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Pituitary Adenomas. Elaine Sunderlin, MD PGY-2 Morning Report March 19, 2010. Overview of Pituitary Adenomas. Most common cause of sellar masses from the third decade on Accounts for up to 10% of all intracranial neoplasms Tumors of the anterior pituitary; almost always benign

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pituitary adenomas

Pituitary Adenomas

Elaine Sunderlin, MD

PGY-2

Morning Report

March 19, 2010

overview of pituitary adenomas
Overview of Pituitary Adenomas
  • Most common cause of sellar masses from the third decade on
  • Accounts for up to 10% of all intracranial neoplasms
  • Tumors of the anterior pituitary; almost always benign
  • Microadenomas: lesions < 1cm
  • Macroadenomas: lesions > 1cm
laboratory evaluation
Laboratory Evaluation
  • Microadenoma
    • Evaluation for hormonal hypersecretion (prolactin, IGF-1, 24hr urine cortisol/overnight dexamethasone suppression test)
    • Informal visual field evaluation
  • Macroadenoma
    • Evaluation for hormonal hypersecretion (prolactin, IGF-1, 24hr urine cortisol/overnight dexamethasone suppression test)
    • Evaluation for hormonal hyposecretion (LH, FSH, testosterone)
    • Formal visual fields
imaging evaluation
Imaging Evaluation
  • Nonfunctioning microadenoma (2-4mm)
    • Likely need no further imaging
  • Nonfunctioning microadenoma (5-9mm)
    • MRI can be done once or twice over the subsequent 2 yrs; if stable, frequency can be decreased
  • Nonfunctioning macroadenoma (< 20mm w/o neurologic abnormalities)
    • Monitor for adenoma size, visual changes, and hormonal hypersecretion in 6 and 12 months, then annually for a few years
prolactinoma
Prolactinoma
  • Most common hormone-secreting pituitary tumors, approximately 40% of all pituitary tumors
  • Microprolactinomas more common
  • Prolactin (PRL) > 200 ng/mL. Levels between 20-200 could be due to a prolactinoma or any other sellar mass
  • Occur most frequently in females aged 20-50 years, gender ratio of 10:1
  • Men: decreased libido, galactorrhea
  • Women: amenorrhea, galactorrhea
  • Occasionally prolactin is co-secreted with GH causing clinical syndrome of both prolactinemia and acromegaly
treatment of prolactinomas
Treatment of Prolactinomas
  • Regardless of size, medical therapy is first line to obtain normalization of prolactin levels
  • Dopamine agonists (DA)
    • Bromocriptine (D2 receptor agonist, D1 antagonist) 2.5-15mg/day divided into 2-3 doses. Occasionally requires doses as high as 20-30mg/day
      • Normalizes PRL levels, restores gonadal function, and decreases tumor size in 80-90% of microadenomas and 70% of macroadenomas
    • Cabergoline (D2 selective agonist) 0.5-1mg/week
      • Works in 95% of microadenomas and 80% of macroadenomas
surgery
Surgery
  • Surgical indications for prolactinomas
    • Sudden vision disturbance, associated w/ severe HA, altered consciousness and vascular collapse 2/2 apoplexy
    • Failure of medical therapy (inadequate PRL reduction on high doses of Das or tumor enlargement)
    • Expanding prolactinomas associated w/ unstable neurological and ophthalmologic deficits unresponding to DAs
pituitary apoplexy
Pituitary Apoplexy
  • Acute infarction or hemorrhage into the pituitary gland
  • Usually life-threatening emergency
  • Severe headaches, visual loss, altered consciousness, and impaired pituitary function
  • Predisposing factors: closed head trauma, blood pressure alterations, h/o pituitary irradiation, cardiac surgery, anticoagulation, treatment with DAs, and pregnancy
  • The majority of patients present with, at least, partial hypopituitarism. Deficit in ACTH leads to acute glucocorticoid deficiency
acromegaly symptoms
Acromegaly Symptoms
  • Sweaty, oily skin; skin tags; macroglossia
  • Broadened hands and feets
  • Jaw thickening, teeth separation, nasal bone hypertrophy
  • Carpal tunnel syndrome, ulnar nerve neuropathy
  • Headache
  • Arthralgias and myalgias
references
References
  • UpToDate
  • Colao, Annamaria. “The Prolactinoma”, Best Practice & Research Clinical Endocrinology & Metabolism;23, 2009;575-596.
  • Chanson MD, Phillipe, et.al. “Acromegaly”, Best Practice & Research Clinical Endocrinology & Metabolism;23, 2009;555-574
  • Murad-Kejbou S, Eggenberg E. “Pituitary apoplexy: evaluation, management, and prognosis”, CurrOpinOphthalmol. 2009,Nov;20(6);456-61
  • Chang, Claudia, et.al. “Pituitary tumor apoplexy”. Arq. Neuro-Psiquiatr. vol.67 no.2a São Paulo June 2009