Pituitary Incidentalomas Endocrinology Rounds Kristin Clemens PGY 5 November 7th, 2012

Objectives Epidemiology of pituitary incidentalomas Underlying causes Outline understanding of natural history Review recent practice guidelines on pituitary incidentalomas Illustrative cases for work up and management

Case – E.A. 70 year old man HTN, hypercholesterolemia Diovan, Crestor No family history Non smoker, rare ETOH, lives independently with wife

Acute onset memory impairment – ER Diagnosis of transient global amnesia CT to rule out stroke demonstrated 2 x 1.9 x 1.6 cm pituitary macroadenoma MRI encroachment of left cavernous sinus, touching L optic nerve

Pituitary MRI

How to assess him at follow-up endocrinology appointment?

Pituitary incidentaloma Previously unsuspected pituitary lesion discovered on an imaging study performed for an unrelated reason Increasingly common

Prevalence Estimated from pituitary adenomas found at autopsy and from imaging inpatients who underwent CT or MRI Combined autopsy data suggests frequency of 10.6%, distributed equally amongst genders, age range MRI and CT incidence of 4-38%

Etiology Rathke cleft cysts Craniopharyngiomas Meningiomas Pituitary hyperplasia Metastases Pituitary adenoma – 10% Macroadenoma >1cm Microadenoma <1 cm, most common Functioning and non-functioning

Pituitary Adenomas Variety of subtypes Data from small observational studies Buurman, 2006 Series of 3048 autopsy cases examined to detect incidence of subclinical adenomas in postmortem pituitaries 1991-2004

Buurman et al Found a total of 334 adenomas out of 3048 cases (10.4%) examined 157 males and 159 females Mean age of 73

Size range from 0.1 to 20 mm Only 3 were macroadenomas Some with multiple adenomas Multiple staining techniques

39.5% stained positive for prolactin 31.7% null cell adenoma/oncocytomas 13.8% stained positive for ACTH 7.2% for gonadotropins 1.8% stained positive for GH 0.6% for TSH 3% for multiple hormones Small percentage unclassified

Clinical history Clinical significance? 99 patients with HTN, 65 with diabetes No symptoms of adenohypophyseal hormone hypersecretion were reported Rare cases of clinical hypo and hyperthyroidism No clear correlation between clinical data and adenoma type in this sample

Natural History?

Small observational cohort studies

Fernandez-Balsells, 2011 Systematic review of longitudinal observational cohort studies that enrolled patients with: Incidentalomas (asymptomatic lesions) Non-functioning pituitary adenomas (mass effect/hypopituitarism) Followed without any treatment from the time of detection

Outcomes of interest including development of visual field defects, neurological defects, alteration in pituitary function, pituitary apoplexy

MEDLINE, EMBASE, Cochrane from 1966 through 2009 Abstraction of data in duplicate Event rate per 100 person years and associated 95% confidence interval

Subgroup analysis specified a priori according to tumour size at presentation (micro vs. macroadenoma), tumour characteristics (solid vs. cystic lesion), patients age and sex

Results 14 publications from 1069 references Small studies Majority single centre studies Limited quality Often >30 % lost to follow up

Median follow up of 3.9 years (range 1-15 years) Frequency of PI/NFPA’s higher in females Wide age range 5 months to 89 years

Among symptomatic patients most common complaint was headache at baseline Most common pituitary dysfunction at baseline was hypogonadism

Outcomes Outcomes reported in aggregate as unable to differentiate between incidentalomas and non-functioning pituitary macroadenomas Event rate per 100 PY’s Tumour growth 5.8 (5-6.5) Pituitary apoplexy 0.2 (0.0-0.2) Worsening of visual field defects 0.7 (0.5-0.8) Overall incidence of new endocrine dysfunction 2.4 (0-6.4) Significant heterogeneity

A priori subgroup analysis Greater event rate of growth in size in macroadenomas (12.5) compared with microadenomas (3.3) and cystic lesions (0.1)

Pituitary Incidentaloma: An Endocrine Society Clinical Practice Guideline 2011 Consensus guided by systematic review of evidence and expert opinion

Evidence developed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to describe strength of recommendations and quality of evidence +Very low quality ++++ High quality

Initial evaluation of a patient with a pituitary incidentaloma?

