pituitary adenoma
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Pituitary Adenoma
Pituitary Adenoma
Dr. Ashraful Huq (Ridoy)FCPS+8801811999070Bangladesh Eye Hospital Ltd. Dhaka, Bangladesh
Introduction
Thepituitary gland, orhypophysis, is anendocrine gland
Produce number of hormones which control the secretions of many other endocrine glands
Its anatomical position is important in ophthalmological view
DevelopmentThe anterior pituitary (adenohypophysis)arises fromRathke's pouch, an upward growth from the ectodermal roof of the stomodeum
Theposterior pituitary (neurohypophysis) arises from a downward growth from the floor of the diencephalon
AnatomyOccupies a cavity of the sphenoid bone called sella turcica at the middle cranial fossa
Roof is formed by diaphragma sellae
The stalk of pituitary is attached above to the floor of third ventricle
Size of a pea (< 8 mm)
It weighs about 0.5 gm.
SecretionsAnterior Lobe:FSHLHACTHTSHProlactinGHPosterior Lobe:ADHOxytocin
Pituitary AdenomaBenign tumors of pituitary gland
EpidemiologyEtiology is unknown
10-15% of all primary brain tumors
75% of adenomas are endocrinogically secreting
25% of those with MEN-I develop pituitary adenomas
ClassificationHormonesClinical featuresSecreting (75%)Chromophobes (50%)ProlactinFemale: Infertility, amenorrhea, galactorrheaMale : Hypogonadism, impotency, sterility, libido, gynecomastia, galactorrheaAcidophils (20%)GHAcromegaly(adult) Gigantism(child)Basophils(5%)ACTH, FSH & TSHCushing disease, FSH & TSH tumorsNonsecreting (25%)
ClassificationMicroadenoma < 10 mm diameterSecreting adenoma
Macroadenoma > 10 mm diameter Mass effectsNon secreting
Clinical presentationLocalized mass effectsChiasmal syndromes
Compression of other adjacent structures ~ Cavernous sinus (paresis of 3rd, 4th or 6th CN causing disorders of extraocular motility)
~ Hypopituitarism (direct pressure, vascular damage)
~ Papilloedema (raised ICP, very rare)
Endocrine effectsHypersecretion
Hyperscretion
Growth HormoneACTH
HyperscretionProlactinFemaleInfertility-amenorrhea- galactorrheaMaleHypogonadism, impotence, sterility, libido, gynecomastia, galactorrhea
HyposcretionGrowth hormone deficitIn children: dwarfismIn adults: weakness,overweight, reduced cardiac output, low blood sugar levels, and reduced exercise tolerance
TSH deficitHypothyroidism
ACTH deficitUnderactive adrenal gland, which causes low blood pressure,hypoglycemia, fatigue, weight loss, vomiting, and low stress tolerance
ADH deficitDiabetes Insipidus
Chiasmal SyndromesBlurred vision
Headache
Diplopia
Colour desaturation
Visual field defect
Optic atrophy
Post fixation blindness
Visual hallucination
See-Saw nystagmus
Visual field defect in pituitary adenomaBitemporal hemianopia
Incongruous homonymous hemianopia
Bitemporal central scotoma
Diffuse scotoma
Junctional scotoma
Bitemporal hemianopiaClassic defect in pituitary adenoma
Occurs in central chiasmal defect
Superotemporal field affected first Lower temporal field defect
Incongruous homonymous hemianopia
Occurs in optic tract lesion
Occurs in post. Chiasmal lesion
Compressing only the macular fibers
Bitemporal central scotoma
Junctional scotomaCentral scotoma in one eye with superotemporal visual field loss in the other eye
Caused by compression to anterior loop to the decussating nasal fibers in posterior optic nerve (Von Wilbrand's knee)
Fundus picture
Bow tie atrophy
Diffuse atrophy
Bow tie atrophy
Pituitary apoplexyLarge adenoma leading to haemorrhage or infarction of pituitary gland
Occur in pregnancy
Compresses hypophysial portal vessels
Presentation: hyperacute chiasmal syndrome
Treatment : high dose steroid / surgery
Ocular ExaminationVisual acuity
RAPD
Color vision
Ocular motility
Fundus examination
InvestigationsEndocrinological evaluation Serum prolactinFSHTSHGHInsulin stress test
Ocular investigationVisual Field AnalysisHess / Lees chart
Imaging MRI / CT scan of brainX-ray skull (Ant. & Lat. view)
TreatmentReferral to Endocrinologist & Neuro-surgeon
Observation
Medical therapyDopamine agonists Cabergoline/Bromocriptine
Surgery When mass causing severe compressionEndoscopic - Transphenoidal, transfrontalCraniotomyVisual recovery is tri-phasic
TransfrontalTrans-sphenoidalSurgeryRadiotherapy ObservationMedical therapy
Radiotherapy Following incomplete removal of tumourPrimary treatment
Gamma knife stereotactic radiotherapyClose proximity to the optic nerveCavernous sinus invasion
Therapeutic Modalities SummarySurgeryRadiotherapyMedicalNon-functioning adenoma1st line2nd line-Prolactinoma2nd line2nd line1st line
Acromegaly1st line2nd line2nd line
Cushings disease1st line2nd line-
Follow-up after treatmentMedical therapy Monthly for large tumors or during pregnancy for tumors of any size6 month intervals in microadenoma for 1 year, then yearly
Surgery Immediately postoperatively4-6 weeks postoperatively4 months intervals for a yearYearly for 5 years Every 2 years
Radiotherapy At the midpoint and end of radiotherapy3 months interval for a year6 months interval for a yearYearly
Evaluation - Visual acuityFundoscopy Visual fieldImaging
Conclusions Pituitary adenomas occurs with a wide spectrum of clinical features
Should be managed between different specialists
Neuro-ophthalmological manifestations are frequent and varied
Physicians must be aware about these in order to refer patients to ophthalmologist for early diagnosis and treatment
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