PitNET/Adenomas—General Management Flashcards
Prolactinoma is the only pituitary tumor for which medical therapy (dopamine agonist) is the primary treatment modality (in certain cases). Which of the following statements is incorrect regarding hormone replacement therapy in patients with
pituitary hormone deficits?
● A. Indication of corticosteroids administration is inadequate cortisol reserve as demonstrated by failing a cosyntropin stimulation test (failure to achieve peak cortisol level of more than 18 μg/dL in response to cosyntropin)
● B. Physiologic replacement dose of cortisol is 20 mg PO every a.m. and 10 mg PO every 4 p.m. and stress doses may be needed
● C. Thyroid replacement is done before giving cortisol in patients with adrenal deficiency
● D. Hypothyroid patients frequently undergo surgery without adequate replacement with no untoward effect
● E. Testosterone replacement can promote tumor growth and should be waited until stabilization of tumor
C. Thyroid replacement is done before giving cortisol in patients with adrenal deficiency
What is the recommended treatment option for tumors secreting growth hormone or ACTH?
● A. An aggressive surgical approach is needed because the secretion product is harmful and effective medical adjuvants are lacking
● B. Growth hormone secreting tumors are pretreated with somatostatin analog therapy to reduce surgical risks
● C. In elderly patients or in tumors more than 4-cm diameter, the tumor is debulked transsphenoidally and then adjuvant radio- or chemotherapy is given
● D. In younger age and tumor size less than 4 cm, radical surgery to remove the whole tumor is done (may utilize cranio-orbito-zygomatic skull base approach)
● E. All of the above
E. All of the above
What is the primary treatment modality for nonfunctioning pituitary adenomas?
● A. Surgical resection
● B. Treatment with dopamine agonists (bromocriptine) and somatostatin analog (octreotide)
● C. Radiotherapy
● D. Only observation
● E. A combination of surgery, radiotherapy, and chemotherapy is needed in all cases
A. Surgical resection
All of the following are included in the surgical indications of nonfunctioning pituitary macroadenomas except?
● A. Tumors causing symptoms by mass effect, for example, visual field deficits
● B. Tumors with no symptoms of endocrine or visual field deficit but elevated chiasma never need surgical intervention at this point of time
● C. Acute or rapid visual or other neurologic deterioration
● D. To obtain tissue for pathological diagnosis
● E. Nelson’s syndrome
B. Tumors with no symptoms of endocrine or visual field deficit but elevated chiasma never need surgical intervention at this point of time
Prolactinomas are essentially the only pituitary adenomas for which medical therapy is sometimes the primary treatment modality. If prolactin levels are more than 500 ng/mL with no acute progression, an initial attempt at purely medical control should be made as the chances of normalizing prolactin surgically with preoperative level more than 500 ng/mL are very low, and these tumors may shrink dramatically with bromocriptine. What are the surgical indications in patients with prolactinomas?
● A. Prolactin levels less than 500 ng/mL in tumors that are not extensively invasive
● B. If there is no significant decrease in prolactin levels in 4 to 6 weeks after medical therapy
● C. If there is no decrease in visual deficits in 4 to 6 weeks after medical therapy
● D. No shrinkage in tumor size on MRI in 4 to 6 weeks after medical therapy
● E. All of the above
E. All of the above
Bromocriptine (Parlodel) is a drug that binds to dopamine receptors (dopamine agonist) on normal and tumor lactotrophs, inhibiting synthesis and secretion of prolactin and other cell processes resulting in decreased cell division and growth. It has side effects of nausea, headache, fatigue, orthostatic hypotension, psychosis, and vasospasm. Following statements regarding bromocriptine therapy are true except?
● A. It frequently reduces the tumor size in 6 to 8 weeks in 75% of patients with macroadenomas
● B. Parlodel is supplied in 2.5 mg scored tablets and 5 mg capsules
● C. Starting dose is 1.25 mg PO every hour, adding 2.5 mg/d as necessary and making dosage change every 2 to 4 weeks for microadenomas and every 3 to 4 days for macroadenomas causing mass effect
● D. To shrink large tumors or for very high prolactin levels, 7.5 mg TID for approximately 6 months is needed, then after that maintenance dose of 5 to 7.5 mg daily is given with initial recheck in about 4 weeks
● E. There is no improvement in tolerance of this medicine with bedtime dosing, with food, or slow dose escalation
E. There is no improvement in tolerance of this medicine with bedtime dosing, with food, or slow dose escalation
Cabergoline (Dostinex) is a selective D2 dopamine agonist with which control of prolactin and resumption of ovulatory cycles may be better than with bromocriptine. It has side effects of headache, GI symptoms, and cardiac valve disease while it is contraindicated in uncontrolled hypertension or in
eclampsia or preeclampsia patients. Which statement regarding its dosage is correct?
