00:01
How do we evaluate
these patients
when we've recognized
that a patient may be presenting
with a pituitary lesion
or a pituitary syndrome,
what should we do?
Well, the first
is to image the patient.
00:12
And that's what was done
in this case
and we used an MRI.
00:15
MRI with and without
gadolinium contrast
to light up these tumors
and with fine cuts
through the sellar region
is one of the most important
initial steps
in evaluating patients
with suspected pituitary lesion.
00:29
Ophthalmologic evaluation
is critical.
00:32
We said that the pituitary gland,
the sella turcica
lies in a close proximity
to the optic chiasm,
which sits just above this region.
00:41
In fact, the pituitary stalk
goes right through the optic chiasm,
and tumors that grow upwards,
which is common
can result in
bitemporal hemianopia,
which should be recognized
either at presentation
or followed with serial assessments
after a lesion has been discovered.
00:58
And then hormonal evaluation
is critical.
01:01
This is a tumor in and around
the pituitary gland.
01:04
What is the pituitary do?
It makes hormones.
01:07
Tumors that compress the pituitary
can result in
reduced hormone function.
01:12
And tumors
that secrete hormone
result in excess hormone secretion,
and hormone function.
01:17
So we got to measure
those things.
01:19
We need to look at prolactin,
fasting morning cortisol,
ACTH, growth hormone,
insulin-like growth factor,
TSH, and free thyroxine.
01:28
We get a lot of blood tests
for these patients.
01:31
In selected cases,
we also want to look at
other pituitary hormone function
like the gonadotropins,
luteinizing and follicle
stimulating hormone
and maybe testosterone
in patients where we suspect
problems in those areas.
01:45
One important note
for the imaging
is that often the tumor
enhances less avidly,
less significantly
than the normal pituitary gland.
01:56
And this is different
than what we see with tumors
in other areas of the body.
02:00
This can be very useful
in determining
the degree of displacement
of the normal gland by the tumor.
02:06
An imaging may show right or left
deviation of the gland
or anterior posterior deviation
of the gland,
which can be important
in our imaging assessment.
02:15
So these, the three things
that really should be done
for any patient presenting
with a suspected pituitary lesion.
02:22
Let's take a closer look at a
really substantial pituitary lesion,
pituitary tumor.
02:28
We're gonna walk through
the MRI imaging,
For this patient,
this patient presented with symptoms
suggested of a pituitary lesion,
headache and problems with vision
of bitemporal hemianopia.
02:39
Here on the T1 image,
this is a sagittal T1 image
prior to contrast administration,
we may or may not see a whole lot.
02:47
There is an extra mass,
extra tissue in the
middle of the brain.
02:50
And when we add contrast,
it lights that tumor up.
02:53
And we see a large lesion
that is beginning likely,
beginning in the sella turcica
right around the pituitary gland
and expanding upwards
in the area of the optic chiasm.
03:02
And this underscores the importance
of optimal logic assessment
in these patients.
03:07
On the axial imaging,
we see a large circumferential
circular lesion
in the midline of the brain.
03:14
And on the coronal imaging
again,
we see that this lesion has expanded
the sella turcica.
03:18
It looks bigger than the images
we saw for our initial patient
and this tumor is growing upwards,
likely resulting in compression of
CSF flow and hydrocephalus.
03:28
What's our differential
for an image of that kind
and a patient who presents
with pituitary symptoms
where we do imaging
that shows this lesion,
what could it be?
Well, first we're going to think
about a pituitary tumor
because that's the most common cause
of a lesion in this area.
03:43
And 90% are nonmalignant lesions
that may not require a treatment.
03:48
The second is a
craniopharyngioma.
03:51
These are histologically benign
but often cystic epithelial tumors.
03:56
They show cysts on the imaging.
03:58
Instead of a large central
homogeneously enhancing lesion,
we see a small nodule with a cyst
that often grows up into the brain.
04:07
Other lesions to know of but not
focus on in significant detail,
are the granular cell tumor
of the sella,
the pituicytoma,
which is actually
a glial based tumor
located in the pituitary,
which is kind of neat
but very rare.
04:21
And the spindle cell
oncocytoma.
04:23
Rare tumors that you may need
to know of but not know about.
04:28
We also see non-neoplastic lesions
occur in this area.
04:31
We see the Rathke cleft cyst,
which is a cyst, it's not a tumor,
and shows up
as a cystic lesion,
and can be confusing from a
craniopharyngioma
for an untrained eye.
04:42
And then rare lesions,
xanthogranulomas,
which are very rare
and epidermoid cysts,
which we talked about at the
cerebellopontine angle.
04:51
So we think about both
neoplastic and nonneoplastic tumors.