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Pituitaryincidentaloma

So-ngernA.

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Pituitarygland

Endocrinegland,weighabout0.5g Locateatmiddlecranialfossa,pituitaryfossa Connectedhypothalamusviapituitarystalk Consistsoftwocomponents:

Anteriorpart:adenohypophysisPosteriorpart:neurohypophysis

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Sellaturcica

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Pituitarygland

Anteriorpituitary:adenohypophysisParsdistalisParsintermediaParstubalis

Posteriorpituitary:neurohypophysis

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Adenohypophysis Somatotropes : GH Lactotropes : PRL Thyrotropes : TSH Gonadotropes : LH ,FSH Corticotropes : ACTH Chromophobes: minimal or no hormonal

content. Melanocyte-stimulatinghormone

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Neurohypophysis Pars nervosa Largely unmyelinated axons from

hypothalamic neurosecretory neurons

Cell bodies in the paraventricular andsupraoptic nuclei of the hypothalamus Oxytocin , Antidiuretic Hormone

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Pituitaryincidentaloma

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DefiniGon Previouslyunsuspectedpituitarylesionthatisdiscoveredonanimagingstudyperformedfor

anunrelatedreason.

Imagingstudynotdoneforrelatedlesion:visualloss,clinicalsignandsymptomof

hypopituitarismorhormoneexcess.

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Microadenoma:/=1cminsize

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EGology 91%werepituitaryadenomasandabout9%werenonpituitaryinorigin:craniopharyngiomaandRathkescleUcysts

Varycaseseries:Mostpituiataryadenoma Immunohistochem:negaGve50%,gonadotroph15%,H10%,plurihormonal20%

CysGclesions:mostRathkescleUcysts,craniopharyngioma

NoncysGclesions:nearlyallpituitaryadenoma,mostclinicallynonfuncGoningpituitaryadenomasaregonadotropeorigin

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Epidemiology

EsGmatedbasedonautopsy,underwentCTorMRIwithotherreason

Autopsyseries:average10.6%ofadenoma CT:microincidentaloma4-20%,macroincidentaloma0.2%

MRI:microincidentaloma10-38%,macroincidentaloma0.16%

Pooleddata10series:45%macro-

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IniGalevaluaGon

RecommendaGons

1.1WerecommendthatpaGentspresenGngwitha

pituitaryincidentalomaundergoacompletehistory

andphysicalexaminaGonthatincludesevaluaGonsforevidenceofhypopituitarismandahormone

hypersecreGonsyndrome.PaGentswithevidenceof

eitherofthesecondiGonsshouldundergoan

appropriatelydirectedbiochemicalevaluaGon

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1.1.1WerecommendthatallpaGentswithapituitaryincidentaloma,includingthosewithoutsymptoms,undergoclinicalandlaboratoryevaluaGonsforhormonehypersecreGon

1.1.2WerecommendthatpaGentswithapituitaryincidentalomawithorwithoutsymptomsalsoundergoclinicalandlaboratoryevaluaGonsforhypopituitarism

1.1.3WerecommendthatallpaGentspresenGngwithapituitaryincidentalomaabu`ngtheopGcnervesorchiasmonmagneGcresonanceimaging(MRI)undergoaformalvisualfield(VF)examinaGon

1.1.4WerecommendthatallpaGentshaveaMRIscan,ifpossible,toevaluatethepituitaryincidentaloma[iftheincidentalomawasiniGallyonlydiagnosedbycomputedtomography(CT)scan]tobeerdelineatethenatureandextentoftheincidentaloma

IniGalevaluaGon

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1.1.1Werecommendthatallpaentswithapituitaryincidentaloma,includingthosewithoutsymptoms,undergoclinicalandlaboratoryevaluaonsforhormonehypersecreon

1.1.2WerecommendthatpaGentswithapituitaryincidentalomawithorwithoutsymptomsalsoundergoclinicalandlaboratoryevaluaGonsforhypopituitarism 1.1.3WerecommendthatallpaGentspresenGngwithapituitaryincidentaloma

abu`ngtheopGcnervesorchiasmonmagneGcresonanceimaging(MRI)undergoaformalvisualfield(VF)examinaGon

