Nonfunctioning Pituitary Adenoma That Changed to a Functional Gonadotropinoma

Objective. Pituitary adenomas can be classified as clinically functional or silent. Depending on the reviewed literature, these are the first or second place in frequency of the total pituitary adenomas. Even rarer is the presence of a functional gonadotropinoma since only very few case reports exist to date. The conversion of a clinically silent to functional pituitary adenoma is extraordinarily rare; the mechanisms that explain these phenomena are unknown or not fully understood. Methods. We report the case of a woman who initially had a nonfunctional gonadotropinoma and in the course of her medical condition showed biochemical changes in her hormonal pituitary profile compatible with a functional gonadotropinoma. Results. We considered that the patient had a functional gonadotropinoma due to the hyperestrogenemia in the context of secondary amenorrhea, resolving the hyperestrogenemia after almost complete resection of the tumor. Conclusion. It is necessary to point out from a clinical and/or biochemical point of view the change in functionality that a nonfunctional pituitary adenoma may have. In the case of our patient, the suspicion of this change in functionality became evident when we found an increase in the FSH/LH ratio and a progressive increase in serum estradiol concentrations when the patient had amenorrhea.

Download Full-text

SAT-269 A Rare Case of Functioning Gonadotroph Producing Pituitary Macroadenoma in Teenage Male

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1041 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Siroj Dejhansathit ◽

Subhanudh Thavaraputta ◽

Genevieve LaPointe ◽

Ana Marcella Rivas Mejia

Keyword(s):

Transcription Factor ◽

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Complete Blood Count ◽

Case Reports ◽

Biologically Active ◽

Total Testosterone ◽

Sellar Mass ◽

Delay In Diagnosis ◽

Orbitozygomatic Approach

Abstract Background: Unlike nonfunctioning gonadotroph pituitary adenomas, functioning gonadotroph pituitary adenomas (FGA) are an uncommon type of pituitary tumors that secrete biologically active gonadotropins (LH, FSH, or both). Clinical Case: A 23-year-old man with no previous medical history presented to the emergency department with three months history of progressive decreased vision and decreased libido. He denied headache, seizure, erectile dysfunction, or weakness. On physical examination, his visual acuity was significantly reduced on the right eye and was only able to perceive light. He had a visual field narrowing on the left eye. Gynecomastia was noted bilaterally and testicles were found to be enlarged (Orchidometer >25 mL). Complete blood count was significant for hemoglobin of 19.2 g/dL (N, 13.7-17.5 g/dL), and hematocrit of 57.0% (N, 40.1-51.0%). Pituitary function tests were as follow: FSH >200.0 mIU/mL (N, 1.5-12.4 mIU/mL), LH 17.0 mIU/mL (N, 1.7-8.6 mIU/mL), total testosterone 41.3 nmol/L (N, 8.6-29.0 nmol/L), free testosterone 1.263 nmol/L (N, 0.148-0.718 nmol/L), and bioavailable testosterone 29.609 (N, 2.110-8.920 nmol/L). Prolactin, TSH, GH, and ACTH were all within the normal range. Magnetic resonance imaging (MRI) showed a sellar mass involving the planum sphenoidal measuring 5.8 x 5.2 x 5.6 cm with optic chiasm displaced superiorly, in addition, subfalcine herniation with mild hydrocephalus was also noted. The patient underwent orbitozygomatic approach resection of the pituitary tumor. Histological examination was consistent with a pituitary adenoma. Cells stained positive for transcription factor steroidogenic factor 1 (SF 1), FSH, LH, and alpha-subunit consistent with a gonadotroph adenoma. They were negative for transcription factor Pit 1 stain and the remaining pituitary hormones including ACTH, GH, prolactin, and TSH stain. Postsurgical hormone assessment showed a significant decline in FSH and LH to 2.3 and 0.4 mIU/mL, respectively and testosterone level decreased to < 0.087 nmol/L on postoperative day 18. The patient’s vision improved postoperatively prior to discharge but he lost follow up thereafter. Conclusion: Most patients with functioning gonadotroph pituitary adenoma present with large tumors that are detected based on the occurrence of symptoms of compression that result from the enlarging sellar mass. Most patients, particularly men and postmenopausal women, do not develop symptoms of hormone excess and the lack of symptomatology results in delay in diagnosis. Our patients presented with significant polycythemia which resulted from excess testosterone and could have prompted earlier tumor detection if he had presented in an earlier stage. The incidence of polycythemia in male patients with functioning gonadotroph pituitary adenoma has previously been described in the literature in a few case reports.

