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Endocrine- Pituitary > Pituitary Tumours > Flashcards

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
Q

What can cause stalk lesions?

A

Trauma e.g. RTA or iatrogenic

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26
Q

A prolactinoma will present earlier in which sex?

A

Females

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27
Q

What is a feature of prolactinoma which occurs in both sexes?

A

Decreased libido

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28
Q

What are some features of a prolactinoma which only occur in females?

A
  • Galactorrhoea
  • Menstrual irregularity
  • Amenorrhoea
  • Infertility
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29
Q

What are some features of a prolactinoma that males are more likely to present with (due to late presentation)?

A
  • Impotence
  • Visual field abnormality
  • Headache
  • Anterior pituitary malfunction
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30
Q

What investigations are used for a prolactinoma?

A
  • Pituitary function tests (PRL concentration and all other hormones)
  • MRI of pituitary gland
  • Examination for visual field abnormalities
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31
Q

What is the treatment for prolactinoma or any kind of raised prolactin?

A

Dopamine agonists e.g. Cabergoline (Dostinex)

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32
Q

How often should Cabergoline be given? How is it taken?

A

Twice a week orally

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33
Q

Cabergoline has minimal side effects. Give two examples?

A

Nausea and headaches

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34
Q

What are the outcomes of treatment with Cabergoline?

A
  • Normal prolactin (96%)
  • Regaining menstruation (94%)
  • Regaining fertility (91%)
  • May cause tumour shrinkage
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35
Q

What is the second most common functional pituitary tumour?

A

Growth hormone secreting

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36
Q

Excess GH causes increased what else?

A

IGF-1

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37
Q

IGF-1 stimulates growth of what?

A

Bone, cartilage and connective tissue

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38
Q

What occurs if there is GH excess before epiphyseal function?

A

Gigantism

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39
Q

What occurs if there is GH excess after epiphyseal function?

A

Acromegaly

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40
Q

What are some features of thickened soft tissues in acromegaly?

A
  • Thick skin
  • Big jaw, hands and feet
  • Sweaty
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41
Q

What cardiac features can acromegaly have?

A

Hypertension, cardiac failure

42
Q

Acromegaly causes headaches. Why?

A

These are vascular due to a lack of blood supply to the head

43
Q

What are the respiratory features of acromegaly?

A

Snoring and sleep apnoea

44
Q

What other endocrine condition is associated with acromegaly?

A

DM

45
Q

Polyps and cancer where are associated with acromegaly?

A

Colon

46
Q

What investigations should be done for suspected GH secreting tumour?

A
  • IGF1
  • Other pituitary hormones
  • Glucose tolerance test
  • Visual field testing
  • CT/MRI of pituitary gland
47
Q

What factors can have an effect on IGF-1?

A

Age and sex

48
Q

Glucose tolerance test for acromegaly is what type of test?

A

Suppression test

49
Q

Explain the GTT for acromegaly?

A

Normally GH < 4macrograms/l after glucose, if this is unchanged or higher there is acromegaly

50
Q

What is the mainstay of treatment for a GH secreting tumour?

A

Pituitary surgery or external radiotherapy to the pituitary fossa

51
Q

After treatment, what results of a GTT are acceptable?

A

< 0.4macrograms/l

52
Q

After treatment, a GTT of > 1 means what?

A

Further drug therapy is needed

53
Q

Drug therapy for acromegaly includes?

A

Dopamine agonist, octreotide, pegvisomant

54
Q

What type of drug is pegvisomant?

A

GH antagonist

55
Q

How are ocreotide and pegvisomant given?

A

SC

56
Q

Do drugs for acromegaly decrease the tumour size?

A

No

57
Q

What do drugs for acromegaly do?

A

Decrease IGF-1

58
Q

What do somatostatin analogues do?

A

Decreased GH and may cause tumour shrinkage

59
Q

What are some side effects of somatostatin analogues?

A
  • Local stinging
  • Short term flatulence, diarrhoea, abdominal pain
  • Long term gastritis, gallstones
60
Q

What does acromegaly follow up include?

A
  • Check all pituitary hormone levels
  • Colon cancer surveillance
  • CV risk factors
  • Sleep apnoea
61
Q

ACTH secreting tumours are usually what kind?

A

Microadenoma

62
Q

What do ACTH secreting adenomas do?

