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ENDOCRINE > Pituitary Tumours > Flashcards

Pituitary Tumours Flashcards

1
Q

At what size does an adenoma of the pituitary cross from a microadenoma to a macroadenoma?

A 
<1cm = microadenoma
>1cm = macroadenoma
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2
Q

What structures can a non-functioning pituitary adenoma compress?

A

Optic chiasma

Cranial nerve 3,4,6

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3
Q

What effect does a non-functioning pituitary adenoma have on hormone release from the pituitary?

A

Too little hormone is released:

  • Hypoadrenalism
  • Hypothyroidism
  • Hypogonadism
  • Diabetes Insipidus
  • GH deficiency
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4
Q

What symptom do patients usually notice if the pituitary adenoma is compressing the optic chiasm?

A

Bitemporal Hemianopoia

Loss of vision in both temporal fields

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5
Q

What are the 3 categories which cause a Prolactinoma?

A

Physiological
Drugs
Pathology

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6
Q

What physiological changes in the body cause a rasied prolactin?

A

breast feeding
pregnancy
stress
sleep

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7
Q

What drugs/medications are known to cause a raised prolactin?

A
  • Dopamine antagonists eg metoclopramide
  • Antipsychotics eg phenothiazines
  • antidepressants eg TCAs, SSRIs
  • other = oestrogens, coccaine
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8
Q

What pathological conditions cause a raised prolactin?

A
  • Hypothyroidism
  • Stalk lesions (iatrogenic/croad accident)
  • Prolactinoma
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9
Q

Males usually present early with prolactin related disease, whilst females present late. TRUE/FALSE?

A

FALSE
females notice symptoms much earlier than men
e.g. irregular/no periods + infertility

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10
Q

What symptoms do males usually present with in a prolactinoma?

A

Impotence
Visual field abnormal
Headache

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11
Q

What symptoms do females experience in a prolactinoma?

A

Galactorrhoea (milk production)
Irregular/no periods
Infertility

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12
Q

How can a prolactinoma be tested for?

A

Serum prolactin concentration (Blood Test)

Pituitary MRI

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13
Q

What class of drugs are used to inhibit release of prolactin?

A

Dopamine agonists

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14
Q

What dopamine agonist is most commonly used?

A

Cabergoline (Dostinex)

  • Once to Twice per week oral
  • Least side effects
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15
Q

What are the advantages of dopamine agonists?

A

Prolactin level = normalised in 96%
Menstruation regained in 94%
Pregnancy rate 91% (Warn pts about this!)
Tumour shrinkage

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16
Q

What side effects are caused by dopamine agonists?

A

Nausea / Vomiting
Low Mood
Fibrosis (heart valves/retroperitoneal) {only at high doses e.g. used in parkinsons disease

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17
Q

In acromegaly, what hormone is in excess?

A

Growth Hormone

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18
Q

What can result if acromegaly presents before bones have fused?

A

Gigantism

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19
Q

What soft tissues are often found to be thickened in acromegaly?

A

skin
large jaw
large hands

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20
Q

What symptom is caused by a thickened nasopharynx in acromegaly?

A

Snoring/ Sleep Apnoea

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21
Q

What cardiovascular complications can arise from acromegaly?

A

Hypertension (heart), cardiac failure

Early CV Death

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22
Q

Patients with acromegaly are at risk of colonic polyps and colon cancer. TRUE/FALSE?

A

TRUE

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23
Q

What is the peripheral hormone that Growth Hormone stimulates?

A

IGF-1

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24
Q

What suppression test can be carried out to test for excess growth hormone?

A

Glucose Tolerance Test
75g Oral Glucose
Check at 0, 30, 60, 90, 120 min)
NORMALLY: GH suppresses to <0.4ug/l after glucose

