1. L E W I S S . B L E V I N S , J R . , M . D .
C A L I F O R N I A C E N T E R F O R P I T U I T A R Y
D I S O R D E R S A T U C S F
Presentation and Management
of Pituitary Lesions
2. Pituitary Lesions
14-27% of autopsied pituitaries demonstrated adenoma
Most under 4mm
40% prolactinomas
18 per 100,000 will present clinically with a pituitary
adenoma
I believe a great proportion of those undetected “did” as
well
Radiographic presentations are the same as above
22% incidental lesion
Some of these Rathke’s cleft cysts, pars intermedia cysts
About 20 per 100,000 with macroadenomas
3. Pituitary Lesions
What determines clinical significance?
Hormone hypersecretion
Hypopituitarism
Mass effects
Other effects on patient and contacts
6. What are the potential consequences of a sellar mass?
Mass effects
Headache
Visual compromise
CN palsies
Epistaxis
Rhinorrhea
Abnormalities of pituitary hormone secretion
Excess
Deficiency
Normal pituitary function
Diabetes insipidus
Suggests a disease process other than a pituitary adenoma
7. Pituitary Excess
Hyperprolactinemia
Acromegaly
Cushing’s Syndrome
Hyperthyroidism
Each of these disorders are associated with important
co-morbidities that often require evaluation.
8. Hyperprolactinemia
Serum PRL level
Macroadenoma and PRL > 200 ng/mL is almost
always a prolactinoma
Atypical prolactinomas often associated with PRL <
200 ng/mL
Microadenomas can be associated with any degree of
PRL elevation
Drugs and stalk effect
PRL usually <150
9. Hyperprolactinemia
Medical Management with Dopamine Agonists
Bromocriptine
Cabergoline
90% normalization of PRL
Tumor regression
Surgical intervention
Success dependent on tumor size and invasion
95% remission in microadenomas
50-75% remission in macroadenomas
10. Acromegaly
IGF-1 level almost always elevated
GH levels not diagnostic but indicative of disease
activity
Oral glucose suppression test occasionally used to
confirm abnormal GH secretion
11. Management of Acromegaly
Surgical intervention
Success dependent on tumor size and invasion
95% remission in microadenomas
50-75% remission in macroadenomas
Debulking can improve situation and lead to better responses to XRT
and medications
Radiotherapy
50-75% control in 7-15 yrs
99% control of tumor growth
Medical management
Dopamine Agonists- 10-40% control
Somatostatin Receptor Agonists- 40-50% control
GH Receptor Antagonists- 69-94% control
12. Cushing’s Syndrome
24-h Urine Free Cortisol
Plasma ACTH level
Other tests under guidance of an Endocrinologist
13. Management of Cushing’s Syndrome
Surgical intervention
Success dependent on tumor size and invasion
95% remission in microadenomas
50-75% remission in macroadenomas
Debulking can result in clinical improvement and responses to XRT
and medical therapy
Radiotherapy
50% control in 3-10 years
Medical Management
Somatostatin Receptor Agonist
Adrenal Biosynthesis Inhibitors
Glucocorticoid Receptor Antagonist
14. Hyperthyroidism
TSH, free T4 and T3 levels
TSH usually elevated but may be inappropriately
“normal” in setting of hyperthyroidism
15. Management of TSH–secreting Adenomas
Surgical intervention
Success rates depend on size and invasiveness of tumor
Most are invasive macroadenomas
Radiotherapy
Useful to prevent tumor growth
Slow and low rates of hormonal control
Medical Therapy
Somatostatin Receptor Agonists control 90% of patients
Rarely… beta-blocker and methimazole also required
16. Rathke’s Cleft Cysts
Surgery indicated when….
Lesions >1cm
Lesions associated with mass effects including loss of pituitary
function
Suspicion of infection
Surgical intervention
9% recurrence non-infected cysts
31% recurrence infected cysts not treated with antibiotics
13% recurrence infected cysts treated with antibiotics
17. Craniopharyngiomas
Intrasellar, suprasellar and hypothalamic locations
Subtotal resection with XRT is favored to spare
neural tissue and especially in children
Not unusual to require multiple treatments
Hormone replacement and management of DI are
essential to QoL
18. Pituitary Insufficiency
Partial or complete loss of one or more anterior pituitary
hormones
Presentation can range from asymptomatic to severe
hyponatremia and prostration
Pituitary deficiency leading to target gland deficiencies
T4 and T3 (Central Hypothyroidism)
Cortisol (Central Adrenal Insufficiency)
Sex Steroids (Central Hypogonadism)
GH deficiency
PRL deficiency
Preoperative therapy guided by needs
19. Suggested Tests for any Pituitary Lesion
PRL
IGF-1, GH
TSH, free T4, T3
Cortisol, ACTH
24-h Urine Free Cortisol if Cushing’s suspected
LH and Testosterone in men
FSH and Estradiol in women with absent or
abnormal menses
Serum sodium and urine osmolarity if DI suspected
20. California Center for Pituitary Disorders at UCSF
Multidisciplinary team approach
Endocrinology, Neuro-ophthalmology, Neuroradiology,
Radiation Oncology, etc
Surgeons
Sandeep Kunwar
Manish Aghi
Philip Theodosopoulos
Busiest and most active center in the US
260-280 surgical cases annually
Thousands of patient visits annually