Pituitary adenoma: symptoms, treatment, types,diagnosis and causes of development

Update: December 2018

The pituitary gland is a central endocrine gland that affects
growth, metabolism and reproductive functions in the human body.
Located in the brain at the base of the Turkish saddle. Dimensions
adult pituitary gland is approximately 9 x 7 x 4 mm, weight
– about 0.5 gr. The pituitary gland consists of two parts – the front,
adenohypophysis, and posterior, neurohypophysis.

The functions of the front end are the production of hormones that
stimulate the activity of the thyroid gland (thyroid stimulating hormone,
TSH), ovaries and testes (follicle-stimulating hormone, FSH and
luteinizing hormone, LH), adrenal glands (adrenocorticotropic
hormone, ACTH), and also regulate the growth of the body (somatotropic
hormone, growth hormone) and lactation (prolactin).

The functions of the neurohypophysis are reduced to the production of antidiuretic
hormone regulating the water – salt metabolism in the body, and
oxytocin, which regulates the process of childbirth and lactation.

With adverse effects glandular tissue may
increase in volume and produce an excess amount
hormones – adenoma develops. Pituitary adenoma is
benign tumor developing from cells
adenohypophysis.

The following types of adenoma are distinguished.

In size:

  • microadenoma – less than 1 cm
  • macroadenoma – more than 1 cm
  • giant adenomas – more than 10 cm

By localization:

  • Intracellular – not extending beyond the Turkish saddle
  • growing to the top of the Turkish saddle – endosuprasellar
  • growing to the bottom – endoinfrasellar
  • sprouting Turkish saddle to the side – endolatherossellar
    adenoma

According to the secretion of hormones:

  • hormonally inactive tumors (about 40%)
  • hormonally active adenomas (60%)

By the nature of the produced hormones:

  • growth hormone
  • gonadotropinoma (FSH or LH)
  • thyrotropinoma
  • prolactinoma
  • corticotropinoma
  • mixed pituitary adenoma (produce several
    hormones are found in 15% of cases)

According to statistics, pituitary adenomas make up 10 – 15% of all
brain tumors. Adenoma occurs at the age of 25 – 50
years, with the same frequency in men and women. Rare disease
can develop in children – 2-6% of all patients with adenoma
make up children and teenagers.

What causes adenoma?

Causes of pituitary adenoma:

  • Neuroinfections:
      • meningitis, encephalitis
      • tuberculosis with damage to the central nervous system
      • brucellosis
      • polio
      • syphilis
  • Negative effects on the fetus during pregnancy (toxic and
    drugs, ionizing radiation)
  • Cranial – brain injuries, intracranial hemorrhages.
  • Heredity. In patients with multiple syndrome
    эндокринного adenomaтоза, передающегося по наследству, при котором
    there are tumors of other glands, the incidence of pituitary adenoma
    higher than other people.
  • Long-lasting autoimmune or inflammatory lesions
    thyroid gland with a decrease in its function (hypothyroidism)
  • Hypogonadism – congenital hypoplasia of the ovaries and testes, or
    acquired lesion of the genital glands due to radioactive
    radiation, autoimmune processes, etc.
  • Long-term use of combined oral contraceptives
    according to recent data, can lead to the development of adenoma, since
    these drugs over many menstrual cycles suppress
    ovulation, the corresponding ovarian hormones are not produced, and
    the pituitary gland has to produce more FSH and LH, then
    there may develop gonadotropinoma.

Symptoms

Признаки, которыми может проявляться adenoma, различаются в
depending on the type of tumor.

Гормонально активная микроadenoma проявляется эндокринными
impaired, and inactive may exist for several years until
will reach significant sizes or will not be accidentally detected when
screening for other diseases. 12% of people exist
asymptomatic microadenomas.

Макроadenoma проявляется не только эндокринными, но еще и
neurological impairment caused by squeezing others
nerves and tissues.

