Common Types of Pituitary Tumors
description
Transcript of Common Types of Pituitary Tumors
![Page 1: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/1.jpg)
Common Types of Pituitary Tumors
Laura Knecht MD
Medical Director of the Barrow Pituitary Center
![Page 2: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/2.jpg)
Introduction
• Pituitary tumors comprise 10-15% of all intracranial tumors– Gliomas – Meningiomas - Pituitary adenomas
• 10% of all surgically resected tumors• Affects up to 20% population (1 in 5)• Majority arise from anterior pituitary gland
![Page 3: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/3.jpg)
Pituitary Adenomas
• Classified based on size, secretory abilities, histology
• <10mm-microadenomas• >10mm-macroadenomas• Beyond sella-giant adenomas
![Page 4: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/4.jpg)
![Page 5: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/5.jpg)
• M:F• Females
– Present with micoadenomas– Age 20-30– Hormone dysfunction
• Menstral irregularities• Infertility
• Males– Present with macroadenomas– Age 40-50– Mass effect
• HA• Visual compromise
![Page 6: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/6.jpg)
• FSH/LH-Gonadotroph adenomas– Nonfunctioning, rarely functions
• Prolactin-Prolactinomas– Most common
• TSH-TSHomas– Rare cause of hyperthyroidism, <1% pituitary
adenomas
![Page 7: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/7.jpg)
• GH-Acromegaly– Can be cosecretors with GH/prolactin
• ACTH-Cushing’s Disease– 2/3 of causes of Cushing’s Syndrome
![Page 8: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/8.jpg)
Nonfunctioning Pituitary Tumors
![Page 9: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/9.jpg)
Nonfunctioning Pituitary Tumors
• 30% of all pituitary tumors• No evidence of hormonal hypersecretion• Large at presentation• Mass effects
– HA– Visual field deficits– Hypopituitarism
![Page 10: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/10.jpg)
Mass Effects
• Hypopituitarism– GHRH – FSH/LH/prolactin – TSH - ACTH
• Elevated prolactin from stalk effect• Compression of optic chiasm
– Bilateral superior temporal hemianopsia
• Lateral growth into cavernous sinus– Cranial nerve palsies
![Page 11: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/11.jpg)
Mass Effects
• Headache– Pressure on dura– Blood products– Cystic components
• Pressure on frontal/temporal lobes– Hydrocephalus– Memory issues
![Page 12: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/12.jpg)
Hormonal Testing
• ACTH, 8am cortisol• TSH, free T4, free T3• Prolactin
– With 1:100 dilution if macroadenoma
• GH, IGF-1• FSH, LH, total testosterone/estradiol• Alpha subunit
![Page 13: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/13.jpg)
MRI
• Pituitary protocol• Gadolinium• 3T• Dynamic protocol• Experience of center
![Page 14: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/14.jpg)
Neuro-ophthalmology Testing
• Formal visual fields
• Visual acuity
• Health of optic nerves
![Page 15: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/15.jpg)
Prolactinomas
![Page 16: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/16.jpg)
Prolactinomas
• Most common hormonally active tumor• F>>M• Microadenomas
– Benign, regress spontaneously, can have no growth
• Macroadenomas– Present w/ pressure symptoms, increase in size, rarely
disappear
![Page 17: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/17.jpg)
Prolactinomas
• Clinical features dependent on prolactin level, mass effects, hypopituitarism
• Gender, age, tumor size• Prolactin stimulates milk in Estrogen-primed
breast• High prolactin inhibits GnRH which decreases
FSH/LH which decreases testosterone/estrogen
![Page 18: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/18.jpg)
When to Treat
• Infertility• Menstral disturbances• Bothersome galactorrhea• Enlarging tumor• Apoplexy w/ headache
![Page 19: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/19.jpg)
Treatment
• Medications– 1st line treatment regardless of size
• Surgery– In resistant prolactinomas– Intolerance to both dopamine agonists
• Radiation– For residual/recurrent tumor
![Page 20: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/20.jpg)
• Cabergoline– Better tolerated– Fewer side effects– More likely to normalize level– No increased risks in pregnancy– ½ life-2-3days– Effective dose 1-1.5mg twice a week, resistant
prolactinomas 7-12mg/week
![Page 21: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/21.jpg)
