pathology of the endocrine organs - i pituitary jaroslava dukov inst. pathol. 1st med. fac. charles...
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Pituitary - history - II H. Rathke (1838) Über die Entstehung der glandula pituitaria Arch Anat. Physiol. u. Wiss. Med., 5, W. Haberfeld (1909) Die Rachendachhypophyse, andere Hypophysengangreste und deren Bedeutung für die Pathologie Beiträge zur path. Anat. u. allg. Pathol., 46,TRANSCRIPT
Pathology of the Endocrine Organs - I
Pituitary
Jaroslava Dušková Inst. Pathol. 1st Med. Fac. Charles Univ. Prague http://www1.lf1.cuni.cz/~jdusk/
Pituitary - history - I
Galenos (2nd cent.) lat. pituita = gr. phlegm = moisture, mucus
A. Vesalius (16th cent.)
glandula pituitam cerebri excepiens
R. Lower (17th cent.) Dissertatio de origine catarrhi – incretion
Pituitary - history - II
H. Rathke (1838)Über die Entstehung der glandula pituitaria
Arch Anat. Physiol. u. Wiss. Med. , 5, 482-5
W. Haberfeld (1909) Die Rachendachhypophyse, andere Hypophysengangreste und deren Bedeutung für die Pathologie Beiträge zur path. Anat. u. allg. Pathol. , 46, 133-
232
1. formation of the Rathke´s pouch & proc. infundibularis
2. splitting of the Rathke´s pouch
3. mature formation
Neuroimmunoendocrine Regulation Messengers
Neurotransmitters Interleukins Hormons
Pituitary - regulation
Higher neural centra
limbic system reticular system
hypothalamus
peripheral endocrine glands
adenohypophysis
tissues
liberins & statins
trophic hormons of the adenohypophysis
hormons of periph. glands
Pituitary – weight
Rasmussen, ATAm.J. Anat. 1928 a 1934
Females505 - 1002 mg(average 660 mg)pregnant women560 - 1220 mg(average 762 mg)
Males400 - 855 mg(average 570 mg)
Pituitary - architecture
adenohypophysis pars infundibularis (tuberalis) pars intermedia neurohypophysis
hypophysis pharyngea (+ hidden islets of pit. cells in the os sphenoides)
Pituitary - cell inclusions
squamous epithelium Rathke´s pouch between AH and NH salivary glands - NH, often with
oncocytes
Pituitary - parts - function
Adenohypophysis secretion of tropins Pars infundibularis (tuberalis)
modulation of AH secretion Pars intermedia Neurohypophysis secretion of neuropeptides hypophysis pharyngea possible secretion
of tropins
Pituitary – cell populations acidophil somatotrophs, lactotrophs basophil corticotrophs, gonadotrophs,
thyreotrophs chromofobe (transitional. +
folliculostellate) oncocytes (or preoncocytes) mesenchymal pituicytes (macroglia) secretion neurons (tractus supraoptico-
et tuberohypophyseus)
Hypophysis - cell population & hormonal production
acidophil PRL , STH basophil ACTH, FSH, LH, TSH chromophobe 0, PRL , STH , ACTH, FSH, LH, TSH
oncocytes 0, PRL , STH , ACTH, FSH, LH, TSH
mesenchymal pituicytes secretion neurons oxytocin, vasopresin
Pituitary - cell population & hormonal production
Hormonal production mostly mixed
(e.g. ACTH+FSH,LH,TSH,PRL)
Pituitary - cell population &hormonal production
Individual producents able of interconversion
following stimulation (e.g. PRL-GH)
L e p t i n 7th chromosome
adipocytes - blood - CSF - hypothalamus (ncl. arcuatus )
regulation of energetic homeostasis correlation with the body fat content in most obese individuals high levels -
resistence?Friedman et al., Nature 1994
Pituitary - regressive changes
Dystrophy (Crooke´s hyaline change) Atrophy - in aging increased fibrosis, no
functional influence NECROSIS
– traumatic (mostly due to the stalk lesion)
– ischemic
Pituitary - vascularisation
a. hypophysea sup. (from ACI)– a. trabecularis directly to AH– long portal veins in the stalk
a. hypophysea inf. (from ACI in sinus c.)– short portal veins
Pituitary - necrosis
incidence 1- 8 % large autopt.
series pathogenesis intracranial
hypertensionischemiavasospasmusatherosclerosisthrombistalk lesion
healing scar focal regenerates possible
meaning – hypofunction only in
case of more than 3/4 of volume destruction
Necrosis hypophysis intra partum
sy. Sheehani
• hyperplasia • shock• ischaemia• necrosis• panhypo- pituitarismus
Pituitary - inflammation
non specific (peri)hypophysitis
purulentanon purulenta
septicpyemicmicroabscesses
lymphocytic– autoimmune
specific tbc
hematogenous dissemination
solitary tuberculoma
lues inbornacquired
Pituitary syndromes
Hypofunctional–panhypopituitarismus–selective hypofunction
Hyperfunctional–monohormonal–combined
Hypopituitarismus
Total >90% AH destroyed
Syndromes: Simmonds Sheehan Falta Lorain
Partialmonohormonalcombined
Regulatory hypofunction
peripheral glands ectopic
production iatrogenous
Petzold S, Keller A, Keller E, Meigen C, Hirsch W, Kratzsch JK, Kiess W, Pfäffle R.