Prolactinoma

The most common tumor of the pituitary gland, occurs in 30-40% of cases
all adenomas. As a rule, the size of prolactinomas do not exceed 2 – 3
mm It is more common in women than in men. Manifested by such
signs like:

  • menstrual disorders in women – irregular cycles,
    lengthening the cycle over 40 days, anovulatory cycles, lack of
    menstruation
  • galactorrhea – permanent or periodic discharge of the thoracic
    milk (colostrum) from the mammary glands, not associated with postpartum
    period
  • inability to get pregnant due to lack of ovulation
  • у мужчин prolactinoma проявляется снижением потенции,
    breast enlargement, erectile dysfunction, impaired
    formation of spermatozoa, leading to infertility.

Growth hormone

It is 20-25% of the total number of pituitary adenomas. In children
the frequency of occurrence ranks third after prolactinomas and
corticotropinomas. Characterized by elevated levels of growth hormone.
in blood. Signs of growth hormones:

  • children show symptoms of gigantism. Baby fast
    gaining weight and height, due to uniform growth
    bones in length and width, as well as the growth of cartilage and soft tissue. how
    usually, gigantism begins in the prepubertal period, for
    some time before puberty and may
    progress until the end of the skeleton formation (approximately
    up to 25 years). Increased adult height is considered gigantism.
    people over 2 – 2.05 m.
  • если growth hormone возникла во взрослом возрасте, она
    manifested by symptoms of acromegaly – an increase in hands, feet, ears,
    nose, tongue, change and coarsening of facial features, the appearance of increased
    hair distribution, beard and mustache in women, menstrual disorders.
    An increase in internal organs leads to a violation of their functions.

Corticotropin

It occurs in 7-10% of cases of pituitary adenoma. Characterized by
overproduction of adrenal hormones
(glucocorticoids), it is called Itsenko-Cushing’s disease.

Symptoms of Corticotropinomas:

  • �”Cushingoid” type of obesity – redistribution occurs
    body fat and fat deposition in the shoulder girdle, on
    neck, supraclavicular zones. A person acquires a “moon-shaped”, round
    form. Limbs become thinner due to atrophic
    processes in the subcutaneous tissue and muscles.
  • skin disorders – stretch marks pink – purple (striae)
    on the skin of the abdomen, chest, thighs; enhanced pigmentation of the skin of the elbows,
    knees, armpits; increased dryness and peeling of the skin
  • arterial hypertension
  • women may have menstrual disorders and hirsutism
    – increased hair growth, beard and mustache growth
  • men often have a decrease in potency

Gonadotropinoma

Rarely found among pituitary adenomas. Manifested by violations
менструального цикла, чаще отсутствием menstruation, снижением
reproductive function in men and women, on the background of reduced or
missing external and internal genital organs.

Thyrotropinomy

Also very rare, only 2 – 3% of pituitary adenomas.
Its manifestations depend on whether the tumor is primary or
secondary

  • for primary tiretropinoma are characterized by the phenomenon of hyperthyroidism –
    weight loss, trembling of limbs and whole body, bug-eyed, poor
    sleep, increased appetite, sweating, high
    blood pressure, tachycardia.
  • for secondary thyrotropinomy, i.e., arising from
    long-existing reduced thyroid function,
    hypothyroidism is characteristic – swelling on the face, slow speech,
    weight gain, constipation, bradycardia, dry, scaly
    skin, hoarse voice, depression.

Neurological manifestations of pituitary adenoma

  • visual impairment – double vision, squint, reduction
    visual acuity in one or both eyes, limiting visual fields.
    Significant adenoma sizes can lead to complete atrophy.
    optic nerve and blindness
  • headache, not accompanied by nausea, not changing
    when changing the position of the body, often do not stop taking
    pain medication
  • nasal congestion caused by germination in the bottom of the Turkish
    saddles

Symptoms недостаточности pituitary gland

Possible development of pituitary insufficiency caused by compression
normal pituitary tissue. Symptoms:

  • hypothyroidism
  • adrenal insufficiency – fatigue,
    low blood pressure, fainting, irritability,
    muscle and joint pain, metabolic electrolytes (sodium and
    potassium), low blood glucose
  • reduced levels of sex hormones (estrogens in women and
    testosterone in men) – infertility, decreased libido and impotence,
    decreased hair growth in men on the face
  • in children, lack of growth hormone leads to stunted growth
    and development

Psychiatric signs

These symptoms of pituitary adenoma are due to a change in
hormonal levels in the body. May be observed
irritability, emotional instability, tearfulness,
depression, aggressiveness, apathy.

