Pituitary and Adrenals Flashcards
1
Q
list homones secreted by the
adrenal cortex
adrenal medulla
A
Cortext
- glucocorticoids - cortisol
- Mineralocorticoids - Aldosterone
- Androgens - testosterone
Medulla
- Epinephrine (80%)
- Norepinephrine (20%),
- Dopamine catecholamines = Chromaffin cells
2
Q
fucntions of cortisol
A
•released at diurnal basal rate with bursts d/t stress response regulated by Anterior pituitary & ACTH via negative feedback loop (hydrocortisone is rx of cortisol)
- Mobilize sugar
- Suppress immune system
- Stimulate Gluconeogenesis = Increase in glucose metabolism and glycogen formation, especially in the liver
- anti-inflammtory effects
3
Q
Mineralocorticoids (aldosterone)- Production in the Zona ______
Androgens - Production in the Zona_____
A
Mineralocorticoids (aldosterone)- Production in the Zona Glomerulosa
Androgens - Production in the Zona Reticularis
4
Q
Adrenal medulla tumor - produce, store, secrete catecholamines
Extra-adrenal originating in ANS
MEN2a/2B
A
Pheochromocytoma
5
Q
si/sx of phenochromocytoma
A
Recurrent episodes that occur suddenly:
- HTN(most common) +/- tachycardia
- HA
- Diaphoresis
- Palpitations
6
Q
dx phenochromocytoma
A
24-hour urine metanephrine,
- VMA (vanillylmandelic acid),
- total catecholamines, creatinine
Abnormal THEN image
Abdominal CT/MRI – mRI preferred
7
Q
dx phenochromocytoma
A
Surgical resection – Laparoscopic if <8mm preferred
Alpha-adrenergic blockade– 10-14 days
Beta adrenergic blockade 2 days prior to surgical resection to prevent intra-operative HTN crisis to prevent intra-operative HTN crisis
- Phenoxybenzamine HCl (Dibenzyline)
- Propranalol or Nadolol
8
Q
2 etiologys of Hyperaldosteronism
A
Primary (Conn’s syndrome)
- Adrenal adenoma
- Bilat cortical nodular hyperplasia - Idiopathic hyperaldosteronism
- Hypersecretion Aldosterone = Renal distal tubular exchange of Na+ K+ and H+ secretion
Secondary: appropriate ↑ aldosterone production d/t RAAS –> low flow through JGA
- Edema (nephrotic syndrome, cirrhosis, CHF)
- Assoc w/ HTN –> Renin overproduction –> ↓ in renal blood flow (ie RAS Renin producing tumor)
9
Q
si/sx of Hyperaldosteronism
A
- Diastolic HTN so HIGH - HA
- Hypokalemia == muscle weakness/fatigue
- Hypernatremia
- Metabolic alkalosis –> Excess H+ secretion = ↑HCO3
10
Q
dx of primary vs secondary Hyperaldosteronism
A
Primary - DEC plasma renin
Secondary - INC plasma Renin
11
Q
dx Hyperaldosteronism
A
Renin hyposecretion w/ volume depletion – STILL ↓renin
- SHOULD - ↑ w/ vol depletion
Failed aldosterone suppression w/ volume expansion – STILL ↑aldosterone
- SHOULD ↓ renin and aldosterone
ECG (flat T-waves, ST depression, U waves)
Hypokalemia / Hypernatremia
CXR
Metabolic alkalosis (↑ HCO3) – Loss of H+ in urine and Shift H+ into cells
12
Q
tx hyperaldosteronisms
A
Adenoma – Surgical excision
Hyperplasia
- Diet Na+ restriction
- Spironolactone
13
Q
criteria for dx of Hyperaldosteronism
A
Diastolic HTN without edema
↓Secretion of renin when stimulated - Stimulate w/ volume depletion
↑Secretion of aldosterone that cannot suppress - Try to suppress w/ volume expansion
No diuretic use
14
Q
Cushings endogogenous vs exogenous causes
A
Endogenous - ↑ cortisol from adrenal cortex
- Pituitary overproduction ACTH (80%) - Cushing’s
- ↓ TSH, FSH, LH, GH, prolactin, and if lrg ?vasopressin(ADH)
- Adrenal adenoma
- Small cell lung ca.
