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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