pituitary tumors
DESCRIPTION
Pituitary Tumors. Jerome M. Volk III, HO V LSU Department of Neurosurgery. Anatomy. The pituitary gland weighs 0.6 g. It is composed of an anterior adenohypophysial component in apposition with a morphologically, embryologically, and functionally distinct posterior neurohypophysial component. - PowerPoint PPT PresentationTRANSCRIPT
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LSUHSC New Orleans Department of Neurosurgery
Pituitary Tumors
Jerome M. Volk III, HO VLSU Department of Neurosurgery
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LSUHSC New Orleans Department of Neurosurgery
Anatomy
• The pituitary gland weighs 0.6 g.• It is composed of an anterior
adenohypophysial component in apposition with a morphologically, embryologically, and functionally distinct posterior neurohypophysial component.
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LSUHSC New Orleans Department of Neurosurgery
Anatomy
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LSUHSC New Orleans Department of Neurosurgery
Anatomy
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LSUHSC New Orleans Department of Neurosurgery
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LSUHSC New Orleans Department of Neurosurgery
Embryology
• Entirely ectodermal in origin– Adenohypophysis
• Develops from Rathke’s pouch
• Upward invagination
– Neurohypophysis• Develops from the
infundibulum• Downward extension of
the floor of the diencephalon
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LSUHSC New Orleans Department of Neurosurgery
Endocrinology
• Anterior portion (Adenohypophysis)– Follicle stimulating hormone (FSH)– Leutinizing hormone (LH)– Adrenocorticotrophic hormone (ACTH)– Thyroid stimulating hormone (TSH)– Prolactin– Growth hormone (GH)
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LSUHSC New Orleans Department of Neurosurgery
Hormone Signs and symptoms of hypersecretion
Signs and symptoms of hyposecretion
Lab Values
FSH, LH Clinically silent Mood swings, impotence, vaginal dryness, hot flashes, osteoporosis, decreased libido
LH, FSH, Serum testosterone, Serum estradiol
ACTH Cushing’s disease-moon facies, buffalo hump, puple striae, hypertension
Weight loss, nausia, hyponatremia and hypoglycemia, hypotension, fatigue
Serum cortisol
TSH Goiter, moist skin, tachycardia, palpitations, insomnia
Weight gain, fatigue, constipation, cold intolerance, bradycardia
TSH, free T4
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LSUHSC New Orleans Department of Neurosurgery
Hormone Signs and symptoms of hypersecretion
Signs and symptoms of hyposecretion
Lab Values
Prolactin Menstrual irregularites, infertility, galactorrhea, weight gain
Silent Prolactin
GH Acromegaly-overgrowth, carpal tunnel, hyperhidrosis
Dwarfism, fatigue, osteoporosis, weight gain
IGF-1, GH
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LSUHSC New Orleans Department of Neurosurgery
Endocrinology
• Posterior gland (Neurohypophysis)– Oxytocin• Uterine contractions and lactation
– Anti-diuretic hormone• SIADH-increased water resorption, low sodium• DI-increased urination, high sodium
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LSUHSC New Orleans Department of Neurosurgery
Epidemiology
• Pituitary tumors account for 10-15% of all primary brain tumors
• Highest incidence between the 3rd and 6th decade
• More common in women• Genetic predisposition seen only in MEN-1.– Although this accounts for only 3% of pituitary
tumors
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LSUHSC New Orleans Department of Neurosurgery
• Sellar masses:– Tumors
• Adenohypophysial origin– Pituitary adenoma (macro and micro)– Pituitary carcinoma
• Neurohypophysial origin– Granular cell tumor
• Nonpituitary origin– Meningioma– Glioma– Craniopharyngioma– Germ cell tumor
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LSUHSC New Orleans Department of Neurosurgery
• Sellar masses:– Cysts and Hamartomas: Epidermoid, arachnoid,
rathke cleft, dermoid, hypothalamic hamartoma– Metastatic: carcinoma, lymphoma– Infammatory: sarcoidosis, langerhans cell
histiocytosis, lymphocytic hypophysitis– Vascular: aneurysm, cavernoma
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LSUHSC New Orleans Department of Neurosurgery
Pituitary Adenoma
• Classified by:– Endocrine/Clinical– Pathology– Imaging
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LSUHSC New Orleans Department of Neurosurgery
Pituitary Adenoma
• Prolactinoma:– 30% of pituitary adenomas• More commonly micradenomas
– Present as amenorrhea with galactorrhea– Prolactin levels > 200 ng/ml (if less worry about
stalk effect)– First line treatment is pharmacologic• Dopamine agonists (bromocriptine
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LSUHSC New Orleans Department of Neurosurgery
• Growth Hormone Secreting Tumor– Most commonly macroadenoma– Occur in the 4th and 5th decade– Coarse facial features, thickening of lips,
enlargement of nose– GH level > 5 ng/ml– Initial treatment is surgery
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LSUHSC New Orleans Department of Neurosurgery
• Corticotroph Secreting Adenomas– 8-10% of pituitary tumors– Cushing’s Disease
• Hypercortisolemic state generated in response to an ACTH-secreting pituitary tumor.
