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Pituitary Tumours Flashcards

1
Q

What is the most common pituitary tumour?

A

Pituitary adenoma

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2
Q

What % of all intra-cranial tumours do pituitary adenomas make up?

A

10%

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3
Q

Pituitary adenomas are derived from cells of where?

A

Anterior pituitary

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4
Q

How are pituitary adenomas classified?

A

Microadenoma < 10mm

Macroadenoma > 10mm

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5
Q

Pituitary adenomas can be sporadic or associated with which genetic condition?

A

MEN1

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6
Q

A pituitary tumour is most likely to grow in which direction and why?

A

Upwards because all other ways are surrounded by bone

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7
Q

What is the most likely problem if a pituitary tumours continues to grow upwards?

A

Compression of the optic chasm leading to bitemporal hemianopia

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8
Q

Are rare, severe pituitary adenomas which spread into the brain and hypothalamus malignant?

A

No

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9
Q

Give some problems which may occur with a non-functioning pituitary adenoma?

A
  • Bitemporal hemianopia
  • Compression of other structures
  • Hypoadrenalism/thyroidism/gonadism
  • GH deficiency
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10
Q

What cranial nerves is a non-functioning pituitary adenoma most likely to compress?

A

CN 3, 4, 6

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11
Q

Does a non-functioning pituitary adenoma normally affect the posterior pituitary?

A

No

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12
Q

What will occur if a non-functioning pituitary adenoma does affect the posterior pituitary?

A

Diabetes insipidus

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13
Q

What are the baseline tests for hormones relating to the pituitary gland?

A
  • TSH, fT4
  • LH, FSH, testosterone
  • GH, IGF-1
  • PRL
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14
Q

What type of test should be performed if there is too much of a hormone being produced?

A

Suppression test

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15
Q

What type of test should be performed if there is too little of a hormone being produced?

A

Stimulation test

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16
Q

What will happen in stimulation/suppression tests if there is a pituitary tumour?

A

They will not work and the levels of the hormones will stay the same

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17
Q

What is the stimulation test for cortisol? Explain this.

A

Synacthen Test- give synthetic ACTH at 0, 30 and 60 mins

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18
Q

What is the stimulation test for insulin? Explain this.

A

Insulin stress test- give cortisol and GH every 30 mins for 2-3 hours and measure the response. Normally cortisol > 500 and GH > 7

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19
Q

What is the stimulation test for ADH? Explain this.

A

Water deprivation test- no water for 8 hours and then check serum and urine osmolalities. Then give IM ADH and check after 4 hours. If urine/serum ratio is > 2 this is normal.

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20
Q

What is the most common functional pituitary adenoma?

A

Prolactinoma

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21
Q

How can prolactin be raised physiologically?

A
  • Pregnancy
  • Breast feeding
  • Stress
  • Sleep
  • Drugs
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22
Q

What drugs can raise prolactin?

A
  • Dopamine antagonists e.g. metaclopramide

- Anti-psychotics e.g. phenothiazines

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23
Q

How can prolactin become raised pathologically?

A
  • Hypothyroidism
  • Stalk lesions
  • Prolactinoma
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24
Q

How will a stalk lesion result in increased prolactin?