Download Full-text

SAT-276 Co-Secreting TSH and Growth Hormone Pituitary Adenoma

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.674 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Hatem Eid

Keyword(s):

Growth Hormone ◽

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Case Reports ◽

Somatostatin Analogs ◽

Signs And Symptoms ◽

Pituitary Hormones ◽

Oral Glucose ◽

Pituitary Macroadenoma ◽

Α Subunit

Abstract Introduction: Secreting pituitary adenoma is exceedingly rare. Less than 15 cases having been reported. Its clinical presentation and diagnosis is challenging. We report a case of pituitary macroadenoma, with features of acromegaly and hyperthyroidism. Case report: A 75 years’ old man presented with new onset atrial fibrillation. He had high FT4 with normal TSH. His ultrasound scan of the neck showed a solitary nodule. He had ablation twice and was started on bisoprolol and anticoagulant. He had MRI scan for headaches and this showed a pituitary macroadenoma. He had high IGF-1. His oral glucose tolerance showed failure of GH suppression. His FT4 was persistently high with normal TSH and he had high a subunits. This suggested the diagnosis of TSH and GH secreting pituitary adenoma. Discussion: TSH-secreting pituitary adenomas are rare and not uncommonly, they co-secrete other pituitary hormones including growth hormones. Somatotrophs and lactotrops share common transcription factors with thyrotrophs. TSH-secreting adenomas are benign but 60% of them are locally invasive. TSH-secreting pituitary adenomas typically present with either symptoms of tumor growth like headache or visual field disturbance or symptoms of hyperthyroidism. Thyroid nodules are common in patients with TSHomas. In patients with TSH-secreting pituitary adenomas, majority will need only surgery and radiation. The medical treatment used to normalize TSH and FT4 levels is somatostatin analogs. This is effective in about 90% of patients with TSH secreting pituitary adenomas TSHoma should be differentiated from resistance to thyroid (RTH). The main difference between TSHoma and RTH is the presence of signs and symptoms of hyperthyroidism in patients with TSHoma, absence of a family history, normal thyroid hormone levels in family members, and the presence of an elevated glycoprotein α-subunit in patients with pituitary tumor. Reference: H Adams and D Adams. A case of a co-secreting TSH and growth hormone pituitary adenoma presenting with a thyroid nodule. EDM case reports 2018 [email protected]

Download Full-text

Rare location of a colloid cyst - case presentation

Romanian Neurosurgery ◽

10.1515/romneu-2015-0011 ◽

2015 ◽

Vol 22 (1) ◽

pp. 94-100

Author(s):

D. Păunescu ◽

M. Gorgan ◽

V. Ciubotaru ◽

Ligia Tătăranu

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Colloid Cyst ◽

Sellar Region ◽

Case Presentation ◽

Therapeutic Challenge ◽

Nonfunctioning Pituitary Adenoma ◽

Rare Location

Abstract Not only pituitary adenomas, but also a number of tumors may arise from within the sella presenting a diagnostic and therapeutic challenge at a multidisciplinary specialist level. This article presents a case of a colloid cyst located in sellar region, with overlapping symptoms of a nonfunctioning pituitary adenoma.

Download Full-text

Volumetry in the Assessment of Pituitary Adenoma Resection: Endoscopy versus Microscopy

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1639618 ◽

2018 ◽

Vol 79 (06) ◽

pp. 538-544 ◽

Cited By ~ 1

Author(s):

Anthony Wang ◽

Ashish Shah ◽

Charif Sidani ◽

Brandon Gaynor ◽

Simon Dockrell ◽

...

