Lect 2-pitutary tumor(1)


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pitutary tumor

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Lect 2-pitutary tumor(1)

  1. 1. Pituitary Adenomas SMS 3023 Dr. Mohanad r. alwan
  2. 2. Function <ul><li>Anterior Lobe: </li></ul><ul><ul><li>FSH </li></ul></ul><ul><ul><li>LH </li></ul></ul><ul><ul><li>ACTH </li></ul></ul><ul><ul><li>TSH </li></ul></ul><ul><ul><li>Prolactin </li></ul></ul><ul><ul><li>GH </li></ul></ul><ul><li>Posterior Lobe: </li></ul><ul><ul><li>ADH </li></ul></ul><ul><ul><li>Oxytocin </li></ul></ul>
  3. 3. Pituitary Adenomas/ Epidemiology <ul><li>Etiology is unknown </li></ul><ul><li>Not associated with environmental factors </li></ul><ul><li>10-15% of all primary brain tumors </li></ul><ul><li>20-25% of pituitary glands at autopsy found to have adenomas </li></ul><ul><li>70% of adenomas are endocrinogically secreting </li></ul><ul><li>25% of those with MEN-I develop pituitary adenomas </li></ul>
  4. 4. Natural History <ul><li>Pituitary adenomas have long natural history </li></ul><ul><li>Vary in size and direction of spread </li></ul><ul><li>Microadenomas < 10 mm – may cause focal bulging </li></ul><ul><li>Macroadenomas > 10 mm – cause problems due to mass effect </li></ul>
  5. 5. Clinical Features of Pituitary Tumors <ul><li>HYPER: Growth, lactation, thyroid, adrenal cortex. </li></ul><ul><li>HYPO: Growth, thyroid, adrenal cortex. </li></ul><ul><li>MASS EFFECT: Visual fields, brain </li></ul><ul><li>bitemporal hemianopsia and superior temporal defects </li></ul><ul><li>Pituitary Apoplexy. </li></ul>
  6. 6. Types of adenoma: - Non-functional 25-35% - Prolactinoma (Prolactin > 200 ng /dl) (N<14 ng/ml). 25-30% -FSH + LH releasing adenoma. -ACTH adenoma 10-15% -GH adenoma 20-25% Mixed 5% -TSH adenoma. Hyperpituitarism and Adenomas of Pituitary
  7. 7. Endocrine-Active Pituitary Adenomas <ul><li>Prolactin – Amenorrhea, galactorrhea, impotence </li></ul><ul><li>Growth hormone – Gigantism and acromegaly </li></ul><ul><li>Corticotropin – Cushing’s disease, Nelson’s syndrome post adrenalectomy </li></ul><ul><li>TSH - Hyperthyroidism </li></ul>
  8. 8. Non-functioning Adenomas <ul><li>25-30 % of patients do not have classical hypersecretory syndromes </li></ul><ul><li>May grow to a large size before they are detected </li></ul><ul><li>Present due to mass effect </li></ul><ul><ul><li>Visual deficits </li></ul></ul><ul><ul><li>HA </li></ul></ul><ul><ul><li>Hormone deficiency </li></ul></ul>
  9. 9. Pathologic Classification <ul><li>Benign or malignant </li></ul><ul><li>Chromophobic – Non-functioning </li></ul><ul><li>Basophilic – Cushing’s </li></ul><ul><li>Acidophilic - Acromegaly </li></ul><ul><li>Mixed </li></ul>
  10. 10. Pituitary adenomas <ul><li>Microadenomas: benign neoplasms < 1 cm, found in 25% of autopsies, 50% are PRL secreting. </li></ul><ul><li>Histo: sheets and cords of uniform, polygonal cells with sparse connective tissue. </li></ul><ul><li>Functional status can not be predicted from morphology. </li></ul>
  11. 11. <ul><li>Adenoma cells are small to medium-sized containing </li></ul><ul><li>moderate to abundant amounts of finely granular cytoplasm </li></ul><ul><li>Round to oval nuclei showing finely-stippled chromatin and indistinct to small nucleoli. </li></ul><ul><li>The cytoplasm can be eosinophilic, basophilic , acidophilic, or chromophobe recapitulating normal pituitary cell types. </li></ul><ul><li>This tumor is arranged in pseudo-acinar formations with a central lumen-like space (arrowhead). </li></ul><ul><li>Tumor necrosis is generally not present unless infarction develops because of rapid growth. </li></ul>
  12. 12. <ul><li>You will see clusters and cords of the tumor cells, and it may be tricky to distinguish the tumor from the surrounding normal pituitary. </li></ul>
  13. 13. Pituitary adenome with extensive interstitial and perivascular fibrosis.
  14. 14. Symptoms <ul><li>Headache </li></ul><ul><li>Lethargy </li></ul><ul><li>Nasal drainage </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Problems with the sense of smell </li></ul><ul><li>Visual changes </li></ul><ul><ul><li>Double vision </li></ul></ul><ul><ul><li>Drooping eyelids </li></ul></ul><ul><ul><li>Visual field loss </li></ul></ul>
  15. 15. Tumor Stages <ul><li>Type A: Tumor bulges into the chiasmatic cistern </li></ul><ul><li>Type B: Tumor reaches the floor of the 3 rd ventricle </li></ul><ul><li>Type C: Tumor is more voluminous with extension into the 3 rd ventricle up to the foramen of Monro </li></ul><ul><li>Type D: Tumor extends into temporal or frontal fossa </li></ul>
