Pituitary disorders

Narendra ReddyClinical LecturerDiabetes, Endocrinology & MetabolismUniversity of Warwick

Grand round, UHCW, June 14th 2011

Plan….

Pituitary anatomy Pituitary physiology Evaluation of Pituitary mass Pituitary dysfunction in Elderly Clinical scenarios/Images

Pituitary anatomy

Pituitary anatomy

Sagittal view

Coronal view

Coronal view

Hormones

Evaluation of Pituitary mass

Local effects

Hypersecretion

Hyposecretion

Pituitary hormone profile

Somatotroph – GH IGF-1 Gonadotroph – FSH,LH Testo/Oest Thyrotroph – TSH FT4,FT3 Corticotroph – ACTH Cortisol (SST) Lactotroph - Prolactin Neurohypophysis Vasopressin (U&E, Paired Osmol)

Case

82 yr old male Headache, diplopia, vomiting- Acute Hypotension- 90/45 mmHg & III N palsy PMH- IHD, Hypertension Drugs- Antihypertensives, Aspirin

Diagnosis?

Investigations

9 am Testo- <0.4 (10-26) LH- 1.2, FSH- 0.7 (2-10) IGF-1 – 4.8 (10-35) PrL- 322 (<300) FT4 8.8 (10-19.5), TSH 2.0 (0.5-4.5) SST – 30’ Cortisol 213 nmol/L Na - 122; Pl Osm & U Osm - normal

Pituitary apoplexy

Pituitary apoplexy

Pituitary apoplexy

Pit apoplexy guidelines

Chronic hypopit’ symptoms

GH- lethargy, reduced strength LH/FSH- libido, infertility, menstrual TSH – hypothyroid PrL- lack of milk in breastfeeding females ACTH – pallor Vasopressin – Diabetes Insipidus

Hypopituitarism Pituitary tumours Radiotherapy Apoplexy,Sheehan syndrome Infiltrative disorders Infective- TB, Pit abscess Trauma Metastasis Russell viper snake bite PIT-1, HESX-1, PROP-1, KAL-1, SOX-2, DAX-1,

AVP-Neurohypophysin-II

Dynamic tests

Insulin Tolerance Test- ACTH & GH Glucagon test – ACTH & GH SST- adrenocortical function Clomifene test – Gonadotrophin GnRH & TRH- rarely used

To take home….

Adenomas do not cause DI

GH>FSH/LH>TSH>ACTH

Long term hypopit patients, treated with steroids can unmask DI

ACTH def–No Pigment/Hyperkalaemia

84 pts over 65 yrs (avg 72.5 yrs) 1975 to 1996 64 % VF defects 20 % hypopituitarism 7% pituitary apoplexy TSA safe in elderly

Pit tumours in elderly

Pituitary Incidentalomas

10% incidence in 18902 pituitaries Minimum 20 years F/U 18-86 years Local, hypersecretion, hyposecretion 10.6% < 1cm 24.1 % if >1cm MRI – 1, 2 & 5 years- stop if no size Hypopit, VF defects & size increase- Sx

Mark Molitch,Best Practice in Clinical Research 23 (2009) 667–675

42 yr man Headaches Reduced libido Erectile dysfunction

Case

2007

20 days

9 months

3 years

Prolactinoma Micro <1cm ; Macro > 1cm Medical treatment- Cabergoline Surgery- DA resistance/intolerance Radiotherapy DA Rx – Cardiac Valve fibrosis

1st line- Sx

2ndline- Mx

3rd line-Dx

Case

20 year old boy Visual field problems Enlarged nose Carpal tunnel Syndrome

Acromegaly

Photos please...

2nd line- Mx

1st line- Sx

3rd line- Dx

Case

40 years old lady 10 years of Diabetes Hypertension Hyperlipidaemia Osteoporosis Wt gain Acne

Cushings disease

Dr Harvey Cushing

Management ONDMST - Cortisol > 50 24 hr Urine Free Cortisol LDDMST >50 HDDMST CRH stimulation test Petrosal sinus sampling Surgery Radiotherapy B/L Adrenalectomy

1st line- Sx

2nd line-Dx

3rd line- Sx

Non functioning Pit Adenomas(NFA)

NFA

?????

Rathkes cyst

???

Craniopharyngioma

40 yr old female,Hypothyroid

?????

Lymphocytic hypophysitis

Lymphocytic hypophysitis

Young women Auto immune Prodromal illness VF defects Hormone deficiencies Bx- diagnostic

Meningioma

Hormones !!