Depending on their size they are broadly classified into:
Although this distinction is largely arbitrary, it is commonly used and does highlight an important fact: small intra-pituitary lesions (microadenomas) present differently and have different surgical and imaging challenges than larger lesions (macroadenomas) that extend into the suprasellar region. As such, it is not unreasonable to discuss them separately. This article is a general overview.
Pituitary adenomas are common, with rates varying widely depending on the definition: population prevalence is approximately 0.1%; autopsy prevalence is around 15% 2. They account for approximately 10% of all intracranial neoplasms and 30-50% of all pituitary region masses 3.
Pituitary macroadenomas are approximately twice as common as microadenomas 3.
A minority of tumours are associated with multiple endocrine neoplasia type I (MEN I), multiple endocrine neoplasia type IV (MEN4), Carney complex, McCune-Albright syndrome, and familial isolated pituitary adenoma.
Pituitary adenomas present either due to hormonal imbalance (both microadenomas and macroadenomas) or mass effect on adjacent structures (macroadenomas), classically the optic chiasm. Rarely presentation can be catastrophic, due to pituitary apoplexy.
Over half of all adenomas are secretory 2, although even when this is the case this may not be the cause of presentation. A lack of libido or even galactorrhoea may not lead to presentation and as such many secreting tumours are only diagnosed when mass effect occurs (see below).
Hormones secreted include:
- secretory: ~65%
- prolactin: ~50%
- growth hormone (GH): 10%
- adrenocorticotropin (ACTH): 6%
- thyrotropin (TSH): 1%
- non-secretory: ~35% most tend to be macroadenomas
It is also important to note that larger tumours can lead to hormonal imbalance due to mass effect rather than secretion. Hypopituitarism or moderately elevated prolactin are both seen, the later due to so-called stalk effect; prolactin release (unlike other pituitary hormones) is tonically inhibited by prolactin inhibitory hormone (a.k.a. dopamine) and as such compression of the pituitary infundibulum can result in elevation of systemic prolactin levels due to interruption of normal inhibition. Also important to remember that numerous drugs that are dopamine antagonists will also elevate prolactin - see elevated prolactin (differential) 9.
Most of the cases presenting due to mass effect are due to non-secreting macroadenomas 3 and the most common structure to be compressed by a macroadenoma is the optic chiasm. Invasion into the cavernous sinus is also encountered, with occasional compression of the oculomotor (CN III) or less frequently abducens (CN VI) nerves. Uncommonly large tumours may result in hydrocephalus (by compressing the midbrain or distorting the third ventricle), orbital or sinonasal symptoms.
Radiographic features are discussed separately:
Treatment and prognosis
Treatment of pituitary adenomas depends on a number of factors:
- size and presence of symptoms related to the mass effect: these will often necessitate surgical decompression regardless of cell type
- cell type: prolactin and growth hormone-secreting tumours can often be treated medically
The most commonly employed approach to pituitary masses is transsphenoidal, whereby the floor of the pituitary fossa is accessed via the nasal cavity. In large tumours, other approaches may be necessary (e.g. craniotomy).
Medical management of prolactinomas relies on administering a dopamine receptor agonist (e.g. bromocriptine or cabergoline). Although it can dramatically reduce the size of a macroadenoma, it has been associated with increased incidence of haemorrhage into the tumour 4.
Growth hormone secreting tumours are usually surgically resected, however in recurrent cases or in patients who are not able to undergo surgery they can be treated with octreotide (a long-acting somatostatin analogue) . This can result in both reduction of the size of the tumour and reduction in the serum levels of growth hormone 4,5.
Radiosurgery is also occasionally used. Its main complications are hypopituitarism (seen in up to 70% of cases). Less common complications include damage to the optic apparatus (optic nerves, chiasm, optic tracts), cranial nerves and internal carotid arteries 7.
Recurrent symptoms requiring further intervention is relatively common, with 18% of patients with non-functioning tumours and 25% of patients with prolactinomas eventually needing further treatment 6.
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- 3. Pisaneschi M, Kapoor G. Imaging the sella and parasellar region. Neuroimaging Clin. N. Am. 2005;15 (1): 203-19. doi:10.1016/j.nic.2005.02.007 - Pubmed citation
- 4. Newton HB, Jolesz FA. Handbook of neuro-oncology neuroimaging. Academic Pr. (2008) ISBN:012370863X. Read it at Google Books - Find it at Amazon
- 5. Lundin P, Edén engström B, Karlsson FA et-al. Long-term octreotide therapy in growth hormone-secreting pituitary adenomas: evaluation with serial MR. AJNR Am J Neuroradiol. 1997;18 (4): 765-72. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- 6. Thapar K. Diagnosis and management of pituitary tumors. Humana Pr Inc. (2001) ISBN:0896034038. Read it at Google Books - Find it at Amazon
- 7. Lunsford LD, Sheehan JP. Intracranial Stereotactic Radiosurgery. Thieme Medical Pub. (2009) ISBN:1604062002. Read it at Google Books - Find it at Amazon
- 8. FRCPath VKMBBSMD, MBBS AKA, Aster JC. Robbins & Cotran Pathologic Basis of Disease, 9e (Robbins Pathology). Saunders. ISBN:1455726133. Read it at Google Books - Find it at Amazon
- 9. Torre DL, Falorni A. Pharmacological causes of hyperprolactinemia. Therapeutics and clinical risk management. 3 (5): 929-51. Pubmed
Pituitary region masses
- pituitary gland anatomy
- pituitary MRI - an approach
pituitary region masses
- most common pituitary region masses
- solid and enhancing pituitary region mass
- mixed cystic and solid pituitary region mass
- mostly/purely cystic pituitary region masses
- purely intrasellar pituitary mass
- pituitary region mass with intrinsic high T1 signal
- abnormal enhancement/bulkiness of the pituitary infundibulum
- enlarged sella turcica
- mnemonic: SATCHMO
- history of imaging the pituitary region
- pituitary adenoma (commonest in the adult population)
- pituitary carcinoma
- pituitary lymphoma
- optic pathway glioma
- dermoid (CNS) / epidermoid / intracranial teratoma
- spindle cell oncocytomas
- pituitary metastases
- granular cell tumour of the pituitary (pituitary choristoma)
- pilocytic astrocytoma of the neurohypophysis (infundibuloma)
- cellular infiltrates
- other lesions
- pituitary tumours