Pituitary Adenomas

Elaine Sunderlin, MD PGY-2 Morning Report March 19, 2010

Overview of Pituitary Adenomas

Most common cause of sellar masses from the third decade on Accounts for up to 10% of all intracranial neoplasms Tumors of the anterior pituitary; almost always benign Microadenomas: lesions < 1cm Macroadenomas: lesions > 1cm

Laboratory Evaluation
Microadenoma
Evaluation for hormonal hypersecretion (prolactin, IGF-1, 24hr urine cortisol/overnight dexamethasone suppression test) Informal visual field evaluation

Macroadenoma
Evaluation for hormonal hypersecretion (prolactin, IGF-1, 24hr urine cortisol/overnight dexamethasone suppression test) Evaluation for hormonal hyposecretion (LH, FSH, testosterone) Formal visual fields

Imaging Evaluation
Nonfunctioning microadenoma (2-4mm)
Likely need no further imaging

Nonfunctioning microadenoma (5-9mm)

MRI can be done once or twice over the subsequent 2 yrs; if stable, frequency can be decreased

Nonfunctioning macroadenoma (< 20mm w/o neurologic abnormalities)

Monitor for adenoma size, visual changes, and hormonal hypersecretion in 6 and 12 months, then annually for a few years

Prolactinoma
Most common hormone-secreting pituitary tumors, approximately 40% of all pituitary tumors Microprolactinomas more common Prolactin (PRL) > 200 ng/mL. Levels between 20-200 could be due to a prolactinoma or any other sellar mass Occur most frequently in females aged 20-50 years, gender ratio of 10:1 Men: decreased libido, galactorrhea Women: amenorrhea, galactorrhea Occasionally prolactin is co-secreted with GH causing clinical syndrome of both prolactinemia and acromegaly

Treatment of Prolactinomas
Regardless of size, medical therapy is first line to obtain normalization of prolactin levels Dopamine agonists (DA)
Bromocriptine (D2 receptor agonist, D1 antagonist) 2.5-15mg/day divided into 2-3 doses. Occasionally requires doses as high as 20-30mg/day
Normalizes PRL levels, restores gonadal function, and decreases tumor size in 80-90% of microadenomas and 70% of macroadenomas

Cabergoline (D2 selective agonist) 0.5-1mg/week

Works in 95% of microadenomas and 80% of macroadenomas

Surgery
Surgical indications for prolactinomas
Sudden vision disturbance, associated w/ severe HA, altered consciousness and vascular collapse 2/2 apoplexy Failure of medical therapy (inadequate PRL reduction on high doses of Das or tumor enlargement) Expanding prolactinomas associated w/ unstable neurological and ophthalmologic deficits unresponding to DAs

Pituitary Apoplexy
Acute infarction or hemorrhage into the pituitary gland Usually life-threatening emergency Severe headaches, visual loss, altered consciousness, and impaired pituitary function Predisposing factors: closed head trauma, blood pressure alterations, h/o pituitary irradiation, cardiac surgery, anticoagulation, treatment with DAs, and pregnancy The majority of patients present with, at least, partial hypopituitarism. Deficit in ACTH leads to acute glucocorticoid deficiency

Acromegaly Symptoms
Sweaty, oily skin; skin tags; macroglossia Broadened hands and feets Jaw thickening, teeth separation, nasal bone hypertrophy Carpal tunnel syndrome, ulnar nerve neuropathy Headache Arthralgias and myalgias

References
UpToDate Colao, Annamaria. The Prolactinoma, Best Practice & Research Clinical Endocrinology & Metabolism;23, 2009;575596. Chanson MD, Phillipe, et.al. Acromegaly, Best Practice & Research Clinical Endocrinology & Metabolism;23, 2009;555574 Murad-Kejbou S, Eggenberg E. Pituitary apoplexy: evaluation, management, and prognosis, Curr Opin Ophthalmol. 2009,Nov;20(6);456-61 Chang, Claudia, et.al. Pituitary tumor apoplexy. Arq. NeuroPsiquiatr. vol.67 no.2a So Paulo June 2009