Disclosures. BMS, Ferring research grant funding NovoNordisk scientific advisory board Chiasma clinical trial investigator

Transcription

1 Pituitary Disorders Ursula B. Kaiser, M.D. Chief, Division of Endocrinology, Diabetes, and Hypertension Brigham and Women s Hospital Professor of Medicine Harvard Medical School

2 Disclosures BMS, Ferring research grant funding NovoNordisk scientific advisory board Chiasma clinical trial investigator

3 Learning Objectives Lecture is a general neuroendocrine review. Goal is to discuss: Neuroendocrine physiology Diagnostic approach and management of pituitary disorders

4 Outline I. Pituitary Physiology II. Causes of Pituitary Disease III. Approach to Evaluation and Management of Pituitary Disease A. Pituitary Hormone Excess B. Pituitary Hormone Deficiency C. Mass Effects

5 Pituitary Gland Anterior Pituitary Adenohypophysis 80% of the gland Derived from Rathke s pouch (oral ectoderm) Comprised of 5 cell types Secretes 6+ hormones Controlled by neuropeptides from the hypothalamus & feedback from target organs Posterior Pituitary Neurohypophysis 20% of the gland Direct extension of the hypothalamus. Terminal axons from SON and PVN of hypothalamic neurons Hormone produced in hypothalamus, stored in pituitary

6 Pituitary Physiology Anterior Pituitary Hypothalamic Releasing/Inhibiting Neuropeptide Anterior Pituitary Hormone Posterior Pituitary Hypothalamus Supraoptic nucleus Paraventricular nucleus Axons Posterior Pituitary Target Organ AVP Oxytocin

7 Approach to Pituitary Disorders Evaluate: Pituitary hyperfunction Baseline and Suppression tests Pituitary hypofunction Baseline and Stimulation tests Mass effects

8 Approach to Pituitary Disorders Posterior Pituitary Overproduction of AVP Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) Underproduction of AVP Diabetes Insipidus (DI) - Central (pituitary) - Nephrogenic - Primary polydipsia

9 Clinical Case 1 39 year old female presented for pituitary evaluation of headaches MRI scan revealed 2x3.2 cm sellar mass, extending suprasellarly to the optic chiasm and into the L cavernous sinus. Normal Adenoma Normal Adenoma

10 Differential Diagnosis of Sellar/Parasellar Lesions Benign Tumors Pituitary adenoma (carcinoma) Meningioma Cell Rest Tumors Craniopharyngioma Rathke s cleft cyst Epidermoid Chordoma Lipoma Colloid cyst Primitive Germ Cell Tumors Germinoma Teratoma Dysgerminoma Oligodendroglioma Ependymoma Astrocytoma Granulomatous, Infectious, and Inflammatory Lymphocytic hypophysitis Abscess Sarcoidosis Tuberculosis Eosinophilic granulomatosis Mycoses Metastatic Tumors Vascular Lesions Hematologic Malignancies Miscellaneous Empty sella syndrome Arachnoid cyst

11 Pituitary Adenomas: Epidemiology Pituitary adenomas are the 3 rd most common brain tumor. They account for 10-15% of all intracranial tumors. MRI studies 14.4% Autopsy series % They are classified according to size. Microadenomas < 10mm Macroadenomas > 10 mm Ezzat Cancer 101: 613, 2004 Daly JCEM 91: 4769, 2006

12 Pituitary Tumorigenesis Lactotrope Gonadotrope Somatotrope Corticotrope Thyrotrope Daly et al. JCEM 91:4769, 2006

13 Patient Evaluation History: Questions regarding endocrine hypo- or hyper-function. Think of anterior & posterior pituitary. Hyperfunction: Hypofunction: Cushings syndrome Hyperthyroidism GH excess Prolactin excess Adrenal insufficiency Hypothyroidism GH deficiency Hypogonadism Neurological symptoms: headache, visual disturbance.

14 Standard Pituitary Laboratory Tests Thyroid TSH, free T4 Reproductive Prolactin FSH, LH, testosterone (men) or estradiol (women) GH IGF-I Adrenal Cortisol Critical to assess prolactin prior proceeding to surgery Extra tests required if GH or ACTH excess is suspected

15 Clinical Case yr old woman G2P2, menses never resumed after d/c OCP s. ROS: HA s, no visual or other neuro c/o. + fatigue, depression, and cold intolerance. Can t seem to lose weight she gained with last pregnancy. + galactorrhea x 6 mos. Meds: none. PE: normal. What should you look for on exam? What is the differential diagnosis?

16 Clinical Case 2-2 Labs. E2 11; LH 6; FSH 5 IGF-1 nl 183, GH 1 a SU 0.8 (nl) cortisol 8 FT4 1, TSH 1.5 Prolactin 283 What is the single most important test to order to exclude a physiologic cause of elevated prolactin? Hematocrit Ferritin Pregnancy test Chest Xray

17 Clinical Case 2-2 Labs. E2 11; LH 6; FSH 5 IGF-1 nl 183, GH 1 a SU 0.8 (nl) cortisol 8 FT4 1, TSH 1.5 Prolactin 283 What is the single most important test to order to exclude a physiologic cause of elevated prolactin? Hematocrit Ferritin Pregnancy test Chest Xray

18 Clinical Case 2-3 Labs. E2 11; LH 6; FSH 5 IGF-1 nl 183, GH 1.0 a-subunit 0.8 (nl) HCG negative cortisol 8.2 FT4 1.0, TSH 1.5 Prolactin 283 How do you interpret the lab values? What is the next step? What is the diagnosis? What are the treatment options?