- Thyroid neoplasm
- Pancreatic neoplasm
Exogenous (most common)
- Chronic steroid use —> HPA suppression
- prednisone, decadron, hydrocortisone
15
Q
si/sx of cushings
A
- Weight gain – central adiposity
- Skin Δ (purple striae, buffalo hump, moon face)
- Proximal muscle weakness
- Neuropsych (depression, cognitive dysfunction)
- DM ( infections, poor wound healing)
- Sexual dysfunction
- Hyperpigmented “healthy glow”
16
Q
dx cushings
A
Stepwise Approach
24-hour urine cortisol >300 diagnostic
1mg Dexamethasone suppression test
- Nl < 5 mcg/dL
CRH/Dex suppression test – >50 is diagnostic
ACTH (independent vs. dependent)
- ACTH level (should be low normally in early afternoon 4p)
- ACTH high? = cranial MRI & high dose dex-suppression test
- ACTH nl or low? = Abd CT/MRI
17
Q
tx cushings
A
Surgical resection (transphenoidal resection) +/- radiation
- Adrenalectomy w/ failed pituitary resection
Medical Mgt:if surgery fails
Ketoconazole: ↓ cortisol production
- Side effects Headache, sedation, nausea, decreased libido, impotence, gynecomastia, elevated LFT’s, irregular menses
Metyrapone: Blocks final step of cortisol synthesis
- Used w/ ketoconazole should it fail to be fully effective
18
Q
Adrenal insufficency (Addisons) shows an overall decrease of ???
A
↓aldosterone
↓cortisol
19
Q
list primary and secondary addisons (adrenal insufficency)
A
Primary – destruction of adrenal cortex
- Anatomic destruction or metabolic failure of the adrenal cortex INCREASE ACTH
Secondary
- Suppression or disease of the HPA axis DECREASE ACTH
- exogenous steroids
20
Q
si/sx of primary addisons (adrenal insuff)
A
- Weakness/fatigue (initially asthenia)
- Dehydration–> hypotension/orthostasis
- Weight loss/anorexia
• Hyperpigmentation
- N/V/D
- Abd pain
21
Q
si/sx of secondary addisons (adrenal insuff)
A
- Weakness/fatigue (initially asthenia)
- Dehydration –> hypotension/orthostasis
- Weight loss/anorexia
- N/V/D
- Abd pain
(NO hyperpigmentation)
Panhypopituitarism
22
Q
dx of addisons (adrenal insuff)
A
Cortosyn stimulation test (Cosyntropin)
- ACTH stimulation test
- Tests functional ability of adrenal cortex to synthesize cortisol
Hyponatremia / Hyperkalemia
↑urine Na, BUN/Cr
ECG (hyperkalemia - TWiFP)
Abd CT
- Calcified adrenals- Tb, histoplasmosis
- Atrophic adrenals- Idiopathic autoimmune
23
Q
Tx of addisons (adrenal insuff)
A
Glucocorticoid - Hydrocortisone +
Mineralocorticoid - Fludrocortisone
Ample sodium intake
24
Q
define adrenal crisis
A
complciation od addisons
Rapid/Severe adrenal collapse
exacerbation of chronic adrenal insufficiency –> Stress precipitant OR Sudden withdrawal/ noncompliance of chronic steroid
Acute hemorrhagic destruction of bilateral adrenal glands
- Waterhouse-Friderichsen syndrome –> Pseudomonas, Meningococcemia septicemia
Anticoagulation
Pregnancy complication
25
dx of adrenal criss
Hypoglycemia
Hyponatremia
Hyperkalemia
metabolic acidosis
26
tx adrenal criss
Treat underlying cause
IVF resuscitation - 2L NS followed by D51/2NS
Stress dose hydrocortisone or Dexamethasone
Sx management (ex. vasopressors)
27
Stressors for adrenal crisis Infection
need to ↑ steroid doses, usually do not
* Trauma
* Surgery
* Vomiting/Diarrhea
* Emotional turmoil
28
adrenal carcinoma classifications of MEN1
**3Ps**
**Hyperparathyroid** (most common)
* Hyperplasia or adenoma
* Symptom's hypercalcemia
* Elevated ionized serum Ca++ and PTH normal
**Pancreatic islets**
* Occurs in parallel w/ hyperparathyroid
* Hyperplasia, adenoma, or carcinoma
* Increase production pancreatic islet cell hormones
**Pituitary**
* Prolactin = prolactinoma (most common)