A

It will stop dopamine getting to the pituitary so PRL will increase

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25
What can cause stalk lesions?
Trauma e.g. RTA or iatrogenic
26
A prolactinoma will present earlier in which sex?
Females
27
What is a feature of prolactinoma which occurs in both sexes?
Decreased libido
28
What are some features of a prolactinoma which only occur in females?
- Galactorrhoea - Menstrual irregularity - Amenorrhoea - Infertility
29
What are some features of a prolactinoma that males are more likely to present with (due to late presentation)?
- Impotence - Visual field abnormality - Headache - Anterior pituitary malfunction
30
What investigations are used for a prolactinoma?
- Pituitary function tests (PRL concentration and all other hormones) - MRI of pituitary gland - Examination for visual field abnormalities
31
What is the treatment for prolactinoma or any kind of raised prolactin?
Dopamine agonists e.g. Cabergoline (Dostinex)
32
How often should Cabergoline be given? How is it taken?
Twice a week orally
33
Cabergoline has minimal side effects. Give two examples?
Nausea and headaches
34
What are the outcomes of treatment with Cabergoline?
- Normal prolactin (96%) - Regaining menstruation (94%) - Regaining fertility (91%) - May cause tumour shrinkage
35
What is the second most common functional pituitary tumour?
Growth hormone secreting
36
Excess GH causes increased what else?
IGF-1
37
IGF-1 stimulates growth of what?
Bone, cartilage and connective tissue
38
What occurs if there is GH excess before epiphyseal function?
Gigantism
39
What occurs if there is GH excess after epiphyseal function?
Acromegaly
40
What are some features of thickened soft tissues in acromegaly?
- Thick skin - Big jaw, hands and feet - Sweaty
41
What cardiac features can acromegaly have?
Hypertension, cardiac failure
42
Acromegaly causes headaches. Why?
These are vascular due to a lack of blood supply to the head
43
What are the respiratory features of acromegaly?
Snoring and sleep apnoea
44
What other endocrine condition is associated with acromegaly?
DM
45
Polyps and cancer where are associated with acromegaly?
Colon
46
What investigations should be done for suspected GH secreting tumour?
- IGF1 - Other pituitary hormones - Glucose tolerance test - Visual field testing - CT/MRI of pituitary gland
47
What factors can have an effect on IGF-1?
Age and sex
48
Glucose tolerance test for acromegaly is what type of test?
Suppression test
49
Explain the GTT for acromegaly?
Normally GH < 4macrograms/l after glucose, if this is unchanged or higher there is acromegaly
50
What is the mainstay of treatment for a GH secreting tumour?
Pituitary surgery or external radiotherapy to the pituitary fossa
51
After treatment, what results of a GTT are acceptable?
< 0.4macrograms/l
52
After treatment, a GTT of > 1 means what?
Further drug therapy is needed
53
Drug therapy for acromegaly includes?
Dopamine agonist, octreotide, pegvisomant
54
What type of drug is pegvisomant?
GH antagonist
55
How are ocreotide and pegvisomant given?
SC
56
Do drugs for acromegaly decrease the tumour size?
No
57
What do drugs for acromegaly do?
Decrease IGF-1
58
What do somatostatin analogues do?
Decreased GH and may cause tumour shrinkage
59
What are some side effects of somatostatin analogues?
- Local stinging - Short term flatulence, diarrhoea, abdominal pain - Long term gastritis, gallstones
60
What does acromegaly follow up include?
- Check all pituitary hormone levels - Colon cancer surveillance - CV risk factors - Sleep apnoea
61
ACTH secreting tumours are usually what kind?
Microadenoma
62
What do ACTH secreting adenomas do?
Cushing's Disease and bilateral adrenocortical hyperplasia
63
Cushing's disease/syndrome causes excess of what hormone?
Cortisol
64
What type of hormone is cortisol?
Stress hormone
65
What are 3 symptoms of protein loss in Cushing's?
Osteoporosis, myopathy, thin skin
66
What are symptoms of altered carbohydrate and lipid metabolism in Cushing's?
Diabetes mellitus and obesity
67
What are symptoms of altered psyche of Cushing's?
Psychosis and depression
68
What are symptoms of excess mineralocorticoid in Cushing's?
Hypertension, oedema
69
What are symptoms of excess androgen in Cushing's?
Virilism, hirsutism, acne, oligo/amenorrhoea
70
What should be considered if a patient is overweight with osteoporosis?
Cushing's
71
What does Cushing's DISEASE mean?
The problem is in the pituitary gland
72
What does Cushing's SYNDROME mean?
The problem is outwith the pituitary gland
73
What are the 3 main origins of Cushing's?
Pituitary, adrenal, ectopic
74
What is pseudo-Cushing's?
False positive from alcohol, depression or steroid medication
75
What is the treatment for pituitary Cushing's?
Hypophysectomy +/- external radiation
76
What is the treatment for adrenal Cushing's?
Adrenalectomy
77
What is the main cause of ectopic Cushing's?
Carcinoid tumours
78
What is the treatment for ectopic Cushing's?
Remove the source, or bilateral adrenalectomy
79
When is drug treatment used for Cushing's? What drug is used?
If other treatments fail or while waiting for radiotherapy to work- Metyrapone
80
What is Pasireolide?
A new somatostatin drug which blocks receptors 2 and 5
81
What is the screening test for Cushing's?
Overnight Dexamethasone suppression test
82
If there is Cushing's, what will be the result of an overnight dexamethasone suppression test?
Cortisol will not suppress and still be > 50nmol/l
83
What is another screening test for Cushing's and what result would indicate Cushing's?
24h urinary cortisol- > 250 = Cushing's
84
What is the definitive test for Cushing's?
Low dose dexamethasone test
85
What happens in a low dose dexamethasone test?
You take 2mg of dexamethasone for 2 days
86
What will be the results of a low dose dexamethasone test if there is Cushing's?
Cortisol will remain > 50nmol/l 6 hours after the last dose of dexamethasone
87
What test is done if a low dose dexamethasone test is positive for Cushing's?
High dose dexamethasone test
88
What does it signify if a high dose dexamethasone test DOES NOT suppress cortisol? What test should then be done?
Adrenal origin- adrenal MRI
89
What does it signify if a high dose dexamethasone test DOES suppress cortisol? What test should then be done?
Pituitary origin- pituitary MRI
90
What test is done for Cushing's if an adrenal MRI is negative? What is the suspected origin?
Full body MRI for ectopic origin
91
Are pituitary carcinomas more likely to be functional or not?
Functional
92
Functional pituitary carcinomas are most likely to produce what?
Prolactin or ACTH
93
When are pituitary carcinomas usually diagnosed?
Once they have metastasised
94
Where are craniopharyngiomas derived from?
Remnants of Rathke's pouch
95
What is a slow growing, often cystic pituitary tumour which may calcify?
Craniopharyngioma
96
Are craniopharyngiomas usually found within the sella turcica?
They can be- but are most likely suprasellar
97
When do craniopharyngiomas usually present?
Between ages 5-15 or in the 6th-7th decades
98
What is the usual presentation of a craniopharyngioma?
Headache and visual disturbance | Can cause growth retardation in children
99
What is the prognosis of craniopharyngioma?
Excellent
100
What may develop following radiation for craniopharyngioma?
SCC

Endocrine- Pituitary (5 decks)

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