• Cabergoline– May be fast metabolizers
• Change to every day or every other day– Valvulopathy
• Mitral valve stenosis• May be reversible• ? role of echocardiogram
![Page 22: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/22.jpg)
• Bromocriptine– Cheaper– ½ life-8hrs– Should be 2-3 times daily– Common dose up to10mg every night or 5mg twice a
day– Doses >20-40mg not more efficacious– Preferred agent in pregnancy– No risk of valvulopathy
![Page 23: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/23.jpg)
Side Effects of Dopamine Agonists
• Nausea• Lightheadedness• Mental fog• Worsening of depression• Psychotic reaction• Minimize if take at night, start low, go slow, take
w/ snack
![Page 24: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/24.jpg)
Use of Hormone Replacement in Prolactinomas (Estrogen)
• Possible growth of tumor• In combo w/ dopamine agonists-safe• No prospective studies when used alone• Would not use if chiasmopathy• Monitor prolactin regularly
![Page 25: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/25.jpg)
Pregnancy
• Risk of micro growing-1-3%• Risk of macro growing-<15%• Stop medication once pregnant• Go thru pregnancy, breastfeeding, restart if
amenorrhea, future fertility• Monitor for headache, vision changes• Can get MRI not Gadolinium• May have issues w/ lactation• Role of debulking if macroadenoma, chiasmopathy
![Page 26: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/26.jpg)
Cushing’s Disease
![Page 27: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/27.jpg)
Clinical Manifestations
• Degree• Duration• Presence/absence androgen excess• Cause• Tumor related symptoms• Age
![Page 28: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/28.jpg)
Clinical Manifestations
![Page 29: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/29.jpg)
Complications
• Fungal infections• Cardiovascular complications
– Stroke, heart attack
• Proximal myopathy• Psychiatric disturbances• Menstrual abnormalities• Osteoporosis• PCOS (Polycystic Ovarian Syndrome)• Diabetes/impaired glucose tolerance
![Page 30: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/30.jpg)
Screening Tests
• 1 mg overnight dexamethasone– Take at 11pm– Draw cortisol at 8am– Cortisol < 1.8g/dL – r/o hypercortisolism– Cortisol > 5mg/dL = hypercortisolism
![Page 31: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/31.jpg)
• 24 hour urinary free cortisol– If >3x normal, diagnostic of true Cushing’s– Lesser elevations require confirmation– False elevations of UFC
• Physical stress• Exercise• Large volume intake• Medications
![Page 32: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/32.jpg)
Late Night Salivary Cortisol
• Bedtime/11pm salivary cortisol (series of 2-3)
![Page 33: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/33.jpg)
Overnight High Dose Dexamethasone Suppression
• Dexamethasone 8mg by mouth at 11pm
• Serum cortisol at 8am
• Will suppress in pituitary source– Cortisol <1.8g/dL– Cortisol <50% of baseline
![Page 34: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/34.jpg)
Inferior Petrosal Sinus Sampling/IPSS
![Page 35: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/35.jpg)
Surgery
• Goal is for cure– Immediate post-op cortisol <2-3g/dl within 24-
72hours
• If not cured, consider– Repeat surgery– Radiation treatment
![Page 36: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/36.jpg)
Ketoconazole
• Dosing 200-400mg BID-TID• Side effects
– HA– Sedation– Nausea/vomiting– Gynecomastia– Decreased libido– Impotence
• Life threatening-reversible hepatotoxicity
![Page 37: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/37.jpg)
Mifepristone (Korlym)
• Dosing 300mg daily• Maximum dose 1200mg daily• Maximum dose in hyperglycemia 600mg daily• Side effects
– Adrenal insufficiency– Peripheral edema– Hypertension– Headache– Hypokalemia– Endometrial hypertrophy
• Cannot follow cortisol levels
![Page 38: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/38.jpg)
Pasireotide
• Dosing 600-900 mcg subcutaneously twice daily• Decrease in cortisol, ACTH, salivary cortisol• Signs and symptoms improved• Side effects
– Hyperglycemia– Diarrhea– Abdominal discomfort– Gallstones
![Page 39: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/39.jpg)
Bilateral Adrenalectomy
• Immediate cure
• Complication-Nelson’s Syndrome– Vision loss– Progression of pituitary tumor– Dependent on glucocorticoids and mineralicorticoids
![Page 40: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/40.jpg)
