Morbidity and Mortality Conference Ann Marie Lam, PGY-2 Emory University School of Medicine Family Medicine Residency Program October 14 th, 2010

Pituitary Adenoma Macroadenoma (>1 cm) Rarely malignant Hormone overproduction/deficiency Can become locally invasive Can lead to CN palsies Can lead to pituitary apoplexy Can be associated with MEN I syndrome Risk of recurrence

Treatment Medical therapy: correction/replacement of hormone overproduction/deficiency Surgical therapy: decompression, resection Radiation an option for adjunctive therapy

Types of Pituitary Adenoma Prolactinoma (PRL) (35%) Acromegaly (GH) (20%) Cushing Disease (ACTH) (7%) Gonadotropin-Producing Adenoma (LH, FSH) (<1%) Non-secretory Adenoma (30%) TSH-Secreting Adenoma (<1%) Diabetes Insipidus (lack of VP)

Prolactinoma Presentation: amenorrhea, galactorrhea, infertility, (in men: impotence, dec libido) Diagnosis: PRL level >200 ng/ml, R/O prolactinemia from mass effect Treatment (large, sympt): Bromocriptine, cabergoline (dopamine analog, inhibits PRL)

Acromegaly Presentation: coarse facial features, oily skin, carpal tunnel syndrome, OA, increased hat/glove/shoe size, DM Diagnosis: elev ILGF-1, elev post-prandial GH on 100 g OGTT (failure to suppress GH to <2 ng/ml diagnostic) Treatment: Octreotide SC (somatostatin analog), bromocriptine

Cushing’s Disease Presentation: truncal obesity, striae, round facies, hirsutism, HTN, DM, thin skin Diagnosis: elev 24-hr urine cortisol, dexamethasone suppression test (1mg dex, night cortisol) Treatment: ketoconazole (inhibits steroid synthesis)

TSH-secreting adenoma Presentation: goiter, thyrotoxicosis, visual impairment Diagnosis: elev TSH, T3, T4 Treatment: surgery, octreotide

Non-secretory adenoma Usually large at time of presentation Presentation: bitemporal hemianopsia, CN defects (cav sinus compression), hypopituitarism Evaluation: assess pituitary function, VF testing Treatment: surgery, +/-radiation

Long-term follow-up Post-op 4-6 wks to confirm adenoma completely removed and hypersecretion resolved Monitor yearly for recurrence, hypopituitarism

Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment

Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment Multi-disciplinary approach led by primary team leading

Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment Multi-disciplinary approach led by primary team leading Consider transferring patient to primary care- providing team

Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment Multi-disciplinary approach led by primary team leading Consider transferring patient to primary care- providing team Patient-oriented care

Discussion Expediency of work-up: delay in diagnostic testing, delay in initiating treatment Multi-disciplinary approach led by primary team leading Consider transferring patient to primary care- providing team Patient-oriented care Patient responsibility

References Harrison’s Principles of Internal Medicine. 16 th edition. Disorders of the anterior pituitary and hypothalamus, Ferri’s Clinical Advisor. Pituitary adenoma, Klibanski, A. Prolactinomas. NEJM 362: , April Melmed, S. Medical Progress: Acromegaly. NEJM 355: , Dec Pituitary adenoma. UpToDate. Accessed 9/29/10.