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;575-
596.
• Chanson MD, Phillipe, et.al. “Acromegaly”, Best Practice &
Research Clinical Endocrinology & Metabolism;23, 2009;555-
574
• 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. Neuro-
Psiquiatr. vol.67 no.2a São Paulo June 2009