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Pituitary disorders

Pituitary disorders

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Pituitary disorders

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  1. Pituitary disorders Narendra Reddy Clinical Lecturer Diabetes, Endocrinology & Metabolism University of Warwick Grand round, UHCW, June 14th 2011

  2. Plan…. • Pituitary anatomy • Pituitary physiology • Evaluation of Pituitary mass • Pituitary dysfunction in Elderly • Clinical scenarios/Images

  3. Pituitary anatomy

  4. Pituitary anatomy

  5. Sagittal view

  6. Coronal view

  7. Coronal view

  8. Hormones

  9. Evaluation of Pituitary mass • Local effects • Hypersecretion • Hyposecretion

  10. Pituitary hormone profile • Somatotroph – GH IGF-1 • Gonadotroph – FSH,LH Testo/Oest • Thyrotroph – TSH FT4,FT3 • Corticotroph – ACTH Cortisol (SST) • Lactotroph - Prolactin • Neurohypophysis Vasopressin (U&E, Paired Osmol)

  11. Case • 82 yr old male • Headache, diplopia, vomiting- Acute • Hypotension- 90/45 mmHg & III N palsy • PMH- IHD, Hypertension • Drugs- Antihypertensives, Aspirin • Diagnosis?

  12. Investigations • 9 am Testo- <0.4 (10-26) • LH- 1.2, FSH- 0.7 (2-10) • IGF-1 – 4.8 (10-35) • PrL- 322 (<300) • FT4 8.8 (10-19.5), TSH 2.0 (0.5-4.5) • SST – 30’ Cortisol 213 nmol/L • Na - 122; Pl Osm & U Osm - normal

  13. Pituitary apoplexy

  14. Pituitary apoplexy

  15. Pituitary apoplexy

  16. Pit apoplexy guidelines

  17. Chronic hypopit’ symptoms • GH- lethargy, reduced strength • LH/FSH- libido, infertility, menstrual • TSH – hypothyroid • PrL- lack of milk in breastfeeding females • ACTH – pallor • Vasopressin – Diabetes Insipidus

  18. Hypopituitarism • Pituitary tumours • Radiotherapy • Apoplexy,Sheehan syndrome • Infiltrative disorders • Infective- TB, Pit abscess • Trauma • Metastasis • Russell viper snake bite • PIT-1, HESX-1, PROP-1, KAL-1, SOX-2, DAX-1, AVP-Neurohypophysin-II

  19. Dynamic tests • Insulin Tolerance Test- ACTH & GH • Glucagon test – ACTH & GH • SST- adrenocortical function • Clomifene test – Gonadotrophin • GnRH & TRH- rarely used

  20. To take home…. • Adenomas do not cause DI • GH>FSH/LH>TSH>ACTH • Long term hypopit patients, treated with steroids can unmask DI • ACTH def–No Pigment/Hyperkalaemia

  21. 84 pts over 65 yrs (avg 72.5 yrs) • 1975 to 1996 • 64 % VF defects • 20 % hypopituitarism • 7% pituitary apoplexy • TSA safe in elderly

  22. Pit tumours in elderly

  23. Pituitary Incidentalomas 10% incidence in 18902 pituitaries Minimum 20 years F/U 18-86 years Local, hypersecretion, hyposecretion 10.6% < 1cm 24.1 % if >1cm MRI – 1, 2 & 5 years- stop if no size Hypopit, VF defects & size increase- Sx Mark Molitch,Best Practice in Clinical Research 23 (2009) 667–675

  24. Case • 42 yr man • Headaches Reduced libido Erectile dysfunction

  25. 2007 20 days 9 months 3 years

  26. Prolactinoma • Micro <1cm ; Macro > 1cm • Medical treatment- Cabergoline • Surgery- DA resistance/intolerance • Radiotherapy • DA Rx – Cardiac Valve fibrosis 1st line- Sx 2ndline- Mx 3rd line-Dx

  27. Case • 20 year old boy • Visual field problems • Enlarged nose • Carpal tunnel Syndrome

  28. Acromegaly

  29. Photos please...

  30. 1st line- Sx 2nd line- Mx 3rd line- Dx

  31. Case • 40 years old lady • 10 years of Diabetes • Hypertension • Hyperlipidaemia • Osteoporosis • Wt gain • Acne

  32. Cushings disease

  33. Dr Harvey Cushing

  34. Management • ONDMST - Cortisol > 50 • 24 hr Urine Free Cortisol • LDDMST >50 • HDDMST • CRH stimulation test • Petrosal sinus sampling • Surgery • Radiotherapy • B/L Adrenalectomy 1st line- Sx 2nd line-Dx 3rd line- Sx

  35. Non functioning Pit Adenomas(NFA)

  36. NFA

  37. ?????

  38. Rathkes cyst

  39. ???

  40. Craniopharyngioma

  41. 40 yr old female,Hypothyroid

  42. ?????

  43. Lymphocytic hypophysitis

  44. Lymphocytic hypophysitis • Young women • Auto immune • Prodromal illness • VF defects • Hormone deficiencies • Bx- diagnostic

  45. Meningioma

  46. Hormones !!