Pituitary

incidentaloma

So-ngern A.

Pituitary gland
Endocrine gland , weigh about 0.5 g Locate at middle cranial fossa , pituitary fossa Connected hypothalamus via pituitary stalk Consists of two components :
Anterior part : adenohypophysis Posterior part : neurohypophysis

Sella turcica

Pituitary gland
Anterior pituitary : adenohypophysis
Pars distalis Pars intermedia Pars tubalis

Posterior pituitary :neurohypophysis

Somatotropes : GH Lactotropes : PRL Thyrotropes : TSH Gonadotropes : LH ,FSH Corticotropes : ACTH Chromophobes : minimal or no hormonal content. Melanocyte-stimulating hormone

Adenohypophysis

Neurohypophysis
Pars nervosa Largely unmyelinated axons from hypothalamic neurosecretory neurons Cell bodies in the paraventricular and supraoptic nuclei of the hypothalamus Oxytocin , Antidiuretic Hormone

Pituitary incidentaloma

DeniGon
Previously un suspected pituitary lesion that is discovered on an imaging study performed for an unrelated reason . Imaging study not done for related lesion : visual loss , clinical sign and symptom of hypopituitarism or hormone excess.

 Microadenoma : < 1 cm in size Macroadenoma : >/= 1 cm in size

 EGology
91 % were pituitary adenomas and about 9 % were nonpituitary in origin :craniopharyngioma and Rathkes cleU cysts Vary case series : Most pituiatary adenoma Immunohistochem : negaGve 50% , gonadotroph 15% , GH 10% , plurihormonal 20% CysGc lesions : most Rathkes cleU cysts ,craniopharyngioma Non cysGc lesions : nearly all pituitary adenoma ,most clinically nonfuncGoning pituitary adenomas are gonadotrope origin

Epidemiology
EsGmated based on autopsy , underwent CT or MRI with other reason Autopsy series : average 10 .6 % of adenoma CT : microincidentaloma 4-20 % ,macroincidentaloma 0.2 % MRI : microincidentaloma 10-38 % , macroincidentaloma 0.16 % Pooled data 10 series : 45% macro-

IniGal evaluaGon
RecommendaGons
1.1 We recommend that paGents presenGng with a pituitary incidentaloma undergo a complete history and physical examinaGon that includes evaluaGons for evidence of hypopituitarism and a hormone hypersecreGon syndrome. PaGents with evidence of either of these condiGons should undergo an appropriately directed biochemical evaluaGon

IniGal evaluaGon
1.1.1 We recommend that all paGents with a pituitary incidentaloma, including those without symptoms, undergo clinical and laboratory evaluaGons for hormone hypersecreGon 1.1.2 We recommend that paGents with a pituitary incidentaloma with or without symptoms also undergo clinical and laboratory evaluaGons for hypopituitarism 1.1.3 We recommend that all paGents presenGng with a pituitary incidentaloma abu`ng the opGc nerves or chiasm on magneGc resonance imaging (MRI) undergo a formal visual eld (VF) examinaGon 1.1.4Werecommend that all paGents have aMRIscan, if possible, to evaluate the pituitary incidentaloma [if the incidentaloma was iniGally only diagnosed by computed tomography (CT) scan] to befer delineate the nature and extent of the incidentaloma

IniGal evaluaGon
1.1.1 We recommend that all pa1ents with a pituitary incidentaloma, including those without symptoms, undergo clinical and laboratory evalua1ons for hormone hypersecre1on

1.1.2 We recommend that paGents with a pituitary incidentaloma with or without symptoms also undergo clinical and laboratory evaluaGons for hypopituitarism 1.1.3 We recommend that all paGents presenGng with a pituitary incidentaloma abu`ng the opGc nerves or chiasm on magneGc resonance imaging (MRI) undergo a formal visual eld (VF) examinaGon 1.1.4Werecommend that all paGents have aMRIscan, if possible, to evaluate the pituitary incidentaloma [if the incidentaloma was iniGally only diagnosed by computed tomography (CT) scan] to befer delineate the nature and extent of the incidentaloma

