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Morbidity and Mortality Conference Ann Marie Lam, PGY-2 Emory University School of Medicine Family Medicine Residency Program October 14 th , 2010. Pituitary Adenoma. Macroadenoma (>1 cm) Rarely malignant Hormone overproduction/deficiency Can become locally invasive Can lead to CN palsies
Morbidity and Mortality ConferenceAnn Marie Lam, PGY-2Emory University School of MedicineFamily Medicine Residency ProgramOctober 14th, 2010
Pituitary Adenoma • Macroadenoma (>1 cm) • Rarely malignant • Hormone overproduction/deficiency • Can become locally invasive • Can lead to CN palsies • Can lead to pituitary apoplexy • Can be associated with MEN I syndrome • Risk of recurrence
Treatment • Medical therapy: correction/replacement of hormone overproduction/deficiency • Surgical therapy: decompression, resection • Radiation an option for adjunctive therapy
Types of Pituitary Adenoma • Prolactinoma (PRL) (35%) • Acromegaly (GH) (20%) • Cushing Disease (ACTH) (7%) • Gonadotropin-Producing Adenoma (LH, FSH) (<1%) • Non-secretory Adenoma (30%) • TSH-Secreting Adenoma (<1%) • Diabetes Insipidus (lack of VP)
Prolactinoma • Presentation: amenorrhea, galactorrhea, infertility, (in men: impotence, dec libido) • Diagnosis: PRL level >200 ng/ml, R/O prolactinemia from mass effect • Treatment (large, sympt): Bromocriptine, cabergoline (dopamine analog, inhibits PRL)
Acromegaly • Presentation: coarse facial features, oily skin, carpal tunnel syndrome, OA, increased hat/glove/shoe size, DM • Diagnosis: elev ILGF-1, elev post-prandial GH on 100 g OGTT (failure to suppress GH to <2 ng/ml diagnostic) • Treatment: Octreotide SC (somatostatin analog), bromocriptine
Cushing’s Disease • Presentation: truncal obesity, striae, round facies, hirsutism, HTN, DM, thin skin • Diagnosis: elev 24-hr urine cortisol, dexamethasone suppression test (1mg dex, night cortisol) • Treatment: ketoconazole (inhibits steroid synthesis)
TSH-secreting adenoma • Presentation: goiter, thyrotoxicosis, visual impairment • Diagnosis: elev TSH, T3, T4 • Treatment: surgery, octreotide
Non-secretory adenoma • Usually large at time of presentation • Presentation: bitemporal hemianopsia, CN defects (cav sinus compression), hypopituitarism • Evaluation: assess pituitary function, VF testing • Treatment: surgery, +/-radiation
Long-term follow-up • Post-op 4-6 wks to confirm adenoma completely removed and hypersecretion resolved • Monitor yearly for recurrence, hypopituitarism
Discussion • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment
Discussion • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment • Multi-disciplinary approach led by primary team leading
Discussion • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment • Multi-disciplinary approach led by primary team leading • Consider transferring patient to primary care-providing team
Discussion • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment • Multi-disciplinary approach led by primary team leading • Consider transferring patient to primary care-providing team • Patient-oriented care
Discussion • Expediency of work-up: delay in diagnostic testing, delay in initiating treatment • Multi-disciplinary approach led by primary team leading • Consider transferring patient to primary care-providing team • Patient-oriented care • Patient responsibility
References • Harrison’s Principles of Internal Medicine. 16th edition. Disorders of the anterior pituitary and hypothalamus, 2005. • Ferri’s Clinical Advisor. Pituitary adenoma, 2010. • Klibanski, A. Prolactinomas. NEJM 362: 1219-1226, April 2010. • Melmed, S. Medical Progress: Acromegaly. NEJM 355: 2558-2573, Dec 2006. • Pituitary adenoma. UpToDate. Accessed 9/29/10.
