Hypothalamic, Pituitary And Other Sellar Masses

HYPOTHALAMIC, PITUITARY AND OTHER SELLAR MASSES

Pituitary tumors , Pituitary adenomas   :

  • Commonest tumors are pitu­itary adenomas. These are benign and their features depend on the cell type from which they occur.
  • They may arise from PRL, GH, ACTH, TSH, LH and FSH producing cells r;esulting in features of hyperse­cretion of the hormones.
  • There is autonomous hormone secretion which does not respond to the inhibitory feedback of these hor­mone levels.
  • Many of these tumors do not produce hypersecretion features.

PITUITARY AND OTHER SELLAR MASSES

HYPOTHALAMIC, PITUITARY AND OTHER SELLAR MASSES


Causes of sellar masses

    • Arachnoid
    • Benign tumors
    • Breast
    • Carotid arteriovenous fistula
    • Chordoma
    • Craniopharyngioma
    • Cysts
    • Dermoid
    • Germ cell tumor (ectopic pinealoma)
    • Lactotroph hyperplasia (during pregnancy)
    • Lung
    • Lymphocytic hypophysitis
    • Malignant tumors
    • Meningiomas
    • Metastatic
    • Pituitary abscess
    • Pituitary adenoma (most common sellar mass)
    • Pituitary carcinoma (rare)
    • Pituitary hyperplasia
    • Primary
    • Rathke’s cleft
    • Sarcoma
    • Somatotroph hyperplasia due to ectopic GHRH
    • Thyrotroph and gonadotroph hyperplasia

 

Other neurologic symptoms —

  • Cerebrospinal fluid rhinorrhea, caused by inferior extension of the adenoma, is an extremely uncommon presentation.
  • Diplopia, induced by oculomotor nerve compression resulting from lateral extension of the adenoma.
  • Headaches, presumably caused by expansion of the sella. The quality of the headache is not specific.
  • Other neurologic symptoms that may cause a patient with a sellar mass to seek medical attention include:
  • Parinaud syndrome, a constellation of neuroophthalmologic findings, most often paralysis of upward conjugate gaze, that result from ectopic pinealomas
  • Pituitary apoplexy induced by sudden hemorrhage into the adenoma, causing excruciating headache and diplopia.

Pituitary carcinoma is rare. Craniopharyngiomas :

  • These are derived from Rathke’s pouch. They arise near the pituitary stalk and extend to supracellar region.
  • They are large, cystic and locally invasive.
  • They may be calcified and seen on x-ray and CT. Age of presentation is less than 20 years.
  • There is raised intracranial pressure with headache, vomiting, papilledema, hydrocephalus, visual field de­fects, cranial nerve damage, weight gain, personality changes, growth retardation.
  • There may also be diabetes insipidus (if the posterior pituitary is involved).

MRI of the pituitary gland

Treatment of pituitary masses

  • Surgical resection and radiation after surgery. Patients may require lifelong pituitary hormone replacement.

Other tumors :

  • Meningiomas, Histiocytosis X, Glio­mas, Germinomas may also occur.

Lab diagnosis of tumors and masses

  • · MRI, CT, visual field examination and other im­aging techniques.
  • · Histopathologic diagnosis of tumor after surgery.
  • · Hormonal evaluation:
    1. 1. Basal PRL (prolactin)
    2. 2. IGF (insulin like growth factor)
    3. 3. 24-hour urinary free cortisol (UFC and or over­night oral dexamethasone 1 mg suppression test)
    4. 4. FSH and LH levels
    5. 5. Thyroid function tests.

Treatment of hypothalamic and pituitary masses

  • Transsphenoidal surgery
  • Stereotactic radiotherapy (gamma knife radio­therapy)
  • Radiation
  • Bromocriptine, the Dopamine agonist for hyperprolactinemia
  • Estrogen replacement for bone loss and hypoestrogenem ia
  • Growth hormone
  • Thyroxine etc.
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