TUMOR PITUITARI

Pembimbing: Ervita Yuda, dr., SpPD, M.Kes

Davin Takaryanto, dr.

Pendahuluan
• Tumor pituitary  80-100/100.000 populasi, dengan insidensi 4 kasus per 100.000
• Tumor pituitary  10-15% semua kasus tumor SSP, dan 25% kasus reseksi tumor SSP

Raverot G, et al. European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas. European
Journal of Endocrinology (2018) 178, G1–G24
Outline
Anatomi dan Fisiologi

Patogenesis

Klasifikasi

Diagnosis dan Terapi

 Anatomi

Ohsu.edu. 2020. Understanding Pituitary Disorders | Brain Institute | OHSU.

[online] Available at: <https://www.ohsu.edu/brain-institute/understanding-
pituitary-disorders> [Accessed 11 August 2020].
Ohsu.edu. 2020. Understanding Pituitary Disorders | Brain Institute | OHSU. [online] Available at:
<https://www.ohsu.edu/brain-institute/understanding-pituitary-disorders> [Accessed 11 August 2020].
Colburn Law. 2020. How Does A Brain Injury Cause Pituitary Gland Damage?. [online] Available at:
<https://www.colburnlaw.com/how-does-a-brain-injury-cause-pituitary-gland-damage/> [Accessed 11 August
2020].
Asa SL, Ezzat S. The Pathogenesis of Pituitary Tumors. Nature Publishing Group. 2002.
Klasifikasi Fungsi
Fungsional

Non-fungsional

Makroadenoma

Klasifikasi
Ukuran
Mikroadenoma

Somatotroph

Lactotroph

Corticotroph

Imunohitokemistri Thyrotroph

Gonadotroph

Null cell

Plurihormonal and double

Asa SL, Ezzat S. The Pathogenesis of Pituitary Tumors. Annu. Rev. Pathol. Mech. Dis. 2009. 4:97–126
tumours
Lopes MBS. The 2017 World Health Organization classifcation of tumors of the pituitary gland: a summary. Acta Neuropathol. 2017.
 Klasifikasi WHO

Lopes MBS. The 2017 World Health Organization classification of tumors

of the pituitary gland: a summary. Acta Neuropathol. 2017.
 Klasifikasi Berdasarkan Adenohypophyseal Cell
Lineage

Lopes MBS. The 2017 World Health Organization classification of tumors of the pituitary gland: a summary. Acta Neuropathol. 2017.
Klasifikasi Imunohistokemistri (WHO 2017)

Lopes MBS. The 2017

World Health Organization
classification of tumors
of the pituitary gland:
a summary. Acta
Neuropathol. 2017.
Patogenesis
• Somatotroph

Asa SL, Ezzat S. The Pathogenesis of Pituitary

Tumors. Annu. Rev. Pathol. Mech. Dis. 2009. 4:97–
126
Pathogenesis
• Lactotroph

Asa SL, Ezzat S. The Pathogenesis of Pituitary

Tumors. Annu. Rev. Pathol. Mech. Dis. 2009. 4:97–
126
Pathogenesis
• Thyrotroph

Asa SL, Ezzat S. The Pathogenesis of Pituitary Tumors.

Annu. Rev. Pathol. Mech. Dis. 2009. 4:97–126
Pathogenesis
• Corticotroph

Asa SL, Ezzat S. The Pathogenesis of Pituitary Tumors. Annu. Rev.

Pathol. Mech. Dis. 2009. 4:97–126
Pathogenesis
• Gonadotroph

Asa SL, Ezzat S. The Pathogenesis of Pituitary Tumors. Annu. Rev.

Pathol. Mech. Dis. 2009. 4:97–126
Manifestasi Klinis
• Tanda dan gejala bergantung gangguan hormonal (co: Hiperkostisolism pada ACTH-secreting adenomas
atau tanda akromegali pada pasien GH-secreting adenomas.
• Tanda dan gejala gangguan mekanik massa di sella tursica: nyeri kepala, gangguan penglihatan, dan
cranial nerve palsies.
• Tanda dan Gejala gangguan fungsi normal pituitari

Arafah BM, Nasrallah MP. Pituitary tumors: pathophysiology, clinical manifestations and management. Endocrine-Related Cancer (2001) 8 287–305.
 Gonadotrophic Adenoma
Non Fungsional
• Gejala umum muncul berupa gangguan mekanik berupa nyeri kepala dan gangguan penglihatan
• Hormon yang disekresikan tidak signifikan  nonfungsional adenoma

Theodros D, Patel M, Ruzevick J, Lim M, Battewgoda C. Pituitary adenomas: historical perspective, surgical management and future directions. CNS Oncol. (2015) 4(6),
411–429
Gonadotrophic Adenoma
Fungsional
• Identikal tumor nonfungsional. Adenoma soft dan well
vascularized. Mikroskopis sel chromophobic membentuk
trabecular, papillary, atau sinusoidal
• Gangguan hormone yang mungkin: peningkatan testosterone
(pria) atau peningkatan estradiol dan hyperplasia endometrium
(wanita)
• Gejala  menstruasi ireguler, ovarian hyperstimulation
syndrome, pembesaran testis

