1 / 58

Common Types of Pituitary Tumors

Common Types of Pituitary Tumors. Laura Knecht MD. Medical Director of the Barrow Pituitary Center. Introduction. Pituitary tumors comprise 10-15% of all intracranial tumors Gliomas – Meningiomas - Pituitary adenomas 10% of all surgically resected tumors

cece
Télécharger la présentation

Common Types of Pituitary Tumors

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Common Types of Pituitary Tumors Laura Knecht MD Medical Director of the Barrow Pituitary Center

  2. Introduction • Pituitary tumors comprise 10-15% of all intracranial tumors • Gliomas – Meningiomas - Pituitary adenomas • 10% of all surgically resected tumors • Affects up to 20% population (1 in 5) • Majority arise from anterior pituitary gland

  3. Pituitary Adenomas • Classified based on size, secretory abilities, histology • <10mm-microadenomas • >10mm-macroadenomas • Beyond sella-giant adenomas

  4. M:F • Females • Present with micoadenomas • Age 20-30 • Hormone dysfunction • Menstral irregularities • Infertility • Males • Present with macroadenomas • Age 40-50 • Mass effect • HA • Visual compromise

  5. FSH/LH-Gonadotroph adenomas • Nonfunctioning, rarely functions • Prolactin-Prolactinomas • Most common • TSH-TSHomas • Rare cause of hyperthyroidism, <1% pituitary adenomas

  6. GH-Acromegaly • Can be cosecretors with GH/prolactin • ACTH-Cushing’s Disease • 2/3 of causes of Cushing’s Syndrome

  7. Nonfunctioning Pituitary Tumors

  8. Nonfunctioning Pituitary Tumors • 30% of all pituitary tumors • No evidence of hormonal hypersecretion • Large at presentation • Mass effects • HA • Visual field deficits • Hypopituitarism

  9. Mass Effects • Hypopituitarism • GHRH – FSH/LH/prolactin – TSH - ACTH • Elevated prolactin from stalk effect • Compression of optic chiasm • Bilateral superior temporal hemianopsia • Lateral growth into cavernous sinus • Cranial nerve palsies

  10. Mass Effects • Headache • Pressure on dura • Blood products • Cystic components • Pressure on frontal/temporal lobes • Hydrocephalus • Memory issues

  11. Hormonal Testing • ACTH, 8am cortisol • TSH, free T4, free T3 • Prolactin • With 1:100 dilution if macroadenoma • GH, IGF-1 • FSH, LH, total testosterone/estradiol • Alpha subunit

  12. MRI • Pituitary protocol • Gadolinium • 3T • Dynamic protocol • Experience of center

  13. Neuro-ophthalmology Testing • Formal visual fields • Visual acuity • Health of optic nerves

  14. Prolactinomas

  15. Prolactinomas • Most common hormonally active tumor • F>>M • Microadenomas • Benign, regress spontaneously, can have no growth • Macroadenomas • Present w/ pressure symptoms, increase in size, rarely disappear

  16. Prolactinomas • Clinical features dependent on prolactin level, mass effects, hypopituitarism • Gender, age, tumor size • Prolactin stimulates milk in Estrogen-primed breast • High prolactin inhibits GnRH which decreases FSH/LH which decreases testosterone/estrogen

  17. When to Treat • Infertility • Menstral disturbances • Bothersome galactorrhea • Enlarging tumor • Apoplexy w/ headache

  18. Treatment • Medications • 1st line treatment regardless of size • Surgery • In resistant prolactinomas • Intolerance to both dopamine agonists • Radiation • For residual/recurrent tumor

  19. Cabergoline • Better tolerated • Fewer side effects • More likely to normalize level • No increased risks in pregnancy • ½ life-2-3days • Effective dose 1-1.5mg twice a week, resistant prolactinomas 7-12mg/week

  20. Cabergoline • May be fast metabolizers • Change to every day or every other day • Valvulopathy • Mitral valve stenosis • May be reversible • ? role of echocardiogram

  21. Bromocriptine • Cheaper • ½ life-8hrs • Should be 2-3 times daily • Common dose up to10mg every night or 5mg twice a day • Doses >20-40mg not more efficacious • Preferred agent in pregnancy • No risk of valvulopathy

  22. Side Effects of Dopamine Agonists • Nausea • Lightheadedness • Mental fog • Worsening of depression • Psychotic reaction • Minimize if take at night, start low, go slow, take w/ snack

  23. Use of Hormone Replacement in Prolactinomas (Estrogen) • Possible growth of tumor • In combo w/ dopamine agonists-safe • No prospective studies when used alone • Would not use if chiasmopathy • Monitor prolactin regularly

