Common Types of Pituitary Tumors
Laura Knecht MD
Medical Director of the Barrow Pituitary Center

• Pituitary tumors comprise 10-15% of all intracranial tumors
– Gliomas – Meningiomas - Pituitary adenomas
• 10% of all surgically resected tumors
• Affects up to 20% population (1 in 5)
• Majority arise from anterior pituitary gland

• Classified based on size, secretory abilities, histology
• <10mm-microadenomas
• >10mm-macroadenomas
• Beyond sella-giant adenomas

• M:F
• Females
– Present with micoadenomas
– Age 20-30
– Hormone dysfunction
• Menstral irregularities
• Infertility
• Males
– Present with macroadenomas
– Age 40-50
– Mass effect
• HA
• Visual compromise

• FSH/LH-Gonadotroph adenomas
– Nonfunctioning, rarely functions
• Prolactin-Prolactinomas
– Most common
• TSH-TSHomas
– Rare cause of hyperthyroidism, <1% pituitary adenomas

• GH-Acromegaly
– Can be cosecretors with GH/prolactin
• ACTH-Cushing’s Disease
– 2/3 of causes of Cushing’s Syndrome

• 30% of all pituitary tumors
• No evidence of hormonal hypersecretion
• Large at presentation
• Mass effects
– HA
– Visual field deficits
– Hypopituitarism

• Hypopituitarism
– GHRH – FSH/LH/prolactin – TSH - ACTH
• Elevated prolactin from stalk effect
• Compression of optic chiasm
– Bilateral superior temporal hemianopsia
• Lateral growth into cavernous sinus
– Cranial nerve palsies

• Headache
– Pressure on dura
– Blood products
– Cystic components
• Pressure on frontal/temporal lobes
– Hydrocephalus
– Memory issues

• ACTH, 8am cortisol
• TSH, free T4, free T3
• Prolactin
– With 1:100 dilution if macroadenoma
• GH, IGF-1
• FSH, LH, total testosterone/estradiol
• Alpha subunit

• Pituitary protocol
• Gadolinium
• 3T
• Dynamic protocol
• Experience of center

• Formal visual fields
• Visual acuity
• Health of optic nerves

• Most common hormonally active tumor
• F>>M
• Microadenomas
– Benign, regress spontaneously, can have no growth
• Macroadenomas
– Present w/ pressure symptoms, increase in size, rarely disappear

• Clinical features dependent on prolactin level, mass effects, hypopituitarism
• Gender, age, tumor size
• Prolactin stimulates milk in Estrogen-primed breast
• High prolactin inhibits GnRH which decreases
FSH/LH which decreases testosterone/estrogen

• Infertility
• Menstral disturbances
• Bothersome galactorrhea
• Enlarging tumor
• Apoplexy w/ headache

• Medications
– 1 st line treatment regardless of size
• Surgery
– In resistant prolactinomas
– Intolerance to both dopamine agonists
• Radiation
– For residual/recurrent tumor

• Cabergoline
– Better tolerated
– Fewer side effects
– More likely to normalize level
– No increased risks in pregnancy
– ½ life-2-3days
– Effective dose 1-1.5mg twice a week, resistant prolactinomas 7-12mg/week

• Cabergoline
– May be fast metabolizers
• Change to every day or every other day
– Valvulopathy
• Mitral valve stenosis
• May be reversible
• ? role of echocardiogram

• Bromocriptine
– Cheaper
– ½ life-8hrs
– Should be 2-3 times daily
– Common dose up to10mg every night or 5mg twice a day
– Doses >20-40mg not more efficacious
– Preferred agent in pregnancy
– No risk of valvulopathy

• Nausea
• Lightheadedness
• Mental fog
• Worsening of depression
• Psychotic reaction
• Minimize if take at night, start low, go slow, take w/ snack

Use of Hormone Replacement in
Prolactinomas (Estrogen
• Possible growth of tumor
• In combo w/ dopamine agonists-safe
• No prospective studies when used alone
• Would not use if chiasmopathy
• Monitor prolactin regularly

• Risk of micro growing-1-3%
• Risk of macro growing-<15%
• Stop medication once pregnant
• Go thru pregnancy, breastfeeding, restart if amenorrhea, future fertility
• Monitor for headache, vision changes
• Can get MRI not Gadolinium
• May have issues w/ lactation
• Role of debulking if macroadenoma, chiasmopathy

• Degree
• Duration
• Presence/absence androgen excess
• Cause
• Tumor related symptoms
• Age

• Obesity
• Moon facies
• Dorsal cervical fat pad
• Exophthalmos
• Periorbital edema
• Conjunctival injection
• Chest/facial plethora
• Growth retardation
• Skin atrophy
• Easy bruisability
• Striae
• Hyperpigmentation
• Hirsutism
• Acne

• Fungal infections
• Cardiovascular complications
– Stroke, heart attack
• Proximal myopathy
• Psychiatric disturbances
• Menstrual abnormalities
• Osteoporosis
• PCOS (Polycystic Ovarian Syndrome)
• Diabetes/impaired glucose tolerance

