Imaging pituitary gland Imaging pituitary gland tumorstumors

Neel Neel VarshneyVarshney, Harvard Medical School Year IV, Harvard Medical School Year IVGillian Lieberman, MDGillian Lieberman, MD

November 2005Neel Varshney, HMS IVGillian Lieberman, MD

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Two categories of presenting signs of a Two categories of presenting signs of a pituitary masspituitary mass

FunctionalFunctional tumors present with tumors present with symptoms due to excess hormone symptoms due to excess hormone release.release.

Excess Excess prolactinprolactin is called a is called a prolactinomaprolactinoma..

Excess ACTH due to a pituitary Excess ACTH due to a pituitary adenoma is called Cushingadenoma is called Cushing’’s disease.s disease.

Excess TSH.Excess TSH.

Excess GH produces Excess GH produces acromegalyacromegaly..

Functional tumors tend to present as Functional tumors tend to present as microadenomasmicroadenomas (a mass <10mm in (a mass <10mm in size).size).

AcromegalyAcromegaly is an exception, as it can is an exception, as it can present as a relatively large mass if present as a relatively large mass if the symptoms of bony growth, like the symptoms of bony growth, like increased hand and foot size, are not increased hand and foot size, are not noticed until late in the disease. noticed until late in the disease.

NonNon--functionalfunctional Tumors present with Tumors present with symptoms due to mass effect.symptoms due to mass effect.

Because they do not produce Because they do not produce symptoms due to excess hormone symptoms due to excess hormone release, they are often release, they are often macroadenomasmacroadenomas (a mass >10mm in (a mass >10mm in size) by time of detection.size) by time of detection.

GonadotropinGonadotropin (FSH, LH) releasing (FSH, LH) releasing tumors usually present as nontumors usually present as non-- functional masses.functional masses.

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Patient 1Patient 1

A 69 year old male presents with aA 69 year old male presents with aheadache and visual field deficits.headache and visual field deficits.

Neel Varshney, HMS IVGillian Lieberman, MD

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Working up a suspected pituitary massWorking up a suspected pituitary mass

WorkWork--up should include a up should include a hormonal evaluation. High hormonal evaluation. High levels of a hormone indicate the levels of a hormone indicate the type of tumor (see table). type of tumor (see table).

Low values are also significant. Low values are also significant. HyposecretionHyposecretion of a hormone of a hormone suggests compressive effect suggests compressive effect and the need for possible and the need for possible replacement.replacement.

Hormone levels also establish a Hormone levels also establish a baseline to monitory success of baseline to monitory success of therapeutic intervention.therapeutic intervention.

Workup should also include a Workup should also include a radiologic evaluation.radiologic evaluation.

High levels High levels ofof……

SuggestSuggest……

ProlactinProlactin ProlactinomaProlactinoma

ACTH + 24hr ACTH + 24hr urine urine cortisolcortisol

CushingCushing’’s diseases disease

TSH + T4TSH + T4 TSHTSH--secreting secreting tumortumor

IGFIGF--1*1* AcromegalyAcromegaly

FSH, LH, sex FSH, LH, sex steroidssteroids

GonadotropinGonadotropin-- secreting tumorsecreting tumor

Neel Varshney, HMS IVGillian Lieberman, MD

*GH is released in a *GH is released in a pulsatilepulsatile manner manner and a single elevated value is not an and a single elevated value is not an accurate marker of disease.accurate marker of disease.

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Choice of imaging modalitiesChoice of imaging modalities

MRI is the modality of choice for imaging the MRI is the modality of choice for imaging the pituitary gland. The standard protocol is:pituitary gland. The standard protocol is:

PrecontrastPrecontrast T1 weighted thin slices through the T1 weighted thin slices through the sellasella ((sagittalsagittal, , coronal planes)coronal planes)

Gadolinium contrastGadolinium contrast

Repeat coronal and Repeat coronal and sagittalsagittal T1 sequencesT1 sequences

T2 sequence not considered part of standard protocol but is T2 sequence not considered part of standard protocol but is useful for detecting cystic changes and hemorrhageuseful for detecting cystic changes and hemorrhage

Use CT in patients with contraindications to MRI.Use CT in patients with contraindications to MRI.

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Reviewing the anatomy of the Reviewing the anatomy of the sellarsellar regionregion

www.neurosurgery.medsch.ucla.eduVictor Haughton, MD and Todd Peebles, MD

http://www.endotext.org/neuroendo/neuroendo4/neuroendo4.htm

Neel Varshney, HMS IVGillian Lieberman, MD

Depiction of sellar anatomy

C: Optic ChiasmA: Pituitary GlandI: Cavernous portion of Internal Carotid Artery*: Sphenoid SinusArrowhead: Pituitary Stalk

Companion patient 1: MRI of the sellar region

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Patient 1 images Patient 1 images

BIDMC PACS system

Neel Varshney, HMS IVGillian Lieberman, MD

MRI of the pituitary gland

Precontrast sagittal T1 image shows a large sellar mass.

T1 with gado in the sagittal plane shows heterogeneous enhancement of the sellar mass.

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Patient 1 imagesPatient 1 images

BIDMC PACS system

Neel Varshney, HMS IVGillian Lieberman, MD

MRI of the pituitary gland

Precontrast coronal T1 image again shows a large sellar mass.

T1 with gado in the coronal plane shows heterogeneous enhancement of the sellar mass. The mass is invading the left cavernous sinus but the left ICA remains patent.

