1. Pituitary disorders Narendra Reddy Clinical Lecturer Diabetes, Endocrinology & Metabolism University of Warwick Grand round, UHCW, June 14 th 2011

2. Plan….  Pituitary anatomy  Pituitary physiology  Evaluation of Pituitary mass  Pituitary dysfunction in Elderly  Clinical scenarios/Images

3. Pituitary anatomy

5. Sagittal view

6. Coronal view

8. Hormones

9. Evaluation of Pituitary mass  Local effects  Hypersecretion  Hyposecretion

10. Pituitary hormone profile  Somatotroph – GH IGF-1  Gonadotroph – FSH,LH Testo/Oest  Thyrotroph – TSH FT4,FT3  Corticotroph – ACTH Cortisol (SST)  Lactotroph - Prolactin  Neurohypophysis Vasopressin (U&E, Paired Osmol)

11. Case  82 yr old male  Headache, diplopia, vomiting- Acute  Hypotension- 90/45 mmHg & III N palsy  PMH- IHD, Hypertension  Drugs- Antihypertensives, Aspirin  Diagnosis?

12. Investigations  9 am Testo- <0.4 (10-26)  LH- 1.2, FSH- 0.7 (2-10)  IGF-1 – 4.8 (10-35)  PrL- 322 (<300)  FT4 8.8 (10-19.5), TSH 2.0 (0.5-4.5)  SST – 30’ Cortisol 213 nmol/L  Na - 122; Pl Osm & U Osm - normal

13. Pituitary apoplexy

16. Pit apoplexy guidelines

17. Chronic hypopit’ symptoms  GH- lethargy, reduced strength  LH/FSH- libido, infertility, menstrual  TSH – hypothyroid  PrL- lack of milk in breastfeeding females  ACTH – pallor  Vasopressin – Diabetes Insipidus

18. Hypopituitarism  Pituitary tumours  Radiotherapy  Apoplexy,Sheehan syndrome  Infiltrative disorders  Infective- TB, Pit abscess  Trauma  Metastasis  Russell viper snake bite  PIT-1, HESX-1, PROP-1, KAL-1, SOX-2, DAX-1, AVP-Neurohypophysin-II

19. Dynamic tests  Insulin Tolerance Test- ACTH & GH  Glucagon test – ACTH & GH  SST- adrenocortical function  Clomifene test – Gonadotrophin  GnRH & TRH- rarely used

20. To take home….  Adenomas do not cause DI  GH>FSH/LH>TSH>ACTH  Long term hypopit patients, treated with steroids can unmask DI  ACTH def–No Pigment/Hyperkalaemia

21.  84 pts over 65 yrs (avg 72.5 yrs)  1975 to 1996  64 % VF defects  20 % hypopituitarism  7% pituitary apoplexy  TSA safe in elderly

22. Pit tumours in elderly

23. Pituitary Incidentalomas  10% incidence in 18902 pituitaries  Minimum 20 years F/U  18-86 years  Local, hypersecretion, hyposecretion  10.6% 1cm  MRI – 1, 2 & 5 years- stop if no size  Hypopit, VF defects & size increase- Sx Mark Molitch,Best Practice in Clinical Research 23 (2009) 667–675

24.  42 yr man  Headaches Reduced libido Erectile dysfunction Case

25. 2007 20 days 9 months 3 years

26. Prolactinoma  Micro 1cm  Medical treatment- Cabergoline  Surgery- DA resistance/intolerance  Radiotherapy  DA Rx – Cardiac Valve fibrosis 1 st line- Sx 2 nd line- Mx 3 rd line-Dx

27. Case  20 year old boy  Visual field problems  Enlarged nose  Carpal tunnel Syndrome

29. Acromegaly

30. Photos please...

31. 2 nd line- Mx 1 st line- Sx 3 rd line- Dx

32. Case  40 years old lady  10 years of Diabetes  Hypertension  Hyperlipidaemia  Osteoporosis  Wt gain  Acne

33. Cushings disease

35. Dr Harvey Cushing

36. Management  ONDMST - Cortisol > 50  24 hr Urine Free Cortisol  LDDMST >50  HDDMST  CRH stimulation test  Petrosal sinus sampling  Surgery  Radiotherapy  B/L Adrenalectomy 1 st line- Sx 2 nd line-Dx 3 rd line- Sx

37. Non functioning Pit Adenomas(NFA)

38. NFA

39. ?????

40. Rathkes cyst

41. ???

42. Craniopharyngioma

43. 40 yr old female,Hypothyroid

44. ?????

45. Lymphocytic hypophysitis

46.  Young women  Auto immune  Prodromal illness  VF defects  Hormone deficiencies  Bx- diagnostic

47. Meningioma

48. Hormones !!