* Growth hormone = acromegaly
* ACTH = Cushing's disease
29
most common P from MEN 1
most common pituitary presentation
**Hyperparathyroid (most common P)**
**Pituitary**: Prolactin = _prolactinoma_ (most common)
30
tx of MEN 1 & MEN 2a
**Surgical resection** (often multiple required)
* Transphenoidal approach w/ pituitary tumors (often difficult b/c multicentric)
* Parathyroidectomy + thyroidectomy
* Subtotal or total pancreatectomy
**Medical management**
* Dopamine agonists (bromocriptine) for prolactinoma
* H2 receptor antagonist, PPI for ZES
31
Dx of MEN 1 and MEN 2a
Hormone/electrolyte assays
* Gastrin level & Glucagon level
* Ca++ and PTH levels
* Hypokalemia, hypochloremia, metabolic acidosis
* Growth hormone
* Prolactin level
* ACTH level
Provocative testing
* Secretin stimulation test w/ gastrin levels
* Short or 72hr fast w/ serum insulin & C-peptide levels
* Dexamethasone suppression test
Radiologic testing --\> CT/MRI
* Annual screening basal and post-prandial pancreatic polypeptides
32
etiology of MEN 2a
most common manifestation?
MTC, Pheo (50%)
**Hyperparathyroidism (15-20%) --\> Most common manifestation**
MTC typically develops in childhood
and \>1cm tumor assoc w/ local and distant metastasis
33
etiology MEN 2b
* MTC, Pheo (\>50%), mucosal neuromas, marfanoid body habitus
* Childhood marfanoid morphology and mucosal neuromas most distinctive
**•MTC develops earlier and is more aggressive than 2a**
34
si/sx of MEN 2b
Angiofibroma skin findings – on nares
35
dx MEN 2b
* Genetic testing
* Annual 24-hour urine - metanephrine/VMA
* Serum Ca++ - PTH q 2-3yrs
36
Tx MEN 2b
**Thyroidectomy w/ central LN dissection** -\> mortality prevented
**Pheo** = unilateral vs bilateral resection?
**Hyperparathyroidism**
* Excise 3 ½ w/ remnant in neck
* Full excision w/ remnant implanted back in forearm
37
location of pituitary
Pea sized gland at base of brain
* below _hypothalamus_ within the sella turcica
* inferior to _optic chiasm_
* Laterally by c_avernous sinu_s
* Receives blood from ophthalmic veins and cerebral veins
* Cranial nerves travel through (III, IV, V1, V2, VI)
* Internal carotid arteries
38
function of anterior vs posterior pituitrayr
**Anterior Pituitary Gland/Lobe (adenohypophysis)**
* Synthesizes and secretes hormones (6)
* Controlled by hormones from the hypothalamus
**Posterior Pituitary Gland/Lobe (neurohypophysis)**
* Does NOT make hormones
* Stores and secretes hormones (2) synthesized in the hypothalamus
* Controlled by nerve impulses from the hypothalamus
39
ant pit hormines
post pit hormones
**Anterior**: GH (FSH, LH, prolactin, TSH, ACTH)
**Posterior**: ADH (oxytocin, vasopressin)
40
ADH --- ____ hydration
ADH - ADDS hydration
41
Anterior pit dz
Posterior pit dz
Ant : Dwarfism
Posterior: DI, Psychogenic polydypsia, SIADH
42
define dwarfism and 2 types
Adult ≤ 4’10”
**Disproportionate Dwarfism**
* Some average-sized parts of the body and some shorter than average parts of the body
* _Achondroplasia_ (70% of all dwarfism)à Disproportionately short limbs, average sized torso, disproportionately large head
**Proportionate Dwarfism**
* Short stature condition with arms, legs, trunk and head being in same proportion (relative size to one another) as in an average-sized person
* _Pituitary Dwarfism_
43
dx dwarfism
Provocative GH Testing-
* GH is low even with provocation of pituitary gland
↓ IGF-1
44
tx dwarfism
Recombinant Human Growth Hormone à Somatotropin injections daily
45
Dwarfism
DI
PP
Sheehan synd
SIADH
For conditions idtentify if they are due to
Posterior / anterior pit
hypo / hyperactivity of pit ??
