Author: Abdulaziz R. Alanzi

1. Pituitary Adenoma
 Abdulaziz R. Alanzi
 Medical Student, Al-Imam University
 Riyadh, Saudi Arabia

2. Overview
 Pituitary adenoma is primary tumor that occur in the pituitary gland.
 99% of pituitary gland tumors are benign
 Most commonly diagnosed in people between the ages of 30 and 50
years
 Accounts for 10-15% of all intracranial tumors.
 Symptomatic prolactinomas and Cushing disease are found more
frequently in women.
 Pituitary adenomas are classified by their cell of origin
(lactotroph, gonadotroph, somatotroph, corticotroph, and thyrotroph)
and their size: microadenoma (diameter < 1cm),
macroadenoma (diameter ≥ 1cm)

3. Risk Factors
Multiple endocrine
neoplasia (MEN)
type 1
Pituitary
Adenoma
Parathyroid
Tumor
Pancreatic
Tumor
Carney
complex
Pituitary
Adenoma
Adrenal
Tumors
Myxomas
Familial isolated
pituitary
adenoma
McCune-Albright
syndrome
Prolactinoma
Acromegaly
Growth Hormone
Secreting Tumor
1
2
3
4

4. Clinical Manifestations
 Mass effect:
 Headache  Visual Defects:
Bitemporal hemianopia
(due to compression of optic chiasm).

5. Clinical Manifestations
Hormonal deficiencies - Clinical effects
Growth hormone
deficiency
• Adults - Increased rate
of cardiovascular
disease, obesity,
reduced muscle
strength and exercise
capacity, and
increased cholesterol
• Infants –Hypoglycemia
• Children - Decreased
height and growth
rate
Gonadotrophin deficiency
• Men - Diminished libido and
impotence; testes shrink in
size, but spermatogenesis
generally preserved
• Women - Diminished libido
and dyspareunia; breast
atrophy in chronic
deficiency
• Children - Delayed or frank
absence of puberty
Thyrotropin
deficiency
•Malaise,
• weight gain,
• lack of energy,
• cold intolerance,
• constipation

6. Clinical Manifestations
Hormonal deficiencies - Clinical effects
Corticotrophin deficiency
• Initially, symptoms nonspecific (eg, weight
loss, lack of energy, malaise); severe
adrenal insufficiency may present as a
medical emergency
Panhypopituitarism
Refers to
deficiency of
several anterior
pituitary
hormones.

7. Clinical Manifestations
Hormonal overproduction - Clinical effects
Prolactin *
• Hypogonadism, if
hyperprolactinemia
sustained
• Women -
Amenorrhea,
galactorrhea, and
infertility
• Men - Decreased
libido, impotence,
and rarely
galactorrhea
Growth hormone
• Children and adolescents - May result
in pituitary gigantism
• Adults – Acromegaly Changes in the
size of the hand and feet, coarseness
of the face, frontal bossing, and
prognathism result. Further changes in
the voice, and hirsutism, confirm the
diagnosis.
• Acromegaly frequently results in
glucose intolerance, with 20% of
patients progressing to diabetes
mellitus.
• Carpal tunnel syndrome is seen
frequently.
Cushing
disease
• Weight gain,
central
obesity,
moon facies,
violet striae,
easy
bruisability.

8. Clinical Examination Finding
Neuro-ophthalmologic examination
 Visual acuity can be decreased in one or both eyes.
 Pupillary light reaction can be abnormal.
 Color vision can be affected.
 Larger lesions may be associated with a bitemporal hemianopsia.
 Optic atrophy is seen frequently

9. Clinical Examination Finding
Hypopituitarism
 Chronic hypopituitarism results in hypotension, generalized weakness,
hypothermia, malaise, and depression.
 Acute sudden hypopituitarism (ie, pituitary apoplexy) is associated with
Prolactinomas
shock, coma, and death.
 In females, galactorrhea may be present on clinical examination.
Women undergoing an infertility evaluation may be found to have
a prolactinoma.
 In males, galactorrhea is infrequent; testicles may be decreased in
size and may be soft to palpation.

