Clinically nonfunctional pituitary adenomas (CNFPAs) are considered here; functional pituitary adenomas (e.g., acromegaly, Cushing syndrome, prolactinoma) are dealt with separately.
Small pituitary tumors (<4 mm) are common and have been reported in up to 10% of MRIs in the general population. Only a small fraction of such tumours are associated with clinical features suggestive of pituitary disorder.
Radiologically, CNFPAs are classified as microadenomas (<1 cm diameter) or macroadenomas (≥1 cm diameter); they may have suprasellar extension toward the optic chiasm, lateral extension into the cavernous sinuses, or downward extension into the sphenoid.
Patients with nonfunctional pituitary microadenomas require limited follow-up, but pituitary macroadenomas need to be followed for life.
Nonfunctional pituitary macroadenomas typically come to medical attention with features of mass effect such as headaches, visual field deficits, hypopituitarism, and rarely cranial nerve palsies.
A modest elevation of prolactin may occur in CNFPAs due to compression of the pituitary stalk and interruption of intrinsic dopaminergic tone.
Transsphenoidal surgery is the first-line therapy for patients with CNFPAs and mass effect.
Pituitary adenomas are the third most common intracranial neoplasms in adults, accounting for about 10% of all intracranial tumors. They are diagnosed when patients present with hormone hypersecretion, plus visual and neurologic deficits and hypopituitarism as a result of mass effect. They may also be found as pituitary incidentalomas. Pituitary adenomas that do not cause a characteristic hormone hypersecretion syndrome (null cell and the majority of gonadotroph adenomas) are referred to as clinically nonfunctional adenomas (CNFPAs). CNFPAs and prolactinomas are the 2 most prevalent pituitary adenomas. CNFPAs are considered here. Functional pituitary adenomas (e.g., acromegaly, Cushing syndrome, prolactinoma) are not covered here.
History and exam
Key diagnostic factors
- longstanding and progressing symptoms
- erectile dysfunction
- soft small testicles
- breast atrophy
- loss of libido
- hot flashes
- weight gain
- decreased visual acuity
- bitemporal hemianopia
- pituitary apoplexy
Other diagnostic factors
- increased central adiposity
- reduced muscle mass
- cold intolerance
- dry skin
- hair loss
- poor memory
- low mood
- weight loss
- facial numbness
- urinary incontinence
- recurrent sinusitis
- multiple endocrine neoplasia type 1 (MEN-1)
- familial isolated pituitary adenomas (FIPA)
- Carney complex (CNC)
1st investigations to order
- insulin-like growth factor 1
- luteinising hormone, follicle-stimulating hormone
- alpha subunit of human pituitary glycoprotein hormones
- thyroid-stimulating hormone, free thyroxine
- morning cortisol
- adrenocorticotropic hormone stimulation test
- adrencorticotropic hormone
- insulin tolerance test for cortisol
- basic metabolic panel
- MRI pituitary with gadolinium enhancement
- contrast-enhanced CT pituitary
Investigations to consider
- growth hormone stimulation test
- lipid panel
- Humphrey or Goldmann formal visual fields test
- immunohistochemical staining
macroadenoma without mass effect and not abutting optic chiasm
macroadenoma without mass effect but abutting optic chiasm
macroadenoma with mass effect
- Prolactin-secreting adenoma (prolactinoma)
- Growth hormone-secreting adenoma (acromegaly)
- Adrenocorticotropic hormone-secreting adenoma (Cushing syndrome)
- Hormonal replacement in hypopituitarism in adults: an Endocrine Society clinical practice guideline
- Pituitary incidentaloma: an Endocrine Society clinical practice guideline
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