hormones involved
46
defien diabetes insipidus
DEC ADH
Condition of decreased release of ADH causing large volumes of dilute urine
47
2 types of DI
most common causes of each
**Central (neurogenic)**: Absent or ↓ synthesis or secretion of ADH
* _Idiopathic – most common cause_
* Hypothalamus-pituitary head trauma, neurosurgery, tumors
* Vascular (Sheehan Syndrome)
* Infection (meningitis, encephalitis, TB)
* Congenital structural malformations or genetic
**Nephrogenic** : Kidneys are unresponsive to ADH secreted
* _Lithium toxicity- most common cause_
* Hypercalcemia
* Acute or CKD- Polycystic kidney disease, pyelonephritis, renal amyloidosis
* Genetic
48
Si/sx of DI
**Polyuria** (No/little ADH or Kidneys unresponsive to ADH)
* Neurogenic- varies based on degree of ADH production/secretion
* Nephrogenic: Adults (\>3L/day), Children (\>2L/m2)
**Nocturia** (Enuresis in children)
Fatigue/sleepiness, irritability
**Polydipsia** (Intense thirst from hyperNa and hyperosmolality)
49
dx difference b/w central and nephrogenic DI
_Central_ - Primary issue with ADH --\> **↓ADH**
_Nephrogenic_ - No issue with ADH --\> **↑ADH**
50
dx DI
**Cranial MRI** – central (Hyperintensities, pituitary stalk thickening)
**BMP ( INC serum osm)**
Hypernatremia / Hypercalcemia / Hypokalemia
**_DEC urine osm, urine Na_**
**_INC ser osms_**
**Water deprivation/ADH stimulation test** - Used to differentiate Central DI from Nephrogenic DI from psychogenic polydipsia
51
tx DI
central
nephrogenic
Lithium toxicity
**Central :**
* Desmopressin - first line
* Alt Chlorpropamide
**Nephrogenic**
* _HCTZ_ –Blocks Na reabsorption in kidneys
* _Indomethacin_ - Inhibits prostaglandin synthesis (prostaglandins are ADH antagonists)
**Lithium Toxicity** - Amiloride
* Blocks lithium from entering cells
52
define Psychogenic polydipsia
INC ADH
Excess intake of fluids not associated with thirst
Polydipsia \> 5 L/day
53
who gets Psychogenic polydipsia
most commonly seen w/ schizophrenia
other psych disorders
54
si/sx of Psychogenic polydipsia
* **Polyuria**
* Polydipsia
* Xerostomia
* **Hyponatremia** (ex. HA, muscle weakness, twitching, AMS, vomiting)
**Severe hyponatremia** --\> cardiac arrest, coma, cerebral edema
55
Dx Psychogenic polydipsia
Dx of exclusion
DEC serum osm
DEC urine osm
DEC ADH
56
dx Psychogenic polydipsia
**Water deprivation/ADH stimulation test**
NORMAL ADH and kidneys --\> depriving
* sosm and uosm to be normal
57
Tx Psychogenic polydipsia
_Asymptomatic_
* Fluid restriction
* High protein, high salt diet
_Symptomatic_
* IV hypertonic saline (3% NaCl)
58
High Serum Osms suggest volume \_\_\_\_
Low Serum Osms suggest volume ____ , dilution of solutes
**High Serum Osms** suggest _volume depletion_
**Low Serum Osms** suggest v_olume overload_, dilution of solutes
59
DI - blood is (conc / dilute)
PP - blood is (conc / dilute)
_DI -_ blood is **conc**
_PP -_ blood is (**dilute**)
60
hyper/hyponaturemia
DI -
PP
SIADH
DI - hyperNA
PP - Hypo Na
SIADH - Hypo Na
61
INC/DEC ADH
DI
PP
SIADH
DI
* central - DEC ADH
* nephrogenic - INC ADH
PP - DEC ADH
SIADH - INC ADH
62
DEC serum osm
DEC urine osm
dx?
