Pituitary Adenoma
Presentation
In many cases, the individuals experience no symptoms if the tumor has not grown in size. In the rest, pituitary adenomas present the following signs and symptoms:
- Cushing’s syndrome
- Hyperthyroidism
- Decreased sexual function in males
- Changes in vision
- Lethargy
- Acromegaly [4]
- Fatigue
- Headache
- Nausea accompanied by vomiting
- Nasal discharge
- Nipple discharge
Entire Body System
Fatigue
- Here we describe the unusual case of a 60-year-old man who presented with progressive fatigue and polyuria, and whose laboratory workup revealed a deficiency of the five hormones associated with the action of the anterior pituitary (thyroid hormone, testosterone[ncbi.nlm.nih.gov]
- Manifestations may include hypogonadism (sexual dysfunction, loss of libido, and impotence), hypothyroidism (fatigue, weakness, weight gain, coarse dry hair and dry skin, cold intolerance, depression), adrenal insufficiency (fatigue, weakness, loss of[pacificneuroscienceinstitute.org]
- A 55-year-old patient presented for erectile dysfunction, loss of libido and fatigue. The biochemical evaluation showed very high FSH serum levels in the presence of central hypogonadism.[ncbi.nlm.nih.gov]
- We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 28, 2019[patientslikeme.com]
- We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: January 31, 2019[patientslikeme.com]
Weakness
- Manifestations may include hypogonadism (sexual dysfunction, loss of libido, and impotence), hypothyroidism (fatigue, weakness, weight gain, coarse dry hair and dry skin, cold intolerance, depression), adrenal insufficiency (fatigue, weakness, loss of[pacificneuroscienceinstitute.org]
- […] or depression Changes to the face (for example, teeth may move further apart) Dizziness Headaches Erectile dysfunction (in men) Irregular menstrual cycles (in women) Growth of your skull, hands and feet Vision problems Unexplained changes in weight Weakness[aurorahealthcare.org]
- A weak TSH response in the TRH test, elevated sex hormone binding globulin (SHBG) levels, and the absence of a family medical history of SITSH or TRβ gene mutations supported the diagnosis of TSH-secreting pituitary adenoma (TSHoma).[ncbi.nlm.nih.gov]
- The results could be growth failure in children (growth hormone deficiency), delayed puberty or loss of sexual function or infertility or menstrual irregularities (low reproductive hormones), weakness fatigue and weight loss (low cortisol), and hypothyroidism[openanesthesia.org]
- The study also found that hirsutism, facial plethora, and muscular weakness and atrophy occurred more often in the patients with microadenomas, while nephrolithiasis, osteopenia, hyperprolactinemia, and galactorrhea occurred at a higher rate in those[emedicine.medscape.com]
Anemia
- Evans' syndrome was diagnosed based on idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia. She had a history of malocclusion and thyroid gland enlargement 4 years prior to admission.[ncbi.nlm.nih.gov]
- Anemia, fatigue, lethargy, menstrual disorders, libido and sexual disorders, constipation or symptoms of hypothyroidism (underactive thyroid) can also occur.[ims.uniklinik-freiburg.de]
- Other symptoms include the following: Diastolic apical rumbling murmur (mimicking mitral stenosis) Holosystolic murmur best heard at apex and radiating to axilla (mitral regurgitation) Tumor "plop" Systemic: Fever Clinical signs of anemia Weight loss[emedicine.medscape.com]
Musculoskeletal
Arthralgia
- The systemic symptoms (eg, fever, arthralgia, elevated sedimentation rate, lupuslike rashes) that accompany some myxomas may be due to the production of the proinflammatory cytokine interleukin-6 by the myxoma.[emedicine.medscape.com]
Eyes
Loss of Peripheral Vision
- Visual Field Examination - Compression of the optic chiasm causes a loss of peripheral vision on both sides. Hormone Testing - Blood, urine, and saliva are tested for abnormal hormone levels.[innerbody.com]
- Usually the optic nerves that connect the eyes to the brain are the next “victim” of tumor compression; this can lead to blurring of the vision or loss of peripheral vision.[urmc.rochester.edu]