Recommendation 1.1.1 (+++) All patients with a pituitary incidentaloma should undergo complete history and physical and evaluation for hormone hypersecretion

What hormones to be assessed? Prolactin Adenoma, stalk compression Recommended as hyperprolactinemia treatable medically

Growth hormone Generally recommended as silent growth hormone secretion has been reported Medical comorbidity

ACTH Variable recommendations Cushing's with significant morbidity and risk of progression to overt Cushing’s One small study noted progression to overt Cushing disease in 4/22 or 18% of cases

Focused assessment of gonadotropins High gonadotropins rarely cause clinical symptoms so screening would not necessarily influence therapy Focused assessment of TSH Rare for TSH secreting adenomas

If hormonal overproduction treat medically or surgically as per guidelines

Recommendation 1.1.2 (+++) We recommend that patients with a pituitary incidentaloma with or without symptoms also undergo clinical and laboratory evaluations for hypopituitarism

Systematic review Hypopituitarism in 7/66 (10%) and 19/46 (40%) patients in smaller observational studies Hypogonadism in 30% Hypothyroidism 28% Adrenal insufficiency in 18% Growth hormone insufficiency in 8%

Favoured testing in macroadenomas but variable amongst contributors

Recommendation 1.1.3 (++++) We recommend that all patients presenting with a pituitary incidentaloma abutting or compressing the optic nerves or chiasm on MRI undergo formal visual field testing

Growth may lead to sight loss 5-15% may have unrecognized visual fields at presentation

Recommendation 1.1.4 (++++) We recommend that all patients have a MRI scan to better delineate the nature and extent of the incidentaloma Specific pituitary protocol with fine cuts through the sella

Follow-up testing of the pituitary incidentaloma?

Recommendation 2.1 (++) Patients with incidentalomas who do not meet criteria for surgical removal, should receive non surgical follow-up with: 2.1.1 MRI scan 6 months after initial scan for macroadenoma or 1 year if microadenoma (++) Repeat MRI every year for macroadenoma MRI every 1-2 years for microadenoma for 3 years and then less frequently Systematic review on natural history

2.1.2 (++++) Visual field testing in those with an incidentaloma that enlarges to abut the chiasm or optic nerves

2.1.3 (++) Clinical and biochemical evaluation for hypopituitarism 6 months after the initial testing and 1 year thereafter in macroadenoma Follow up to continue for several years

Indications for surgical therapy of the pituitary incidentaloma?

Recommendation 3.1 (++++) Refer for surgery if: Evidence of VF defect or other visual field abnormalities Relatively higher value put on prevention of VF abnormalities than on avoiding the morbidity (hypopituitarism) and cost of the surgery Lesion abutting or compressing the optic nerves or chiasm on MRI Pituitary apoplexy Hypersecreting tumours other than prolactinomas

Recommendation 3.2 (++) Surgery if: Clinically significant growth of the incidentaloma Loss of endocrine function A lesion close to the chiasm with a plan to become pregnant Unremitting headache

Transphenoidal approach favoured

Algorithm No prospective testing of algorithm

Although guidelines, variable practice among clinicians Given prevalence of pituitary adenomas, cost concern

Randall et al, 2010 Single institution review of patients with pituitary tumour, adenoma, Cushing disease, acromegaly, prolactinoma 2002-2009 Pituitary tumours that were discovered incidentally were about 15% of sample

King et al, 1997 Cost effective analysis using Markov modeling to compare strategies for management of asymptomatic patient with incidental pituitary microadenoma Expectant- no management unless symptoms PRL screening with treatment Panel of hormone secreting tests – PRL, IGF 1, cortisol after dexamethasone administration with treatment Follow up MRI screening – 6 and 12 months with hormone testing if size change

Incorporated natural history, pharmacological and surgical treatment outcomes Direct medical costs - costs of hormone testing, MRI’s, hospitalization for surgery and physician services into analysis Mortality, morbidity from endocrine and neurological dysfunction, anxiety about knowing about the tumour Quality of life (QALY)- measure of quality of life that assigns to each year, a weight of quality of life

Results most sensitive to patient anxiety and shifts to endocrine panel Concluded that single PRL may be most cost effective screen for microadenoma

Thus…. Some groups suggest only prolactin for hyperfunction and other hormonal work up depending on clinical suspicion No routine visual field testing No routine screening for hormone hypofunction