IniGal evaluaGon
IdenGfy : Hormone hypersecreGon , hypopituitarism , mass eect EvaluaGon hypersecreGon: PRL , GH , ACTH Data on retrospecGve study of hormone secreGon :
in Belgian : 0.542/1000 In Finland : 0.04/1000

IniGal evaluaGon
ProlacGn level : low ---- > diluted serum (Hook eect) HyperprolacGnemia : prolacGnoma , compression pituitary stalk (mild to moderate elevaGons) Trial of Dopamine agonists therapy

IniGal evaluaGon
Silent somatotroph-secreGng tumor :rare 1/11 macroincidentaloma were found to have elevaGon of IGF-1 :subclinical GH excess IniGal treatment for GH-secreGng tumor can be cured surgically Screening with IGF-1 is warranted If IGF1 elevated ,further evaluaGon for GH is suggest

IniGal evaluaGon
No systemic screening of incidentaloma for subclinical glucocorGcoid excess has been report Consider corGcotroph secreGng tumor when clinically suspected : Hyperpigment,DM,HT,obesity,osteoporosis ,Hi rsuGsm,other Some expert opinion suggest to measure ACTH level

IniGal evaluaGon
1.1.1 We recommend that all paGents with a pituitary incidentaloma, including those without symptoms, undergo clinical and laboratory evaluaGons for hormone hypersecreGon

1.1.2 We recommend that pa1ents with a pituitary incidentaloma with or without symptoms also undergo clinical and laboratory evalua1ons for hypopituitarism

1.1.3 We recommend that all paGents presenGng with a pituitary incidentaloma abu`ng the opGc nerves or chiasm on magneGc resonance imaging (MRI) undergo a formal visual eld (VF) examinaGon 1.1.4Werecommend that all paGents have aMRIscan, if possible, to evaluate the pituitary incidentaloma [if the incidentaloma was iniGally only diagnosed by computed tomography (CT) scan] to befer delineate the nature and extent of the incidentaloma

IniGal evaluaGon
Small two observaGonal studies :hypopituitarism 7/66 and 19/46 paGent Decit of Gonadotropins : up to 30 % Decit of ACTH : up to 18% Decit of TSH : up to 28 % Decit of GH : up to 8 %

IniGal evaluaGon
Size of mass may also be relevant to risk for hypopituitarism Favor rouGne screening for hypopituitarism in macroincidentaloma , larger microincidentaloma (6-9 mm ) No specic data on prevalence of hypopituitarism in larger or smaller incidentaloma Recent data hypopituitarism can occur in microincidentaloma

IniGal evaluaGon
Some expert screening : fT4 ,morning corGsol ,testosterone Some expert screening :TSH,LH , FSH ,LH ,IGF-I If baseline tesGng suggests hypopituitarism, further sGmulaGon tests should be performed

IniGal evaluaGon
1.1.1 We recommend that all paGents with a pituitary incidentaloma, including those without symptoms, undergo clinical and laboratory evaluaGons for hormone hypersecreGon 1.1.2 We recommend that paGents with a pituitary incidentaloma with or without symptoms also undergo clinical and laboratory evaluaGons for hypopituitarism

1.1.3 We recommend that all pa1ents presen1ng with a pituitary incidentaloma abu>ng the op1c nerves or chiasm on magne1c resonance imaging (MRI) undergo a formal visual eld (VF) examina1on
1.1.4Werecommend that all paGents have aMRIscan, if possible, to evaluate the pituitary incidentaloma [if the incidentaloma was iniGally only diagnosed by computed tomography (CT) scan] to befer delineate the nature and extent of the incidentaloma

IniGal evaluaGon
Baseline VF tesGng for all paGent Even without visual symptom In one study : 5 % unrecognized VF abnormality

