Pituitary Incidentaloma An Initial Assessment

Endocrinology

Case Report ID/CC

50 year old female w/ PMH: AIDS (CD4 81) non compliant with HAART, DM2 (diet controlled) admitted for acute onset AMS. Brought in by son who reports a history of confusion x 24 hours. Pt also reports ongoing nausea, vomiting and headaches x 1 year (pattern unchanged).

Case Report Physical Exam

Vitals in ED: BP 103/73 HR 130 RR 18 T98F O2

99% - Prior to being seen by Endo 1 temperature of 100.3F

Pertinents of PE:

-Difficulty following commands -Decreased Right peripheral vision

Case Report Imaging

CT scan: _____ MRI: 22 mm mass with edema DDX: Benign vs

Malignant vs Infectious given history of AIDS

Case Report Labs

Prolactin elevated at 66.80

ACTH <5
Cortisol 0.74

Case Report Assessment

Consults:
Neurology Neurosurgery Infectious Disease Endocrinology

Pituitary Incidentaloma?
a previously unsuspected pituitary lesion that is discovered on an imaging study Macroincidentaloma 1 cm Microincidentaloma 1 cm Functional vs nonfunctional

Differential Diagnosis of a sellar mass

Craniopharyngioma Meningioma carotid aneurysm Lymphoma Infectious Metastasis Chordoma Stalk lesion: germ cell

(Toxoplasmosis) Abcess prolactinoma

tumors, Langerhans granulomatosis (histiocytosis X), lymphocytic hypophysitis, and sarcoidosis.

Clinical Presentations of Pituitary Tumors

1.Functioning tumors 1. Prolactinoma 2. Acromegaly 3. Cushing disease 4. Hyperthyroidism 2.Mass effects 1. Hypopituitarism 2. i. Adrenal insufficiencyii. Hypothyroidism iii. Hypogonadism iv. Growth hormone deficiency 3. Headaches 4. Neurological deficits i. Visual changes: decreased visual acuity, visual field deficits, ophthalmoplegia ii. Ptosis iii. Facial sensory syndromes 5. Cerebrospinal fluid leakage +/ meningitis 6. Nasopharyngeal obstruction 3.Pituitary apoplexy 4.Asymptomatic

Diagnosis
detailed history and physical examination, MRI

scan, and pituitary hormone testing A detailed visual field examination should be included in the evaluation of any potential pituitary mass evaluation of anterior pituitary hormones:
prolactin, 8:00 am cortisol, free thyroxine (T4), TSH,

IGF-I, GH, LH, FSH, and testosterone (in men).

MEN-1?

Medical Therapy
for apoplexy: rapid corticosteroid administration

surgical decompression for prolactinoma: dopamine agonists (e.g. Cabergoline, bromocriptine) for Cushing's: serotonin antagonist (cyproheptadine), inhibition of cortisol production (ketoconazole) for acromegaly: somatortati.n analogue (octreotide) bromocriptine endocrine replacement therapy

Follow up
Clinical and biochemical testing for

hypopituitarism 6 months after initial testing and 1 year after for MACRO No need to continue biochemical testing for hypopit in MICRO incases where the MRI does not change over time Pts who develop signs/sxs of increasing size should have more frequent MRI evaluations

Indications for surgery:

presence of a VF due to

the lesion
Other deficits of the

visual field such as opthalmoplegia, due to compression

Compression of the optic

chiasm or optic nerves as seen by the MRI Important in women planning to become pregnant
Hypersecreting tumors

other than prolactinomas

No size cut off, clinically

significant growth
Headaches (low quality

of evidence)

Back to our patient

References
Melmed S, Jameson JL. Chapter 339. Disorders of the Anterior Pituitary

and Hypothalamus. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com/content.aspx?aID=9139876. Accessed March 20, 2013.
Pituitary Incidentaloma: An Endocrine Society Clinical Practise Guidline.

Journal of Clinical Endocrinology and Metabolism, April 2011, 96(4):894904