• Weight gain, truncal obesity, buffalo hump• Free cortisol level
– no cortisol suppression on low-dose dexamethasone testing, cortisol suppression on high-dose dexamethasone testing, and moderately elevated ACTH levels
• Surgery is best option
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LSUHSC New Orleans Department of Neurosurgery
• Thyrotroph adenomas– Less than 1% of pituitary adenomas– Manifest with signs of hyperthyroidism– High TSH with high Free T4– Surgery is first option
• Clinically silent– 1/4th of pituitary tumors– Surgery is first option
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LSUHSC New Orleans Department of Neurosurgery
• Presenting signs and symptoms:– Pituitary hyperfunction– Pituitary insufficiency– Mass effect• Headache-pressure on V1 at diagphragma sella• Loss of vision-compression of optic chiasm• Hydrocephalus-compression on third ventricle• Hypothalamic abnormality-sleep, alertness, emotion
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LSUHSC New Orleans Department of Neurosurgery
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LSUHSC New Orleans Department of Neurosurgery
• Labs and images– Imaging:• MRI brain with and without IV contrast (include thing
cuts through pituitary)– Tumor enhances less than gland
– Labs:• Prolactin, FSH, LH, GH, ACTH, testosterone, GH,
cortisol, IGF-1
– Visual Fields:• To be performed by an ophthomalogist
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LSUHSC New Orleans Department of Neurosurgery
Visual Fields
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LSUHSC New Orleans Department of Neurosurgery
9 months later
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LSUHSC New Orleans Department of Neurosurgery
MRI
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LSUHSC New Orleans Department of Neurosurgery
MRI
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LSUHSC New Orleans Department of Neurosurgery
• Surgical indications:– Progressive mass effect• Worsening of vision
– Failure of prior treatment• Pharmacologic
– Prolactinoma– Cushing’s disease
• Radiation
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LSUHSC New Orleans Department of Neurosurgery
• Surgical indications:– Pituitary Apoplexy• The abrupt and occasionally catastrophic acute
hemorrhagic infarction of a pituitary adenoma• Present with acute headache, meningismus, visual
impairment, ophthalmoplegia, and alteration in consciousness• Glucocorticoid replacement is the most important first
step due to adrenal insufficiency– Followed by urgent surgical decompression
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LSUHSC New Orleans Department of Neurosurgery
Pituitary Apoplexy
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LSUHSC New Orleans Department of Neurosurgery
• Surgical Approaches:– Transsphenoidal• Endoscopic• Endonasal• Sublabial transseptal
– Transcranial• Pterional• Subfrontal
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LSUHSC New Orleans Department of Neurosurgery
Transsphenoidal
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LSUHSC New Orleans Department of Neurosurgery
Transsphenoidal
Endonasal Sublabial
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LSUHSC New Orleans Department of Neurosurgery
Transsphenoidal
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LSUHSC New Orleans Department of Neurosurgery
Transsphenoidal
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LSUHSC New Orleans Department of Neurosurgery
Transsphenoidal
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LSUHSC New Orleans Department of Neurosurgery
Transcranial
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LSUHSC New Orleans Department of Neurosurgery
Transcranial
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LSUHSC New Orleans Department of Neurosurgery
Transcranial
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LSUHSC New Orleans Department of Neurosurgery
Transcranial
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LSUHSC New Orleans Department of Neurosurgery
Transcranial
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LSUHSC New Orleans Department of Neurosurgery
• Post-operative Complications:– Diabetes Insipidus• Follow urine output and Sodium levels
– CSF leak• Check for rhinorrhea
– Hemorrhage/Apoplexy• Worsening vision
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LSUHSC New Orleans Department of Neurosurgery
Thank you