1.1.4WerecommendthatallpaGentshaveaMRIscan,ifpossible,toevaluatethepituitaryincidentaloma[iftheincidentalomawasiniGallyonlydiagnosedby

computedtomography(CT)scan]tobeerdelineatethenatureandextentoftheincidentaloma

IniGalevaluaGon

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IdenGfy:HormonehypersecreGon,hypopituitarism,masseffect

EvaluaGonhypersecreGon:PRL,H,ACTH DataonretrospecGvestudyofhormonesecreGon:

inBelgian:0.542/1000InFinland:0.04/1000

IniGalevaluaGon

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ProlacGnlevel:low---->dilutedserum(Hookeffect)

HyperprolacGnemia:prolacGnoma,compressionpituitarystalk(mildtomoderate

elevaGons)

TrialofDopamineagoniststherapy

IniGalevaluaGon

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Silentsomatotroph-secreGngtumor:rare 1/11macroincidentalomawerefoundtohaveelevaGonofIF-1:subclinicalHexcess

IniGaltreatmentforH-secreGngtumorcanbecuredsurgically

ScreeningwithIF-1iswarranted

IfIF1elevated,furtherevaluaGonforHissuggest

IniGalevaluaGon

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NosystemicscreeningofincidentalomaforsubclinicalglucocorGcoidexcesshasbeenreport

ConsidercorGcotrophsecreGngtumorwhenclinicallysuspected:Hyperpigment,DM,HT,obesity,osteoporosis,HirsuGsm,other

SomeexpertopinionsuggesttomeasureACTHlevel

IniGalevaluaGon

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1.1.1WerecommendthatallpaGentswithapituitaryincidentaloma,includingthosewithoutsymptoms,undergoclinicalandlaboratoryevaluaGonsforhormonehypersecreGon

1.1.2Werecommendthatpaentswithapituitaryincidentalomawithorwithoutsymptomsalsoundergoclinicalandlaboratoryevaluaonsforhypopituitarism

1.1.3WerecommendthatallpaGentspresenGngwithapituitaryincidentalomaabu`ngtheopGcnervesorchiasmonmagneGcresonanceimaging(MRI)undergoaformalvisualfield(VF)examinaGon

1.1.4WerecommendthatallpaGentshaveaMRIscan,ifpossible,toevaluatethepituitaryincidentaloma[iftheincidentalomawasiniGallyonlydiagnosedbycomputedtomography(CT)scan]tobeerdelineatethenatureandextentoftheincidentaloma

IniGalevaluaGon

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IniGalevaluaGon

SmalltwoobservaGonalstudies:hypopituitarism7/66and19/46

paGent

Deficitofonadotropins:upto30% DeficitofACTH:upto18% DeficitofTSH:upto28%

DeficitofH:upto8%

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1.1.1WerecommendthatallpaGentswithapituitaryincidentaloma,includingthosewithoutsymptoms,undergoclinicalandlaboratoryevaluaGonsforhormonehypersecreGon

1.1.2WerecommendthatpaGentswithapituitaryincidentalomawithorwithoutsymptomsalsoundergoclinicalandlaboratoryevaluaGonsforhypopituitarism

1.1.3Werecommendthatallpaentspresenngwithapituitaryincidentalomaabu>ngtheopcnervesorchiasmonmagnecresonanceimaging(MRI)undergoaformalvisualfield(VF)examinaon

1.1.4WerecommendthatallpaGentshaveaMRIscan,ifpossible,toevaluatethepituitaryincidentaloma[iftheincidentalomawasiniGallyonlydiagnosedbycomputedtomography(CT)scan]tobeerdelineatethenatureandextentoftheincidentaloma

IniGalevaluaGon

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BaselineVFtesGngforallpaGent EvenwithoutvisualsymptomInonestudy:5%unrecognizedVFabnormality

IniGalevaluaGon

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1.1.1WerecommendthatallpaGentswithapituitaryincidentaloma,includingthosewithoutsymptoms,undergoclinicalandlaboratoryevaluaGonsforhormonehypersecreGon

1.1.2WerecommendthatpaGentswithapituitaryincidentalomawithorwithoutsymptomsalsoundergoclinicalandlaboratoryevaluaGonsforhypopituitarism

