Pituitary disorders Narendra Reddy Clinical Lecturer Diabetes, Endocrinology & Metabolism University of Warwick Grand round, UHCW, June 14 th 2011
Plan…. Pituitary anatomy Pituitary physiology Evaluation of Pituitary mass Pituitary dysfunction in Elderly Clinical scenarios/Images
Pituitary anatomy
Sagittal view
Coronal view
Hormones
Evaluation of Pituitary mass Local effects Hypersecretion Hyposecretion
Pituitary hormone profile Somatotroph – GH IGF-1 Gonadotroph – FSH,LH Testo/Oest Thyrotroph – TSH FT4,FT3 Corticotroph – ACTH Cortisol (SST) Lactotroph - Prolactin Neurohypophysis Vasopressin (U&E, Paired Osmol)
Case 82 yr old male Headache, diplopia, vomiting- Acute Hypotension- 90/45 mmHg & III N palsy PMH- IHD, Hypertension Drugs- Antihypertensives, Aspirin Diagnosis?
Investigations 9 am Testo- <0.4 (10-26) LH- 1.2, FSH- 0.7 (2-10) IGF-1 – 4.8 (10-35) PrL- 322 (<300) FT4 8.8 ( ), TSH 2.0 ( ) SST – 30’ Cortisol 213 nmol/L Na - 122; Pl Osm & U Osm - normal
Pituitary apoplexy
Pit apoplexy guidelines
Chronic hypopit’ symptoms GH- lethargy, reduced strength LH/FSH- libido, infertility, menstrual TSH – hypothyroid PrL- lack of milk in breastfeeding females ACTH – pallor Vasopressin – Diabetes Insipidus
Hypopituitarism Pituitary tumours Radiotherapy Apoplexy,Sheehan syndrome Infiltrative disorders Infective- TB, Pit abscess Trauma Metastasis Russell viper snake bite PIT-1, HESX-1, PROP-1, KAL-1, SOX-2, DAX-1, AVP-Neurohypophysin-II
Dynamic tests Insulin Tolerance Test- ACTH & GH Glucagon test – ACTH & GH SST- adrenocortical function Clomifene test – Gonadotrophin GnRH & TRH- rarely used
To take home…. Adenomas do not cause DI GH>FSH/LH>TSH>ACTH Long term hypopit patients, treated with steroids can unmask DI ACTH def–No Pigment/Hyperkalaemia
84 pts over 65 yrs (avg 72.5 yrs) 1975 to 1996 64 % VF defects 20 % hypopituitarism 7% pituitary apoplexy TSA safe in elderly
Pit tumours in elderly
Pituitary Incidentalomas 10% incidence in pituitaries Minimum 20 years F/U years Local, hypersecretion, hyposecretion 10.6% 1cm MRI – 1, 2 & 5 years- stop if no size Hypopit, VF defects & size increase- Sx Mark Molitch,Best Practice in Clinical Research 23 (2009) 667–675
42 yr man Headaches Reduced libido Erectile dysfunction Case
days 9 months 3 years
Prolactinoma Micro 1cm Medical treatment- Cabergoline Surgery- DA resistance/intolerance Radiotherapy DA Rx – Cardiac Valve fibrosis 1 st line- Sx 2 nd line- Mx 3 rd line-Dx
Case 20 year old boy Visual field problems Enlarged nose Carpal tunnel Syndrome
Acromegaly
Photos please...
2 nd line- Mx 1 st line- Sx 3 rd line- Dx
Case 40 years old lady 10 years of Diabetes Hypertension Hyperlipidaemia Osteoporosis Wt gain Acne
Cushings disease
Dr Harvey Cushing
Management ONDMST - Cortisol > 50 24 hr Urine Free Cortisol LDDMST >50 HDDMST CRH stimulation test Petrosal sinus sampling Surgery Radiotherapy B/L Adrenalectomy 1 st line- Sx 2 nd line-Dx 3 rd line- Sx
Non functioning Pit Adenomas(NFA)
NFA
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Rathkes cyst
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Craniopharyngioma
40 yr old female,Hypothyroid
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Lymphocytic hypophysitis
Young women Auto immune Prodromal illness VF defects Hormone deficiencies Bx- diagnostic
Meningioma
Hormones !!