Anterior Pituitary Disorders: Acromegaly and Hypopituitarism

Question 1

What can happen if you have a Pituitary Tumour? (Gland too large?)

Answer 1

Presses on adjacent structures

Question 2

What can happen if you have a Pituitary Tumour? (to hormones…) (2 things)

Answer 2

Excess hormone secretion Deficient hormone secretion

Question 3

How can deficient hormone secretion happen?

Answer 3

post surgery or radiotherapy pressure on normal cells from tumour

Question 4

How do we tackle a Pituitary Problem? (3 things)

Answer 4

Take the History Examine the patient Do relevant special investigations

Question 5

Most pituitary tumours are …

Answer 5

benign

Question 6

How do we tackle a Pituitary Problem?

Answer 6

• Discuss management with the multidisciplinary pituitary team and the person with the problem - Decide on best personalised treatment (surgery, radiotherapy, medication, watch and wait)

Question 7

What are 4 personalised treatment options for a pituitary problem?

Answer 7

Surgery Radiotherapy Medication Watch and wait

Question 8

Pituitary History - check 6 things

Answer 8

Presenting Complaint Past History Family History Personal History Gynaecological History Systemic Inquiry

Question 9

Examination for Pituitary

Answer 9

ENT - biopsy of nasal mass Histology - Pituitary Tumour

Question 10

What is this showing?

What is it for?

What test is it?

Answer 10

phoropter - used during an eye examination to measure refractive error and determine eyeglass prescriptions. Typically, the patient sits behind the phoropter and looks through it at an eye chart

Goldman vision test

Question 11

What is the most common way to remove a pituitary tumour?

Answer 11

Transsphenoidal surgery.

Transsphenoidalmeans that the surgery is done through the sphenoid sinus, a hollow space in the skull behind the nasal passages and below the brain. The back wall of the sinus covers the pituitary gland

Question 12

What is Transsphenoidal hypophysectomy ?

Answer 12

Transsphenoidal hypophysectomy is an effective surgical technique for the removal of pituitary and other intrasellar tumors with minimal morbidity and hospital sta

Question 13

What is Bitemporal hemianopsia (or Bitemporal hemianopia) ?

Answer 13

The medical description of a type of partial blindness where vision is missing in the outer half of both the right and left visual field.

Question 14

What is a Pituitary adenoma?

Answer 14

They are benign (not cancerous) slow-growing tumors in the pituitary gland.

Question 15

pPost Op Progress - What Clinical Problems?

Answer 15

Polyuria due to Diabetes Insipidus

Question 16

What is prescribed for polyuria as a result of Diabetes Insipidus?

Answer 16

DDAVP (desmopressin acetate tablets)

it is an antidiuretic replacement therapy

Question 17

Biochemistry after surgery for pituitary tumour - what can be an issue?

Answer 17

Low Thyroxine levels

Question 18

What is prescribed for low thyroxine levels?

Answer 18

Levothyroxine

Question 19

What test is perfomed to check if your adrenal glands are producing enough cortisol? (after surgery)

Answer 19

Short synacthen test checks if your adrenal glands are producing enough steroid hormone called cortisol.

Question 20

If you have a poor cortisol response, what happens?

Answer 20

hydrocortisone

Question 21

Estrogen Deficiency Symptoms after surgery.

What do you do?

Answer 21

Estrogel prescribed

mirena intrauterine system

Question 22

What is the GHRH Arginine stimulation test?

Answer 22

GHRH stimulates growth hormone production by the pituitary gland, which is a small gland beneath the brain. You will also be given an injection of arginine, a natural amino acid (the building blocks of proteins) that also stimulates growth hormone release.

This test is used to assess your body’s ability to make growth hormone

Question 23

Why is the GHRH Arginine Stimulation test done in adults Post op?

Answer 23

In adults, a lack of growth hormone sometimes reduces their quality of life. It may also affect their body composition (the amounts of fat and muscle in the body), with a tendency to have more fat and less muscle.

