Successfully reported this slideshow.
Your SlideShare is downloading. ×

Pituitary adenomas

Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad
Ad
Loading in …3
×

Check these out next

1 of 22 Ad

More Related Content

Recently uploaded (20)

Advertisement

Pituitary adenomas

  1. 1. L E W I S S . B L E V I N S , J R . , M . D . C A L I F O R N I A C E N T E R F O R P I T U I T A R Y D I S O R D E R S A T U C S F Presentation and Management of Pituitary Lesions
  2. 2. Pituitary Lesions  14-27% of autopsied pituitaries demonstrated adenoma  Most under 4mm  40% prolactinomas  18 per 100,000 will present clinically with a pituitary adenoma  I believe a great proportion of those undetected “did” as well  Radiographic presentations are the same as above  22% incidental lesion  Some of these Rathke’s cleft cysts, pars intermedia cysts  About 20 per 100,000 with macroadenomas
  3. 3. Pituitary Lesions  What determines clinical significance?  Hormone hypersecretion  Hypopituitarism  Mass effects  Other effects on patient and contacts
  4. 4. Sellar Masses
  5. 5. Differential Diagnosis of Sellar and Parasellar Masses  Pituitary Adenoma  Craniopharyngioma, Meningioma, Pituicytoma, Germinoma  Metastases (breast, lung, melanoma, GBM)  Rathke’s Cleft Cyst, Arachnoid Cyst, Pars Intermedia Cyst  Langerhans Cell Histiocytosis, Sarcoidosis  Hypophysitis: Lymphocytic, Granulomatous, IgG4- mediated
  6. 6. What are the potential consequences of a sellar mass?  Mass effects  Headache  Visual compromise  CN palsies  Epistaxis  Rhinorrhea  Abnormalities of pituitary hormone secretion  Excess  Deficiency  Normal pituitary function  Diabetes insipidus  Suggests a disease process other than a pituitary adenoma
  7. 7. Pituitary Excess  Hyperprolactinemia  Acromegaly  Cushing’s Syndrome  Hyperthyroidism Each of these disorders are associated with important co-morbidities that often require evaluation.
  8. 8. Hyperprolactinemia  Serum PRL level  Macroadenoma and PRL > 200 ng/mL is almost always a prolactinoma  Atypical prolactinomas often associated with PRL < 200 ng/mL  Microadenomas can be associated with any degree of PRL elevation  Drugs and stalk effect PRL usually <150
  9. 9. Hyperprolactinemia  Medical Management with Dopamine Agonists  Bromocriptine  Cabergoline  90% normalization of PRL  Tumor regression  Surgical intervention  Success dependent on tumor size and invasion  95% remission in microadenomas  50-75% remission in macroadenomas
  10. 10. Acromegaly  IGF-1 level almost always elevated  GH levels not diagnostic but indicative of disease activity  Oral glucose suppression test occasionally used to confirm abnormal GH secretion
  11. 11. Management of Acromegaly  Surgical intervention  Success dependent on tumor size and invasion  95% remission in microadenomas  50-75% remission in macroadenomas  Debulking can improve situation and lead to better responses to XRT and medications  Radiotherapy  50-75% control in 7-15 yrs  99% control of tumor growth  Medical management  Dopamine Agonists- 10-40% control  Somatostatin Receptor Agonists- 40-50% control  GH Receptor Antagonists- 69-94% control
  12. 12. Cushing’s Syndrome  24-h Urine Free Cortisol  Plasma ACTH level  Other tests under guidance of an Endocrinologist
  13. 13. Management of Cushing’s Syndrome  Surgical intervention  Success dependent on tumor size and invasion  95% remission in microadenomas  50-75% remission in macroadenomas  Debulking can result in clinical improvement and responses to XRT and medical therapy  Radiotherapy  50% control in 3-10 years  Medical Management  Somatostatin Receptor Agonist  Adrenal Biosynthesis Inhibitors  Glucocorticoid Receptor Antagonist
  14. 14. Hyperthyroidism  TSH, free T4 and T3 levels  TSH usually elevated but may be inappropriately “normal” in setting of hyperthyroidism
  15. 15. Management of TSH–secreting Adenomas  Surgical intervention  Success rates depend on size and invasiveness of tumor  Most are invasive macroadenomas  Radiotherapy  Useful to prevent tumor growth  Slow and low rates of hormonal control  Medical Therapy  Somatostatin Receptor Agonists control 90% of patients  Rarely… beta-blocker and methimazole also required
  16. 16. Rathke’s Cleft Cysts  Surgery indicated when….  Lesions >1cm  Lesions associated with mass effects including loss of pituitary function  Suspicion of infection  Surgical intervention  9% recurrence non-infected cysts  31% recurrence infected cysts not treated with antibiotics  13% recurrence infected cysts treated with antibiotics
  17. 17. Craniopharyngiomas  Intrasellar, suprasellar and hypothalamic locations  Subtotal resection with XRT is favored to spare neural tissue and especially in children  Not unusual to require multiple treatments  Hormone replacement and management of DI are essential to QoL
  18. 18. Pituitary Insufficiency  Partial or complete loss of one or more anterior pituitary hormones  Presentation can range from asymptomatic to severe hyponatremia and prostration  Pituitary deficiency leading to target gland deficiencies  T4 and T3 (Central Hypothyroidism)  Cortisol (Central Adrenal Insufficiency)  Sex Steroids (Central Hypogonadism)  GH deficiency  PRL deficiency  Preoperative therapy guided by needs
  19. 19. Suggested Tests for any Pituitary Lesion  PRL  IGF-1, GH  TSH, free T4, T3  Cortisol, ACTH  24-h Urine Free Cortisol if Cushing’s suspected  LH and Testosterone in men  FSH and Estradiol in women with absent or abnormal menses  Serum sodium and urine osmolarity if DI suspected
  20. 20. California Center for Pituitary Disorders at UCSF  Multidisciplinary team approach  Endocrinology, Neuro-ophthalmology, Neuroradiology, Radiation Oncology, etc  Surgeons  Sandeep Kunwar  Manish Aghi  Philip Theodosopoulos  Busiest and most active center in the US  260-280 surgical cases annually  Thousands of patient visits annually
  21. 21. WWW.PITUITARYWORLDNEWS.ORG Pituitary World News

×