● A. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.25 mg every 4 weeks with typical dosage of 0.5 to 1 mg twice weekly
● B. It is started at 0.5 mg PO twice weekly and each dose is increased by 0.25 mg every 4 weeks with typical dosage of 0.5 to 1 mg twice weekly
● C. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.5 mg every 4 weeks with typical dosage of 0.5 to 1 mg twice weekly
● D. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.25 mg every 4 weeks with typical dosage of 5 to 10 mg twice weekly
● E. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.25 mg every 8 weeks with typical dosage of 0.5 to 1 mg twice weekly
A. It is started at 0.25 mg PO twice weekly and each dose is increased by 0.25 mg every 4 weeks with typical dosage of 0.5 to 1 mg twice weekly
If response to dopamine agonist therapy is satisfactory then treatment is given for 1 to 4 years. What is the indication of discontinuation of this drug?
● A. Decrease in size of prolactinoma to the point with no mass effect and prolactin levels to normal
● B. Microadenomas or macroadenomas that are no longer visible on MRI
● C. Prolactin levels less than 20 ng/mL
● D. Decreasing symptoms of mass effect or prolactin levels
● E. None of the above
B. Microadenomas or macroadenomas that are no longer visible on MRI
Asymptomatic elderly patients do not require surgery while for other patients, surgery (transsphenoidal) is currently the best initial therapy, providing more rapid reduction in GH levels and decompression. Which of the following statements is correct regarding medical management of acromegaly?
● A. Medical therapy is reserved for patients who are not cured by surgery or who cannot tolerate surgery
● B. Bromocriptine (Parlodel) decreases GH level to less than 10 ng/mL in 54% of cases and to less than 5 ng/mL in only 5% of cases while tumor shrinkage occurs only in 20% of cases
● C. Octreotide (Sandostatin) is a somatostatin analog that reduces GH levels in 71% of cases, reduces IGF 1 level in 93% of cases, while tumor volume is reduced in only 30% of cases
● D. Pegvisomant (Somavert) reduces IGF 1 levels in 97% of cases with treatment for more than 12 months and is given in case of failure of somatostatin therapy
● E. All of the above
E. All of the above
Which of the following is not included in the medical management of Cushing’s disease?
● A. If pituitary MRI shows a mass, then transsphenoidal surgery is indicated
● B. If pituitary MRI is negative and IPS sampling is positive, surgery is recommended to look for source and its removal
● C. If pituitary surgery is performed but biochemical cure could not be obtained, then re-exploration is never considered
● D. Stereotactic radiosurgery or medical therapy is indicated in case of failure of surgery to remove the whole tumor
● E. Adrenalectomy can also be considered in patients with failure of all options to remove the pituitary source
C. If pituitary surgery is performed but biochemical cure could not be obtained, then re-exploration is never considered
Corticosteroid replacement therapy is indicated when cosyntropin stimulation test fails to achieve a peak cortisol level of what?
● A. > 10 μg/dL
● B. > 12 μg/dL
● C. > 15 μg/dL
● D. > 18 μg/dL
● E. > 20 μg/dL
D. > 18 μg/dL
After cosyntropin test for cortisol reserves, hormone replacement therapy was advised. What is the physiologic replacement dose?
● A. 20 mg a.m., 20 mg 4 p.m.
● B. 20 mg a.m., 10 mg 4 p.m.
● C. 10 mg a.m., 10 mg 4 p.m.
● D. 10 mg a.m., 20 mg 4 p.m.
● E. 0.5 mg PO at 11 p.m.
B. 20 mg a.m., 10 mg 4 p.m.
What is the recommended treatment in an elderly patient or > 4-cm size tumor secreting GH/ACTH?
● A. Radical surgery via FTOZ
● B. Transsphenoidal debulking
● C. Medical treatment only
● D. SRS + somatostatin
● E. Pretreatment with somatostatin followed by transsphenoidal debulking
E. Pretreatment with somatostatin followed by transsphenoidal debulking
What is the typical maintenance dose of Parlodel for prolactinoma?
● A. 1.25 mg
● B. 2.5 to 15 mg
● C. 20 mg
● D. 30 mg in divided doses
● E. 50 mg/wk in divided doses
B. 2.5 to 15 mg
For medical management of acromegaly, Sandostatin long acting release (LAR) depot injections are given initially at 20 mg intramuscularly at what interval?
● A. Alternative days
● B. Twice weekly
● C. Fortnightly
● D. Every month
● E. After 6 months
D. Every month