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Residual Tumor ◽

Extent Of Resection ◽

Volumetric Analysis ◽

Complete Resection ◽

Tumor Control ◽

Consecutive Series ◽

Complication Rates ◽

Recurrence Rates

Background Assessment of the extent of resection after surgical resection of pituitary adenomas is most commonly reported in terms of the presence or absence of residual tumor. A quantitative comparison of volumetric resection between endonasal endoscopy (EE) and microsurgery (MS) has rarely been done. Methods A retrospective analysis was performed on a consecutive series of 154 patients with pituitary adenomas treated by the same surgeon at a single institution. We employed volumetric analysis pre- and postoperatively on two cohorts of pituitary adenoma patients treated through MS (n = 37) versus EE approach (n = 117). Results Volumetric analysis revealed a higher incidence of complete resection (64.4 vs. 56.8%) and mean volume reduction in the EE cohort (92.7 vs. 88.4%), although not significant. Recurrence rates were significantly lower in the EE group (7.7% vs 24.3%, p = 0.015). Subgroup analysis identified that patients with preoperative tumor volumes >1 mL were less likely to recur through EE (7.8 vs. MS: 29.6%; p = 0.0063). A higher incidence of complete resection was also noted in patients with favorable Knosp grades (0–1) (EE: 87.8 vs. MS: 63.2%; p = 0.036). Postoperative complication rates were not significantly different between both techniques. Conclusion Both microscopy and endoscopy are well-tolerated, effective approaches in the treatment of pituitary adenomas. Our series demonstrated that EE may be superior to MS in preventing tumor recurrence and achieving a complete resection in certain subsets of patients. EE provides a slight advantage in tumor control outcomes that may justify the paradigm shift to pure endoscopy at our center.

Download Full-text

Aggressive Cushing disease five years after the treatment of a nonfunctional pituitary adenoma

Problems of Endocrinology ◽

10.14341/probl201662577-78 ◽

2016 ◽

Vol 62 (5) ◽

pp. 77-78

Author(s):

Minodora Betivoiu ◽

Sorina Martin ◽

Iulia Soare ◽

Alexandra Nila ◽

Simona Fica

Keyword(s):

Pituitary Adenoma ◽

Gamma Knife ◽

Pituitary Adenomas ◽

Histopathological Examination ◽

Case Reports ◽

Dependent Diabetes Mellitus ◽

Ki 67 ◽

The Right ◽

Gamma Knife Therapy

Introduction. Cushing's disease (CD) represents 10%–12% of all pituitary adenomas and is seen predominantly in women, with a female-to-male ratio of 8:1. Although most patients with ACTH-secreting adenomas present with benign, small tumors, some have invasive macroadenomas. Rarely, nonfunctional pituitary adenomas (NFPAs) may gain secretory function, but there have been a few case reports of metamorphosis to CD.Case report. We report the case of a 59-year-old female diagnosed in 2007 with a NFPA and panhypopituitarism. She had two transsphenoidal surgeries and Gamma Knife therapy and started replacement treatment with levothyroxine 75mcg/day and prednisone 5mg/day. The postoperative course was favorable and imagistic follow-up between 2007-2014 showed progressive reduction of the residual tumor and empty sella. From personal history we note noninsulin-dependent diabetes mellitus, postmenopausal osteoporosis treated with bisphosphonates. In January 2015 she suffered visual loss on the right eye. Pituitary MRI showed supra and parasellar tumor recurrence of 27/24/17mm, infiltrating the right side of the cavernous sinus, extending around the right internal carotid artery and optic nerve, compressing the optic chiasm. In March 2015 a third transsphenoidal partial excision of the tumor was performed and in August Gamma Knife therapy was repeated. The histopathological examination was consistent with a pituitary adenoma but immunohistochemical staining for ACTH was positive, with Ki-67=25%. She had no non-specific cushingoid features. Laboratory test: glucose=116mg/dl, HbA1c=7.5%, FSH=3.34mIU/ml, LH=0.585mIU/ml TSH=0.044mcIU/ml, FT4=1.13ng/dl. Prednisone replacement therapy was stopped and CD was confirmed: 8AMcortisol=13.3mcg/dl, 23PMcortisol=11.3mcg/dl, ACTH=70.2pg/ml, 8AMcortisol after 1mg dexamethasone overnight=13.8mcg/dl. Ophthalmic exam: blindness in the right eye, slightly decreased visual field in the left eye. Pituitary MRI 8-month postsurgery revealed a 28/31/28mm invasive tumor. We started treatment with Cabergoline 3mg/week and recommended closely biological and imagistic follow-up, hoping for a good response to radiotherapy.Conclusions: Our case stresses the importance of regular, lifelong follow-up of patients with NFPAs. Chiloiro et al have reported that pituitary adenomas with Ki-67≥1.5% have a higher risk of recurrence. Although the characteristics of patients with CD have been well known for decades, the diagnosis and management of this disease are often challenging.

