1. Morbidity and Mortality Conference Ann Marie Lam, PGY-2 Emory University School of Medicine Family Medicine Residency Program October 14 th, 2010

2. Pituitary Adenoma Macroadenoma (>1 cm) Rarely malignant Hormone overproduction/deficiency Can become locally invasive Can lead to CN palsies Can lead to pituitary apoplexy Can be associated with MEN I syndrome Risk of recurrence

3. Treatment Medical therapy: correction/replacement of hormone overproduction/deficiency Surgical therapy: decompression, resection Radiation an option for adjunctive therapy

4. Types of Pituitary Adenoma Prolactinoma (PRL) (35%) Acromegaly (GH) (20%) Cushing Disease (ACTH) (7%) Gonadotropin-Producing Adenoma (LH, FSH) (<1%) Non-secretory Adenoma (30%) TSH-Secreting Adenoma (<1%) Diabetes Insipidus (lack of VP)

5. Prolactinoma Presentation: amenorrhea, galactorrhea, infertility, (in men: impotence, dec libido) Diagnosis: PRL level >200 ng/ml, R/O prolactinemia from mass effect Treatment (large, sympt): Bromocriptine, cabergoline (dopamine analog, inhibits PRL)

6. Acromegaly Presentation: coarse facial features, oily skin, carpal tunnel syndrome, OA, increased hat/glove/shoe size, DM Diagnosis: elev ILGF-1, elev post-prandial GH on 100 g OGTT (failure to suppress GH to <2 ng/ml diagnostic) Treatment: Octreotide SC (somatostatin analog), bromocriptine

7. Cushing’s Disease Presentation: truncal obesity, striae, round facies, hirsutism, HTN, DM, thin skin Diagnosis: elev 24-hr urine cortisol, dexamethasone suppression test (1mg dex, night cortisol) Treatment: ketoconazole (inhibits steroid synthesis)

8. TSH-secreting adenoma Presentation: goiter, thyrotoxicosis, visual impairment Diagnosis: elev TSH, T3, T4 Treatment: surgery, octreotide

9. Non-secretory adenoma Usually large at time of presentation Presentation: bitemporal hemianopsia, CN defects (cav sinus compression), hypopituitarism Evaluation: assess pituitary function, VF testing Treatment: surgery, +/-radiation

10. Long-term follow-up Post-op 4-6 wks to confirm adenoma completely removed and hypersecretion resolved Monitor yearly for recurrence, hypopituitarism

11. Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment

12. Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment Multi-disciplinary approach led by primary team leading

13. Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment Multi-disciplinary approach led by primary team leading Consider transferring patient to primary care- providing team

14. Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment Multi-disciplinary approach led by primary team leading Consider transferring patient to primary care- providing team Patient-oriented care

15. Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment Multi-disciplinary approach led by primary team leading Consider transferring patient to primary care- providing team Patient-oriented care Patient responsibility

16. References Harrison’s Principles of Internal Medicine. 16 th edition. Disorders of the anterior pituitary and hypothalamus, 2005. Ferri’s Clinical Advisor. Pituitary adenoma, 2010. Klibanski, A. Prolactinomas. NEJM 362: 1219- 1226, April 2010. Melmed, S. Medical Progress: Acromegaly. NEJM 355: 2558-2573, Dec 2006. Pituitary adenoma. UpToDate. Accessed 9/29/10.