Download Free Medical Diagnosis and Treatment of Pituitary Tumors PowerPoint Presentation

Diagnosis and Treatment of Pituitary Tumors PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : Check out this medical presentation on Carney Complex, which is titled "Diagnosis and Treatment of Pituitary Tumors", to know about pituitary tumors and their treatment.

Tags : Carney Complex, Diagnosis, Treatment, Pituitary Tumors

Published on : May 13, 2021 | Views : 3116 | Downloads : 7

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Diagnosis and Treatment of Pituitary Tumors Kevin O. Lillehei, M.D. Professor of Neurosurgery Chairmen, Dept of Neurosurgery University of Colorado Health Sciences Center
Slide 2-

Pituitary Hormones Critical Roles in Growth, Reproduction, Metabolism and Stress Response
Slide 3-

Pituitary Gland Regulation Schneider HJ. Hypopituitarism. 2007 Lancet 369:1461-1470 Complex Integration Of Signals: Higher CNS Centers Thalamus Limbic System RAS Retina Nutritional Status Hormone Cross-Talk
Slide 4-

Assessment of Pituitary Hormones Evaluation-Signs/Symptoms, Physical Exam and Biochemical Evaluation EXCESS DEFICIENCY GH Acromegaly GH Deficiency PRL Hypogonadism Failed Lactation FSH/LH Rarely Clinically Evident Hypogonadism ACTH Cushing’s Disease Adrenal Insufficiency TSH Hyperthyroidism Hypothyroidism ADH SIADH Diabetes Insipidus
Slide 5-

DIAGRAMMATIC REPRESENTATION OF PITUITARY GLAND
Slide 6-

Sagittal post-contrast, T1-weighted MRI, demonstrating normal adult anterior and posterior pituitary gland and sellar region anatomy. Courtesy R.Bert
Slide 7-

Normal Pituitary Pituitary Mamillary Body Optic chiasm Infundibulum Tuber cinereum
Slide 8-

Pituitary Pathology Pituitary Adenomas (10-15% of intracranial tumors) Rathke’s Cleft cyst Craniopharyngiomas Mesenchymal/stromal tumors (i.e., meningiomas,chordomas) Germ Cell Tumors (i.e., Germinomas, Teratomas) Neuronal/paraneuronal tumors (i.e., Gangliocytomas, Neuroblastoma) Miscellaneous-Inflammatory/infiltrative disease, aneurysm, metastatic disease Pituitary carcinomas (<0.1%)
Slide 9-

Pituitary Adenoma Clinically-apparent disease: prevalence~1:3,000-10,000 Pituitary adenoma distribution: Sporadic, monoclonal disease (>95%) Familial, genetic mutations (5%) Multiple Endocrine Neoplasm 1 (MEN1), Familial isolated pituitary adenoma (AIP), Multiple Endocrine Neoplasm 4 (p27Kip1/CDKN1B), Carney Complex (PRKAR1A) Generally younger age of onset (<30 yrs.), and larger/more aggressive pituitary tumors
Slide 10-

University of Colorado Series (Lillehei) : 1986 – 2017 1,964 Transsphenoidal Procedures 1,016 (52%) Non-Secretors (Gonadothroph / Null) 214 (11%) ACTH (Cushing’s) 175 (9%) Rathke’s Cleft Cysts 165 (8%) Prolactinomas 141 (7%) GH (Acromegaly/Gigantism) 59 (3%) Plurihormonal (GH/PRL) 6 (0.3%) TSH 178 (9%) “Other”
Slide 11-

PITUITARY ADENOMAS: Clinical Presentation Hormone hypersecretion Acromegaly Cushing’s Disease Amenorrhea / Galactorrhea Symptoms from mass effect Headaches Vision loss Pituitary gland dysfunction
Slide 12-

Surgery is generally the first line of treatment for all pituitary tumors except for tumors that secrete prolactin. Tumors that secrete both prolactin and growth hormone generally are candidates for surgical intervention
Slide 13-

Prolactinomas-The Basics Most Common Functional Pituitary adenoma (30-40%) Female:Male Prevalence-10:1, median age of diagnosis-34 yrs. Microadenomas Macroadenomas Impairs GnRH pulse generator
Slide 14-

Prolactinoma Diagnosis Random PRL level (gender-based normative ranges) Levels usually correlate with tumor size >100-150 ng/dl with microadenomas >200-250 ng/dl with macroadenomas Pituitary MRI (with/without contrast)
Slide 15-

Prolactinoma Treatment : MEDICATIONS, surgery, radiation Treatment: medications, surgery , rarely XRT
Slide 16-

Dopamine Agonists Bromocriptine (Parlodel) 2.5 mg tab. “Start low and go slow” Common Side Effects: GI upset, Nasal Congestion, Orthostatic Dizzyness. Preferred only if planned pregnancy Cabergoline (Dostinex) 0.5 mg tab Greater efficacy and better tolerated than bromocriptine 1st Line agent in most cases
Slide 17-

WHY? Pre Treatment Post Treatment
Slide 18-

Pre Treatment Post Treatment
Slide 19-

Problems of GH Excess GIGANTISM-Growth hormone excess before puberty (before closure of the growth plates). ACROMEGALY-GH excess after puberty (after completion of linear growth).
Slide 20-

