Nonfunctioning Pituitary Macroadenoma Research Articles

An unusual case of primary pituitary abscess due to Corynebacterium pseudodiphtheriticum.

Pituitary abscesses are an uncommon cause of pituitary lesions. A 77-year-old woman presented for elective resection of a presumed non-functioning pituitary macroadenoma in the context of a progressive left-sided visual field deficit. She proceeded to trans-sphenoidal resection of the pituitary lesion, with purulent fluid found upon opening the pituitary capsule. Culture of operative samples yielded Corynebacterium pseudodiphtheriticum, susceptible to penicillin. Following debridement, treatment with 10-weeks of directed antimicrobials achieved good clinical response. This is the first reported case of primary C. pseudodiphtheriticum infection of the central nervous system, representing a rare but important differential for a slow growing pituitary lesion.

Comparative mortality in pituitary adenomas subtypes: a tertiary referral center study.

Mortality in pituitary adenomas (PAs) has been extensively compared to general population. However, direct comparisons between PA subtypes are scarce. We aimed to compare mortality in various subtypes of PA (acromegaly, Cushing's disease (CD), macroprolactinomas and non-functioning pituitary macroadenomas (MacroNFPA)), within a single referral center. We retrospectively analyzed mortality and survival time in all 962 PAs admitted in our department between 2011 and 2023: acromegaly (n = 306), CD (n = 69), macroprolactinoma (n = 168) and MacroNFPA (n = 419). Median follow-up was 10.2 (5.2, 15.2) years. The overall survival probability was 90.9% and 78.1% after 10 and 20 years respectively with age at diagnosis as the only significant predictor. There were no significant differences in survival probability between various PA subtypes in the whole cohort. In patients over 45 years of age at diagnosis there was a significant difference in survival probability between the four groups (p = 0.01) in the first 15 years of follow-up. In head-to-head comparisons CD had a significantly higher mortality risk than patients with acromegaly (HR 3.38 [CI 95% 1.07 to 10.60]) even after adjusting for age and sex. Patients diagnosed with CD after 45 years of age have a significantly lower survival probability than other PA subtypes in the first 15 years of follow-up. All other PA subtypes had a similar survival probability after adjusting for age and sex. Due to advances in medical treatment of hormone secreting tumors, mortality in patients with PAs might increasingly depend more on tumor mass than on hormonal hypersecretion.

6823 A Puzzling Case: Complete Regression of Pituitary Macroadenoma

Abstract Disclosure: N.T. Mazengia: None. D.R. Vangipuram: None. S.K. Majumdar: None. Introduction: The natural course of nonfunctioning pituitary macroadenomas remains poorly understood, largely because the majority are surgically treated [1]. There are a few case reports describing the spontaneous regression of nonfunctioning pituitary macroadenomas. Here we describe a case of pituitary macroadenoma which completely regressed following childbirth and two months of cabergoline therapy. Case Presentation: A 25-year-old female presented with bilateral nipple discharge and persistently elevated prolactin levels ranging from 31µg/liter to 45.9 µg/liter (NV <25 µg/L). She did not have any signs and symptoms of hypo or hypersecretion of the pituitary hormones. All her pituitary hormone levels were within normal range. Initial MRI revealed a pituitary mass measuring 9x13x9mm (AP, TR, CC). Given her lack of symptoms, the decision was made to follow up without any intervention. A repeat MRI after one year showed the size of the mass to be 11x13x11mm. Two years after her initial diagnosis, the patient had a spontaneous pregnancy, during which she remained asymptomatic with normal pituitary hormone levels. She had Cesarean delivery at term with no complication. She was lost to follow-up for about two years after childbirth then presented with breast discomfort and galactorrhea at which time, she was started on cabergoline. A subsequent MRI done two months after the start of cabergoline showed asymmetric fullness of the pituitary gland on the right with no discrete measurable lesion. Conclusion: We currently lack a comprehensive explanation for the regression observed in our patient. Silent ischemia may have played a role, particularly considering the natural increase in pituitary gland size during pregnancy. We are not sure if the regression can be solely attributed to the two months of cabergoline treatment. In asymptomatic patients diagnosed with nonfunctioning pituitary macroadenoma, tumor regression can potentially occur through either a "wait and watch" strategy or medical management using dopamine agonists, specifically cabergoline. However, the use of cabergoline as a primary treatment for asymptomatic nonfunctioning pituitary adenoma warrants further investigation. This is especially crucial given that, in most cases, nonfunctioning pituitary macroadenomas tend to increase in size during follow-up without any intervention.