Diagnosis of pituitary adenoma

If a pituitary adenoma is suspected, counseling is indicated.
Endocrinologist, neurologist, neurosurgeon and oculist. Assigned
the following diagnostic methods:

Hormonal studies

  • the level of prolactin in the blood, the rate is less than 20 ng / ml for
    женщин и менее 15 нг/мл для мужчин
  • test with tiroliberin – normal after intravenous administration
    thyroliberin an increase in production of prolactin occurs already through
    30 minutes at least twice. Low prolactin levels after
    thyroliberin may indicate in favor of prolactinomas
    pituitary gland
  • somatotropic hormone (STH) level in the blood, the norm for children
    from year to 18 years – 2–20 mIU / l, for men 0–4 µg / l, for
    women – 0-18 µg / l.
  • adrenocorticotropic hormone (ACTH) in plasma, normal in the morning
    at 8.00 o’clock – less than 22 pmol / l, in the evening at 22.00 less than 6 pmol / l,
    plasma cortisol in the morning 200 – 700 nmol / l, in the evening 55 – 250
    nmol / l.
  • diurnal rhythm of cortisol in the blood
  • the study of daily urine on the level of cortisol, the norm – 138 –
    524 nmol / day.
  • the study of electrolytes in the blood – sodium, potassium, calcium,
    phosphorus, etc.
  • dexamethasone test – a study of the level of cortisol in the blood and
    urine after taking large or small doses dexamethasone
  • the level of follicle-stimulating hormone (FSH) in the blood, the norm
    women – on the 7th – 9th day of the menstrual cycle 3.5 – 13.0 IU / l, on 12
    – 14 days – 4.7 – 22.0 IU / l, on 22 – 24 days – 1.7 – 7.7 IU / l. Have
    FSH men are normal – 1.5 – 12.0 IU / l.
  • the level of luteinizing hormone (LH) in the blood, the norm – by 7 – 9
    cycle day 2 – 14 IU / l, for 12 – 14 days – 24 – 150 IU / l, for 22 – 24
    day – 2 – 17 IU / l. Have мужчин – 0.5 – 10 МЕ/л.
  • serum testosterone in men, the rate of total fraction – 12
    – 33 nmol / l.
  • the level of thyrotropic hormone (TSH), and thyroid hormones
    glands (T3, T;) in the blood, the norm – TSH – 0.4 – 4.0 mIU / ml, T3 – 2.63
    – 5.70 pmol / l, T4 – 9.0 – 19.1 pmol / l.
  • The standards may vary slightly in laboratories.
    different medical institutions

radiography of the skull

MRI of the brain (in the absence of equipment – CT of the brain
brain)

иммуноцитохимическое исследование клеток аденомы pituitary gland

visual field examination

how лечить аденому pituitary gland?

The choice of treatment method for each patient is determined by
individually, depending on the hormonal activity of the tumor,
clinical manifestations and size of adenoma.

With prolactinoma with a level of prolactin in the blood of more than 500 ng / ml
used drug therapy, and at the level of prolactin less
500 ng / ml, or more than 500 ng / ml, but with no effect from
medication – indicated surgical treatment.

При growth hormoneх, corticotropinomaх, гонадотропиномах,
гормонально неактивных макроadenomaх показано оперативное лечение в
combination with radiation therapy. The exceptions are somatotropinomas.
with asymptomatic type of flow – they can be treated without
operations.

Drug treatment

Assigned такие группы препаратов:

  • антагонисты гормонов гипоталамуса и pituitary gland – сандостатин
    (octreotide), lanreotide
  • drugs that block the formation of adrenal hormones
    (ketoconazole, citadren and others)
  • dopamine agonists – cabergoline (dostinex), bromocriptine

Drug treatment приводит к регрессу опухоли в 56%
cases, to stabilize hormonal levels – in 31%.