- […] of peripheral vision), drooping eyelids or changes in color vision Headache Lack of energy Nasal drainage of clear fluid Nausea and vomiting Problems with the sense of smell In rare cases, these symptoms occur suddenly and can be severe ( pituitary apoplexy[mountsinai.org]
- This pressure can lead to loss of peripheral vision. Surgery can remove such tumors and relieve the pressure on surrounding structures. (2) How is this surgery performed? Most pituitary tumors can be removed transsphenoidally.[pituitary.mgh.harvard.edu]
Psychiatrical
Decreased Libido
- In addition to decreased libido, abnormal menstrual cycles and infertility- pituitary adenomas can cause other physical and psychological symptoms. Many patients report challenges with memory, headaches, depression or fatigue.[uranj.com]
- In men, hyperprolactinemia causes hypogonadism manifested by decreased libido, impotence, infertility, and, rarely, galactorrhea.[clinicaladvisor.com]
- Abstract Pituitary tumors cause symptoms by secreting hormones (prolactin, PRL, responsible for amenorrhea-galactorrhea in women and decreased libido in men; growth hormone, GH, responsible for acromegaly; adrenocorticotropic hormone, ACTH, responsible[ncbi.nlm.nih.gov]
- A 53-YEAR-OLD MAN had a 1-month history of headaches, lethargy, decreased libido, and increased thirst. Subsequently, he developed diplopia, bitemporal hemianopsia, and a right third nerve palsy.[doi.org]
Breast
Nipple Discharge
- The other and more serious symptoms include gigantism, crushing syndrome, reduced sexual function in men, hyperthyroidism and nipple discharge. Diagnosis Diagnosis includes blood and urine tests to determine the hormonal levels.[symptoma.com]
- They typically include symptoms such as abnormal nipple discharge of milk (galactorrhea) and reproductive dysfunction.[lucasresearch.org]
- discharge and irregular or absent menstrual periods in women Decreased sexual function in men Symptoms caused by pressure from a larger pituitary tumor may include: Changes in vision such as double vision, visual field loss (loss of peripheral vision[mountsinai.org]
- Prolactinoma and nonfunctioning pituitary adenoma: infertility amenorrhea (absence of menses or menstrual periods) oligomenorrhea (irregular/sparse menstruation) decreased libido (interest in sex) galactorrhea (breast milk production / leakage / nipple[pituitary.mgh.harvard.edu]
Urogenital
Amenorrhea
- CASE DESCRIPTION: An otherwise healthy 27-year-old woman presented with secondary amenorrhea and moderately elevated prolactin levels. A macroprolactinoma was suspected on magnetic resonance imaging, and cabergoline was initiated.[ncbi.nlm.nih.gov]
- On presentation, she exhibited right hemiparesis and left-sided visual loss, associated with amenorrhea. A massive ( 5 cm) intra- and suprasellar lesion was seen on imaging, and her serum prolactin level was 4408 ng/ml.[ncbi.nlm.nih.gov]
- Typical presenting manifestations include amenorrhea, infertility, visual field abnormalities, and headache. Diagnosis is often made with brain MRI , visual field testing, and serum hormone assay.[medlink.com]
- In premenopausal women, hyperprolactinemia causes hypogonadism leading to symptoms of infertility, oligomenorrhea or amenorrhea, and galactorrhea.[clinicaladvisor.com]
- Prolactinomas, the most common secretory microadenoma, are diagnosed more frequently in women, possibly because of the more striking presenting features such as amenorrhea and/or galactorrhea.[emedicine.medscape.com]
Workup
The following tests will be done to diagnose pituitary adenomas:
- Blood and urine tests to determine the levels of hormones.
- Vision test to determine the eye sight which would confirm whether the tumor has affected the eyes.
- Imaging studies such as MRI and CT scan of the brain that would help determine the size as well as the exact location of the tumor. Intraoperative MRI may be used during surgery to prevent unexpected tumor remnants from being left behind [5].
- Several tests to determine the functioning of the endocrine system will also be done.
