Pituitary tumours (E&M) Flashcards
Define pituitary tumours.
Benign tumours that arise sporadically from the anterior pituitary gland
What are the causes of pituitary tumours? (2)
- most occur sporadically
- multiple endocrine neoplasia (MEN) type 1 - associated with 3Ps (pituitary tumour, parathyroid adenoma, pancreatic tumour - insulinoma)
What symptoms would point towards MEN Type 1 (cause of pituitary tumours)? (3)
- peptic ulceration
- galactorrhoea
- hypercalcaemia
Pituitary tumour, Parathyroid adenoma, Pancreatic tumour (insulinoma)
What are two ways of classifying pituitary tumours?
- size:
- microadenoma (</=10mm)
- macroadenoma (>10mm)
- hormonal status - functional (secretes hormones) vs non-functional (does not produce excess hormones):
- prolactinoma (prolactin-secreting)
- acromegaly (GH-secreting)
- Cushing’s disease (ACTH-secreting)
How can non-functioning pituitary tumours spread? (3)
- suprasellar extension towards optic chiasm (–> bitemporal hemianopia)
- lateral extension into cavernous sinuses (CN palsies)
- downward extension into sphenoid
What is carcinoid syndrome?
Due to neuroendocrine tumour (NET) secreting serotonin
What are the clinical features of carcinoid syndrome? (6)
- flushing
- diarrhoea
- SOB
- abdominal pain
- Cushing’s-like symptoms due to ACTH secretion
- cardiac problems - tricuspid insufficiency and pulmonary stenosis
What is the first-line investigation for carcinoid syndrome?
Urinary 5-HIAA
What is the first-line management for carcinoid syndrome?
Octreotide (somatostatin analogue)
What are the clinical features of a non-functioning pituitary tumour? (4+3)
- headache
- bitemporal hemianopia - due to pressure on the optic chiasm
- panhypopituitarism - tumour may compress other parts of pituitary –> generalised panhypopituitarism:
- low ACTH –> tiredness, postural hypotension
- low FSH/LH –> amenorrhoea, infertility, loss of libido, small testes, loss of axillary and pubic hair
- low TSH –> feeling cold, constipation
- hyperprolactinaemia (due to low dopamine) –> acne, hirsutism, amenorrhoea, galactorrhoea, gynaecomastia
How can bitemporal hemianopia in non-functioning pituitary tumours be classified further? (2)
- if upper quadrant defect > lower quadrant defect –> inferior chiasmal compression caused by a pituitary tumour
- if lower quadrant defect > upper quadrant defect –> superior chiasmal compression caused by a craniopharyngioma
What are some features of panhypopituitarism, seen in non-functional pituitary tumours? (3)
- low ACTH –> tiredness, postural hypotension
- low FSH/LH –> amenorrhoea, infertility, loss of libido, small testes, loss of axillary and pubic hair
- low TSH –> feeling cold, constipation
How do prolactinomas present (pituitary tumours) in men vs women?
- men - impotence, loss of libido, galactorrhoea
- women - amenorrhoea, infertility, galactorrhoea, osteoporosis
What additional macroadenoma signs can you see in prolactinomas? (3)
- headache
- visual disturbances
- hypopituitarism signs - prolactinoma compresses pituitary stalk
How would acromegaly (pituitary tumours) present? (5)
- OSA
- excess sweating
- large tongue (macroglossia)
- increase in hand and shoe size
- cardiomyopathy
- (coarsening of facial features, prognathism, large nose)
What is the first-line investigation done for pituitary tumours?
Brain MRI (identify if micro- or macroadenoma)
What specific bloods do we do for pituitary tumours?
Pituitary blood profile - to determine whether mass is functioning or non-functioning
- GH
- prolactin
- ACTH
- FSH
- LH
- TFTs
What investigations would we do for suspected acromegaly (pituitary tumour)?
- initial: serum IGF-1 (elevated)
- then, as diagnostic investigation: OGTT with serial GH measurements - would see a paradoxical rise (no suppression) in GH following glucose load
- serum GH is less reliable as an Ix as it is pulsatile
What investigation do we do for suspected prolactinoma (pituitary tumour)?
Serum prolactin - will be high
What can cause lactotroph hyperplasia?
Pregnancy
What other investigation can we do for pituitary tumours?
Visual field testing - identify bitemporal hemianopia
How do we manage a microadenoma or asymptomatic macroadenoma (pituitary tumours)?
Observation
(Consider hormone replacement, consider trans-sphenoidal surgery)
How do we manage a symptomatic macroadenoma (pituitary tumour)?
Trans-sphenoidal pituitary surgery
Consider hormone replacement, dopamine agonist or somatostatin analogue (octreotide)
What is the first-line management of pituitary apoplexy (acute)?
Glucocorticoid +/- levothyroxine
What is the management plan for prolactinomas (pituitary tumours)?
- 1st line: cabergoline/bromocriptine (dopamine agonists)
- 2nd line: surgery (trans-sphenoidal if >1cm)
- radiotherapy
What is the management plan for acromegaly (pituitary tumours)?
- 1st line: trans-sphenoidal surgery
- 2nd line: octreotide (somatostatin analogue)
What are some complications of pituitary tumours? (6)
- hypopituitarism
- diabetes insipidus
- meningitis
- pituitary apoplexy
- visual loss
- prolactinoma - reduced fertility, osteoporosis
Describe the prognosis of pituitary tumours.
Patients with clinically non-functioning pituitary adenomas generally have a good prognosis
