Pituitary tumor

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Pituitary Tumor Microchapters

Patient Information

Overview

Classification

Pituitary adenoma
Pituitary carcinoma
Craniopharyngioma
Urethritis
Asymptomatic bacteriuria

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Michael Maddaleni, B.S.; Ammu Susheela, M.D. [2]

## Overview

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Pituitary tumors are tumors that occur in the pituitary gland and account for about 10% of intracranial neoplasms. Pituitary adenomas are often remain undiagnosed. Small pituitary tumors are found in 6 to 24 percent of adults at autopsy. Pituitary tumors arise within the anterior lobe (adenohypophysis) of the gland. They may be classified according to the size of the tumor and type of hormone secretion. Pituitary adenomas subtypes include corticotrophic, somatotrophic, thyrotrophic, gonadotrophic, and lactrotrophic adenomas. There are no established causes for pituitary tumors. Patients with pituitary tumors may progress to develop lethargy, headache, nausea, and vomiting. Common complications of pituitary adenoma include bitemporal hemianopia, anosmia, acromegaly, gigantism, and Cushing's syndrome. Prognosis is generally good, and approximately 18% of patients with macroadenoma require further treatment. Pharmacologic medical therapy is recommended among patients with prolactinoma, thyrotrophic, somatotrophic, and adrenocorticotropic adenomas. The transsphenoidal microsurgical approach is the mainstay of treatment for growth hormone producing adenomas, adrenocorticotropic hormone-(ACTH) producing adenomas, and macroadenomas.

## Classification

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Pituitary tumors classified according to the 2017 World Health Organization (WHO):[1]

| Pituitary adenomas|

| Somatotroph adenoma|

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| Pituitary carcinoma|

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| Pituitary blastoma|

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| Tumors of posterior pituitary|

| Pituicytoma|

| Pituitary tumors|

| Craniopharyngioma|

| Adamantinomatous craniopharyngioma|

| Mesenchymal and stromal tumors|

| Meningioma|

| Hematolymphoid tumors|

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| Germ cell tumors|

| Germinoma|

| Secondary tumors|

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## Differential Diagnosis

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Disease | Clinical Findings | Laboratory Findings | Management

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Somatotroph adenoma:

Acromegaly

| Clinical features of acromegaly are due to high level of human growth hormone (hGH):

* Soft tissue swelling of the hands and feet
* Brow and lower jaw protrusion
* Enlarged hands
* Enlarged feet
* Arthritis and carpal tunnel syndrome
* Increase in teeth spacing
* Macroglossia (enlarged tongue)
* Heart failure
* Kidney failure
* Compression of the optic chiasma leading to loss of vision in the outer visual fields (typically bitemporal hemianopia)
* Headache
* Diabetes mellitus
* Hypertension
* Cardiomegaly

* Elevated insulin-like growth factor-1 (IGF-1) levels
* Elevated growth hormone levels

* Medical management:
* Octreotide
* Bromocriptine
* Surgical management:
* Endonasal transsphenoidal surgery
* Radiation therapy

Corticotroph adenoma:

Cushing's syndrome

| Clinical features of Cushing's syndrome are due to increased levels of cortisol:

* Rapid weight gain, particularly of the trunk and face with sparing of the limbs (central obesity)
* Proximal muscle weakness
* A round face often referred to as a "moon face"
* Excess sweating
* Headache
* The excess cortisol may also affect other endocrine systems and cause, for example:
* Insomnia
* Reduced libido
* Impotence
* Amenorrhea
* Infertility
* Patients frequently suffer various psychological disturbances, ranging from euphoria to psychosis. Depression and anxiety are also common.