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DDX of a DDX of a SellarSellar MassMass

Benign tumor Benign tumor

Micro/Micro/macroadenomasmacroadenomas (this is the most common cause of a (this is the most common cause of a sellarsellar mass)mass)

CraniopharyngiomaCraniopharyngioma

MeningiomaMeningioma

Malignant primary tumorsMalignant primary tumors

Metastatic tumorsMetastatic tumors

LungLung

BreastBreast

Pituitary hyperplasiaPituitary hyperplasia

CystCyst

RathkeRathke’’ss cleftcleft

AbcessAbcess

Lymphocytic Lymphocytic hypophysitishypophysitis

Carotid AV fistulaCarotid AV fistula

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Imaging the pituitaryImaging the pituitary

MacroadenomasMacroadenomas easily detected on imagingeasily detected on imaging

MicroadenomasMicroadenomas more difficult to detect because more difficult to detect because of smaller sizeof smaller size

Appear as a focal area of low signal on nonAppear as a focal area of low signal on non--contrast contrast T1.T1.

Peak enhancement of the Peak enhancement of the microadenomamicroadenoma occurs after occurs after normal tissue.normal tissue.

Therefore, scanning immediately after giving contrast Therefore, scanning immediately after giving contrast bolus, in a method called bolus, in a method called ‘‘dynamicdynamic’’ MR imaging, MR imaging, increases test sensitivity.increases test sensitivity.

Functional adenomas not distinguishable on MRI.Functional adenomas not distinguishable on MRI.

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Dynamic imaging of Dynamic imaging of microadenomasmicroadenomas

Victor Haughton, MD and Todd Peebles, MD http://www.endotext.org/neuroendo/neuroendo4/neuroendo4.htm

Neel Varshney, HMS IVGillian Lieberman, MD

Companion patient 2: Advantage of dynamic MRI in imaging microadenomas

A small area of low signal intensity within the pituitary gland prior to contrast (left image) is more distinguishable immediately after gado is given (right image).

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Pituitary apoplexy: a Pituitary apoplexy: a sequelasequela of of macroadenomamacroadenoma

Acute onset of neurologic Acute onset of neurologic symptoms caused by symptoms caused by tumor hemorrhage and tumor hemorrhage and expansion of glandexpansion of gland

Occurs in 3Occurs in 3--26% of 26% of macroadenomasmacroadenomas

T1 and T2 weighted T1 and T2 weighted images together suggest images together suggest age of hemorrhageage of hemorrhage

Treatment includes Treatment includes steroids, endocrine steroids, endocrine evaluation, surgical evaluation, surgical decompressiondecompression

DulipsinghDulipsingh L and L and LassmanLassman MN (2000). MN (2000). Images in Clinical Medicine: Pituitary Apoplexy. Images in Clinical Medicine: Pituitary Apoplexy. NEJM. 342:550.NEJM. 342:550.

Neel Varshney, HMS IVGillian Lieberman, MD

Companion patient 3: MRI image

Coronal T1 image shows areas of high and moderate intensity, suggestive of hemorrhage.

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Surgical treatment and postSurgical treatment and post--op imagingop imaging

Immediately postImmediately post--op, op, mass size may appear mass size may appear unchanged due to unchanged due to packing materialspacking materials

Volume of mass Volume of mass decreases over next decreases over next few monthsfew months

http://www.pituitarysociety.org/public/specific/acromegaly/imagehttp://www.pituitarysociety.org/public/specific/acromegaly/images/pituitarysurgery.gifs/pituitarysurgery.gif

Neel Varshney, HMS IVGillian Lieberman, MD

Transsphenoidal approach to pituitary surgery

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ConclusionsConclusions

Functional tumors present with symptoms, signs Functional tumors present with symptoms, signs related to excess hormone.related to excess hormone.

Panel of hormonal tests helps determine type of tumor.Panel of hormonal tests helps determine type of tumor.

Functional tumors are challenging to detect Functional tumors are challenging to detect radiographicallyradiographically because they are more likely because they are more likely microadenomasmicroadenomas at time of detection.at time of detection.

Nonfunctional pituitary masses present due to mass Nonfunctional pituitary masses present due to mass effects and are more easily detected on imaging.effects and are more easily detected on imaging.

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ReferencesReferences

DulipsinghDulipsingh L and L and LassmanLassman MN (2000). MN (2000). Images in Clinical Medicine: Pituitary Images in Clinical Medicine: Pituitary Apoplexy. Apoplexy. NEJM. 342:550.NEJM. 342:550.

Greenberg MS. Handbook of Neurosurgery 5Greenberg MS. Handbook of Neurosurgery 5thth edition. edition. ThiemeThieme, New York: 2001., New York: 2001.

Haughton, V and Peebles T. Pituitary Gland Imaging in endotext.com. http://www.endotext.org/neuroendo/neuroendo4/neuroendo4.htm

NaidichNaidich MJ and Russell EJ (1999). MJ and Russell EJ (1999). Current approaches to imaging of the Current approaches to imaging of the sellarsellar region region and pituitary. and pituitary. EndocrinolEndocrinol MetabMetab ClinClin North Am. 28(1): 45North Am. 28(1): 45--79. 79.

Snyder PJ. Causes, presentation, and evaluation of sellar masses. www.uptodate.com

www.neurosurgery.medsch.ucla.edu

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AcknowledgementsAcknowledgements

Larry Larry BarbarasBarbaras, webmaster, webmaster

Gillian Lieberman, MDGillian Lieberman, MD

Pamela Pamela LepkowskiLepkowski

Neel Varshney, HMS IVGillian Lieberman, MD