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
Gonadotrophic Adenoma

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
Gonadotrophic Adenoma

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
 Gonadotroph Adenoma
Diagnosis
• Hormon level GnRH, LH, FSH, estradiol, testosterone
• MRI

Treatment
• Medikamentosa (dopamine agonists (DAs), somatostatin analogs, dan GnRH agonists dan antagonists )
• Radiasi
• Operasi

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
Gonadotroph
Adenoma

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
Gonadotroph
Adenoma

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning
Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism,
99(12), pp.4423-4433.
 Corticotrophic (ACTH Secreting)
Adenoma
• Penyebab tersering hypercortisolemia endogen (2/3 kasus)
• ACTH-secreting pituitary adenomas (Penyakit cushing) 4.8%–10% dari endocrine-secreting pituitary
adenomas
• Manifestasi klinis  berat badan naik, diabetes, hipertensi, gangguan psikiatri dan neurokognitif, libido
menurun, dan osteoporosis

Mathioudakis, N., Pendleton, C., Quinones-Hinojosa, A., Wand, G. and Salvatori, R., 2011. ACTH-secreting pituitary adenomas: size does not correlate with hormonal
activity. Pituitary, 15(4), pp.526-532.
Mehta, G. and Lonser, R., 2016. Management of hormone-secreting pituitary adenomas. Neuro-Oncology, p.now130.
 Corticotrophic (ACTH
Secreting) Adenoma
Terapi
• Operasi
• Radiasi
• Medikamentosa
• Adrenal steroidogenesis inhibitors (ketoconazole,
metyrapone, mitotane, dan etomidate)
• Somatostatin analogue (pasireotide)
• Mifepristone  inhibisi glucocorticoid receptor 
menghambat efek sistemik

Mehta, G. and Lonser, R., 2016. Management of hormone-secreting pituitary

adenomas. Neuro-Oncology, p.now130.
Prolactinoma
• Prolactinomas merupakan hormone-secreting pituitary adenomas terbanyak (69%–80%).
• Manifestasi klinis  amenore, galaktore, nyeri kepala, infertile, ejakulasi dini, gangguan ereksi, dan atau
hipogonadism

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
 Prolactinoma
Diagnosis Tatalaksana

• Anamnesis dan pemeriksaan fisik • Medikamentosa

• Serum prolactin >250 μg/L • Dopamine-agonist  mengecilkan ukuran,
memperbaiki infertilitas, menormalkan prolactin
• Resolusi tinggi dan postcontrast gradient echo (Derivat ergot  bromocriptine dan cabergoline).
(GRE) magnetic resonance (MR)-imaging • Cabergoline (D2 receptor-specific) Operasi
• Radiasi (SRS, FSRT, or CFRT)

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
Prolactinoma

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
 Growth Hormone Secreting Adenoma
• GH-secreting adenomas sekitar13%–20% dari endocrine-secreting pituitary adenomas.
• Manifestasi klinis  gigantisme, akromegali, pembesaran akral, coarse facial, keringat berlebih, CTS,
nyeri kepala, osteoarthritis, resistensi insulin, gangguan kardiovaskular.

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
 Growth Hormone Secreting Adenoma
Diagnosis Tatalaksana

• peningkatan serum insulin-like growth factor-1
(IGF-1)  diagnosis akromegali
• Oral glucose tolerance test (OGTT)  supresi
GH rendah <1 μg /L  diagnosis akromegali
• postcontrast GRE MR imaging of the pituitary
gland is used to assess the size and location of
the adenoma.
• Operasi (reseksi)  remisi biokemistri 70%
• Medikamentosa:
• somatostatin analogues (ocreotide)aktivasi
somatostatin receptors  inhibisi sekresi GH
• Radiasi

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
Growth Hormone Secreting Adenoma

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
Tumor Pituitari Fungsional Lain
Thyrotrophic Adenomas Gonadotroph Adenomas

• Resitensi hormon tiroid  eutiroid atau • Sebagian besar non fungsional, fungsional sangat
hipotiroid atau dapat dengan goiter dan jarang  0.2%)
hiperparatiroid ringan • Wanita premenopaus oligo- atau amenorrhea,
• TSH-secreting pituitary adenomas sangat jarang infertil, atau galaktore.
(1%–2%) • Pria  pembesaran testis dan hipogonadism.
• Manifestasi Klinis  gejala hipertiroid
• Diagnosis  manifestasi klinis, MRI,
• Tatalaksana: laboratorium hyperestrogenism (LH-secreting)
• Operasi (reseksi) pada wanita premenopause dan peningkatan FSH
• Radiasi pada pria
• Somatostatin analog • Tatalaksana  operasi, radiasi

Ntali, G., Capatina, C., Grossman, A. and Karavitaki, N., 2014. Functioning Gonadotroph Adenomas. The Journal of Clinical Endocrinology & Metabolism, 99(12),
pp.4423-4433.
Theodros D, Patel M, Ruzevick J, Lim M, Battewgoda C. Pituitary adenomas: historical perspective, surgical management and future directions. CNS Oncol. (2015) 4(6),
411–429
Freda PU, et al. Pituitary Incidentaloma: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, April 2011, 96(4):894 –904
TERIMA KASIH