Download Pituitary Adenoma Diagnosis and Management Anatomical land

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Pituitary Adenoma
Diagnosis and Management
Anatomical land marks
Suprasellar space
Anteriorly
Laterally
Posteriorly
Inferiorly
Superiorly
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- Tuberculum sella
- Medial temporalLobes
- Brain stem
- Diaphragm sella
- Basifrontal lobes
Pituitary Gland ( pituitary/ hypophysis Cerebri )
 Lies in pituitary fossa in sphenoid bone.
Adenohypophysis
Neurohypophysis
A horizontally placed ovoid
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Transverse
body
12-15mm
Ant:post:
8-10mm
Height
5-7mm
Weight
0.5-0.7gm
0.8-1gm (Pregnant lady)
- Anterior pituitary
- Posterior pituitary
Function of Pituitary Gland
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Regulates the function of thyroid glands, the adrenal glands, ovaries and testes
Controls the lactation, uterine contractions during labor and linear growth and it regulates
the osmolality and intravascular fluid, through kidneys.
Comprised of anterior and posterior lobes.
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Eight peptide hormone, two from posterior and six from anterior.
Disorders, causing s/s are due to,
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(i) excess or deficient hormone secretion
(ii) extrinsic compression
(iii) interruption of blood supply.
Pituitary hormones
ANTERIOR PITUITARY
 Adrenocorticotropin
 Thyroid stimulating hormone
 Follicle stimulating hormone
 Leutinizing hormone
 Growth hormone
 Prolactin
ACTH
TSH
FSH
LH
GH
PRL
POSTERIOR PITUITARY
 Antidiuritic hormone
 Oxytocin
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ADH
Clinical assessment
Assessment of pituitary function:
Clinical evaluation for hormonal deficiency or excess.
Laboratory testing of the various pituitary- target organ axes.
Endocrine evaluation confirms endocrinopathy and help in establishing the diagnosis.
Endocrine values may be used as prognostic index for those going under the treatment,
surgery or radiation therapy.
Pituitary tumors
Pituitary tumors
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Benign
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Malignant
Pituitary tumors
Benign tumors are:-
Non secretary
Secretary
1-Prolactinoma
2-Growth hormone secretary tumors
3-ACTH secretary tumors
4-Others
Epidemiology of pituitary adenoma
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10% of all intracranial tumors
Most common in 3rd and 4th decade of life
Equally affect both sexes
Clinical presentation of pituitary tumors
Mass Effects
Endocrinological disturbances
Clinical presentations
Mass Effects
Visual disturbance(bi-temporal hemianopsia,)
Obstructive hydrocephalus
Pituitary apoplexy and ischemia
Clinical presentations
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Hypersecretions of a particular hormones
The symptoms depends upon the hormonal secretions.
Include variety of symptoms and signs
FUNCTIONAL PITUITARY TUMORS
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The most common functional pituitary tumors secrete one of the following:
1-prolactin (PRL): prolactinomas are the most common secretory adenoma. Causes amenorrheagalactorrhea syndrome (AKA Forbes-Albright syndrome, AKA Ahumada-del Castillo syndrome) in
females,
impotence in males, and often infertility in either sex. Also causes bone loss
FUNCTIONAL PITUITARY TUMORS
2-adrenocorticotropic hormone (ACTH): AKA corticotropin. This is Cushing's disease. Elevated
ACTH causes either:
A. endogenous hypercortisolism (Cushing's disease
B. Nelson's syndrome: hyperpigmentation (due to melanin stimulating hormone (MSH) cross
reactivity with ACTH). Develops in 10·30% of patients who have undergone adrenalectomy for
treatment of Cushing's syndrome
FUNCTIONAL PITUITARY TUMORS
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3-Growth hormone (GH): causes
acromegaly in adults (see below).
In prepubertal children (before epiphyseal closure), it produces gigantism (very rare)
FUNCTIONAL PITUITARY TUMORS
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Rare pituitary adenomas secrete:
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1-Thyrotropin (TSH): produces thyrotoxicosis
2-Gonadotropins (leutinizing hormone (LH) andlor follicle stimulating hormone (FSH)): usually
does not produce a clinical syndrome
Diagnostic tools
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Radiology:- CT scan, MRI Scan with pituitary protocol
Visual perimetery
Hormonal quantitative assessment
Histopathology
Radiology
X-Ray Skull lateral view
Radiology
CT and MRI scans
Radiology
CT and MRI scans
Visual Perimetery
Hormonal Assessment
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May give indication of tumor type
May indicate the need of hormonal replacement if there is any deficiency preoperatively.
May serve as a baseline to compare with post operative deficiency.
Hormonal assessment
Endocrinological Screening
1-8 Am serum cortisol level
2-Serum Prolactin levels
3-T4 and TSH levels
4-Somatomedin-c(IGF-1 level)
5-Fasting Blood Glucose
Hormonal Assessment
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Detailed Hormonal assessment of a particular pituitary axis depends upon history physical
examination and results of hormonal screening.
Management
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Medical
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Replacement of deficient hormones
Treatment of some functional tumors such as Prolactinomas and GH tumors
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Surgical
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Functioning tumors such as Acromegaly, Cushing’s, Prolactinomas
Non-functioning tumors Visual effects & Hypopituitarism,
Radiotherapy / Radiosurgery
Medical Management
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Prolactinoma:- Most of the prolactinomas are treated by drugs including:1-Dopamine Agonist like Bromocriptine(Parlodel),pergolide,cabergoline
Growth Hormone secretary adenoma:1-Dopamine agonist
2-Pegvisomant(competitive GH recep Antagonist)
3-Octerotide(GH secretion suppressor)
Rationale For Surgical Management
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Apart from cosmetic considerations, patients with active Acromegaly are unhealthy, and
their life span is shortened significantly. Unless treated successfully by either medical or
surgical means,
Prolactinomas have consequences that are profound for physical and psychological
health as well as fertility.
Cushing’s disease becomes disabled rapidly by a range of cortisol produced
complications, and a shortened life expectancy is a certain consequence of uncontrolled
hypercortisolism.
Goals Of Surgery For Pituitary Adenomas
Surgical Approaches
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Endoscopic
Transsphenoidal endoscopic surgery
Radiation Therapy
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Conventional XRT usually consists of 40-50 Gy administered over 4-6 weeks.
Gamma Knife:-is better mode of radiation therapy with less side effects
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