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LSUHSC New Orleans
Department of Neurosurgery
Pituitary Tumors
Jerome M. Volk III, HO V
LSU Department of Neurosurgery
LSUHSC New Orleans
Department of Neurosurgery
Anatomy
• The pituitary gland weighs 0.6 g.
• It is composed of an anterior
adenohypophysial component in apposition
with a morphologically, embryologically, and
functionally distinct posterior
neurohypophysial component.
LSUHSC New Orleans
Department of Neurosurgery
Anatomy
LSUHSC New Orleans
Department of Neurosurgery
Anatomy
LSUHSC New Orleans
Department of Neurosurgery
LSUHSC New Orleans
Department of Neurosurgery
Embryology
• Entirely ectodermal in
origin
– Adenohypophysis
• Develops from Rathke’s
pouch
• Upward invagination
– Neurohypophysis
• Develops from the
infundibulum
• Downward extension of
the floor of the
diencephalon
LSUHSC New Orleans
Department of Neurosurgery
Endocrinology
• Anterior portion (Adenohypophysis)
– Follicle stimulating hormone (FSH)
– Leutinizing hormone (LH)
– Adrenocorticotrophic hormone (ACTH)
– Thyroid stimulating hormone (TSH)
– Prolactin
– Growth hormone (GH)
LSUHSC New Orleans
Department of Neurosurgery
Hormone
Signs and
symptoms of
hypersecretion
Signs and
symptoms of
hyposecretion
Lab Values
FSH, LH
Clinically silent
Mood swings,
impotence, vaginal
dryness, hot
flashes,
osteoporosis,
decreased libido
LH, FSH, Serum
testosterone,
Serum estradiol
ACTH
Cushing’s diseasemoon facies,
buffalo hump,
puple striae,
hypertension
Weight loss, nausia, Serum cortisol
hyponatremia and
hypoglycemia,
hypotension,
fatigue
TSH
Goiter, moist skin,
tachycardia,
palpitations,
insomnia
Weight gain,
fatigue,
constipation, cold
intolerance,
bradycardia
TSH, free T4
LSUHSC New Orleans
Department of Neurosurgery
Hormone
Signs and
symptoms of
hypersecretion
Signs and
symptoms of
hyposecretion
Lab Values
Prolactin
Menstrual
irregularites,
infertility,
galactorrhea,
weight gain
Silent
Prolactin
GH
Acromegalyovergrowth, carpal
tunnel,
hyperhidrosis
Dwarfism, fatigue,
osteoporosis,
weight gain
IGF-1, GH
LSUHSC New Orleans
Department of Neurosurgery
Endocrinology
• Posterior gland (Neurohypophysis)
– Oxytocin
• Uterine contractions and lactation
– Anti-diuretic hormone
• SIADH-increased water resorption, low sodium
• DI-increased urination, high sodium
LSUHSC New Orleans
Department of Neurosurgery
Epidemiology
• Pituitary tumors account for 10-15% of all
primary brain tumors
• Highest incidence between the 3rd and 6th
decade
• More common in women
• Genetic predisposition seen only in MEN-1.
– Although this accounts for only 3% of pituitary
tumors
LSUHSC New Orleans
Department of Neurosurgery
• Sellar masses:
– Tumors
• Adenohypophysial origin
– Pituitary adenoma (macro and micro)
– Pituitary carcinoma
• Neurohypophysial origin
– Granular cell tumor
• Nonpituitary origin
–
–
–
–
Meningioma
Glioma
Craniopharyngioma
Germ cell tumor
LSUHSC New Orleans
Department of Neurosurgery
• Sellar masses:
– Cysts and Hamartomas: Epidermoid, arachnoid,
rathke cleft, dermoid, hypothalamic hamartoma
– Metastatic: carcinoma, lymphoma
– Infammatory: sarcoidosis, langerhans cell
histiocytosis, lymphocytic hypophysitis
– Vascular: aneurysm, cavernoma
LSUHSC New Orleans
Department of Neurosurgery
Pituitary Adenoma
• Classified by:
– Endocrine/Clinical
– Pathology
– Imaging
LSUHSC New Orleans
Department of Neurosurgery
Pituitary Adenoma
• Prolactinoma:
– 30% of pituitary adenomas
• More commonly micradenomas
– Present as amenorrhea with galactorrhea
– Prolactin levels > 200 ng/ml (if less worry about
stalk effect)
– First line treatment is pharmacologic
• Dopamine agonists (bromocriptine
LSUHSC New Orleans
Department of Neurosurgery
• Growth Hormone Secreting Tumor
– Most commonly macroadenoma
– Occur in the 4th and 5th decade
– Coarse facial features, thickening of lips,
enlargement of nose
– GH level > 5 ng/ml
– Initial treatment is surgery
LSUHSC New Orleans
Department of Neurosurgery
• Corticotroph Secreting Adenomas
– 8-10% of pituitary tumors
– Cushing’s Disease
• Hypercortisolemic state generated in response to an
ACTH-secreting pituitary tumor.