Download Full-text

Return of Gonadal Function with Resection of Nonfunctioning Pituitary Adenoma

Neurosurgery ◽

10.1227/00006123-198802000-00019 ◽

1988 ◽

Vol 22 (2) ◽

pp. 386-387 ◽

Cited By ~ 1

Author(s):

K. Patrick Ober ◽

David L. Kelly

Keyword(s):

Pituitary Adenoma ◽

Pituitary Adenomas ◽

Pituitary Tumor ◽

Gonadal Function ◽

Nonfunctioning Pituitary Adenoma ◽

Pituitary Tissue ◽

Testicular Failure

Abstract A 42-year-old man with severe testicular failure (testosterone 24 ng/dl, normal 300-1100) was found to have a nonfunctioning chromophobe pituitary adenoma. Resection of the pituitary tumor resulted in recovery of gonadal function (testosterone 359 ng/dl). Hypogonadism caused by pituitary adenomas is usually attributed to either hyperprolactinemia or irreversible destruction of normal pituitary tissue, neither of which is applicable to this patient. The recovery of our patient's gonadal function after operation suggests that a reversible compression of viable tissue or impairment of hypothalamic-pituitary communications was responsible for his endocrine deficiency. (Neurosurgery 22:386-387, 1988)

Download Full-text

Cushing’s Disease (CD) Due to ACTH-Secreting Pituitary Microadenoma Incidentally Discovered on a Sestamibi Scan for Primary Hyperparathyroidism

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1182 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A579-A580

Author(s):

Hassan Mehmood ◽

Murray B Gordon

Keyword(s):

Pituitary Adenoma ◽

Primary Hyperparathyroidism ◽

Pituitary Adenomas ◽

Case Reports ◽

Adrenal Hyperplasia ◽

Pituitary Microadenoma ◽

Free Cortisol ◽

Sestamibi Scan ◽

The Right ◽

Acth Secreting

Abstract Introduction: MIBI scintigraphy is commonly being used for the preoperative localization of parathyroid adenomas. Multiple studies showed MIBI uptake in pituitary adenomas are likely due to higher metabolic activity. When hyperfunctioning pituitary adenomas were reported, both had CD [1,2]. We present the third case of increased pituitary uptake on a MIBI scan later confirmed as CD. CaseA 64-year-old Caucasian female s/p renal transplantation for RPGN who presented for evaluation of hypercalcemia. Evaluation confirmed primary hyperparathyroidism with persistently elevated PTH levels 74-108 pg/ml (11-68), serum calcium levels 10.0-10.4 mg/dl (8.4-10.3), albumin 4.1-4.3 g/dl (3.6-5.1), phosphorus 3.0-3.2 mg/dl (2.5-4.5), creatinine 0.94-1.07 mg/dl. 24-hour urine calcium 60 mg/day (35-250). Vitamin D-25 OH level was 37 ng/dL (30-100). A sestamibi scan showed uptake in the right lower parathyroid, the midsternal chest region and the pituitary gland. MRI of the pituitary revealed a 7mm cystic pituitary microadenoma in the right posterior pituitary. CD was confirmed by the findings of persistently elevated 8 AM serum cortisol levels of 28.4 and 24.2 mcg/dl (4-22), ACTH levels of 59 and 39 pg/ml (10-48), and an elevated plasma free cortisol of 1.43 mcg/dl (0.07-0.93). CT of the abdomen showed L adrenal thickening suggesting adrenal hyperplasia from CD. Plasma cortisol suppressed to 1.2 mg/dl following 1 mg of dexamethasone. 24 urine for free cortisol 26.7 mcg/day (4-50). The patient had no proximal muscle weakness, striae or Cushingoid facial features. She had no hyperglycemia or hypertension. Patient was diagnosed with an ACTH secreting pituitary microadenoma with mild CD and adrenal hyperplasia. Her DXA scan showed osteoporosis. Genetic testing for MEN1 mutation was negative. Patient did not wish surgery for either her hyperparathyroidism or her CD and is being evaluated for medical treatment of hypercortisolism. Conclusion: There are two prior case reports of an incidentally discovered pituitary adenoma on sestamibi scan later diagnosed as CD [1,2]. Corticotrophs may have a strong affinity for sestamibi. Our case is the first, to our knowledge, of pituitary MRI confirmation of the ACTH secreting pituitary incidentaloma initially suspected by pituitary uptake on a sestamibi scan in a patient with hyperparathyroidism. Reference1. Kuhadiya ND et al. Incidentally Discovered ACTH-Secreting Pituitary Adenoma on a Sestamibi Scan in a Patient With Hyperparathyroidism. AACE Clinical Case Reports. 2015;1(3):e152-5. 2. Gierach M et al. The case of Cushing’s disease imaging by SPECT examination without manifestation of pituitary adenoma in MRI examination. Nuclear Medicine Review. 2005;8(2):137-9.

