1. Jerome M. Volk III, HO V LSU Department of Neurosurgery
Pituitary Tumors
Jerome M. Volk III, HO V
LSU Department of Neurosurgery

2. Anatomy The pituitary gland weighs 0.6 g.
It is composed of an anterior adenohypophysial component in apposition with a morphologically, embryologically, and functionally distinct posterior neurohypophysial component.

3. Anatomy

4. Anatomy

6. Embryology Entirely ectodermal in origin Adenohypophysis
Develops from Rathke’s pouch
Upward invagination
Neurohypophysis
Develops from the infundibulum
Downward extension of the floor of the diencephalon

7. Endocrinology Anterior portion (Adenohypophysis)
Follicle stimulating hormone (FSH)
Leutinizing hormone (LH)
Adrenocorticotrophic hormone (ACTH)
Thyroid stimulating hormone (TSH)
Prolactin
Growth hormone (GH)

8. Hormone
Signs and symptoms of hypersecretion
Signs and symptoms of hyposecretion
Lab Values
FSH, LH
Clinically silent
Mood swings, impotence, vaginal dryness, hot flashes, osteoporosis, decreased libido
LH, FSH, Serum testosterone, Serum estradiol
ACTH
Cushing’s disease-moon facies, buffalo hump, puple striae, hypertension
Weight loss, nausia, hyponatremia and hypoglycemia, hypotension, fatigue
Serum cortisol
TSH
Goiter, moist skin, tachycardia, palpitations, insomnia
Weight gain, fatigue, constipation, cold intolerance, bradycardia
TSH, free T4

9. Hormone
Signs and symptoms of hypersecretion
Signs and symptoms of hyposecretion
Lab Values
Prolactin
Menstrual irregularites, infertility, galactorrhea, weight gain
Silent GH
Acromegaly-overgrowth, carpal tunnel, hyperhidrosis
Dwarfism, fatigue, osteoporosis, weight gain
IGF-1, GH

10. Endocrinology Posterior gland (Neurohypophysis) Oxytocin
Uterine contractions and lactation
Anti-diuretic hormone
SIADH-increased water resorption, low sodium
DI-increased urination, high sodium

11. Epidemiology
Pituitary tumors account for 10-15% of all primary brain tumors
Highest incidence between the 3rd and 6th decade
More common in women
Genetic predisposition seen only in MEN-1.
Although this accounts for only 3% of pituitary tumors

12. Sellar masses: Tumors Adenohypophysial origin Neurohypophysial origin
Pituitary adenoma (macro and micro)
Pituitary carcinoma
Neurohypophysial origin
Granular cell tumor
Nonpituitary origin
Meningioma
Glioma
Craniopharyngioma
Germ cell tumor

13. Sellar masses:
Cysts and Hamartomas: Epidermoid, arachnoid, rathke cleft, dermoid, hypothalamic hamartoma
Metastatic: carcinoma, lymphoma
Infammatory: sarcoidosis, langerhans cell histiocytosis, lymphocytic hypophysitis
Vascular: aneurysm, cavernoma

14. Pituitary Adenoma
Classified by:
Endocrine/Clinical
Pathology
Imaging

15. Pituitary Adenoma Prolactinoma: 30% of pituitary adenomas
More commonly micradenomas
Present as amenorrhea with galactorrhea
Prolactin levels > 200 ng/ml (if less worry about stalk effect)
First line treatment is pharmacologic
Dopamine agonists (bromocriptine

16. Growth Hormone Secreting Tumor
Most commonly macroadenoma
Occur in the 4th and 5th decade
Coarse facial features, thickening of lips, enlargement of nose
GH level > 5 ng/ml
Initial treatment is surgery

17. Corticotroph Secreting Adenomas
8-10% of pituitary tumors
Cushing’s Disease
Hypercortisolemic state generated in response to an ACTH-secreting pituitary tumor.
Weight gain, truncal obesity, buffalo hump
Free cortisol level
no cortisol suppression on low-dose dexamethasone testing, cortisol suppression on high-dose dexamethasone testing, and moderately elevated ACTH levels
Surgery is best option

18. Thyrotroph adenomas Clinically silent
Less than 1% of pituitary adenomas
Manifest with signs of hyperthyroidism
High TSH with high Free T4
Surgery is first option
Clinically silent
1/4th of pituitary tumors

19. Presenting signs and symptoms:
Pituitary hyperfunction
Pituitary insufficiency
Mass effect
Headache-pressure on V1 at diagphragma sella
Loss of vision-compression of optic chiasm
Hydrocephalus-compression on third ventricle
Hypothalamic abnormality-sleep, alertness, emotion

21. Labs and images Imaging: Labs: Visual Fields:
MRI brain with and without IV contrast (include thing cuts through pituitary)
Tumor enhances less than gland
Labs:
Prolactin, FSH, LH, GH, ACTH, testosterone, GH, cortisol, IGF-1
Visual Fields:
To be performed by an ophthomalogist

22. Visual Fields

23. 9 months later

24. MRI

25. MRI

26. Surgical indications:
Progressive mass effect
Worsening of vision
Failure of prior treatment
Pharmacologic
Prolactinoma
Cushing’s disease
Radiation

27. Surgical indications:
Pituitary Apoplexy
The abrupt and occasionally catastrophic acute hemorrhagic infarction of a pituitary adenoma
Present with acute headache, meningismus, visual impairment, ophthalmoplegia, and alteration in consciousness
Glucocorticoid replacement is the most important first step due to adrenal insufficiency
Followed by urgent surgical decompression

28. Pituitary Apoplexy

29. Surgical Approaches: Transsphenoidal Transcranial Endoscopic Endonasal
Sublabial transseptal
Transcranial
Pterional
Subfrontal

30. Transsphenoidal

31. Transsphenoidal
Endonasal
Sublabial

32. Transsphenoidal

33. Transsphenoidal

34. Transsphenoidal

35. Transcranial

36. Transcranial

37. Transcranial

38. Transcranial

39. Transcranial

40. Post-operative Complications:
Diabetes Insipidus
Follow urine output and Sodium levels
CSF leak
Check for rhinorrhea
Hemorrhage/Apoplexy
Worsening vision

41. Thank you