X-Ray
Enlarged Sella
- sella with an intact floor Grade III: Localized erosion or destruction of the sellar floor Grade IV: Diffusely eroded or destroyed floor Treatment Overview [ edit ] Observation for select nonsecreting microadenomas and small prolactinomas Microadenoma[en.wikibooks.org]
Microbiology
Streptococcus Pneumoniae
- Gram-positive organisms (coagulase-negative staphylococci, Streptococcus pneumonia, and S viridans) predominated in meningitis, whereas gram-negative organisms (Klebsiella pneumonia, Enterobacter aerogenes, and Escherichia coli) predominated in bacteremia[ncbi.nlm.nih.gov]
Toxoplasma Gondii
- Seropositivity for Toxoplasma gondii, but neither immunodeficiency nor intracerebral spread, was found. During a postoperative follow-up period of 15 months, the patient did not show any recurrence.[ncbi.nlm.nih.gov]
Treatment
There are several factors that determine the type of treatment to be employed for pituitary adenomas. The size of the tumor, its location, age of the individual and overall health all need to be taken into consideration before deciding the treatment plan. The following methods are employed for treating pituitary adenomas:
- Surgery is often the first line of treatment even in adenomas that appear inactive [6]. It is required if the tumor has grown in size and is exerting pressure on the optic nerve. In majority of the cases, the tumor is removed through nose or sinuses. Such a type of surgical procedure is known as endoscopic transnasal transphenoidal approach [7]. An alternate nasal surgical approach known as the extended endoscopic endonasal approach (EEEA) is implored in difficult cases of resection [8]. Another surgical procedure that is done when the former method cannot be used is the transcranial approach.
- Radiation therapy is done when surgery is not possible. The rays cause the tumor to shrink in size. Neuroscience research have identified the use of fractionated steriotactic radiation therapy (FSRT) to be very effective in the treatment of pituitary adenomas [9]. The use of a gamma knife may prevent the incidence of post-radiation panhypopituitarism in treated patients [10].
- Medications are also given to shrink the tumors.
- In instances, when the size of the tumor is small, then no interventions are carried out and the patient is called for yearly examination of the tumor through MRI and CT scan.
Prognosis
Pituitary adenomas are benign tumors that can cause serious complications if not treated on time. If the tumors remain small in size and do not grow then the individuals would seldom experience any symptoms. Prognosis is generally good if treatment is initiated at the right time. In addition, if the entire tumor is removed then outcome is favorable.
Complications
Pituitary adenomas can cause the following life threatening complications:
- Blindness if the tumor damages the optic nerve
- Permanent hormonal imbalances in post radiation panhypopituitarism [2]
- Diabetes insipidus
- Pituitary apoplexy characterized by sudden bleeding of the tumor
- Cerebrovascular disease or stroke [3]
Etiology
The abnormal growth of cells in the pituitary gland gives rise to the condition known as pituitary adenomas. The exact phenomenon that triggers the growth of cells in an abnormal fashion is yet to be identified.
Pituitary adenomas are not inherited and occur spontaneously. However, there are small pieces of evidence backed up with clinical studies that suggest heredity as a factor for development of adenomas. But, this happens in very rare cases. Researches have implicated pituitary adenomas as a defect in gene mutation [1]. Individuals suffering from multiple endocrine neoplasia type 1 (MEN 1) also suffer from pituitary adenomas as a secondary complication.
Epidemiology
Pituitary adenomas are a common condition affecting individuals across the globe. It has been estimated that about 1 in every 5 adults develop tiny tumors in the pituitary gland. In majority of the cases, the tumors do not grow in size and cause no problems as well. However, these are diagnosed when individuals undergo imaging studies of the brain for some other complaint.
Pathophysiology
Pituitary gland is located at the base of the brain and is known as the master gland as it regulates the hormonal balance of the body. Benign tumors that develop in this gland are known as pituitary adenomas. The development of tumors in this gland damages the normal hormone producing cells of pituitary. This in turn disrupts the body’s hormonal balance which triggers several other conditions disturbing the body’s normal functioning.
The pituitary gland releases hormones such as prolactin, growth hormones, thyroid stimulating hormone, luteinizing hormone, follicle stimulating hormone and adrenocorticotropic hormone.
Prevention
So far no guidelines have been given to prevent the development of pituitary adenomas. The exact cause that triggers the development of tumors is unknown and therefore it is difficult to prevent this disease condition.