19 Clinical Presentation of Hyperprolactinemia Galactorrhea ** Hypogonadism ** Oligo/amenorrhea Infertility Erectile dysfunction Growth arrest / delayed puberty Mass effects if tumor is large

20 DDx: Hyperprolactinemia Physiologic states: Pregnancy, Lactation, Exercise, Stress, Sleep Medications Primary hypothyroidism Systemic disorders: Neurogenic chest wall lesion, renal failure, cirrhosis, seizures Hypothalamic-pituitary stalk damage Radiation, infiltrations, cysts, tumors, trauma Prolactinoma Idiopathic Macroprolactinemia E 2 TRH Suckling DA Lactotrope Prolactin Breast

21 Medications and Hyperprolactinemia Common DA receptor blockers Phenothiazines, haloperidol, resperidone, olanzepine Domperidone DA synthesis inhibitors Methyldopa Estrogens Antihistamines Cholinergic agonists Anesthetics Anticonvulsant GI motility agents Cimetidine, metoclopramide Less Common Antihypertensives Methyldopa, reserpine, verapamil Antidepressants Tricyclics, SSRIs (minimal) Opiates

22 Prolactinomas Accounts for 30-40% of pituitary tumors More common in women (3 fold higher) than men Premenopausal women usually present earlier with clinical symptoms and microadenomas. Postmenopausal women and men usually present later with macroadenomas

23 Prolactinomas: Treatment Options General Treatment Options: Medical therapy with DA agonists Cabergoline (preferred), bromocriptine Transsphenoidal resection Radiation Second line therapy in most cases Generally reserved for resistant or aggressive tumors Melmed et al. JCEM. 96: , 2011

24 Clinical Case yr old male with multiple medical problems who recently presented to PCP with SOB, CP. Found to have new onset CHF, hypoxia LVEF 25%, cardiac cath normal. PMH: Rheumatoid arthritis, gout, nephrolithiasis, colon polyps, carpal tunnel syndrome, COPD. Meds: Captopril, allopurinol, ASA, prednisone 5mg/d, methotrexate.

25 Clinical Case 3-2 PE: 126/88 P82. HEENT: PERRLA, EOMI, VF full to confrontation, Fundoscopic exam normal. Large tongue. Upper/lower dentures. Neck: moderate symmetrical thyromegaly, no nodules palpated. Lungs: bibasilar rales. RRR +S3 Abd: obese, o/w normal. Ext: Large doughy hands. Shoe size 13, wide. No active joint inflammation. Multiple skin tags. What diagnosis are you considering? What lab tests would you like?

26 Clinical Features of Acromegaly Soft tissue hypertrophy Arthritis / carpal tunnel syndrome Increased head, hand, foot size. Organomegaly Cardiomegaly with CHF Metabolic Disturbances Diabetes mellitus Obstructive sleep apnea Dental malocclusion Colon polyps/cancer Increased mortality

27 Clinical Case 3-3 Labs: GH 2.4; IGF (high) FT4 = 0.7 (normal ), TSH 0.4 FSH 11, LH 7.4, testosterone 234 (low normal) Prolactin 7 (normal) What diagnosis are you considering now? Would you order any radiologic tests at this time?

28 Clinical Case 3-4 What test can be used to confirm GH hypersecretion? A. Midnight salivary GH B. Oral glucose tolerance test for GH suppression C. Urinary IGF-1 D. Serum IGFBP-3

29 Clinical Case 3-4 What test can be used to confirm GH hypersecretion? A. Midnight salivary GH B. Oral glucose tolerance test for GH suppression C. Urinary IGF-1 D. Serum IGFBP-3

30 Surgery Acromegaly: Treatment Medical Therapy Somatostatin analogs Octreotide LAR Lanreotide Pasireotide Cabergoline Pegvisomant Radiation Conventional Radiosurgery Goal is biochemical cure : Normal IGF-I Normal GH suppression

31 Clinical Case yr old woman referred to evaluate weight gain. Reports rapid 50lb wt gain. No HA, visual, neuro complaints. Dr. you must do something about this weight!!! PMH: hypothyroidism, HTN, borderline DM. FMH: obesity, thyroid disease Meds: L-T4, lisinopril, ASA PE: 176/90 P72 Moon face, dorsocervical and supraclavicular fat pads Thyroid 30g pebbly CTA B, RRR Central obesity Abd: +purple striae 1+ edema Neuro: normal What would you recommend?