  24. Pregnancy • Risk of micro growing-1-3% • Risk of macro growing-<15% • Stop medication once pregnant • Go thru pregnancy, breastfeeding, restart if amenorrhea, future fertility • Monitor for headache, vision changes • Can get MRI not Gadolinium • May have issues w/ lactation • Role of debulking if macroadenoma, chiasmopathy

  25. Cushing’s Disease

  26. Clinical Manifestations • Degree • Duration • Presence/absence androgen excess • Cause • Tumor related symptoms • Age

  27. Clinical Manifestations • Obesity • Moon facies • Dorsal cervical fat pad • Exophthalmos • Periorbital edema • Conjunctival injection • Chest/facial plethora • Growth retardation • Skin atrophy • Easy bruisability • Striae • Hyperpigmentation • Hirsutism • Acne

  28. Complications • Fungal infections • Cardiovascular complications • Stroke, heart attack • Proximal myopathy • Psychiatric disturbances • Menstrual abnormalities • Osteoporosis • PCOS (Polycystic Ovarian Syndrome) • Diabetes/impaired glucose tolerance

  29. Screening Tests • 1 mg overnight dexamethasone • Take at 11pm • Draw cortisol at 8am • Cortisol < 1.8mg/dL – r/o hypercortisolism • Cortisol > 5mg/dL = hypercortisolism

  30. 24 hour urinary free cortisol • If >3x normal, diagnostic of true Cushing’s • Lesser elevations require confirmation • False elevations of UFC • Physical stress • Exercise • Large volume intake • Medications

  31. Late Night Salivary Cortisol • Bedtime/11pm salivary cortisol (series of 2-3)

  32. Overnight High Dose Dexamethasone Suppression • Dexamethasone 8mg by mouth at 11pm • Serum cortisol at 8am • Will suppress in pituitary source • Cortisol <1.8mg/dL • Cortisol <50% of baseline

  33. Inferior Petrosal Sinus Sampling/IPSS

  34. Surgery • Goal is for cure • Immediate post-op cortisol <2-3mg/dl within 24-72hours • If not cured, consider • Repeat surgery • Radiation treatment

  35. Ketoconazole • Dosing 200-400mg BID-TID • Side effects • HA • Sedation • Nausea/vomiting • Gynecomastia • Decreased libido • Impotence • Life threatening-reversible hepatotoxicity

  36. Mifepristone (Korlym) • Dosing 300mg daily • Maximum dose 1200mg daily • Maximum dose in hyperglycemia 600mg daily • Side effects • Adrenal insufficiency • Peripheral edema • Hypertension • Headache • Hypokalemia • Endometrial hypertrophy • Cannot follow cortisol levels

  37. Pasireotide • Dosing 600-900 mcg subcutaneously twice daily • Decrease in cortisol, ACTH, salivary cortisol • Signs and symptoms improved • Side effects • Hyperglycemia • Diarrhea • Abdominal discomfort • Gallstones

  38. Bilateral Adrenalectomy • Immediate cure • Complication-Nelson’s Syndrome • Vision loss • Progression of pituitary tumor • Dependent on glucocorticoids and mineralicorticoids

  39. Post-op Management • Adrenal insufficiency results • Treat w/ decreasing doses of steroids • Initial dosing – hydrocortisone 40-80mg daily • Wean over 6-24months • Cosyntropin stimulation testing once off to confirm normal axis

  40. Monitoring • Lifelong • Patients usually feel symptoms prior to abnormalities in testing • Yearly cortisol, ACTH • Scheduled MRIs • Consider hypercortisolemia testing • Late night salivary testing • 24 hour urine free cortisol • 1mg overnight dexamethasone suppression

  41. Acromegaly

  42. Acromegaly • M=F • Mean age 42-44 • Usually have diagnosis 7-10 years prior • Premature mortality from cardiovascular disease with risk decreasing when normalize IGF-1, GH

  43. Symptoms • Change in facial features • Enlargement in forehead, mandible, tongue, gap in teeth • Enlargement of hands/feet • Excessive sweating • Dental malocclusions • Sleep apnea

  44. Signs/Symptoms • Diabetes • Hypertension • Colon polyps • Arthralgias • Skin tags • Carpal tunnel

  45. Co-morbidities • Cardiomyopathy/Congestive Heart Failure • Diabetes/Insulin resistance • Hypertension • Obstructive sleep apnea • Precancerous colon polyps • Thyroid nodules

  46. Lab Values • Elevated GH • Elevated IGF-1 • Lack of GH suppression to glucose load

  47. Treatment • Surgery • 1st line treatment by experienced surgeon • Medications • Has been used as adjunctive vs primary medical therapy • Radiation

  48. Surgery • Post op day 1 GH<5 highly predictive of remission • Remission if GH<1 after OGTT • IGF-1 takes weeks to months to decrease because of delayed clearance

  49. Medical Treatment • Somatostatin analogs • Dopamine agonists • GH receptor antagonist

More Related