IniGal evaluaGon
1.1.1 We recommend that all paGents with a pituitary incidentaloma, including those without symptoms, undergo clinical and laboratory evaluaGons for hormone hypersecreGon 1.1.2 We recommend that paGents with a pituitary incidentaloma with or without symptoms also undergo clinical and laboratory evaluaGons for hypopituitarism 1.1.3 We recommend that all paGents presenGng with a pituitary incidentaloma abu`ng the opGc nerves or chiasm on magneGc resonance imaging (MRI) undergo a formal visual eld (VF) examinaGon

1.1.4Werecommend that all pa1ents have aMRIscan, if possible, to evaluate the pituitary incidentaloma [if the incidentaloma was ini1ally only diagnosed by computed tomography (CT) scan] to beMer delineate the nature and extent of the incidentaloma

IniGal evaluaGon
MRI : pituitary protocols +/- Gd administraGon Fine cuts thorough the sella

IndicaGon for surgery aUer evaluGon

IndicaGon for surgery aUer evaluGon

3.1 We recommend that paGents with a pituitary incidentaloma be referred for surgery if they have the following A VF decit due to the lesion Loss of endocrinological funcGon Other visual abnormaliGes, such as ophthalmoplegia or neurological compromise due to compression by the lesion. Lesion abu`ng or compressing the opGc nerves or chiasm on MRI Pituitary apoplexy with visual disturbance. HypersecreGng tumors other than prolacGnomas

Follow up tesGng
RecommendaGon

2.1 PaGents with incidentalomas who do not meet criteria for surgical removal of the tumor should receive nonsurgical follow-up with clinical assessments and the following tests: 2.1.1 MRI scan of the pituitary 6 months aUer the iniGal scan if the incidentaloma is a macroincidentaloma and 1 yr aUer the iniGal scan if it is a microincidentaloma In paGents whose incidentaloma does not change in size, we suggest repeaGng theMRIevery year for macroincidentalomas and every 12 yr in microincidentalomas for the following 3 yr, and gradually less frequently thereaUer

Follow up tesGng

2.1.2VF tesGng in paGents with a pituitary incidentaloma that enlarges to abut or compress the opGc nerves or chiasm on a follow-up imaging study . We suggest that clinicians do not need to test VF in paGents whose incidentalomas are not close to the chiasm and who have no new symptoms and are being followed closely by MRI 2.1.3 Clinical and biochemical evaluaGons for hypopituitarism 6 months aUer the iniGal tesGng and yearly thereaUer in paGents with a pituitary macroincidentaloma, although typically hypopituitarism develops with the nding of an increase in size of the incidentaloma We suggest that clinicians do not need to test for hypopituitarism in paGents with pituitary microincidentalomas whose clinical picture, history, and MRI do not change over Gme

 Most incidentaloma grow slowly ,some do enlarged but true proliferaGve nature is unknown If no growth is detected ,interval of MRI can be increased Enlarged of incidentaloma especially macroincidentaloma ----- > VF abnormality Hypopituiarism : macroadenoma (apoplexy),rare in microincidentaloma

Follow up tesGng
Recommenda)on 2.2 PaGents who develop any signs or symptoms potenGally related to the incidentaloma or who show an increasein size of the incidentaloma onMRIshould undergo more frequent or detailed evaluaGons as indicated clinically

IndicaGon for surgery aUer Follow up

3.2 We suggest that surgery be considered for paGents with a pituitary incidentaloma if they have the following Clinically signicant growth of the pituitary incidentaloma. . A lesion close to the opGc chiasm and a plan to become pregnant. Unremi`ng headache.

 Signicant growth on follow up risk to vision Depend on age , surgeon experGse , risk to Surgery Some surgical series show hypopituitarism can improve with surgery

Medical therapy
Not systemaGcally study Dopamine agonist : hyperprolacGnemia Somatostain analogue

Thank you for your afenGon Thanks you all for your quesGons

P.S. Tomorrow .. Dont miss