Question 24

What does lack of growth hormone do in adults?

Answer 24

Reduce quality of life

Question 25

After the operation, what will you have? (3 things)

Answer 25

Follow up MRIS

Annual Clinic visits - discuss medications, biochemical testing, discussion with specialist nurse

Check visual fields

Question 26

Skin Tags in Acromegaly, what does it increse risk of?

Answer 26

Colon Cancer

Question 27

What is Acromegaly?

Answer 27

Acromegaly is a hormonal disorder that develops when your pituitary gland produces too much growth hormone during adulthood.

Question 28

To test if too much growth hormone and confirm diagnosis what do you do?

Answer 28

IFG1. The insulin-like growth factor-1 (IGF-1) test is an indirect measure of the average amount of growth hormone (GH) being produced by the body

Glucose tolerance test + Growth hormones

Question 29

Glucose tolerance test + Growth hormones, what results do you expect and what do you see in acromegaly?

Answer 29

glucose should supress growth hormone

in acromegaly, failure to supress the growth hormone

Question 30

Answer 30

Yes - tumour is present

Question 31

Possible further work up for acromegaly - tests normal

Answer 31

Vision - visual fields (Goldmans)

Cardiac (ECG, Echocardiogram)

Lung Function / Sleep Study (e.g. obstructive sleep apnoea)

Colonoscopy

Question 32

What do you check levels of to screen for pituitary hormone deficiency in acromegaly?

Answer 32

Cortisol

Thryoxine

FSH / LH (not done in menstruating)

Arginine Vasopressin (if symptoms of diabetes insipidus or abnormal serum sodium)

Question 33

Discharge from hospital after surgery for acromegaly, what 3 things must be done?

Answer 33

Information

Hydrocortisone replacement

Pituitary clinic appointment

Question 34

Post Op Tests for Acromegaly

Answer 34

Assess growth hormone

Asssess other hormones (free thyroxine, synacthen test for cortisol levelts)

E and Urea

Prolactin

Question 35

Do we need to normalise the growth hormone?

Answer 35

Yes - increases survival

Question 36

How to make the IFG1 normal…

surgery? yes or no

medications? yes or no

radiotherapy? yes or no

Answer 36

Further surgery? no - no safe surgical target

medications - yes

dopamine agonist (Carbergoline)

long acting somatostatin analogue (sandostatin LAR)

GH receptor antagonist (Pegvisomant - very expensive, not given often)

Radiotherapy - yes - to neurooncologist

Question 37

Why is Pegvisomant (GH receptor antagonist) not prescribed often to make the IGF1 normal?

Answer 37

very expensive

Question 38

What constitutes a pituitary service?

Answer 38

Biochemists with good assays

Clinical nurse specialists

Endocrinologists

Histopathologists

MDT co-ordinator

Medical Secretaries

Neurooncologists

Neuroradiologists

Neurosurgeons

The person with the problem

Question 39

Acromegaly change what features?

Answer 39

facial features

Question 40

What is this showing?

Answer 40

Prominent orbital and occipital ridging

Question 41

Clinical manifestations of acromegaly: the hands?

Answer 41

Increased size of hands and feet - rings tight, carpal tunnel

Question 42

What is this showing?

Answer 42

Increased size of feet in acromegaly

Question 43

Clinical manifestations of acromegaly - mouth/jaw

Answer 43

Overgroth of mandible

Prognathism

Question 45

What other hormone levels do you check in acromegaly?

Answer 45

Prolactin levels

Serum Calcium

Question 46

Discussion regarding diagnosis and management of acromegaly.

Where do you visit?

whos involved?

what surgery?

Answer 46

Combined Pituitary clinic

• advanced pituitary nurse
• patient representative
• pituitary surgeon

= transsphenoidal hypophysectomy - surgery

Question 47

Post op visit to CPC - what questions ? (Acromegaly)

Answer 47

General wellbeing

change in physical signs

vision

sense of smell

urine flow? (diabetes insipidus)

view histology (pituitary adenoma?)

post op tests