Pituitary adenoma

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Pituitary Adenoma Dr. Ashraful Huq (Ridoy) FCPS +8801811999070 Bangladesh Eye Hospital Ltd. Dhaka, Bangladesh

Transcript of Pituitary adenoma

Pituitary Adenoma

Pituitary Adenoma

Dr. Ashraful Huq (Ridoy)FCPS+8801811999070Bangladesh Eye Hospital Ltd. Dhaka, Bangladesh

Introduction

Thepituitary gland, orhypophysis, is anendocrine gland

Produce number of hormones which control the secretions of many other endocrine glands

Its anatomical position is important in ophthalmological view

DevelopmentThe anterior pituitary (adenohypophysis)arises fromRathke's pouch, an upward growth from the ectodermal roof of the stomodeum

Theposterior pituitary (neurohypophysis) arises from a downward growth from the floor of the diencephalon

AnatomyOccupies a cavity of the sphenoid bone called sella turcica at the middle cranial fossa

Roof is formed by diaphragma sellae

The stalk of pituitary is attached above to the floor of third ventricle

Size of a pea (< 8 mm)

It weighs about 0.5 gm.

SecretionsAnterior Lobe:FSHLHACTHTSHProlactinGHPosterior Lobe:ADHOxytocin

Pituitary AdenomaBenign tumors of pituitary gland

EpidemiologyEtiology is unknown

10-15% of all primary brain tumors

75% of adenomas are endocrinogically secreting

25% of those with MEN-I develop pituitary adenomas

ClassificationHormonesClinical featuresSecreting (75%)Chromophobes (50%)ProlactinFemale: Infertility, amenorrhea, galactorrheaMale : Hypogonadism, impotency, sterility, libido, gynecomastia, galactorrheaAcidophils (20%)GHAcromegaly(adult) Gigantism(child)Basophils(5%)ACTH, FSH & TSHCushing disease, FSH & TSH tumorsNonsecreting (25%)

ClassificationMicroadenoma < 10 mm diameterSecreting adenoma

Macroadenoma > 10 mm diameter Mass effectsNon secreting

Clinical presentationLocalized mass effectsChiasmal syndromes

Compression of other adjacent structures ~ Cavernous sinus (paresis of 3rd, 4th or 6th CN causing disorders of extraocular motility)

~ Hypopituitarism (direct pressure, vascular damage)

~ Papilloedema (raised ICP, very rare)

Endocrine effectsHypersecretion

Hyperscretion

Growth HormoneACTH

HyperscretionProlactinFemaleInfertility-amenorrhea- galactorrheaMaleHypogonadism, impotence, sterility, libido, gynecomastia, galactorrhea

HyposcretionGrowth hormone deficitIn children: dwarfismIn adults: weakness,overweight, reduced cardiac output, low blood sugar levels, and reduced exercise tolerance

TSH deficitHypothyroidism

ACTH deficitUnderactive adrenal gland, which causes low blood pressure,hypoglycemia, fatigue, weight loss, vomiting, and low stress tolerance

ADH deficitDiabetes Insipidus

Chiasmal SyndromesBlurred vision

Headache

Diplopia

Colour desaturation

Visual field defect

Optic atrophy

Post fixation blindness

Visual hallucination

See-Saw nystagmus

Visual field defect in pituitary adenomaBitemporal hemianopia

Incongruous homonymous hemianopia

Bitemporal central scotoma

Diffuse scotoma

Junctional scotoma

Bitemporal hemianopiaClassic defect in pituitary adenoma

Occurs in central chiasmal defect

Superotemporal field affected first Lower temporal field defect

Incongruous homonymous hemianopia

Occurs in optic tract lesion

Occurs in post. Chiasmal lesion

Compressing only the macular fibers

Bitemporal central scotoma

Junctional scotomaCentral scotoma in one eye with superotemporal visual field loss in the other eye

Caused by compression to anterior loop to the decussating nasal fibers in posterior optic nerve (Von Wilbrand's knee)

Fundus picture

Bow tie atrophy

Diffuse atrophy

Bow tie atrophy

Pituitary apoplexyLarge adenoma leading to haemorrhage or infarction of pituitary gland

Occur in pregnancy

Compresses hypophysial portal vessels

Presentation: hyperacute chiasmal syndrome

Treatment : high dose steroid / surgery

Ocular ExaminationVisual acuity

RAPD

Color vision

Ocular motility

Fundus examination

InvestigationsEndocrinological evaluation Serum prolactinFSHTSHGHInsulin stress test

Ocular investigationVisual Field AnalysisHess / Lees chart

Imaging MRI / CT scan of brainX-ray skull (Ant. & Lat. view)

TreatmentReferral to Endocrinologist & Neuro-surgeon

Observation

Medical therapyDopamine agonists Cabergoline/Bromocriptine

Surgery When mass causing severe compressionEndoscopic - Transphenoidal, transfrontalCraniotomyVisual recovery is tri-phasic

TransfrontalTrans-sphenoidalSurgeryRadiotherapy ObservationMedical therapy

Radiotherapy Following incomplete removal of tumourPrimary treatment

Gamma knife stereotactic radiotherapyClose proximity to the optic nerveCavernous sinus invasion

Therapeutic Modalities SummarySurgeryRadiotherapyMedicalNon-functioning adenoma1st line2nd line-Prolactinoma2nd line2nd line1st line

Acromegaly1st line2nd line2nd line

Cushings disease1st line2nd line-

Follow-up after treatmentMedical therapy Monthly for large tumors or during pregnancy for tumors of any size6 month intervals in microadenoma for 1 year, then yearly

Surgery Immediately postoperatively4-6 weeks postoperatively4 months intervals for a yearYearly for 5 years Every 2 years

Radiotherapy At the midpoint and end of radiotherapy3 months interval for a year6 months interval for a yearYearly

Evaluation - Visual acuityFundoscopy Visual fieldImaging

Conclusions Pituitary adenomas occurs with a wide spectrum of clinical features

Should be managed between different specialists

Neuro-ophthalmological manifestations are frequent and varied

Physicians must be aware about these in order to refer patients to ophthalmologist for early diagnosis and treatment