PP
63
INC serosm
DEC urosm
dx?
DI
64
DEC serosms
INC urosms
Dx
SIADH
65
define SIADH
Secretion of ADH (vasopressin) in excess of what is appropriate for hyperosmolality or intravascular volume depletion --\> Retain fluid
* Something causes pituitary to secrete to excess ADH (infection, drugs)
* Something else is secreting ADH (**small cell lung Ca)**
* Something is causing ADH to be stimulated more in the kidneys (genetic)
66
etiology SIADH
**Tumors**: _Lung carcinoma (particularly small-cell type)_
**CNS disorders**
* Masses: _Tumor_, abscess, hematoma, congenital malformation
* _Infections_: Encephalitis, meningitis, AIDs related CNS opportunistic infection
* _Cerebrovascular occlusions,_ _hemorrhage_, cavernous sinus thrombosis
* Hydrocephalus, Head trauma, MS, ALS, GB
**Pulmonary disorders**
* _Infections: PNA (bacterial or viral_), abscess, cavitation
**Drugs**
* Vasopressin (DDAVP), chlorpromide, clofibrate, carbamazepine, narcotics
* _Antidepressants: TCAs, MOAIs, SSRIs_
67
si/sx of SIADH
DEC urine output
Hyponatremia w/o edema --\> Symptoms depend on how acute and severe hypoNa is
* Mild: Weakness, nausea
* Mod: Headache, vomiting, confusion
* Severe: Lethargy, myoclonus, tremors, asterixis, generalized seizures, comasi/sx DIASH
68
dx SIADH
**Euvolemic hypotonic, hyponatremic**
* DEC serum osm
* INC urine osm
**Blood**
* ↓Sodium
* ↓Osmolality
**Urine**
* ↑Sodium
* ↑Osmolality
CXR
Heat CT/MRI
Abdominopelvic CT
Addt. labs
69
tx SIADH
_Asymptomatic/mild Sx_
* Fluid restriction \<500-1000
* High protein, high salt diet
_Symptomatic (mod-severe)_
* IV hypertonic saline
* Furosemide
* Salt tablets
* ADH receptor antagonists - Tolvaptan , Conivaptan
* Demecycline
* Urea - ↑urine output
70
Severe post-partum hemorrhage ® ischemic necrosis
Pituitary increases in size during gestation but blood supply does not
dx?
Sheehan syndrome (panhypopituitarism)
71
si/sx of Sheehan synd
**Mild :** Variable, insidious onset
**Mod**
* Failure of postpartum lactation & menses
* Hair loss
* Anorexia/weight loss
* Fatigue
**Severe**
* Lethargy
* Anorexia/weight loss
* Inability to lactate after delivery
72
dx sheeham synd
**MRI**
* _Early_- Enlarged pituitary, _Ring enhancement_
* _Late_ – Small pituitary in normal sella or _Empty sella_
**Pituitary hormones (ACTH)**
Adrenal insufficiency must be evaluated immediately
* Anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, fever, confusion, or coma =\> death
73
tx sheehan synd
## Footnote
ACTH deficiency
TSH deficiency
LH and FSH deficiency
GH deficiency
Prolactin deficiency
**ACTH deficiency** --\> hydrocortisone (immediately)
**TSH deficiency** --\> levothyroxine
**LH and FSH deficiency**
* _Interested in fertility_: Gonadotropins (LH & FSH)
* _Not interested in fertility_: Estradiol & progesterone
**GH deficiency** --\> Recombinant GH (not routine in adults)
**Prolactin deficiency --\>** No available treatment
74
name if value is high or low in central vs nephrogenic DI
Serosms
ur osms
serum Na
urine Na
Urine volume
ADH
75
name if value is high or low in PP vs SIADH
Serosms
ur osms
serum Na
urine Na
Urine volume
ADH
76
Most common cause of sellar masses in 3rd decade and above
name types
**Pituitary adenoma**
* **Functional** -=- Produce hormones, MOST common
* **Non-functional** --== Don’t produce hormones
77
size and cell types (w/ hormones) of pit adenomas
most common?