Acromegaly: GH unchanged/no suppression
=> GH remains >1ug/l after glucose

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25
Surgery is the first line treatment for acromegaly. TRUE/FALSE?
TRUE | **can sometimes also have radiotherapy alongside surgery**
26
How many micro and macroadenomas are cleared by surgery?
90% cure if microadenoma | 50% cure if macroadenoma
27
What drugs can be used to treat acromegaly?
Somatostatin Analogues Dopamine Agonists GH Antagonists
28
How are somatostatin analogues usually administered?
Injection (IM or SC)
29
What are the advantages of somatostatin analogues
- Tumour shrinkage - Can be used pre-op - relieves headache in 1 hr - Improved outcome
30
What are the short term adverse effects of somatostatin analogues?
- Local Stinging - Flatulence - Diarrhoea - Abdominal pains
31
What is the main long term side effect of somatostatin analgoues?
Gallstones (60%)
32
When can dopamine agonists be used to treat a pituitary tumour in acromegaly?
If the tumour co-secretes GH and prolactin
33
Why are GH antagonists not commonly prescribed in acromegaly?
No decrease in tumour size (possible slight increase) | Expensive (£36,000 a year)
34
What should be checked at an acromegaly follow up?
- Check other pituitary hormones especially thyroid - Cancer surveillance (Colon and tubulo-villous adenoma) - Cardiovacular risk factors - Sleep apnoea
35
What is responsible for the headache symptom experienced in acromegaly?
Turbulent blood flow through vasculature
36
Cushing's syndrome occurs as a result of what hormone excess?
Cortisol
37
What are the main indications of protein loss in Cushing's syndrome?
Myopathy; wasting Osteoporosis; fractures Thin skin; striae, bruising
38
What can the altered carbohydrate and lipid metabolism in Cushing's Disease cause?
Diabetes mellitus | Obesity
39
What pschyiatric problems do Cushing's patients present with?
Psychosis | depression
40
What can excess mineralocorticoid result in?
hypertension | oedema
41
What symptoms do patients experience if they have excess androgens?
- Virilism (females develop secondary male characteristics) - Hirsutism (excess body hair in both genders) - Acne - oligo/amenorrhoea
42
What features differentiate Cushing's from obesity?
- Thin Skin - Proximal myopathy - Frontal balding in women - Conjunctival oedema (chemosis) - Osteoporosis
43
What facial symptoms are often seen in Cushings?
Moon face | with red/plethoric cheeks
44
In Cushing's syndrome patients experience central obesity with very slim limbs. TRUE/FALSE?
TRUE | thin arms and legs due to muscle wasting
45
What suppression test can be used as screening test for cushings?
Overnight 1mg dexamethasone suppression test (oral)
46
What other tests are used to screen for Cushing's syndrome?
- Urine free cortisol (24h urine collection) | - Diurnal cortisol variation (Midnight/8am)
47
How does a dexamethasone suppresion test work?
Dexamethasone = exogenous steroid | => should take place of cortisol and inhibit CRH/ ACTH to produce less cortisol
48
Explain the difference between the normal and abnormal overnight dexamethasone suppression tests
<50nmol/l next morning = normal >100nmol/L = ABnormal
49
Why is a diurinal cortisol variation test used?
Cortisol is lowest at midnight and highest in the morning | => sample should be taken before patient has had anything to eat/drink to determine if levels = consistently high
50
What test can DIAGNOSE Cushiing's?
Low dose Dexamethasone Suppression Test 2mg/day for 2 days Cortisol <50 nmol/l 6 hrs after last dose = Normal Cortisol >130 nmol/l = Cushings
51
What is the difference between Cushing's Disease and Cushing's syndrome?
Cushing's DISEASE affects pituitary | All other manifestations = Cushing's syndrome
52
Aside from pituitary disease, what other pathologies can cause Cushing's?
- Adenoma of adrenal gland - Ectopic Tissue => Thymus => Lung => Pancreas
53
What can cause Pseudo-Cushing's?
Alcohol and Depression | Steroid medication
54
What levels of ACTH would differentiate between pituitary, adrenal or ectopic disease?
``` <300 = pituitary disease <1 = adrenal disease >300 = ectopic disease (i.e. ACTH being secreted from elsewhere) ```
55
How are the pituitary causes of Cushing's treated?
- Hypophysectomy - external radiotherapy if recurs - Bilateral adrenalectomy
56
How are the Adrenal causes of Cushing's treated?
Adrenalectomy
57
How are the ectopic causes of Cushing's usually treated?
Remove source | OR bilateral adrenalectomy
58
What non-surgical treatments can be used in Cushing's?
Metyrapone - if other treatments fail - while waiting for radiotherapy to work Ketoconazole (**hepatotoxic**) Pasireotide LAR (10-20mg monthly) - somatostatin analogue - receptor 2 and 5 blocked
59
Describe the concept of Pan Hypopituitarism
Decrease in all hormonal output from the pituitary
60
What can a decrease in all pituitary hormones cause?
``` Anterior Pituitary GH = growth failure TSH = hypothyroidism LH/FSH = Hypogonadism ACTH = hypoadrenal Prolactin = **none known** ``` Posterior Pituitary Diabetes Insipidus
61
What are the main causes of hypopituitarism
- Pituitary Tumours - Secondary metastatic lesions (lung, breast) - Local brain tumours - Granulomatous diseases - Vascular diseases - Trauma - Hypothalamic diseases - Iatrogenic (surgery) - Autoimmune - Infection
62
What hypothalamic diseases can result in hypopituitarism?
Syphilis | meningitis
63
What granulomatous diseases can result in hypopituitarism?
TB Histiocytosis X sarcoidosis
64
What local brain tumours can give rise to hypopituitarism?
Glioma Meningioma Astrocytoma
65
What symptoms present in hypopituitarism if only the anterior pituitary is affected?
- Menstrual irregularities (F) - Loss of axillary and pubic hair (M&F) - Infertility, impotence - Gynaecomastia (M) - Loss of facial hair (M) - Abdominal obesity - Dry skin and hair - Hypothyroid faces - growth retardation (children)
66
What dose of thyroxine is used as replacement therapy in pan hypopituitarism?
100-150mcg daily
67
How is cortisol replaced in the body in panhypopituitarism?
Hydrocortisone 10-25 mg/day (am/pm)
68
What formulations are available for ADH replacement?
Desmospray (nasal) or tablets
69
How is growth hormone replacement usually administered and when?
nightly subcutaneous injection
70
How are sex hormones replaced in pan hypopituitarism?
HRT/Combined pill for female | Testosterone for males
71
In what ways can testosterone be administered?
``` IM injection every 3-4 weeks (Sustanon) Skin gel (Testogel, Tostran) Prolonged IM injection 10-14 wks (Nebido) RARE = Oral tablets (Restandol) ```
72
What are the drawbacks of testosterone replacement?
- Prostate Enlargement => Does NOT cause cancer but may make it grow Polycythaemia (thickened blood) => more at risk of MI/Stroke Hepatitis (only for oral tablets) -
73
What are the usual causes of Diabetes Insipidus?
Familial - Sometimes DIDMOAD (DI, DM, optic atrophy, deaf) Acquired - Idiopathic in 50% - Trauma; road accidents, surgery, skull fracture RARE - Tumour, sarcoid, ext irradiation, meningitis
74
How is a water deprivation test usually carried out?
serum and urine osmolalities for 8h, and then 4h after giving IM Desmopressin (vasopressin) If Ur/Serum Osmol ratio >2 = normal => otherwise DI
75
How can Diabetes insipidus be treated?
``` Desmospray (nasal) Desmopressin tablets (oral) Desmopressin injection (only used in emergency or post pituitary sugery) ```

ENDOCRINE (22 decks)

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