Post-op Management
• Adrenal insufficiency results
• Treat w/ decreasing doses of steroids– Initial dosing – hydrocortisone 40-80mg daily– Wean over 6-24months– Cosyntropin stimulation testing once off to confirm
normal axis
![Page 41: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/41.jpg)
Monitoring
• Lifelong• Patients usually feel symptoms prior to
abnormalities in testing• Yearly cortisol, ACTH• Scheduled MRIs• Consider hypercortisolemia testing
– Late night salivary testing– 24 hour urine free cortisol– 1mg overnight dexamethasone suppression
![Page 42: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/42.jpg)
Acromegaly
![Page 43: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/43.jpg)
Acromegaly
• M=F• Mean age 42-44• Usually have diagnosis 7-10 years prior• Premature mortality from cardiovascular disease
with risk decreasing when normalize IGF-1, GH
![Page 44: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/44.jpg)
Symptoms
• Change in facial features– Enlargement in forehead, mandible, tongue, gap in teeth
• Enlargement of hands/feet• Excessive sweating• Dental malocclusions• Sleep apnea
![Page 45: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/45.jpg)
Signs/Symptoms
• Diabetes• Hypertension• Colon polyps• Arthralgias• Skin tags• Carpal tunnel
![Page 46: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/46.jpg)
Co-morbidities
• Cardiomyopathy/Congestive Heart Failure• Diabetes/Insulin resistance• Hypertension• Obstructive sleep apnea• Precancerous colon polyps• Thyroid nodules
![Page 47: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/47.jpg)
Lab Values
• Elevated GH
• Elevated IGF-1
• Lack of GH suppression to glucose load
![Page 48: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/48.jpg)
Treatment
• Surgery– 1st line treatment by experienced surgeon
• Medications– Has been used as adjunctive vs primary medical
therapy
• Radiation
![Page 49: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/49.jpg)
Surgery
• Post op day 1 GH<5 highly predictive of remission
• Remission if GH<1 after OGTT
• IGF-1 takes weeks to months to decrease because of delayed clearance
![Page 50: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/50.jpg)
Medical Treatment
• Somatostatin analogs
• Dopamine agonists
• GH receptor antagonist
![Page 51: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/51.jpg)
Somatostatin analogs-Octreotide LAR(Sandostatin)/Lanreotide
(Somatuline)
• Improvement in symptoms - 90%
• Lower GH - 90%
• Normalize IGF-1 - 50-60%
• Reduce tumor size by 25%
![Page 52: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/52.jpg)
Somatostatin Analogs-Octreotide LAR(Sandostatin)/Lanreotide
(Somatuline)
• Side effects– Transient abdominal discomfort– Diarrhea– Gallstones – 18%
![Page 53: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/53.jpg)
Dopamine Agonists-Bromocriptine/Cabergoline
• Improvement in symptoms - 90%
• Normalize IGF-1<20%
• Likely more effective in co-secreting tumors
![Page 54: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/54.jpg)
GH receptor Antagonist – Pegvisomant (Somavert)
• Elevates GH• Normalize IGF-1 - 89-97% at 1 year• Shot subcutaneously daily• Can be combined w/ somatostatin analog once or
twice weekly– Decrease dose of somatostatin analog– Improvement in cost savings
![Page 55: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/55.jpg)
GH receptor Antagonist – Pegvisomant (Somavert)
• Side effects
– Hepatitis picture• Resolves w/ stopping med
– Enlargement of tumor• Likely from termination of somatostatin analog
![Page 56: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/56.jpg)
Radiation Treatment
• Adjunctive therapy after surgery for residual/recurrent disease
• Starts working in 3-6mo, continues working 3-10 years
• GH falls 50% every 2-3years• Normalization of IGF-1 rare prior to 5 years• Normalize IGF-1 - 60-80%
![Page 57: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/57.jpg)
Screening Tests w/ Diagnosis
• Baseline echo, repeat 1 year, prn• Colonoscopy every 5years• Thyroid u/s, fine needle aspirate all nodules >1cm• A1c, Fasting lipid panel• Hypertension• Obstructive sleep apnea• Carpal tunnel• Joint pain/hip x-rays• Bone density/DXA if hypogonadism,
hyperprolactinemia
![Page 58: Common Types of Pituitary Tumors](https://reader036.fdocuments.in/reader036/viewer/2022062322/56813bbc550346895da4ea91/html5/thumbnails/58.jpg)
A Special Thanks to our Sponsors
Barrow Neurological Institute
Corcept
Ipsen
KARL STORZ Endoskope