Pituitary IncidentalomaAn Initial Assessment

Endocrinology

Case ReportID/CC50 year old female w/ PMH: AIDS (CD4 81)

non compliant with HAART, DM2 (diet controlled) admitted for acute onset AMS. Brought in by son who reports a history of confusion x 24 hours. Pt also reports ongoing nausea, vomiting and headaches x 1 year (pattern unchanged).

Case ReportPhysical ExamVitals in ED: BP 103/73 HR 130 RR 18

T98F O2 99%- Prior to being seen by Endo 1

temperature of 100.3F

Pertinents of PE:

-Difficulty following commands-Decreased Right peripheral vision

Case ReportImagingCT scan: _____

MRI: 22 mm mass with edema – DDX: Benign vs Malignant vs Infectious given history of AIDS

Case ReportLabsProlactin elevated at 66.80ACTH <5Cortisol 0.74

Case ReportAssessmentConsults:

NeurologyNeurosurgeryInfectious DiseaseEndocrinology

Pituitary Incidentaloma?“ a previously unsuspected pituitary lesion

that is discovered on an imaging study”

Macroincidentaloma ≥ 1 cmMicroincidentaloma ≤ 1 cm

Functional vs nonfunctional

Differential Diagnosis of a sellar mass

CraniopharyngiomaMeningiomacarotid aneurysmLymphomaInfectious

(Toxoplasmosis)Abcessprolactinoma

MetastasisChordomaStalk lesion: germ

cell tumors, Langerhans granulomatosis (histiocytosis X), lymphocytic hypophysitis, and sarcoidosis.

Clinical Presentations of Pituitary Tumors

1.Functioning tumors1. Prolactinoma2. Acromegaly3. Cushing disease4. Hyperthyroidism

2.Mass effects1. Hypopituitarism2. i. Adrenal insufficiencyii. Hypothyroidism iii. Hypogonadism

iv. Growth hormone deficiency3. Headaches4. Neurological deficits

i. Visual changes: decreased visual acuity, visual field deficits, ophthalmoplegia ii. Ptosis iii. Facial sensory syndromes

5. Cerebrospinal fluid leakage +/– meningitis6. Nasopharyngeal obstruction

3.Pituitary apoplexy4.Asymptomatic

1. Nonfunctioning tumors

Diagnosisdetailed history and physical examination,

MRI scan, and pituitary hormone testing A detailed visual field examination

should be included in the evaluation of any potential pituitary mass

 evaluation of anterior pituitary hormones:prolactin, 8:00 am cortisol, free thyroxine

(T4), TSH, IGF-I, GH, LH, FSH, and testosterone (in men).

MEN-1?

Medical Therapyfor apoplexy: rapid corticosteroid

administration ± surgical decompression• for prolactinoma: dopamine agonists (e.g.

Cabergoline, bromocriptine)• for Cushing's: serotonin antagonist

(cyproheptadine), inhibition of cortisol production (ketoconazole)

• for acromegaly: somatortati.n analogue (octreotide) ± bromocriptine

• endocrine replacement therapy

Follow up Clinical and biochemical testing for

hypopituitarism – 6 months after initial testing and 1 year after for MACRO

No need to continue biochemical testing for hypopit in MICRO incases where the MRI does not change over time

Pts who develop signs/sxs of increasing size should have more frequent MRI evaluations

Indications for surgery:• presence of a VF due to the lesion•Other deficits of the visual field such as opthalmoplegia, due to compression•Compression of the optic chiasm or optic nerves as seen by the MRI

• Important in women planning to become pregnant

•Hypersecreting tumors other than prolactinomas •No size cut off, “clinically significant growth”•Headaches (low quality of evidence)

Back to our patient……

References Melmed S, Jameson JL. Chapter 339. Disorders of the Anterior

Pituitary and Hypothalamus. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com/content.aspx?aID=9139876. Accessed March 20, 2013.

Pituitary Incidentaloma: An Endocrine Society Clinical Practise Guidline. Journal of Clinical Endocrinology and Metabolism, April 2011, 96(4):894-904