* Dexamethasone suppression test
* 24 hour urinary measurement of cortisol

* Medical management:
* Pasireotide
* Cabergoline
* Ketoconazole
* Metyrapone
* Mitotane
* Mifepristone
* Surgical management:
* Transsphenoidal pituitary resection

Hypothyroidism | Clinical features of hypothyroidism are due to deficiency of thyroxine:

* Fatigue
* Cold intolerance
* Decreased sweating
* Hypothermia
* Coarse skin
* Weight gain
* Hoarseness
* Goiter
* Fullness in the throat and neck
* Depression
* Emotional lability
* Attention deficit

* Elevated TSH
* Low T4
* Low T3
* Elevated anti-thyroid antibodies(anti-TPO)

* Levothyroxine

Chronic renal failure | There are no pathognomonic symptoms associated with chronic renal failure. Common non-specific symptoms of chronic renal failure include:

* Malaise
* Nausea
* Unintentional weight loss
* Pruritus
* Lower extremity edema
* Sleep disorders

| Urinalysis:

* Albuminuria
* Hematuria
* Pyuria
* Red cell or white cell casts and crystals

Fluid and electrolyte disturbances:

* Hyponatremia
* Hyperkalemia
* Hyperphosphatemia
* Hyperchloremia
* Metabolic acidosis
* Hypocalcemia

Endocrine and metabolic disturbances:

* Hyperuricemia
* Hypertriglyceridemia
* Decreased HDL levels
* Vitamin D deficiency
* Increased Parathyroid hormone levels

Hematologic abnormalities:

* Normocytic normochromic anemia
* Lymphocytopenia
* Leukopenia
* Thrombocytopenia

* Medical management:
* Blood pressure management
* Control of blood glucose
* Protein restriction
* Management of anemia
* Management of electrolyte disturbance
* Dialysis
* Surgical management
* Kidney transplant

Liver disease: Cirrhosis | The clinical features of liver cirrhosis are very nonspecific. These include:

* Right upper quadrant abdominal pain
* Fever
* Fatigue and weakness
* Loss of appetite
* Diarrhea
* Nausea and vomiting
* Weight loss
* Abdominal pain and bloating when fluid accumulates in the abdomen
* Itching
* Menstrual irregularities

* Elevated aminotransferases (AST & ALT)
* Elevated alkaline phosphatase (ALP)
* Elevated gamma-glutamyl transpeptidase
* Elevated bilirubin
* Low albumin
* Elevated prothrombin time
* Elevated globulin
* Hyponatremia
* Anemia
* Leukopenia and neutropenia
* Thrombocytopenia

* Medical management:
* Treatment is usually directed towards the treatment of complications like ascites, esophageal varices, hepatic encephalopathy, hepatorenal syndrome, and spontaneous bacterial peritonitis.
* Some chronic constitutional symptoms that should be treated include:
* Pruritis: Cholestyramine is the drug of choice
* Hypogonadism: Topical testosterone preparations
* Osteoporosis: Calcium and vitamin D
* Pain management: NSAIDS, celecoxib, opioids
* Nutrition: Adequate caloric and protein intake, and multivitamin supplementation
* Surgical management: Liver transplantation

Seizure disorder | The clinical features of seizure disorder may include:

* Change in alertness, orientation and time perception
* Mood changes, such as unexplainable fear, panic, joy, or laughter
* Changes in sensation of the skin, usually spreading over the arm, leg, or trunk
* Vision changes, including seeing flashing lights
* Rarely, hallucinations (seeing things that aren't there)
* Falling, loss of muscle control, occurs very suddenly
* Muscle twitching that may spread up or down an arm or leg
* Muscle tension or tightening that causes twisting of the body, head, arms, or legs
* Shaking of the entire body
* Tasting a bitter or metallic flavor

* Electroencephalogram

* Medical management:
* Antiepileptic medications

Medication-induced | Clinical features of hyperprolactinemia after a specific period of regular medication ingestion  |

* Discontinuation of the medication for 3 days and remeasurement of prolactin levels[2]

* Change to alternate medication

## References

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1. ↑ Lopes MBS (2017). "The 2017 World Health Organization classification of tumors of the pituitary gland: a summary". Acta Neuropathol. 134 (4): 521–535. doi:10.1007/s00401-017-1769-8. PMID 28821944.
2. ↑ Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA; et al. (2011). "Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline". J Clin Endocrinol Metab. 96 (2): 273–88. doi:10.1210/jc.2010-1692. PMID 21296991.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)

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