Surgery

There are two ways to quickly remove adenoma ^

  • transsphenoidal – through the nasal cavity
  • transcranial – with craniotomy

In recent years, in the presence of microadenomas or macroadenomas,
have significant effects on surrounding tissues, is performed
transsphenoidal removal of adenoma. При гигантских adenomaх (более
10 cm in diameter) shows transcranial removal.

Транссфеноидальное удаление аденомы pituitary gland возможно, если
the tumor is only in the Turkish saddle or beyond
пределы не более, чем на 20 mm Carried out after consultation
neurosurgeon in the hospital. Under general anesthesia to the patient
endoscopic equipment is introduced (fiber optic
endoscope) through the right nasal passage to the anterior cranial fossa. Further
the wall of the sphenoid bone is incised, freeing access to the area
турецкого saddles. Аденома pituitary gland иссекается и удаляется.

All manipulations are carried out under the control of the endoscope, and
enlarged image is displayed on the monitor, allowing you to expand
overview of the surgical field. The duration of the operation is 2 –
3 hours. On the first day after surgery, the patient may
be activated, and on the fourth day it can be discharged from
hospital in the absence of complications. Complete cure of adenoma with
This operation is achieved in almost 95% of cases.

Transcranial (open) surgery is performed in severe
cases by trepanning the skull under general anesthesia. Because of the high
the morbidity of this operation and the high risk of complications
modern neurosurgeons try to resort to it only when
the inability to carry out endoscopic removal of adenoma,
for example, in case of pronounced germination of a tumor in the tissue of the head
the brain.

Radiation therapy

Применяется при микроadenomaх с низким уровнем активности. Can
administered in combination with drug treatment. In the last
time is common method of stereotactic radiosurgery adenoma with
Cyber ​​- Knife application – radioactive
beam directly onto the tumor tissue. Also continues to be
Current gamma therapy is radiation from a source outside the body.

Are there any complications after surgery?

The risk of complications in the postoperative period varies
depending on the surgical technique:

  • with transsphenoidal access, complications develop in 13%, and
    operating mortality is 3%
  • with transcranial access – 27.9% and 7%, respectively.

Of the complications can develop:

  • tumor recurrence – develops in 15 – 16%
  • adrenal gland dysfunction
  • vision loss
  • thyroid dysfunction
  • hypopituitarism – partial or complete failure
    pituitary gland
  • speech, memory, attention
  • infectious inflammation
  • кровотечение из сосудов pituitary gland после операции

Prevention of complications after surgery is medication.
Correction of hormonal background in the body according to the results
survey.

Осложнения аденомы pituitary gland без операции

In the absence of medical or surgical treatment
significant size tumors can lead to gross violations
vision and blindness that every third patient is fraught
disability. Возможно кровоизлияние в ткани pituitary gland с развитием
his apoplexy and acute vision loss.

В подавляющем большинстве случаев adenoma pituitary gland без лечения
leads to male and female infertility.

Forecast

Forecast при своевременной диагностике и лечении благоприятный –
cure after surgery comes in 95% when
medical support before, during and after surgery
regression of symptoms and hormonal disorders occurs in 94%
cases. With a combination of drugs and surgery with radiation therapy
no recurrence of the tumor in the first year after the onset
treatment is 80%, and in the first five years – 69%.

Forecast по восстановлению зрения благоприятный в случае, если
adenoma не больших размеров и существовала у пациента до начала
treatment less than a year.

An examination of the ability to work is carried out by a clinical expert.
commission after discharge from the hospital. The patient may be
assigned disability III, II, or I group with endocrine –
metabolic, trophic, oftalmo – neurological disorders, and
also in cases of pronounced dysfunctions and inability to perform
work, for example, with acromegaly, loss of vision, insufficiency
adrenal cortex, disorders of carbohydrate metabolism, etc.

Temporary disability (sick leave) for employees
patients is determined for a period of 2 to 3 months for primary
hospital examinations, 1.5 – 2 months with radiation therapy, 2 –
3 месяца при операции по поводу удаления аденомы pituitary gland. Further
in case of a questionable labor forecast, referral to ITU.

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