10. Clinical Examination Finding
Cushing Disease
Findings are prominent and include obesity, centripetal fat deposition,
proximal myopathy, moon facies, buffalo hump, posterior subcapsular
cataracts, arterial hypertension, bruises, and skin striae.

11. Clinical Examination Finding
Acromegaly
 Large hands and feet (with thick fingers and toes) and coarse facial features
with frontal bossing. Women may appear masculinized. Other findings might
include prognathism, carpal tunnel syndrome, and voice quality changes.

12. Differential Diagnosis
 Craniopharyngioma
 Rathke's cleft cyst
 Meningioma
 Brainstem Gliomas
 Glioblastoma Multiforme
 Germinoma
 Pituitary hyperplasia
 Ependymoma
 Low-Grade Astrocytoma
 Primary CNS Lymphoma

13. Diagnosis
Blood chemistry tests: pituitary hormones level:
 Prolactinomas: Serum prolactin level
 Growth hormone abnormalities: Growth hormone (GH) levels -
insulin-like growth factor-1 (IGF-1) - Oral glucose tolerance test
 Cushing disease: 24 hrs urine collection for free cortisol,
Dexamethasone suppression test, Serum levels of ACTH.
 Thyroid hormones, including thyrotropin (TSH), thyroxine (T4) and
triiodothyronine (T3)
 Luteinizing hormone (LH) - follicle-stimulating hormone (FSH) -
estrogen - estradiol - testosterone
Imaging Tests: MRI, CT-Scan

14. Staging
Classification for pituitary adenomas based on imaging
0 Pituitary gland appears normal.
I Microadenoma enclosed within the sella turcica.
II Macroadenoma enclosed within the sella turcica.
III Tumour invades into the sella turcica locally (in one place).
IV Tumour invades into the sella turcica diffusely (in more than one place).
Grading for suprasellar extension
A 0–10 mm suprasellar extension occupying the suprasellar cistern
B 10–20 mm extension and elevation of the third ventricle
C 20–30 mm extension occupying the anterior (front) of the third ventricle
D
Larger than 30 mm extension, beyond the foramen of Monro, or grade C with lateral
extensions

15. Management - Hormonal deficiencies

16. Management - Hormonal overproduction
Prolactinoma:
Dopaminergic agonists
(bromocriptine,
cabergoline and
Quinagolide)
Growth hormone-secreting tumors:
Gonadotropin-secreting pituitary tumor:
Thyrotropin-secreting tumors
• Surgery, often followed by radiation
therapy.
• Medical treatment (Octreotide)
Nonsecretory pituitary adenomas
• Surgery
• If surgery is contraindicated,
medical treatment (Bromocriptine or Octreotide)

17. Management - Hormonal overproduction
Corticotropin-secreting pituitary tumors:
• surgery and radiation therapy
# Medical therapy:
• Central acting agents:
(bromocriptine, valproic acid, and cyproheptadine).
• Peripheral acting agents:
(ketoconazole, mitotane, and metyrapone).

18. Complications
 Vision loss
 Pituitary hormone insufficiency, including
diabetes insipidus, hypothyroidism, and
hypogonadism, may occur.
 Pituitary apoplexy: is bleeding into or impaired
blood supply of the pituitary gland at the base of
the brain.

19. Summary
 99% of pituitary gland tumors are benign
 Accounts for 10-15% of all intracranial tumors.
 Risk factors include MEN type 1, Carney complex, Familial isolated
pituitary adenoma…etc
 Clinical manifestation include headache, visual defects, and other
symptoms depending on which pituitary hormone involved in the
disease.
 The diagnosis is confirmed by testing hormone levels, and by
radiographic imaging of the pituitary.
 Management include surgery, radiation therapy, medical therapy
depending of the type of pituitary adenoma.
 Complications might include vision loss, pituitary hormone
insufficiency, pituitary apoplexy.

20. References

21. Thank You
AbdulazizROA@gmail.com
@Azizocyte