A

Cushing’s Disease and bilateral adrenocortical hyperplasia

63
Q

Cushing’s disease/syndrome causes excess of what hormone?

A

Cortisol

64
Q

What type of hormone is cortisol?

A

Stress hormone

65
Q

What are 3 symptoms of protein loss in Cushing’s?

A

Osteoporosis, myopathy, thin skin

66
Q

What are symptoms of altered carbohydrate and lipid metabolism in Cushing’s?

A

Diabetes mellitus and obesity

67
Q

What are symptoms of altered psyche of Cushing’s?

A

Psychosis and depression

68
Q

What are symptoms of excess mineralocorticoid in Cushing’s?

A

Hypertension, oedema

69
Q

What are symptoms of excess androgen in Cushing’s?

A

Virilism, hirsutism, acne, oligo/amenorrhoea

70
Q

What should be considered if a patient is overweight with osteoporosis?

A

Cushing’s

71
Q

What does Cushing’s DISEASE mean?

A

The problem is in the pituitary gland

72
Q

What does Cushing’s SYNDROME mean?

A

The problem is outwith the pituitary gland

73
Q

What are the 3 main origins of Cushing’s?

A

Pituitary, adrenal, ectopic

74
Q

What is pseudo-Cushing’s?

A

False positive from alcohol, depression or steroid medication

75
Q

What is the treatment for pituitary Cushing’s?

A

Hypophysectomy +/- external radiation

76
Q

What is the treatment for adrenal Cushing’s?

A

Adrenalectomy

77
Q

What is the main cause of ectopic Cushing’s?

A

Carcinoid tumours

78
Q

What is the treatment for ectopic Cushing’s?

A

Remove the source, or bilateral adrenalectomy

79
Q

When is drug treatment used for Cushing’s? What drug is used?

A

If other treatments fail or while waiting for radiotherapy to work- Metyrapone

80
Q

What is Pasireolide?

A

A new somatostatin drug which blocks receptors 2 and 5

81
Q

What is the screening test for Cushing’s?

A

Overnight Dexamethasone suppression test

82
Q

If there is Cushing’s, what will be the result of an overnight dexamethasone suppression test?

A

Cortisol will not suppress and still be > 50nmol/l

83
Q

What is another screening test for Cushing’s and what result would indicate Cushing’s?

A

24h urinary cortisol- > 250 = Cushing’s

84
Q

What is the definitive test for Cushing’s?

A

Low dose dexamethasone test

85
Q

What happens in a low dose dexamethasone test?

A

You take 2mg of dexamethasone for 2 days

86
Q

What will be the results of a low dose dexamethasone test if there is Cushing’s?

A

Cortisol will remain > 50nmol/l 6 hours after the last dose of dexamethasone

87
Q

What test is done if a low dose dexamethasone test is positive for Cushing’s?

A

High dose dexamethasone test

88
Q

What does it signify if a high dose dexamethasone test DOES NOT suppress cortisol? What test should then be done?

A

Adrenal origin- adrenal MRI

89
Q

What does it signify if a high dose dexamethasone test DOES suppress cortisol? What test should then be done?

A

Pituitary origin- pituitary MRI

90
Q

What test is done for Cushing’s if an adrenal MRI is negative? What is the suspected origin?

A

Full body MRI for ectopic origin

91
Q

Are pituitary carcinomas more likely to be functional or not?

A

Functional

92
Q

Functional pituitary carcinomas are most likely to produce what?

A

Prolactin or ACTH

93
Q

When are pituitary carcinomas usually diagnosed?

A

Once they have metastasised

94
Q

Where are craniopharyngiomas derived from?

A

Remnants of Rathke’s pouch

95
Q

What is a slow growing, often cystic pituitary tumour which may calcify?

A

Craniopharyngioma

96
Q

Are craniopharyngiomas usually found within the sella turcica?

A

They can be- but are most likely suprasellar

97
Q

When do craniopharyngiomas usually present?

A

Between ages 5-15 or in the 6th-7th decades

98
Q

What is the usual presentation of a craniopharyngioma?

A

Headache and visual disturbance

Can cause growth retardation in children

99
Q

What is the prognosis of craniopharyngioma?

A

Excellent

100
Q

What may develop following radiation for craniopharyngioma?

A

SCC

Endocrine- Pituitary (5 decks)

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