1.1.3WerecommendthatallpaGentspresenGngwithapituitaryincidentalomaabu`ngtheopGcnervesorchiasmonmagneGcresonance

imaging(MRI)undergoaformalvisualfield(VF)examinaGon

1.1.4WerecommendthatallpaentshaveaMRIscan,ifpossible,toevaluatethepituitary

incidentaloma[iftheincidentalomawasiniallyonlydiagnosedbycomputedtomography(CT)scan]tobeerdelineatethenatureandextentoftheincidentaloma

IniGalevaluaGon

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MRI:pituitaryprotocols+/-dadministraGon Finecutsthoroughthesella

IniGalevaluaGon

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IndicaGonforsurgeryaUerevaluGon

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IndicaGonforsurgeryaUerevaluGon

3.1WerecommendthatpaGentswithapituitaryincidentalomabereferredforsurgeryiftheyhavethefollowing

AVFdeficitduetothelesionLossofendocrinologicalfuncGon

OthervisualabnormaliGes,suchasophthalmoplegiaorneurologicalcompromiseduetocompressionbythelesion.

Lesionabu`ngorcompressingtheopGcnervesorchiasm

onMRIPituitaryapoplexywithvisualdisturbance.

HypersecreGngtumorsotherthanprolacGnomas

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FollowuptesGng

RecommendaGon

2.1PaGentswithincidentalomaswhodonotmeetcriteriaforsurgicalremovalofthetumorshouldreceivenonsurgicalfollow-upwithclinical

assessmentsandthefollowingtests: 2.1.1MRIscanofthepituitary6monthsaUertheiniGalscaniftheincidentalomaisamacroincidentalomaand1yraUertheiniGalscanifitisamicroincidentalomaInpaGentswhoseincidentalomadoesnotchangeinsize,wesuggestrepeaGngtheMRIeveryyearformacroincidentalomasandevery12yrinmicroincidentalomasforthefollowing3yr,andgraduallylessfrequentlythereaUer

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FollowuptesGng

2.1.2VFtesGnginpaGentswithapituitaryincidentalomathat

enlargestoabutorcompresstheopGcnervesorchiasmonafollow-upimagingstudy.WesuggestthatcliniciansdonotneedtotestVFinpaGentswhoseincidentalomasarenotclose

tothechiasmandwhohavenonewsymptomsandarebeingfollowedcloselybyMRI

2.1.3ClinicalandbiochemicalevaluaGonsforhypopituitarism6monthsaUertheiniGaltesGngandyearlythereaUerinpaGents

withapituitarymacroincidentaloma,althoughtypicallyhypopituitarismdevelopswiththefindingofanincreaseinsizeoftheincidentalomaWesuggestthatcliniciansdonotneedtotestforhypopituitarisminpaGentswithpituitarymicroincidentalomaswhoseclinicalpicture,history,andMRIdonotchangeoverGme

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Mostincidentalomagrowslowly,somedoenlargedbuttrueproliferaGvenatureisunknown

Ifnogrowthisdetected,intervalofMRIcanbeincreased Enlargedofincidentalomaespeciallymacroincidentaloma----->VFabnormality

Hypopituiarism:macroadenoma(apoplexy),rareinmicroincidentaloma

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Recommenda)on

2.2PaGentswhodevelopanysignsorsymptomspotenGallyrelatedtothe

incidentalomaorwhoshowanincreaseinsize

oftheincidentalomaonMRIshouldundergo

morefrequentordetailedevaluaGonsas

indicatedclinically

FollowuptesGng

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3.2WesuggestthatsurgerybeconsideredforpaGentswithapituitaryincidentalomaiftheyhavethefollowing

Clinicallysignificantgrowthofthepituitaryincidentaloma.

.

AlesionclosetotheopGcchiasmandaplanto

becomepregnant.

nremi`ngheadache.

IndicaGonforsurgeryaUerFollowup

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Significantgrowthonfollowuprisktovision Dependonage,surgeonexperGse,risktoSurgery

Somesurgicalseriesshowhypopituitarismcanimprovewithsurgery

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Medicaltherapy

NotsystemaGcallystudy Dopamineagonist:hyperprolacGnemia Somatostainanalogue

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