A prismatic case: A 31-year old man who did not miss his pituitary. lab. panhypopituitarismus – dg. at the age of 13 MRI- empty sella growth retardation correction, cryptorchidism, hypoglycemie, He felt better without hormonal therapy, hypogenitalism, normal
professional life & mental status
Hormones (Athens). 2008 Jul-Sep;7(3):203-4.
Pituitary Adenomas
no galactorea-amenorea acromegaly hypercortisolism chiasma opticum compression hypopituitarism
Clin. symptomes 9%9%
Pituitary Adenomas
1. chiasma opticum compression 432. acromegaly 233. galactorea-amenorea 74. hypopituitarism 7
Clin. symptomes in surgically treated (n=80)
54%28%
9%9%
Pituitary Adenomas
Guanine nucleotide- binding protein (G protein) mutations - signal transduction- uncontrolled proliferation (40% GH adenomas and som ACTH have GNAS I gene mutations)
Familiar pituitary adenomas: MEN I, CDKN I B, PRKAR I A, AIP
TP 53 mutations – aggressive behaviour
pathogenesis 9%9%
The WHO Classificationof Adenohypophysial Neoplasms .
A proposed five-tier scheme
1. endocrine activity2. imaging/ surgery3. histology4. immunohistochemistry5. ultrastructure
Kovacs, K., Scheithauer, B., Horvath Eva, Lloyd, R Cancer 1996, 78,502-10
Pituitary Adenomas
acidophillic basophillic chromophobe mixed
Acidophillic adenomas
somatotroph lactotroph mixed somatotroph and lactotroph somatolactotroph densely granulated
onkocytic
Basophillic adenomas
corticotrophic thyreotrophic gonadotrophic densely granulated
m. Cushing paraneopl. pituitary ad.
m. Cushing periph. hypothalamic
Chromophobe adenomas
all types of hormonal productionsscarcely
granulated
null cell
HyperpituitarismusMonohormonal
Syndromes:1. gigantismus/acromegaly2. hyperprolactinemia
(galaktorea, amenorea)
3. Cushing4. hyperthyreosis5. (hypergonadotropinismus)
Combined1+2, 1+3, 1+4, 2+3, 3+4
Regulatory hyperfunctionperiph. glandsectopic productioniatrogenous
Plurihormonal and PlurifunctionalPituitary Adenoma with Acromegaly Syndroma
doc. MUDr Jaroslava Dušková, CSc*,prof. MUDr Josef Marek, DrSc**, prof. MUDr Ctibor Povýšil,DrSc*
F 75 yrs
30 yrs lasting acromegaly refused surgery Symptomatic therapy
– hyperfunction thyr . – Carbimazol– cardiomegaly - cardiotonica– 5 yrs prior tu death ca coli – surg. removed– 6 yrs prior tu death corticoid substitution– death cardial failure
Plurihormonal and PlurifunctionalPituitary Adenoma
with Acromegaly
STH +++ Prl ++ ACTH ++
TSH +++FSH (beta)+LH (beta)+
Pituitary INCIDENTALOMA- algorithm of Investigation and treatment
m e d ik a m e n t . th .b r o m o c r ip t in
p r o la k t in o m
o p e r a c e
j in ý
h y p e r f .
k o n e c s le d .
b e ze z m ě n y
o p a k o v a t N M R z a 1 ,2 ,5 ,le t
< 1 cm
o p e r a c e
r ů st tu m o rup o r u ch a z o r . p o le
h y p o p itu ita rism u s)
o p a k o v a t N M R z a 0 ,5 1 ,2 ,5 ,le t
z o r n é p o lev y l . h y p o p itu ita r ism u s
> 1 c m
F u n k c e h y p o fý z yPituitary function
other
operation
repeat NMR in1,2,5 yrs
no change
visual field, excl. hypopituit.
repeat NMR in 0.5,1,2,5 yrs
end check- ups
operation
neoplasm growth, visual field def., hypopituitarism
Other Pituitary Tumours
craniopharyngeoma metastases
WHO Histological Typing of Tumours of the CNS
TUMOURS OF THE SELLA REGION & TUMOUR LIKE LESIONS
– craniopharyngeoma– Rathke´s cyst– epidermoid cyst– dermoid cyst– colloid cyst of 3rd ventricle– enterogenous cyst, pituicytoma, nasal glioma
WHO Histological Typing of Tumours of the CNS
TUMOUR LIKE LESIONS OF THE SELLA REGION – diff. dg.!!!
– Rathke´s cyst– epidermoid cyst– dermoid cyst– colloid cyst of 3rd ventricle– enterogenous cyst
Other Pituitary Tumours
craniopharyngeoma metastases