Summary
Pituitary adenomas are tumors of the pituitary gland. These tumors are benign in nature and generally do not cause any harm. It has been estimated that about 10% cases of pituitary adenomas go undiagnosed. The individuals are also unaware of the tumor development as it does not produce any significant symptoms.
The pituitary gland is the part of the brain that regulates the body hormonal balance. Therefore, disorders of this gland can cause an imbalance in its hormonal regulation activity. There are several types of pituitary adenomas that are classified on the basis of size, hormone secretion and aggressiveness of the tumors.
Patient Information
Definition
Tumors that develop in the pituitary gland are termed as pituitary adenomas. These are benign in nature and in many cases go undiagnosed as the tumors do not cause any symptoms. It has been estimated that probably about 10% of individuals have pituitary adenomas and would not even know about it. Tumors in the pituitary gland gravely affect the body’s hormonal balance.
Cause
The exact mechanism that triggers the uncontrolled growth of cells in the pituitary gland is yet to be figured out. Pituitary adenomas often occur as a secondary complication to MEN 1.
Symptoms
Symptoms of pituitary adenomas include changes in vision, lethargy, headache, nausea, vomiting, change in sense of smell and nasal discharge of clear fluid. The other and more serious symptoms include gigantism, crushing syndrome, reduced sexual function in men, hyperthyroidism and nipple discharge.
Diagnosis
Diagnosis includes blood and urine tests to determine the hormonal levels. Imaging studies such as CT scan and MRI of the brain to determine the size and location of the tumor.
Treatment
Surgery is first option for treating pituitary adenomas. If surgery cannot be done then radiation therapy is given to shrink the tumor. In many cases, medications are also given to shrink the tumor. If the tumor is small in size and is not causing any problems then it is not disturbed and is just regularly monitored through tests.
References
Article
- Chahal HS, Stals K, Unterlander M, et al. AIP mutation in pituitary adenomas in the 18th century and today.N Engl J Med. Jan 6 2011;364(1):43-50
- Parhar PK, Duckworth T, Shah P, et al. Decreasing Temporal Lobe Dose with Five-Field Intensity-modulated Radiotherapy for Treatment of Pituitary Macroadenomas. Int J Radiat Oncol Biol Phys. Dec 14 2009;
- Sattler MG, Vroomen PC, Sluiter WJ, Schers HJ, van den Berg G. Incidence, causative mechanisms, and anatomic localization of stroke in pituitary adenoma patients treated with postoperative radiation therapy versus surgery alone. Int J Radiat Oncol Biol Phys. 2013; 87(1):53-9
- Ramírez C, Hernández-Ramirez LC, Espinosa-de-los-Monteros AL. Ectopic acromegaly due to a GH-secreting pituitary adenoma in the sphenoid sinus: a case report and review of the literature. BMC Res Notes. 2013; 6:411
- Berkmann S, Fandino J, Zosso S, et al. Intraoperative magnetic resonance imaging and early prognosis for vision after transsphenoidal surgery for sellar lesions. J Neurosurg. Sep 2011; 115(3):518-27.
- Greenman Y, Stern N. How should a nonfunctioning pituitary macroadenoma be monitored after debulking surgery? Clin Endocrinol (Oxf). Jun 2009; 70(6):829-32.
- Han S, Ding X, Tie X, Liu Y, Xia J, and Yan A, et al. Endoscopic endonasal trans-sphenoidal approach for pituitary adenomas: Is one nostril enough? Acta Neurochir (Wien). Jun 5 2013
- Sankhla SK, Jayashankar N, Khan GM. Surgical management of selected pituitary macroadenomas using extended endoscopic endonasal transsphenoidal approach: early experience. Neurol India. Mar-Apr 2013; 61(2):122-30.
- Elhateer H, Muanza T, Roberge D, et al. Fractionated stereotactic radiotherapy in the treatment of pituitary macroadenomas. Curr Oncol. Dec 2008;15(6):286-92
- Marek J, Jezkova J, Hana V, et al. Is it possible to avoid hypopituitarism after irradiation of pituitary adenomas by the Leksell gamma knife? Eur J Endocrinol. Feb 2011; 164(2):169-78.