Download Full-text

Long-term Outcomes After Gamma Knife Radiosurgery for Patients With a Nonfunctioning Pituitary Adenoma

Neurosurgery ◽

10.1227/neu.0b013e31821bc44e ◽

2011 ◽

Vol 69 (2) ◽

pp. 284-293 ◽

Cited By ~ 73

Author(s):

Rupa Gopalan ◽

David Schlesinger ◽

Mary Lee Vance ◽

Edward Laws ◽

Jason Sheehan

Keyword(s):

Pituitary Adenoma ◽

Diabetes Insipidus ◽

Pituitary Adenomas ◽

Tumor Volume ◽

Gamma Knife Radiosurgery ◽

Hormone Deficiency ◽

Tumor Control ◽

Nonfunctioning Pituitary Adenoma

Abstract BACKGROUND: Nonfunctioning pituitary adenomas recur after microsurgery. Gamma Knife radiosurgery (GKRS) has been used to treat recurrent adenomas. OBJECTIVE: To evaluate the long-term rates of tumor control and development of hypopituitarism in patients with nonfunctioning pituitary adenomas after GKRS. METHODS: Forty-eight patients with a nonfunctioning pituitary adenoma treated between 1991 and 2004 at the University of Virginia were studied. All patients had more than 4 years of clinical and imaging follow-up. RESULTS: All patients underwent follow-up imaging and endocrine evaluations, with a duration ranging from 50 to 215 months (median, 80.5 months) and 57 to 201 months (median, 95 months), respectively. New hormone deficiency after GKRS occurred in 19 of 48 patients (39%). Corticotropin/cortisol deficiency developed in 8% of patients, thyroid hormone deficiency in 20.8%, gonadotropin deficiency in 4.2%, growth hormone/insulin-like growth factor 1 in 16.7%, and diabetes insipidus in 2%. Panhypopituitarism including diabetes insipidus developed in 1 patient. Overall, control of tumor volume was 83%. Tumor volume decreased in 36 patients (75%), increased in 8 patients (17%), and was unchanged in 4 patients (8%). Tumor volumes greater than 5 mL at the time of GKRS were associated with a significantly greater rate of growth (P = .003) compared with an adenoma with a volume of 5 mL or less. CONCLUSION: GKRS resulted in a high and durable rate of tumor control in patients with a nonfunctioning pituitary adenoma. A higher preoperative tumor volume was associated with an increased rate of tumor growth.

Download Full-text

Pituitary Adenoma Associated With Rathke’s Cleft Cyst: Report of 15 Cases

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.252 ◽

2017 ◽

Vol 45 (1) ◽

pp. 68-75 ◽

Cited By ~ 4

Author(s):

Wenhao Wu ◽

Guijun Jia ◽

Wang Jia ◽

Guilin Li ◽

Junting Zhang ◽

...

Keyword(s):

Pituitary Adenoma ◽

Case Reports ◽

Complete Resection ◽

Test Results ◽

Rathke’S Cleft Cyst ◽

Rathke's Cleft Cyst ◽

Nonfunctional Pituitary Adenomas ◽

The Mean ◽

Rathke's Cleft

AbstractObjective: The concomitant presence of pituitary adenoma (PA) with Rathke’s cleft cyst (RCC) is rare, and most of the literature published is case reports. RCC’s clinicopathological features have not been well described. Methods: We retrospectively reviewed the data of 15 patients with PA associated with RCC. We also provide a systematic review of the literature. Results: The patients included males and seven females. The transsphenoidal approach was adopted for all patients except one, who underwent right frontal craniotomy. Complete resection was achieved in nine cases, with grossly complete resection in five and partial removal in one. Of the PA subtypes available, five patients had nonfunctional pituitary adenomas, three had multiple-hormone secreting PAs, three had prolactin-producing adenomas, and one had a growth hormone-secreting adenoma. All of the patients’ symptoms and abnormal endocrine test results resolved or were relieved after surgery. The mean follow-up time was 27.6±16.6 months. All of the patients recovered well and had no signs of recurrence during their follow-up, except for one patient. Conclusions: A cyst-like signal indicated on images or cystic materials encountered during operation in a patient with PA suggest the possibility of PA associated with RCC. Transsphenoidal surgery is the preferred approach and can resolve or relieve patients’ symptoms to a great extent. Histologically, nonfunctional PA and prolactinoma are the most common types of PA coexisting with RCC; the mechanisms of PA associated with RCC need to be investigated further.

Download Full-text