Workup/Staging

Question 1

With what signs/Sx do pts with nonsecretory pituitary tumors present?

Answer 1

Bitemporal hemianopsia (optic chiasm compression), HA (↑ ICP), oculomotor deficits: CNs III–IV, VI, V1–V2 (cavernous sinus compression), hydrocephalus (3rd ventricle compression), hyperprolactinemia (disruption of PL suppression from hypothalamus d/t compression of pituitary stalk), or panhypopituitarism (from general glandular disruption).

Question 2

With what signs/Sx do pts with secretory pituitary tumors present?

Answer 2

PL secreting (50%): galactorrhea, amenorrhea, infertility, and vaginal dryness for women, loss of libido, erectile dysfunction and infertility for men

GH secreting (25%): acromegaly

ACTH secreting (20%): Cushing Dz

TSH secreting (≤1%): hyperthyroid Sx

Question 3

What is the DDx of a pt with a pituitary mass?

Answer 3

Pituitary tumor, craniopharyngioma, meningioma, glioma, suprasellar germ cell, mets, and benign lesions (cyst, aneurysm, empty sella syndrome)

Question 4

What is the workup of a pt with a pituitary tumor?

Answer 4

Pituitary tumor workup: H&P (physical: CNs, visual field, endocrinopathy), labs, including hormone levels, thin-slice MRI through the base of skull, and tissue Dx (transsphenoidal resection)

Question 5

What lab findings are suggestive of a prolactinoma?

Answer 5

Normal prolactin is ∼2–25. If >100–200, prolactinoma is suspected, particularly in the setting of a pituitary mass.

Question 6

What are other causes of elevated PL?

Answer 6

Pregnancy, lactation, polycystic ovary syndrome, hypothyroidism (thyroid-releasing hormone from hypothalamus stimulates PL secretion), seizures, and cirrhosis

Question 7

What lab findings are suggestive of a GH adenoma?

Answer 7

GH >10 (not suppressed by glucose) and elevated IGF-1 are findings that suggest GH adenoma.

Question 8

What lab abnormalities are noted in Cushing Dz?

Answer 8

High cortisol not suppressed by low-dose dexamethasone and normal or ↑ ACTH

Question 9

What is Cushing syndrome?

Answer 9

Cushing syndrome is elevated cortisol d/t a variety of causes (e.g., adrenal production, exogenous use). Pts have low ACTH, unlike in Cushing Dz.

Question 10

What primary malignancies most commonly metastasize to the pituitary?

Answer 10

Breast and lung cancer. Usually in the setting of diffuse metastatic Dz with >4 other sites.