32 Clinical Features of Cushing s Syndrome Clinical presentation can vary dramatically Central obesity Skin changes Hirsutism Menstrual irregularities Hypertension, CAD Muscle weakness Osteoporosis Mood disturbances

33 Clinical Case 4-2 You are concerned about Cushing s syndrome in this patient. What is the best first step in evaluating this patient? A. Screen for hypercortisolism B. Obtain a pituitary MRI C. Obtain a CT scan of the adrenal glands D. Perform inferior petrosal sinus sampling to determine if the source of excess cortisol is an ACTH producing pituitary adenoma

34 Clinical Case 4-2 You are concerned about Cushing s syndrome in this patient. What is the best first step in evaluating this patient? A. Screen for hypercortisolism B. Obtain a pituitary MRI C. Obtain a CT scan of the adrenal glands D. Perform inferior petrosal sinus sampling to determine if the source of excess cortisol is an ACTH producing pituitary adenoma

35 Obesity and Cushing s Syndrome Many signs/symptoms/co-morbidities overlap and are common in the general population: Obesity / weight gain Hypertension DM Sleep apnea / sleep disorders Depression / stress This is a rare disease. The challenge is deciding who to screen for CS.

36 Screening for Cushing s Syndrome Endocrine Society Clinical Guidelines Patients with unusual features for age Osteoporosis, hypertension, etc Patients with multiple and progressive clinical features of Cushing s syndrome Children with decreasing height percentile and increasing weight Patients with adrenal incidentalomas Nieman L et al. JCEM 93(5):

37 Cushing s Syndrome Step 1: Document syndrome of hypercortisolism Screening tests for hypercortisolism include: 24 hour urine free cortisol (x2) Late night salivary cortisol levels (x2) 1 mg overnight dexamethasone test Step 2: Determine whether it is ACTH dependent or independent. Step 3: Localize tumor and remove.

38 Thyrotropinomas Very rare! (approx % of pituitary adenomas) Clinical presentation: Hyperthyroidism, goiter Patients often treated previously with thyroidectomy / I % present with macroadenomas Diagnosis: elevated T4, T3 Inappropriately NORMAL or elevated TSH ******* elevated a-subunit, molar ratio a-subunit/tsh>1 Treatment: Surgery (treatment of choice), somatostatin analogs

39 Nonfunctioning Adenomas Appear clinically inactive. Often secrete a-subunit, FSHb or LHb subunit or intact gonadotropins. One third of all pituitary tumors. Often present with mass effect symptoms only and no evidence of hormonal overactivity. Some patients with large tumors present with panhypopituitarism. Treatment of choice is surgery

40 Pituitary Adenomas: Therapeutic Considerations Treat symptoms related to mass effects. Restore or preserve vision Neurologic improvements cranial nerves, headaches Correct pituitary hyperfunction. Aim for biochemical cure Medical hormone replacement for hypopituitarism.

41 Perioperative Management Preoperative Evaluation: Assess pituitary function Replace as needed Thyroid & cortisol most important Stress-dose glucocorticoids if necessary Early Inpatient Management: Assess for complications: Neurologic status Endocrine Diabetes insipidus SIADH Adrenal insufficiency Long Term Management Patients typically evaluated 1, 6, 12 weeks postoperatively. MRI typically repeated at 12 week visit to serve as new baseline. Follow-up annually or as dictated by clinic status. Hormone assessment MRI Long term assessment of hormone status and tumor recurrence required Woodmansee WW et al. AACE Clinical Review Endoc Prac. 21:

42 Treatment based on correcting hormone deficiencies. Adrenal - hydrocortisone or prednisone. Use lowest dose possible. Stress dose coverage Mineralocorticoid replacement not necessary. Thyroid levothyroxine, after adrenal replacement ** remember TSH cannot guide Rx. Gonadal - Men require testosterone, women may require estrogenprogestin replacement. Gonadotropins for fertility. Growth hormone Need provocative testing. Can treat with rhgh. Prolactin - no replacement available or required. Posterior pituitary desmopressin (DDAVP). Medical Alert Jewelry Hypopituitarism Management

43 Pituitary Disease Summary Take Home Messages: When evaluating patients with pituitary disorders, let pituitary physiology be your guide. Evaluate: Pituitary hyperfunction GH (acromegaly) ACTH (Cushing s disease hypercortisolism) Prolactin (galactorrhea, menstrual disorders, erectile dysfunction) TSH (hyperthyroidism) Pituitary hypofunction all hormone systems Mass effects (headache, visual dysfunction) Treatment is aimed at restoring normal pituitary function and can include: surgery, hormone replacement, medications

44 Thank You

45 General References/ Additional Reading Prolactinomas/ hyperprolactinemia Melmed S et al. Diagnosis & Treatment of Hyperprolactinemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab : Klibanski, A. Prolactinomas. N Engl J Med : Acromegaly Katznelson L. et al. Acromegaly: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab : Cushing s Syndrome Nieman LK et al. The Diagnosis of Cushing s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab : Nieman LK et al. Treatment of Cushing s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab : Hypopituitarism Fleseriu M et al. Hormonal Replacement in Hypopituitarism in Adults An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab : Peri-operative Management Woodmansee WW et al. AACE/ACE Disease State Clinical Review: Postoperative Management Following Pituitary Surgery. Endocrine Practice :