• 1 mg overnight dexamethasone
– Take at 11pm
– Draw cortisol at 8am
– Cortisol < 1.8
m g/dL – r/o hypercortisolism
– Cortisol > 5mg/dL = hypercortisolism

• 24 hour urinary free cortisol
– If >3x normal, diagnostic of true Cushing ’ s
– Lesser elevations require confirmation
– False elevations of UFC
• Physical stress
• Exercise
• Large volume intake
• Medications

• Bedtime/11pm salivary cortisol (series of 2-3)

Overnight High Dose
Dexamethasone Suppression
• Dexamethasone 8mg by mouth at 11pm
• Serum cortisol at 8am
• Will suppress in pituitary source
– Cortisol <1.8
m g/dL
– Cortisol <50% of baseline

Inferior Petrosal Sinus Sampling/IPSS

• Goal is for cure
– Immediate post-op cortisol <2-3 m g/dl within 24-
72hours
• If not cured, consider
– Repeat surgery
– Radiation treatment

• Dosing 200-400mg BID-TID
• Side effects
– HA
– Sedation
– Nausea/vomiting
– Gynecomastia
– Decreased libido
– Impotence
• Life threatening-reversible hepatotoxicity

• Dosing 300mg daily
• Maximum dose 1200mg daily
• Maximum dose in hyperglycemia 600mg daily
• Side effects
– Adrenal insufficiency
– Peripheral edema
– Hypertension
– Headache
– Hypokalemia
– Endometrial hypertrophy
• Cannot follow cortisol levels

• Dosing 600-900 mcg subcutaneously twice daily
• Decrease in cortisol, ACTH, salivary cortisol
• Signs and symptoms improved
• Side effects
– Hyperglycemia
– Diarrhea
– Abdominal discomfort
– Gallstones

• Immediate cure
• Complication-Nelson’s Syndrome
– Vision loss
– Progression of pituitary tumor
– Dependent on glucocorticoids and mineralicorticoids

• Adrenal insufficiency results
• Treat w/ decreasing doses of steroids
– Initial dosing – hydrocortisone 40-80mg daily
– Wean over 6-24months
– Cosyntropin stimulation testing once off to confirm normal axis

• Lifelong
• Patients usually feel symptoms prior to abnormalities in testing
• Yearly cortisol, ACTH
• Scheduled MRIs
• Consider hypercortisolemia testing
– Late night salivary testing
– 24 hour urine free cortisol
– 1mg overnight dexamethasone suppression

• M=F
• Mean age 42-44
• Usually have diagnosis 7-10 years prior
• Premature mortality from cardiovascular disease with risk decreasing when normalize IGF-1, GH

• Change in facial features
– Enlargement in forehead, mandible, tongue, gap in teeth
• Enlargement of hands/feet
• Excessive sweating
• Dental malocclusions
• Sleep apnea

• Diabetes
• Hypertension
• Colon polyps
• Arthralgias
• Skin tags
• Carpal tunnel

• Cardiomyopathy/Congestive Heart Failure
• Diabetes/Insulin resistance
• Hypertension
• Obstructive sleep apnea
• Precancerous colon polyps
• Thyroid nodules

• Elevated GH
• Elevated IGF-1
• Lack of GH suppression to glucose load

• Surgery
– 1 st line treatment by experienced surgeon
• Medications
– Has been used as adjunctive vs primary medical therapy
• Radiation

• Post op day 1 GH<5 highly predictive of remission
• Remission if GH<1 after OGTT
• IGF-1 takes weeks to months to decrease because of delayed clearance

• Somatostatin analogs
• Dopamine agonists
• GH receptor antagonist

Somatostatin analogs-Octreotide
LAR(Sandostatin)/Lanreotide
(Somatuline)
• Improvement in symptoms - 90%
• Lower GH - 90%
• Normalize IGF-1 - 50-60%
• Reduce tumor size by 25%

Somatostatin Analogs-Octreotide
LAR(Sandostatin)/Lanreotide
(Somatuline)
• Side effects
– Transient abdominal discomfort
– Diarrhea
– Gallstones – 18%

• Improvement in symptoms - 90%
• Normalize IGF-1<20%
• Likely more effective in co-secreting tumors

• Elevates GH
• Normalize IGF-1 - 89-97% at 1 year
• Shot subcutaneously daily
• Can be combined w/ somatostatin analog once or twice weekly
– Decrease dose of somatostatin analog
– Improvement in cost savings

• Side effects
– Hepatitis picture
• Resolves w/ stopping med
– Enlargement of tumor
• Likely from termination of somatostatin analog

• Adjunctive therapy after surgery for residual/recurrent disease
• Starts working in 3-6mo, continues working 3-10 years
• GH falls 50% every 2-3years
• Normalization of IGF-1 rare prior to 5 years
• Normalize IGF-1 - 60-80%

• Baseline echo, repeat 1 year, prn
• Colonoscopy every 5years
• Thyroid u/s, fine needle aspirate all nodules >1cm
• A1c, Fasting lipid panel
• Hypertension
• Obstructive sleep apnea
• Carpal tunnel
• Joint pain/hip x-rays
• Bone density/DXA if hypogonadism, hyperprolactinemia

Barrow Neurological Institute
Corcept
Ipsen
KARL STORZ Endoskope