space occupation and management of pituitary tumoura?

Question 1

what does this MRI show?

Answer 1

Question 2

in what direction does a pituitary tumour grow?

Answer 2

upwards

Question 3

label the different features of this MRI?

Answer 3

Question 4

what visual feild defect is caused by a pituitary adenoma?

Answer 4

Question 5

how is hypersecretion caused by pituitary tumours managed?

Answer 5

dopamine agonists (prolactinoma)

somatostatin analogues (acromegaly)

GH receptor antagonist (acromegaly)

Question 6

how is hyposecretion from pituitary tumours managed?

Answer 6

cortisol, T4, sex steroids, GH
desmopressin

Question 7

how is the pituitary tumour itself managed?

Answer 7

surgery (mostly transsphenoidal)
radiotherapy

Question 8

Wife was watching a TV programme on acromegaly
Symptoms for 7-10 years
Shoe size up by 5-6 sizes, ring no longer fits
Headaches and sweats
O/e Clinical features of acromegaly
Visual field restriction
IGF1 150nmol/l(N: 15-38)
GH 10-17mcg/l, OGTT – failed to suppress

what would the treatment be for this man?

Answer 8

IGF1 150nmol/l(N: 15-38)
GH 10-17mcg/l, No suppression on OGTT
MRI 5cm pituitary tumour
Transphenoidal Surgery April 2009
Lanreotide (SSA) 2008-2011
Radiotherapy 2010
Pegvisomant (GHR antagonist) 2010-
Nebido (Testosterone injection)

Question 9

when is pituitary surgery via transphenoidal approach nessecary?

Answer 9

for non-functional pituitary
tumours and Cushing’s disease

Question 10

what are the beneficial effects of somatostatin analogues in acromegaly?

Answer 10

Improve soft tissue overgrowth, sweating, headache, sleep apnoea in most patients

Normalise GH and IGF-1 levels in over 50% patients

Induce tumour shrinkage in the majority

Reduce morbidity & mortality from acromegaly

Question 11

how are somatostatin analogues administered?

Answer 11

Question 12

what are adverse effects of somatostatin analogues?

Answer 12

Nausea, cramps, diarrhoea, flatulence (often transient)

Cholesterol gallstones occur in 20-30% (mostly asymptomatic)

Slow-release preparations require monthly IM/SC injections

High cost (£6-12,000 annually)

Question 13

what are the negative effects of pituitary radiotherapy?

Answer 13

use declining, acts slowly,
causes hypopituitarism

Question 14

how is Microprolactinoma treated?

Answer 14

Treatment with dopamine agonists

Usually women with galactorrhoea, amenorrhoea, infertility & serum PRL <5000 mU/l (N<500)
With cabergoline normoprolactinaemia, ovulatory cycles & fertility restored in 70-90%
Most shrink

Question 15

what are typical responses to treatment of macroprolactinome with dopamine agonists?

Answer 15

Rapid fall in serum PRL (hours)
Tumour shrinkage (days/weeks)
Visual improvement (often within days)
Often recovery of pituitary function

80-90% tumours show these responses & most will shrink by at least one half

Question 16

Visual failure (6 months) (L) 6/60, (R) 6/24
Impotence (5 years)
Serum PRL 102,000 mU/l (N<300)
Expressible galactorrhoea
MRI: 3cm macroadenoma

how would treatment follow?

Answer 16

Has completed 16 years of cabergoline therapy
Now reduced to one tablet weekly (0.5mg)
Serum PRL 200 mU/l
Suprasellar extension gone
Vision essentially normal