**Size**
* Macroadenoma \>1cm
* Microadenoma \<1 cm
**Cell type**
* Gonadotroph – LH & FSH
* Thyrotroph – TSH
* Corticotroph - ACTH
* _Lactrotroph – prolactin (most common)_
* Somatotroph – growth hormone
* Lactrotroph/somatotroph – GH+prolactin
78
si/sx of pit adenomas
Asymptomatic
Neurologic symptoms
* Visual changes \*
* Headache
* CSF rhinorrhea (rare)
* Hormonal abnormality sx’s
Blurry vision
Diplopia
**Bitemporal hemianopia (#3 ) tunnel vision**
Visual field defect
Diminished visual acuity
79
dx pit adenomas
**Hormonal evaluation**
* _Serum prolactin_ (lactotroph adenomas)
* _Insulin-like growth factor 1_ : IGF-1 (somatotroph adenomas)
* _24 hour urinary free cortisol & elevated ACTH_ (corticotroph adenomas)
**thyrotroph** adenoma suspected
* Alpha subunit
* Total or free thyroxine (T4)
* (TSH)
**Gonadotroph adenoma** - LH / FSH
80
tx pit adenomas
Surgical excision + hypercortisolism
Relieve visual/neurologic Sx
Management of hormonal deficiencies
+/- adjuvant radiation
81
Incidentaloma pit adenomas Evaluation :
**\> 10 mm typical hormone evaluation**
**\< 10 mm without clinical findings of pituitary dysfunction**
* Only measure serum prolactin concentration
* Could consider MRI at 6 months and 12 months
* No evaluation for hormone hyposecretion
* No evaluation for visual abnormalities
82
common complication of pit adenomas
Pituitary Apoplexy infarct or hemorrhage into the adenoma
83
si/sx of Pituitary Apoplexy
**•Severe acute onset headache(89%)**
* Vomiting (57%)
* Visual field deficits (51%) – diplopia/BTH ]
* Other (III, IV, V, VI) cranial nerve dysfunction (46%)
* Fever (16%), neck stiffness (25%)
* Impaired consciousness/AMS (14%)
84
Hyperprolactinemia causes
**Physiological Causes**
* Sleep, Physical exertion, Food, Stress/trauma, Coitus , Pregnancy / Postpartum state / Nursing/nipple stimulation , Surgery
**Hypothalamic-pituitary disease**
* Lactotroph adenomas (prolactinomas)
* Decreased dopaminergic inhibition of prolactin secretion(drugs or damage)
* Disease in or near hypothalamus/pituitary(tum or,infiltrative dz)
**Drug induced** – dec dopamine
* Ranitidine
* Cocaine/Amphetamines
* Metoclopramide , Opioids
* Risperidone , SSRI’s
* Verapamil , Hydroxyzine
85
Hyperprolactinemia is seen w/ MEN 1 or MEN 2a or b
(MEN1) syndrome
Parathyroid, Pancreatic islets, Pituitary
86
si/sx of Hyperprolactinemia
* Galactorrhea
* Infertility
* Osteopenia
DEC libido nonresponsive to hormonal therapy
+/- visual Δ
* •Dysmenorrhea
* •Estrogen deficiency
* •Dyspareunia
* •Acne/hirsutism
* •Anxiety/depression
* •ED
* •Gynecomastia
* •Hypogonadism
87
dx Hyperprolactinemia
**Diluted fasting prolactin \>200**
Hormonal evaluation
**MRI** with and without gadolinium--\> pituitary lesion/adenoma
Formal visual field eval
**INC serum prolactin**
88
tx Hyperprolactinemia
**Dopamine agonists – first choice**
* _Cabergoline_: First choice
* _Bromocriptine_: First choice for women wanting pregnancy
Surgery
Radiation
89