Back to E.A History No headaches, visual impairment, facial weakness or parasthesias No overt symptoms of hormone hyperfunction No symptoms of hypofunction

Physical exam No orthostatic change in vitals Normal visual fields to confrontation, normal extraocular movements Clinical euthyroid, no features of acromegaly, Cushing’s, well-androgenized Clinical suspicion for hormone dysfunction low

Investigations Cortisol 498 nmol/L LH 4.8 IU/L, FSH 12.9 IU/L, total testosterone 14 nmol/L Prolactin 5 ug/L TSH 1.57 mIU/L, free T4 15 pmol/L, free T3 4.4 pmol/L IGF 1 normal

Visual fields unreliable with multiple false positives and negatives Repeat examination normal

Follow-up Repeat MRI at 6 months stable Repeat MRI at 1 year stable Plan to repeat visual fields and assess for hormone hypofunction

Case 2 – Z.K. 78 year old man CVA, HTN “Blood pressure pill” No family history Non smoker, no alcohol, lives independently with wife

Presented to ER with history of headache CT showed 3.1 x 2.8 x 3.8 cm macroadenoma MRI demonstrated suprasellar extension and extension into the sphenoid sinus and R cavernous sinus Mild compression of the optic chiasm

Pituitary MRI

Endocrine follow-up Son translator Headaches improved Denied vision impairment, facial weakness or parasthesia No symptoms of pituitary hyperfunction ?Cold intolerance – multiple layers of clothing around the house

Physical exam No orthostatic change in vitals, no lightheadedness Visual fields difficult to assess No features of Cushing’s or acromegaly, well androgenized Wearing double layers and hat in summer

Investigations AM cortisol 144 nmol/L LH 1 IU/L, FSH 3.1 IU/L, total testosterone <0.1 nmol/L TSH 1.14 mIU/L, free T4 9 pmol/L, free T3 3.5 pmol/L Prolactin 21 ug/L IGF 1 <15 ug/L

What next?

Started hydrocortisone 20 mg q am and 10 mg q pm Levothyroxine 75 micrograms po daily BMD and consideration of testosterone replacement Growth hormone replacement?

Case Visual field examination unreliable as language barrier Suggested ongoing MRI’s for follow up

Repeat MRI at 6 months stable Plan for 1 year repeat exam Low threshold for surgical management

Case #3 – R. J. 50 year old lady Colonic polyps, hypercholesterolemia, thyroid nodule Previous hysterectomy Family history of DMII Previous smoker

ENT for feelings of oropharyngeal swelling and shortness of breath Referred for “incidental” 14 x 21 x 21 mm macroadenoma on sinus CT MRI mild stalk deviation, suprasellar extension Encroachment of right optic nerve without compression

MRI

History Increased shoe size and hand size over last several year 20 lb weight gain Flushing Snoring Voice deepening No galactorrhea No symptoms suggestive of hormone insufficiency

Physical Exam No orthostatic change in blood pressure Normal visual fields to confrontation Several clinical manifestations of acromegaly

Investigations ACTH, cortisol normal LH 2.2 IU/L, FSH 4.7 IU/L, estradiol 164 pmol/L TSH 0.93 mIU/L, fT4 14 pmol/L, fT3 5.9 pmol/L Prolactin 40 ug/L GH 35 ug/L, IGF 1 711 ug/L

Management 75 g OGTT confirmed acromegaly Visual field testing normal Referral for surgical management

Take home messages With increased imaging, more pituitary incidentalomas Relatively common endocrinology referral Pituitary adenomas among other etiologies

Clinical guidelines helpful but need to consider individual patient Detailed history and physical Screen for hormone hyperfunction – prolactin, IGF 1, others if clinically suspicious Screen for hormone hypofunction – macroadenomas Refer for visual field assessment if close to the optic chiasm Consider medical or surgical management Long term monitoring for clinical changes

References Buurman H, Saeger W. Subclinical adenomas in postmortem pituitaries: classification and correlations to clinical data. European Journal of Endocrinology 2006; 154: 753-758. King JT et al. Management of incidental pituitary microadenomas: a cost effectiveness analysis. JCEM 1997; 82: 3625-3632. Pituitary Incidentaloma: An Endocrine Society Clinical Practice Guideline 2011 Randall BR et al. Cost of evaluation of patients with pituitary incidentaloma. Pituitary 2010; 13: 383-384.

Thanks!