7102 Pituitary Apoplexy with Eventual Complete Tumour Involution

Abstract Disclosure: A. Ng: None. R. Lai: None. Pituitary apoplexy is an endocrinological emergency resulting from infarction or haemorrhage of the pituitary gland. We present a case of pituitary apoplexy from a non-functioning pituitary macroadenoma, complicated by pituitary insufficiency and subsequent tumour involution. An 80-year-old gentleman presented to the Emergency Department with sudden severe headaches and persistent vomiting and admitted for further evaluation. Computed tomography (CT) imaging of the brain showed a prominent pituitary gland and magnetic resonance imaging (MRI) confirmed a large sellar hyperintense lesion containing blood and proteinaceous material. It measured 1.6 cm by 1.2 cm by 1 cm and indented the optic chiasm. CT angiography did not reveal any aneurysms or intracranial haemorrhage. There were no neurological or visual field deficits at presentation. There was no indication for surgery upon neurosurgical consultation. Initial evaluation of the pituitary axis was consistent with central hypocortisolism (cortisol 75 nmol/L, adrenocorticotropic hormone 1.4 pmol/L [reference range (RR) 1.6-13.9]) and hypoprolactinaemia (prolactin 56 mIU/L, RR 73-351). Luteinising hormone levels were < 1 IU/L (RR 1-9); follicle stimulating hormone levels were 3 IU/L (RR 1-19) and testosterone levels were < 1 nmol/L (RR 5 to 30) as the patient was on androgen deprivation therapy for prostate cancer. Hydrocortisone was started and he was monitored for development of frank diabetes insipidus. He did not require regular desmopressin. He later developed anti-diuretic hormone mediated hyponatraemia (serum sodium nadir of 125 mmol/L, serum osmolality 275 mmol/kg, urine osmolality 390 mmol/kg) that was managed with fluid restriction and solute loading. He also developed central hypothyroidism on day 19 of admission (free thyroxine 11 pmol/L, thyroid stimulating hormone 0.49 mIU/L, RR 0.45-4.5) and oral levothyroxine was started. He was discharged with oral hydrocortisone and levothyroxine replacement. A repeat MRI of the pituitary 2 months later showed complete resolution of the mass and resolution of the mass effects. He was kept on oral hydrocortisone and levothyroxine replacement with regular follow-up.Most pituitary macroadenomas are non-functional, and can present with complications of apoplexy, mass effects or hormonal disturbances. However, the natural history of non-functional macroadenomas is not well known as most are operated on. Spontaneous regression of the tumour can rarely occur, notably in the setting of apoplexy and lymphocytic hypophysitis. Recovery of the pituitary axis may also accompany tumour regression. As spontaneous remission of pituitary macroadenomas may occur, close observation of tumours without visual field defects or significant mass effects may be an alternative to surgery. Presentation: 6/1/2024 12:15:00 PM

8203 A Solitary Fibrous Tumor Mimicking a Non-functional Pituitary Macroadenoma

Abstract Disclosure: L. Bernacet Rivera: None. S. Omay: None. A. Huttner: None. S.E. Inzucchi: None. Background: A solitary fibrous tumor (SFT), also known as hemangiopericytoma (HPC), is a rare subset of soft tissue tumors of mesenchymal origin. This type of tumor tends to have aggressive behavior and a high risk of recurrence. Approximately less than 1% of central nervous system (CNS) tumors have been identified as part of this subtype. Case Presentation: A 73-year-old female with medical history of primary hypothyroidism, myelodysplastic syndrome (MDS), and IgM kappa MGUS initially presented to her primary care physician for evaluation of progressive visual loss over several weeks, accompanied by worsening headaches. Ophthalmologic exam revealed bitemporal hemianopsia which prompted urgent imaging. Pituitary MRI with IV contrast revealed a solid sellar mass with suprasellar extension measuring 1.8 x 1.3 x 1.9 cm. The lesion was noted to superiorly displace the optic chiasm as well as to cause mild impingement of the anterior cerebral arteries. Patient was urgently referred to neurosurgery and endocrinology for further evaluation. Initial neuroendocrine laboratory assessment, performed at 8 am, revealed a cortisol 16.5 ug/dL, free T4 1.2 ng/dL, TSH 0.77 mIU/L, prolactin 9.9 ng/mL, IGF-1 17 ng/mL, the latter value consistent with adult growth hormone deficiency. Her LH and FSH were 4.3 mIU/mL and 12.6 mIU/mL, respectively, lower than expected for a post-menopausal woman. She underwent a transnasal transsphenoidal resection of the sellar lesion. Surgery was difficult due to the fibrous nature of the tumor, for which complete resection was not achieved. Post-operative course was complicated by thrombocytopenia due to MDS. Hormonal workup following surgery was consistent with central adrenal insufficiency, hypogonadotropic hypogonadism, and central hypothyroidism. Pathology showed densely cellular spindle cell neoplasm with a collagenous background consistent with hemangiopericytoma. She underwent fractionated radiotherapy and tumor has since remained stable in size. Her visual symptoms resolved quickly following surgery. Discussion: SFT is an aggressive mesenchymal tumor which rarely appears in the sellar region. There are no identified brain MRI findings that would suggest the nature of this tumor. As a result, endocrinologists should be aware of this rare condition while evaluating pituitary neoplasms. Presentation: 6/3/2024

Long Term Effect of Gamma Knife Radiosurgery versus Surgical Excision on Pituitary Hormones in Patients with Non-Compressive Non-Functioning Pituitary Macro Adenomas: A Systematic Review