Hyperprolactinemia Indications for Surgery
1. Visual field defects unresponsive to medical therapy
2. Macroadenomas unresponsive to medical therapy
3. Tumor growth while on medical therapy
4. Intolerance to dopamine agonist therapy
5. Pituitary apoplexy (rare)
6. Cerebrospinal rhinorrhea due to prolactinoma erosion into sphenoid sinus (rare)
90
define Acromegaly/ gigantism & co-morbidities
INC GH & IGF-1
_Acromegaly Co-morbidities_
* Hypertension and heart disease
* Sleep apnea
* Insulin-resistant diabetes
* Cerebrovascular events and headache
* Arthritis
91
si/sx of Acromegaly/ gigantism
**•Prognathism (protruding jaw)**
* HA
* Visual Δ
* Skin tags
* Macroglossia
**•Frontal bossing – flat nose**
**•Coarse features**
**•Enlarged hands/feet & tongue**
92
dx Acromegaly/ gigantism
Hormonal eval
**INC IGF-1**
**OGTT** -\>\> GH suppression
Formal visual field eval
Glucose
LFTs
BUN/Cr
93
tx Acromegaly/ gigantism
**Surgical debunking - Transphenoidal pituitary microsurgery (70% fail surgery only)**
**Medical:**
* _Dopamine agonists_ - Bromocriptine, Cabergoline (mixed)
* _Somatostatin analogs_ (Octreotide, Lanreotide)
* _Pegvisomant_ - GH receptor antagonists
**Radiation** - Stereotactic radiosurgery
94
Acromegaly/ gigantism goals of therapy
Control tumor size
IGF-I normal
and OGTT suppression of GH \<1
95
list Dopamine agonists used in Acromegaly/ gigantism
Bromocriptine
Cabergoline
96
list somastostatin analogs used in Acromegaly/ gigantism
Octreotide
Lanreotide
97
list GH R antagonists used in Acromegaly/ gigantism
Pegvisomant
98
Stereotactic radiosurgery is used to tx??
Acromegaly/ gigantism
99
list malignant Pituitary carcinoma
Pituicytoma
Germ cell tumor
Chordomas
Primary lymphomas
Mets from breast ca (F) & lung ca (M)
100
* Arises from posterior pituitary
* Presents as sellar mass; usually mistaken for pituitary adenoma
Pituicytoma
101
•Parinaud’s syndrome (paralysis of upward gaze) is assoc w/ what type of pit tumor?
Germ cell tumor
102
Germ cell tumor dx?
Tx?
Imaging shows mass in third ventricle
↑Serum concentrations of B-hCG or AFP
**Tx:**
* _Radiation_ - Highly radiosensitive
* Highly malignant and metastasize readily
103
pit tumor w/ si/sx
## Footnote
* HA
* Visual impairment
* Ant. pituitary hormonal deficiencies
Chordomas
104
MRI - sellar mass with variable extrasellar extension
dx of what pit tumor??
Primary lymphomas
105
dx of what pit tumor?
## Footnote
* Retroorbital pain and ophthalmoplegia
* Diabetes insipidus
* Visual field defects
Mets from breast ca (F) & lung ca (M)
106
•Visual & oculomotor deficits assoc w/ what pit tumor
Primary lymphomas
107
↑Serum concentrations of B-hCG or AFP
what pit tumor?
Germ cell tumor
108
Presents as sellar mass; usually mistaken for pituitary adenoma
what pit tumor??
Pituicytoma
109
Arises from posterior pituitary
pit tumor??
Pituicytoma
110
most common cancers assoc w/ metastesiszes of pit tumor?
men??
women??
breast cancer in women
lung cancer in men
