pituitary adenoma

Pituitary

macroadenoma co-existent with supraclinoid internal carotid artery cerebral aneurysm: a case report and review of the literature. Axial (A) and Coronal (B) view of T2-weighted MRI showing a round flow-void mass in the right supraclinoid ICA associated with a pituitary macroadenoma.

casesjournal.biomedcentral.com • CC-by-2.0

Magnetic

resonance imaging of sellar and juxtasellar abnormalities in the paediatric population: an imaging review. Pituitary adenomas. Sagittal post-contrast fat-suppressed T1WI (a) shows an heterogenously enhancing pituitary macroadenoma which contains a non-enhancing portion with high signal on T2WI (b). secondary to cystic degeneration. Coronal post-contrast fat-suppressed T1WI (c) shows a pituitary microadenoma which shows less early contrast enhancement than the normal pituitary tissue

insightsimaging.springeropen.com • Open Access

Pituitary

microadenoma • Pituitary microadenoma - Ganzer Fall bei Radiopaedia

Gaillard, F. Pituitary microadenoma. Case study, Radiopaedia.org. (accessed on 20 Oct 2022) https://doi.org/10.53347/rID-4725 • CC by-nc-sa 3.0 (modified)

Pituitary

macroadenoma • Pituitary macroadenoma - null cell - Ganzer Fall bei Radiopaedia

Gaillard, F. Pituitary macroadenoma - null cell. Case study, Radiopaedia.org. (accessed on 20 Oct 2022) https://doi.org/10.53347/rID-5562 • CC by-nc-sa 3.0 (modified)

Pituitary

adenoma/PitNET • Prolactinoma - medically treated - Ganzer Fall bei Radiopaedia

Jabaz D, Prolactinoma - medically treated. Case study, Radiopaedia.org (Accessed on 19 Apr 2024) https://doi.org/10.53347/rID-158348 • CC by-nc-sa 3.0 (modified)

Radiopaedia • CC-by-nc-sa 3.0 • de

Pituitary adenomas are primary tumors that occur in the pituitary gland and are one of the most common intracranial neoplasms.

Depending on their size they are broadly classified into:

pituitary microadenoma: less than 10 mm in size
pituitary macroadenoma: greater than 10 mm in size

Although this distinction is largely arbitrary, it is commonly used and does highlight an important fact: small intrapituitary lesions (microadenomas) present differently and have different surgical and imaging challenges from larger lesions (macroadenomas) that extend into the suprasellar region. As such, it is not unreasonable to discuss them separately. This article is a general overview.

Epidemiology

Pituitary adenomas are common, with rates varying widely depending on the definition: population prevalence is approximately 0.1%; autopsy prevalence is around 15% . They account for approximately 10% of all intracranial neoplasms and 30-50% of all pituitary region masses .

Pituitary macroadenomas are approximately twice as common as microadenomas .

A minority of tumors are associated with multiple endocrine neoplasia type I (MEN I), multiple endocrine neoplasia type IV (MEN4), Carney complex, McCune-Albright syndrome, and familial isolated pituitary adenoma.

Clinical presentation

Pituitary adenomas present either due to hormonal imbalance (both microadenomas and macroadenomas) or mass effect on adjacent structures (macroadenomas), classically the optic chiasm. Rarely presentation can be catastrophic, due to pituitary apoplexy.

Hormone imbalance

Over half of all adenomas are secretory , although even when this is the case this may not be the cause of presentation. A lack of libido or even galactorrhea may not lead to presentation and as such many secreting tumors are only diagnosed when mass effect occurs (see below).

Hormones secreted include:

secretory: ~65%
- prolactin: ~50%
- growth hormone (GH): 10%
- adrenocorticotropin (ACTH): 6%
- thyrotropin (TSH): 1%
- mixed
non-secretory: ~35% most tend to be macroadenomas

It is also important to note that larger tumors can lead to hormonal imbalance due to mass effect rather than secretion. Hypopituitarism or moderately elevated prolactin are both seen, the later due to so-called stalk effect; prolactin release (unlike other pituitary hormones) is tonically inhibited by prolactin inhibitory hormone (PIH - a.k.a. dopamine) and as such compression of the pituitary infundibulum can result in elevation of systemic prolactin levels due to interruption of normal inhibition. It is also important to remember that numerous drugs that are dopamine antagonists will also elevate prolactin - see elevated prolactin (differential) .

Mass effect

Most of the cases presenting due to mass effect are due to non-secreting macroadenomas and the most common structure to be compressed by a macroadenoma is the optic chiasm. Invasion into the cavernous sinus is also encountered, with occasional compression of the oculomotor (CN III) or less frequently abducens (CN VI) nerves. Uncommonly large tumors may result in hydrocephalus (by compressing the midbrain or distorting the third ventricle), orbital or sinonasal symptoms.

Pathology

Location

Very rarely pituitary adenomas may be seen in extra-sellar ectopic locations, most commonly within sphenoid sinus. It may also be found in suprasellar region, cavernous sinus, parasellar region, clivus, nasal cavity, nasopharynx, temporal bone and third ventricle.

Radiographic features

Radiographic features are discussed separately:

Treatment and prognosis

Treatment of pituitary adenomas depends on a number of factors:

size and presence of symptoms related to the mass effect: these will often necessitate surgical decompression regardless of cell type
cell type: prolactin and growth hormone-secreting tumors can often be treated medically

Surgical management

The most commonly employed approach to pituitary masses is transsphenoidal, whereby the floor of the pituitary fossa is accessed via the nasal cavity. In large tumors, other approaches may be necessary (e.g. craniotomy).

Medical management

Medical management of prolactinomas relies on administering a dopamine receptor agonist (e.g. bromocriptine or cabergoline). Although it can dramatically reduce the size of a macroadenoma, it has been associated with an increased incidence of hemorrhage into the tumor .

Growth hormone-secreting tumors are usually surgically resected, however, in recurrent cases or in patients who are not able to undergo surgery they can be treated with octreotide (a long-acting somatostatin analog). This can result in both reduction of the size of the tumor and reduction in the serum levels of growth hormone .

Stereotactic radiosurgery

Radiosurgery is also occasionally used. Its main complications are hypopituitarism (seen in up to 70% of cases). Less common complications include damage to the optic apparatus (optic nerves, chiasm, optic tracts), cranial nerves and internal carotid arteries .

Prognosis

Recurrent symptoms requiring further intervention is relatively common, with 18% of patients with non-functioning tumors and 25% of patients with prolactinomas eventually needing further treatment .