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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
Q

Surgery is the first line treatment for acromegaly. TRUE/FALSE?

A

TRUE

can sometimes also have radiotherapy alongside surgery

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26
Q

How many micro and macroadenomas are cleared by surgery?

A

90% cure if microadenoma

50% cure if macroadenoma

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27
Q

What drugs can be used to treat acromegaly?

A

Somatostatin Analogues
Dopamine Agonists
GH Antagonists

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28
Q

How are somatostatin analogues usually administered?

A

Injection (IM or SC)

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29
Q

What are the advantages of somatostatin analogues

A
  • Tumour shrinkage
  • Can be used pre-op
  • relieves headache in 1 hr
  • Improved outcome
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30
Q

What are the short term adverse effects of somatostatin analogues?

A
  • Local Stinging
  • Flatulence
  • Diarrhoea
  • Abdominal pains
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31
Q

What is the main long term side effect of somatostatin analgoues?

A

Gallstones (60%)

32
Q

When can dopamine agonists be used to treat a pituitary tumour in acromegaly?

A

If the tumour co-secretes GH and prolactin

33
Q

Why are GH antagonists not commonly prescribed in acromegaly?

A

No decrease in tumour size (possible slight increase)

Expensive (£36,000 a year)

34
Q

What should be checked at an acromegaly follow up?

A
  • Check other pituitary hormones especially thyroid
  • Cancer surveillance (Colon and tubulo-villous adenoma)
  • Cardiovacular risk factors
  • Sleep apnoea
35
Q

What is responsible for the headache symptom experienced in acromegaly?

A

Turbulent blood flow through vasculature

36
Q

Cushing’s syndrome occurs as a result of what hormone excess?

A

Cortisol

37
Q

What are the main indications of protein loss in Cushing’s syndrome?

A

Myopathy; wasting
Osteoporosis; fractures
Thin skin; striae, bruising

38
Q

What can the altered carbohydrate and lipid metabolism in Cushing’s Disease cause?

A

Diabetes mellitus

Obesity

39
Q

What pschyiatric problems do Cushing’s patients present with?

A

Psychosis

depression

40
Q

What can excess mineralocorticoid result in?

A

hypertension

oedema

41
Q

What symptoms do patients experience if they have excess androgens?

A
  • Virilism (females develop secondary male characteristics)
  • Hirsutism (excess body hair in both genders)
  • Acne
  • oligo/amenorrhoea
42
Q

What features differentiate Cushing’s from obesity?

A
  • Thin Skin
  • Proximal myopathy
  • Frontal balding in women
  • Conjunctival oedema (chemosis)
  • Osteoporosis
43
Q

What facial symptoms are often seen in Cushings?

A

Moon face

with red/plethoric cheeks

44
Q

In Cushing’s syndrome patients experience central obesity with very slim limbs. TRUE/FALSE?

A

TRUE

thin arms and legs due to muscle wasting

45
Q

What suppression test can be used as screening test for cushings?

A

Overnight 1mg dexamethasone suppression test (oral)

46
Q

What other tests are used to screen for Cushing’s syndrome?

A
  • Urine free cortisol (24h urine collection)

- Diurnal cortisol variation (Midnight/8am)

47
Q

How does a dexamethasone suppresion test work?

A

Dexamethasone = exogenous steroid

=> should take place of cortisol and inhibit CRH/ ACTH to produce less cortisol

48
Q

Explain the difference between the normal and abnormal overnight dexamethasone suppression tests

A

<50nmol/l next morning = normal

> 100nmol/L = ABnormal

49
Q

Why is a diurinal cortisol variation test used?

A

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
Q

What test can DIAGNOSE Cushiing’s?

A

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
Q

What is the difference between Cushing’s Disease and Cushing’s syndrome?

A

Cushing’s DISEASE affects pituitary

All other manifestations = Cushing’s syndrome

52
Q

Aside from pituitary disease, what other pathologies can cause Cushing’s?

A
  • Adenoma of adrenal gland
  • Ectopic Tissue
    => Thymus
    => Lung
    => Pancreas
53
Q

What can cause Pseudo-Cushing’s?

A

Alcohol and Depression

Steroid medication

54
Q

What levels of ACTH would differentiate between pituitary, adrenal or ectopic disease?

A 
<300 = pituitary disease
<1 = adrenal disease
>300 = ectopic disease (i.e. ACTH being secreted from elsewhere)
55
Q

How are the pituitary causes of Cushing’s treated?

A
  • Hypophysectomy
  • external radiotherapy if recurs
  • Bilateral adrenalectomy
56
Q

How are the Adrenal causes of Cushing’s treated?

A

Adrenalectomy

57
Q

How are the ectopic causes of Cushing’s usually treated?

A

Remove source

OR bilateral adrenalectomy

58
Q

What non-surgical treatments can be used in Cushing’s?

A

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
Q

Describe the concept of Pan Hypopituitarism

A

Decrease in all hormonal output from the pituitary

60
Q

What can a decrease in all pituitary hormones cause?

A 
Anterior Pituitary
GH = growth failure
TSH = hypothyroidism
LH/FSH = Hypogonadism
ACTH = hypoadrenal
Prolactin = **none known**

Posterior Pituitary
Diabetes Insipidus

61
Q

What are the main causes of hypopituitarism

A
  • Pituitary Tumours
  • Secondary metastatic lesions (lung, breast)
  • Local brain tumours
  • Granulomatous diseases
  • Vascular diseases
  • Trauma
  • Hypothalamic diseases
  • Iatrogenic (surgery)
  • Autoimmune
  • Infection
62
Q

What hypothalamic diseases can result in hypopituitarism?

A

Syphilis

meningitis

63
Q

What granulomatous diseases can result in hypopituitarism?

A

TB
Histiocytosis X
sarcoidosis

64
Q

What local brain tumours can give rise to hypopituitarism?

A

Glioma
Meningioma
Astrocytoma

65
Q

What symptoms present in hypopituitarism if only the anterior pituitary is affected?

A
  • 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
Q

What dose of thyroxine is used as replacement therapy in pan hypopituitarism?

A

100-150mcg daily

67
Q

How is cortisol replaced in the body in panhypopituitarism?

A

Hydrocortisone 10-25 mg/day (am/pm)

68
Q

What formulations are available for ADH replacement?

A

Desmospray (nasal) or tablets

69
Q

How is growth hormone replacement usually administered and when?

A

nightly subcutaneous injection

70
Q

How are sex hormones replaced in pan hypopituitarism?

A

HRT/Combined pill for female

Testosterone for males

71
Q

In what ways can testosterone be administered?

A 
IM injection every 3-4 weeks (Sustanon)
Skin gel (Testogel, Tostran)
Prolonged IM injection 10-14 wks (Nebido)
RARE = Oral tablets (Restandol)
72
Q

What are the drawbacks of testosterone replacement?

A
  • 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
Q

What are the usual causes of Diabetes Insipidus?

A

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
Q

How is a water deprivation test usually carried out?

A

serum and urine osmolalities for 8h, and then 4h after giving IM Desmopressin (vasopressin)

If Ur/Serum Osmol ratio >2 = normal
=> otherwise DI

75
Q

How can Diabetes insipidus be treated?

A 
Desmospray (nasal)
Desmopressin tablets (oral)
Desmopressin injection (only used in emergency or post pituitary sugery)

Endocrine (24 decks)

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