pituitary incidental om a
TRANSCRIPT
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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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