Pituitary adenoma overview

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Pituitary adenoma from other Diseases

Epidemiology and Demographics

Risk Factors

Natural history, Complications and Prognosis

Diagnosis

Staging

History and Symptoms

Physical Examination

Laboratory Findings

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ahmad Al Maradni, M.D. [2]

Overview

Pituitary adenomas are tumors that occur in the pituitary gland and account for about 10% of intracranial neoplasms. Pituitary adenomas are often remain undiagnosed. Small pituitary adenoms are found in 6 to 24 percent of adults at autopsy. Pituitary adenomas arise within the anterior lobe (adenohypophysis) of the gland. Pituitary adenomas may be classified according to the size of the adenoma and type of hormone secretion. Pituitary adenomas subtypes include corticotrophic, somatotrophic, thyrotrophic, gonadotrophic, and lactrotrophic adenomas. Adenomas less than 10mm are called microadenomas. There are no established causes for pituitary adenoma. Patients with pituitary adenoma may progress to develop lethargy, headache, nausea, and vomiting. Common complications of pituitary adenoma include bitemporal hemianopia, anosmia, acromegaly, gigantism, and Cushing's syndrome. Prognosis is generally good, and approximately 18% of patients with macroadenoma require further treatment. Pharmacologic medical therapy is recommended among patients with prolactinoma, thyrotrophic, somatotrophic, and adrenocorticotropic adenomas. The transsphenoidal microsurgical approach is the mainstay of treatment for growth hormone-(GH) producing adenomas, adrenocorticotropic hormone-(ACTH) producing adenomas, and macroadenomas.

Historical Perspective

Pituitary adenoma was first described by Pierre Marie, a French neurologist in 1886.[1]

Classification

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency may be classified into several subtypes based on severity, time of onset (mild, moderate, and severe), and the presence of virilization (stage I to stage V).

Pathophysiology

On gross pathology, a well circumscribed suprasellar mass is a characteristic finding of pituitary adenoma. On microscopic histopathological analysis, a monomorphic expansion of usually one cell type with lack of reticulin network among neoplastic cells is a characteristic finding of pituitary adenoma.

Causes

There are no established causes for pituitary adenoma.

Differential Diagnosis

Pituitary adenoma must be differentiated from other diseases such as craniopharyngioma, meningioma, arachnoid cyst, and pituitary carcinoma.

Epidemiology and Demographics

The prevalence of pituitary adenoma is approximately 100 per 100,000 individuals worldwide. In the USA, the incidence pituitary adenoma is approximately 3.12 per 100,000 individuals.

Risk Factors

The most potent risk factor in the development of pituitary adenoma is a positive family history of either pituitary tumor, multiple endocrine neoplasia type 1 (MEN1), or McCune-Albright syndrome.

Pituitary adenoma natural history, complications, and prognosis

Patients with pituitary adenoma may progress to develop lethargy, headache, nausea, and vomiting. Common complications of pituitary adenoma include bitemporal hemianopia , anosmia, acromegaly, gigantism, and Cushing's syndrome. Prognosis is generally good, and approximately 18% of patients with macroadenoma require further treatment.

Diagnosis

Staging

According to the American Joint Committee on Cancer classification and staging system for pituitary tumors, there is no staging system available for pituitary adenoma.

History and Symptoms

The hallmark of pituitary adenoma is increased intracranial pressure. A positive history of visual field defect, headache, and menstrual irregularities is suggestive of pituitary adenoma. The most common symptoms of pituitary adenoma include galactorrhea, oligomenorrhea , erectile dysfunction, and loss of libido.

Physical Examination

The presence of altered mental status, nausea, lethargy, and visual filed defect (bitemporal hemianopsia) on physical examination is suggestive of pituitary adenoma.

Laboratory Findings

Laboratory findings consistent with the diagnosis of pituitary adenoma include elevated serum prolactin level and elevated or decreased serum levels of other pituitary hormones.

CT

On head CT scan may be helpful in the diagnosis of pituitary adenoma. Findings on CT scan suggestive of pituitary adenoma include a large suprasellar mass that invades surrounding structures, calcification, and rarely hemorrhage.

MRI

On brain MRI, pituitary adenoma is characterized by a large mass with heterogeneous signal. Other findings may include remodeling of the floor of the sella and deviation of the pituitary infundibulum to the opposite side.

Other Imaging Studies

Historically, before the advent of MRI, lateral skull x-rays were performed to look for remodelling of the pituitary fossa.[2]

Other Diagnostic Studies

Inferior petrosal sinus sampling may be performed to detect hormonally active pituitary microadenoma.

Treatment

Medical Therapy

Pharmacologic medical therapy is recommended among patients with prolactinoma, thyrotrophic, somatotrophic, and adrenocorticotropic adenomas.

Surgery

The transsphenoidal microsurgical approach is the mainstay of treatment for growth hormone-(GH) producing adenomas, adrenocorticotropic hormone-(ACTH) producing adenomas, and macroadenomas.

Primary Prevention

There are no primary preventive measures available for pituitary adenoma.

Secondary Prevention

Secondary prevention strategies following pituitary adenoma include a regular check up of pituitary hormones serum levels and regular neuro-ophthalmic examination.

References

  1. Marie P. Hyertrophie singuliere non congenital des extremites superieures, inferieures et cephalique. Rev Medicine. 1886;6:297–333.
  2. Pituitary Microadenoma. Dr Amir Rezaee and Dr Frank Gaillard. Radiopaedia.org 2015. http://radiopaedia.org/articles/pituitary-microadenoma

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