• Weight gain, truncal obesity, buffalo hump
• Free cortisol level
– no cortisol suppression on low-dose dexamethasone testing,
cortisol suppression on high-dose dexamethasone testing, and
moderately elevated ACTH levels
• Surgery is best option
LSUHSC New Orleans
Department of Neurosurgery
• Thyrotroph adenomas
– Less than 1% of pituitary adenomas
– Manifest with signs of hyperthyroidism
– High TSH with high Free T4
– Surgery is first option
• Clinically silent
– 1/4th of pituitary tumors
– Surgery is first option
LSUHSC New Orleans
Department of Neurosurgery
• Presenting signs and symptoms:
– Pituitary hyperfunction
– Pituitary insufficiency
– Mass effect
•
•
•
•
Headache-pressure on V1 at diagphragma sella
Loss of vision-compression of optic chiasm
Hydrocephalus-compression on third ventricle
Hypothalamic abnormality-sleep, alertness, emotion
LSUHSC New Orleans
Department of Neurosurgery
LSUHSC New Orleans
Department of Neurosurgery
• Labs and images
– Imaging:
• MRI brain with and without IV contrast (include thing
cuts through pituitary)
– Tumor enhances less than gland
– Labs:
• Prolactin, FSH, LH, GH, ACTH, testosterone, GH, cortisol,
IGF-1
– Visual Fields:
• To be performed by an ophthomalogist
LSUHSC New Orleans
Department of Neurosurgery
Visual Fields
LSUHSC New Orleans
Department of Neurosurgery
9 months later
LSUHSC New Orleans
Department of Neurosurgery
MRI
LSUHSC New Orleans
Department of Neurosurgery
MRI
LSUHSC New Orleans
Department of Neurosurgery
• Surgical indications:
– Progressive mass effect
• Worsening of vision
– Failure of prior treatment
• Pharmacologic
– Prolactinoma
– Cushing’s disease
• Radiation
LSUHSC New Orleans
Department of Neurosurgery
• Surgical indications:
– Pituitary Apoplexy
• The abrupt and occasionally catastrophic acute
hemorrhagic infarction of a pituitary adenoma
• Present with acute headache, meningismus, visual
impairment, ophthalmoplegia, and alteration in
consciousness
• Glucocorticoid replacement is the most important first
step due to adrenal insufficiency
– Followed by urgent surgical decompression
LSUHSC New Orleans
Department of Neurosurgery
Pituitary Apoplexy
LSUHSC New Orleans
Department of Neurosurgery
• Surgical Approaches:
– Transsphenoidal
• Endoscopic
• Endonasal
• Sublabial transseptal
– Transcranial
• Pterional
• Subfrontal
LSUHSC New Orleans
Department of Neurosurgery
Transsphenoidal
LSUHSC New Orleans
Department of Neurosurgery
Transsphenoidal
Endonasal
Sublabial
LSUHSC New Orleans
Department of Neurosurgery
Transsphenoidal
LSUHSC New Orleans
Department of Neurosurgery
Transsphenoidal
LSUHSC New Orleans
Department of Neurosurgery
Transsphenoidal
LSUHSC New Orleans
Department of Neurosurgery
Transcranial
LSUHSC New Orleans
Department of Neurosurgery
Transcranial
LSUHSC New Orleans
Department of Neurosurgery
Transcranial
LSUHSC New Orleans
Department of Neurosurgery
Transcranial
LSUHSC New Orleans
Department of Neurosurgery
Transcranial
LSUHSC New Orleans
Department of Neurosurgery
• Post-operative Complications:
– Diabetes Insipidus
• Follow urine output and Sodium levels
– CSF leak
• Check for rhinorrhea
– Hemorrhage/Apoplexy
• Worsening vision
LSUHSC New Orleans
Department of Neurosurgery
Thank you