Excess growth hormone secretion results in pituitary gigantism; man at left is 5' 7” and patient at right is 8‘ 5” tall. Inset: note comparison in these two men’s hand sizes ('acral megaly' = acromegaly).
Slide 21-

Clinical Presentation of Acromegaly
Slide 22-

Growth Hormone Excess Diagnosis Clinical Features of GH excess (old pictures are helpful), AND Elevated IGF-1 level (age and gender matched)-best screening test. Integrated 24 h secretion. Long-half life. Conversely, GH levels fluctuate widely over 24 hrs and normal values can overlap with GH-secreting tumors. OGTT-GH test for equivocal cases, or post-op assessment of cure. Pituitary MRI-macroadenomas are detected in >80% of acromegaly. Molitch M. Clinical Manifestations of Acromegaly. Endocrinol Metab Clin North America. 1992;21:597-614
Slide 23-

Acromegaly Treatment A multi-modal and disciplinary approach a dedicated team of: Neurosurgeons, Endocrinologists, Neuropathologists, Radiologists and Radiation/Oncologists. Treatment Approach Surgery Medical Therapies Somatostatin Analogs Growth Hormone Receptor Antagonist Radiation Therapies
Slide 24-

Holdaway, IM, et al. J Clin Endocrinol Metab. 2004;89:667-674. Copyright © 2004 The Endocrine Society. Mortality Rates in Acromegaly 1 0.8 0.6 0.4 0.2 0 Probability 0 5 10 15 20 25 30 Time (years) GH <1 ng/mL Controls GH <2 ng/mL GH <5 ng/mL GH >5 ng/mL A large difference in mortality rates is seen with a small change in the control of GH (large shift between GH <1 and <2 ng/mL).
Slide 25-

Cushings Disease Incidence: 2-3 cases per 1 million/year. ~10-15% of Functional Pituitary adenomas Female, Middle-aged predominance 50% of MRI’s are normal
Slide 26-

The Complications of Chronic Cortisol Excess Changes in Carbohydrate, Protein and Fat Metabolism Peripheral Wasting of Fat/Muscle Central obesity, Moon facies, fat pads Osteoporosis Diabetes Hypertriglyceridemia Changes in Sex Hormones Amenorrhea/Infertility Excess hair growth (♀) Impotence Salt and Water Retention HTN and Edema Impaired Immunity Neurocognitive Changes
Slide 27-

Cortisol Excess (Hypercortisolism) Newell-Price, J et. al., Endocr. Rev. 1998 19:647-672 70-75% 25-30%
Slide 28-

Screening Tests for Cushing’s Syndrome Disrupted Circadian Rhythm Midnight Salivary or Serum Cortisol Increased Filtered Cortisol Load 24 hr Urine Free Cortisol Attenuated Negative Feedback Low Dose (1 mg) Dexamethasone Suppression test (11-12 p.m.) Raff 2004 Curr Opin Endocrin Diabetes 11:271-5 Normal Subject Mild Cushing’s Severe Cushing’s Clock Time Cortisol (nmol/L)
Slide 29-

Inferior Petrosal Venous Sinus Sampling (IPSS) Sample both Sides for ACTH If ACTH >2-3 times higher than ACTH in peripheral vein Then ACTH source is the Pituitary
Slide 30-

Specific Signs of Cushing’s Syndrome Plethoric/moon facies Wide (>1 cm), violaceous striae (abdominal, axillary) Spontaneous Ecchymoses Proximal Muscle Weakness Early/Atypical Osteoporosis (atraumatic rib fx)
Slide 31-

with permission
Slide 32-

ppt slide no 32 content not found
Slide 33-

ppt slide no 33 content not found
Slide 34-

Sx of mass effect: Headache Vision loss Pituitary hormone dysfunction Cranial Nerve Abn.
Slide 35-

Surgery
Slide 36-

Approaches
Slide 37-

Transnasal Microscopic Approach
Slide 38-

Transnasal Microscopic Approach
Slide 39-

The Set-up Transnasal Endoscopic Approach
Slide 40-

ppt slide no 40 content not found
Slide 41-

Transnasal Endoscopic Approach
Slide 42-

Thank you
Slide 43-

Ontogeny and primary transcription factors for pituitary cell type lineage (Adapted from Asa SL. Practical pituitary pathology: what does the pathologist need to know? Arch Pathol Lab Med 2008, 132: 1231–1240)
Slide 44-

Pituitary Adenoma SRS 18 Gy tumor <8 Gy optic chiasm Radiation therapy: critical need for expert Neuro-oncologist: Dr. Laurie Gaspar and colleagues
Slide 45-

Radiotherapy Conventional Multi-fractional 40 years experience Stereotactic Single fraction Less radiation to surrounding tissues Limited experience Gamma knife LINAC Proton beam Gamma knife LINAC Proton beam
Slide 46-

Anatomy Sellar & Parasellar Rhoton
Slide 47-

Anatomy Sellar & Parasellar Rhoton
Slide 48-

Anatomy Optic Nerve & Chiasm Rhoton
Slide 49-

Anatomy Cavernous Sinus Rhoton
Slide 50-

Anatomy: Cavernous Sinus
Slide 51-

A, Child at age 9 years prior to development of an ACTH-secreting pituitary adenoma. B, Same child as in Figure 29.27A, now at age 11 years with severe Cushing’s disease, photographed just prior to surgical removal of his corticotroph adenoma. Note plethora and truncal obesity. A B