  16. 16. Evaluation <ul><li>MRI </li></ul><ul><li>Visual field assessment </li></ul><ul><li>Endocrine evaluation </li></ul><ul><ul><li>Tests of normal gonadal, thyroid, and adrenal function </li></ul></ul><ul><ul><li>Radioimmunoassays – for hormone levels </li></ul></ul>
  17. 17.
  18. 19. Prolacinomas <ul><li>Present in  : </li></ul><ul><li>Abnormal milk flow from the breast in a woman who is not pregnant or nursing (galactorrhea) </li></ul><ul><li>Breast tenderness </li></ul><ul><li>Decreased sexual interest </li></ul><ul><li>Headache </li></ul><ul><li>Infertility </li></ul><ul><li>Stopping of menstruation not related to menopause </li></ul><ul><li>Vision changes </li></ul>
  19. 20. Prolacinomas <ul><li>Present in  : </li></ul><ul><li>Decreased sexual interest </li></ul><ul><li>Enlargement of breast tissue (gynecomastia) </li></ul><ul><li>Headache </li></ul><ul><li>Impotence </li></ul><ul><li>Infertility </li></ul><ul><li>Vision changes </li></ul>
  20. 21. <ul><li>A- The tumor consists of multiple densely irregular sheets cellular micronodular structures with disruption of normal pituitary sinusoidal vasculostromal network. (see arrow) </li></ul><ul><li>Multinucleation and discrete cytoplasmic accumulations of finely granular eosinophilic material (secretory granules) displacing the nucleus at the periphery </li></ul>
  21. 22. Benign tumor from ( Rathke's cleft – source of adenohypophysis). -Suprasellar expansion. -Often cystic, similar structure as adamantinoma of the jaws. Craniopharyng i oma
  22. 23. Gross picture: Large capsulated solid or cystic mass. Areas of calcification. Microscopic picture: Masses of squamoid and columnar epithelium lining cystic spaces filled with oily fluid in a loose fibrous stroma. Craniopharyng i oma.
  23. 24. Craniopharyng i oma.
  24. 25. Craniopharyng i oma.
  25. 26. Multiple endocrine neoplasia (MEN) I <ul><li>Multiple endocrine neoplasia (MEN) type I is an inherited disorder in which one or more of the endocrine glands are overactive or form a tumor. Endocrine glands most commonly involved include: </li></ul><ul><li>Pancreas </li></ul><ul><li>Parathyroid </li></ul><ul><li>Pituitary </li></ul><ul><li>Cause </li></ul><ul><li>MEN I is caused by a defect in a gene that carries the code for a protein called menin. </li></ul><ul><li>The disorder may occur at any age, and it affects men and women equally. A family history of this disorder raises your risk. </li></ul>
  26. 27. Symptoms <ul><li>Abdominal pain, Bloated feeling after meals, Black, tarry stools </li></ul><ul><li>Anxiety </li></ul><ul><li>Burning, aching, or hunger discomfort in the upper abdomen or lower chest that is relieved by antacids, milk, or food </li></ul><ul><li>Decreased sexual interest, </li></ul><ul><li>Fatigue, Weakness </li></ul><ul><li>Lack of menstrual periods, infertility, or failure to produce breast milk (in women) </li></ul><ul><li>Loss of appetite, Loss of body or facial hair (in men) </li></ul><ul><li>Loss of coordination </li></ul><ul><li>Mental changes or confusion </li></ul><ul><li>Headache, Muscle pain </li></ul><ul><li>Nausea and vomiting, Unintentional weight loss </li></ul><ul><li>Sensitivity to the cold </li></ul><ul><li>Vision problems </li></ul><ul><li>Coma (if low blood sugar is untreated), High blood calcium level </li></ul><ul><li>Kidney stones, Low blood pressure, Low blood sugar </li></ul>
  27. 28. Blood Tests <ul><li>Calcitonin level </li></ul><ul><li>Blood alkaline phosphatase </li></ul><ul><li>Blood calcium </li></ul><ul><li>Blood phosphorus </li></ul><ul><li>Urine catecholamines </li></ul><ul><li>Urine metanephrine </li></ul>
  28. 29. Treatment <ul><li>The method of treatment depends on the type and size of the tumor </li></ul><ul><li>Observation and medication </li></ul><ul><li>Surgery </li></ul><ul><ul><li>Transphenoidal endoscopic tumor removal </li></ul></ul><ul><ul><li>Transcranial tumor removal </li></ul></ul><ul><li>Radiation Treatment </li></ul><ul><ul><li>Stereotactic radiosurgery </li></ul></ul><ul><ul><li>External-beam radiation </li></ul></ul><ul><li>Hormone Therapy </li></ul>
  29. 30. Question????? <ul><li>72 year old male inpatient recently admitted for fatigue and hyponatremia who complains of progressively worsening vision in both eyes over the past few years, also he had hypertension, hypercholesterolemia, alcohol abuse, chronic pancreatitis. Regarding to his cause: </li></ul><ul><li>What is your more likely diagnosis. Why? </li></ul><ul><li>Histopathology of these disease. </li></ul><ul><li>Mention the important blood test which used to confirm the disease. </li></ul>