00:01
In this lecture, we're gonna talk
about pituitary adenomas.
00:04
That third most common brain tumor,
primary brain tumor,
that arises in the midline structure
of the sella turcica,
the pituitary gland.
00:14
Let's start with a case.
00:16
This is a 67-year-old woman
who presented with a 10-year history
of chronic recurrent headaches
that initially began
after a motor vehicle accident.
00:25
In that accident,
she suffered a nasal bone fracture,
followed by repair
and reconstruction of the nose.
00:32
A gadolinium-enhanced MRI
showed an asymmetric enhancing mass
within the right side
of the sella turcica
expanding into the cavernous sinus.
00:42
And that expanding indicates
that this may be a tumor.
00:46
Laboratory workup,
which is important for this patient
was significant for a
serum prolactin of 696,
which is significantly elevated.
00:55
And we're going to learn that
prolactin can be mildly elevated
from tumors that impair and impede,
and compress the pituitary stock
or substantially
elevated from tumors
that generate prolactin secretion
on their own.
01:10
The patient had
normal serum cortisol,
thyroid-stimulating hormone,
free thyroxin,
and insulin-like growth factor,
other hormones made by
the pituitary,
and physiologically appropriate
follicle-stimulating hormone or FSH,
and luteinizing hormone or LH.
01:26
Ooh, big case.
What's the diagnosis?
Well, let's walk through this.
01:32
First of all, we see that the lesion
is a lesion in the sella turcica.
01:36
And that expansion
of this area suggests
that this may be
a tumor or a mass.
01:42
The laboratory evaluation for this
patient is extremely important
and we see a
significantly elevated prolactin,
and this is going to point us
towards a prolactin secreting tumor,
which is called a prolactinoma.
01:55
And we see that there's
normal hormone function
for the other pituitary hormones,
things like cortisol, TSH, free T4,
insulin-like growth factor,
FSH, and LH.
02:07
This patient
would undergo imaging.
02:09
And we read and heard about the MRI,
and here you see that here.
02:13
This is a T1 image,
a coronal T1 image,
with gadolinium-enhancement
with contrast.
02:19
And we can see the brain.
02:21
Beneath the brain in the midline
is the optic chiasm.
02:25
And then we see this bone,
this area of bone,
that is the sella turcica, the seat,
that the pituitary gland sits in.
02:32
In that area we see an
enhancing mass,
it's homogeneously enhancing,
it's all white, and it's extending.
02:38
It appears to be extending out
of the pituitary gland
towards the cavernous sinus,
which you can see here
and the green arrows,
and that extension out
in the white arrow.
02:47
This is an asymmetric
enhancing mass
that appears to be arising
from the pituitary stalker gland
and extending along
the dural surface.
02:56
So what's the diagnosis?
Is this a brain metastasis,
meningioma, pituitary adenoma,
glioma, or vestibular schwannoma?
Well, this doesn't seem like
a vestibular schwannoma.
03:07
It's not in the right location.
03:08
And this is not
the typical presentation,
for of a patient with hearing loss.
03:12
Gliomas are uncommon
outside of the brain
or in the pituitary region.
03:17
And this looks more like something
that is developing
in a specific location,
as opposed to
in the brain parenchyma itself.
03:24
Brain metastasis
can form in this location,
but would often progress
more rapidly
than this patient who has a
10-year history of headaches
suggesting a more slowly
growing lesion.
03:35
Meningiomas can occur
in that outer surface
that outer covering of the brain,
the meninges,
but typically those develop
from the meninges first,
and grow into or over
the pituitary and sella turcica
as opposed to this lesion,
which starts in the pituitary
and grows out.
03:51
So this is our classic presentation
of a pituitary adenoma.
03:54
This is a benign slow growing tumor
that has been developing probably
over the course of 10 years.
04:00
It sits within the sella turcica
and is either impairing
hormone function,
or secreting hormone itself.
04:06
And for this patient,
we would favor a prolactinoma.
04:12
How is this patient treated?
Well, we'll get to treatment
of pituitary tumors.
04:16
This patient was treated
with a hormonal agent,
cabergoline,
which is a dopamine agonist.
04:22
She was treated 0.5 milligrams,
two times per week.
04:25
And we see on this image
dramatic reduction of that tumor
over the course of one year.
04:30
And you can see that enhancing mass
that was filling the sella turcica
that was obstructing, and
compressing the pituitary gland
is now significantly smaller.
04:40
And we also would see improvement
in this patient's prolactin level.
04:44
So substantial response
to hormonal treatment
which we'll talk about
in the lecture.