-1226, April 2010.
  • Melmed, S. Medical Progress: Acromegaly. NEJM 355: 2558-2573, Dec 2006.
  • Pituitary adenoma. UpToDate. Accessed 9/29/10.