Abstract Background Pituitary adenomas (PAs) are the second most common brain tumors comprise around 10%– 25% of all intracranial tumors of all primary brain tumors. Their clinical classification is defined on the basis of hormonal level into; Non-Functioning adenomas (68.8%) and Functioning ones (31.2%). Aim of the Work Aim of the work is to compare the surgical approach vs gamma knife radiosurgery for treatment of non-functioning pituitary macro adenomas in all age groups. We highlight the feasibility of each treatment modality and evaluate its advantages and limitations regarding hormonal outcomes. Patients and Methods We searched PubMed, Google scholar search engine, Cochrane database of systematic reviews, EMBASE and science Direct, using the following keywords “Pituitary adenoma/tumor, endoscopy or endoscopic, non-functioning pituitary adenoma, skull base surgery, gamma knife, stereotactic radiosurgery, hormonal effect ”. The mentioned databases were searched for studies published during period from 1 January 2000 to 1 September 2023. Results The total number of patients in included studies was 1237 patients. The mean age of patients was 56.55 years (range 54.2 - 59 years). The mean follow up duration of the included studies was 10.94 months (range 6 - 12.7) months. The mean tumor size was 29.03 mm (range 24.8 - 36.3) mm. All the surgical studies patients were treated using endoscopic trans sphenoidal approach. Basic study details and patient characteristics treated with Gamma Knife Radiosurgery (GKR). Again, all the included studies were retrospective in nature. The total number of patients treated in the GKR studies were 243 patients. Across all studies, 51.85% of patients were men, and the median age was 59.75 years (range: 50–69) Conclusion Endoscopic trans sphenoidal surgery and gamma knife radiosurgery are valid options as a treatment of non-functioning pituitary macro adenoma, however endoscopic transsphenoidal surgery offer better hormonal outcomes and less adverse effects when compared to gamma knife radiosurgery.

7460 An Atypical Presentation of a Nonfunctional Pituitary Macroadenoma Found in a Patient with Chronic Sinusitis

7460 An Atypical Presentation of a Nonfunctional Pituitary Macroadenoma Found in a Patient with Chronic Sinusitis

Early Surgical Intervention in Nonfunctioning Pituitary Macroadenomas in Adult Patients without Optic Apparatus Compression—Should We Consider It? A Matched Case-Control Study

BackgroundSurgical decompression is the recommended treatment for patients with non-functioning pituitary macroadenomas (NFPMAs) with associated visual impairment. Other relative indications for surgery include endocrinopathies, craniopathies, and headaches. Nevertheless, patients without those 'classical indications' who would otherwise be considered asymptomatic with regards to the NFPMAs, and treated conservatively with clinical radiological surveillance, may suffer higher rates of other morbidities related to the NFPMAs. We aimed to evaluate the prevalence of newly diagnosed comorbidities in conservatively treated patients with NFPMAs. MethodsWe reviewed the medical records of 55 patients with NFPMAs from 2012-2022 who lacked classical indications for surgery at diagnosis. During the follow-up period we searched for any of the following potentially associated newly reported symptoms and signs: headache, dizziness, syncope, GI symptoms, hyponatremia, falls, weakness and general deterioration, CVA related, and endocrine-related including DM-2. Patients were compared to a matched control group. Cohort patients were further analyzed to discover specific endocrine axes deficiencies, and tumor volumes were measured using MRI scans at diagnosis. Results55 patients were included in the final cohort. NFPMAs were associated with the development of newly diagnosed headaches, hypertension and Hypopituitarism. Other symptoms associated with NFPMAs included – dizziness, syncope/pre-syncope, GI-related symptoms, hyponatremia, general weakness and falls, infectious-related symptoms. Average associated ER visits in this group were higher compared to the control group. ConclusionsThese results may suggest the advantages of early surgical intervention for NFPMAs to mitigate comorbidities and improve health-related quality of life.

Postoperative Hormonal and Water Balance Disturbances After Non-Functioning Pituitary Macroadenoma Surgery

Non-functioning pituitary adenomas (NFPAs) are common sellar region tumors. Certain pituitary adenomas are categorized as functional, as they arise from specific cell types that excessively secrete hormones. In contrast, non-functional adenomas do not secrete hormones but can potentially compress the surrounding regions. The lack of hormonal activity in NFPAs often leads to a delayed diagnosis. It becomes clinically significant when the adenoma gets larger and starts causing symptoms. A 52-year-old man presented with visual field impairment since two years ago and throbbing headaches for the last three months. He was found to have pituitary macroadenoma and no hormonal excess was detected. He was diagnosed with non-functioning pituitary macroadenoma, then underwent endonasal endoscopic transsphenoidal hypophysectomy as a surgical procedure in our institute. A surgical procedure to remove pituitary adenomas can lead to high chance of complications in pituitary hormone regulation due to the manipulation of the pituitary gland and its stalk, such as water balance imbalance and hormonal disturbances. Endonasal endoscopic transsphenoidal hypophysectomy as a surgical procedure in treating pituitary macroadenoma has proven effective, resulting in good outcomes. A multidisciplinary approach involving specialists in endocrinology, ophthalmology, and neurosurgery is essential for the comprehensive evaluation of patients with pituitary adenoma.

Lanreotide versus placebo for tumour reduction in patients with a 68Ga-DOTATATE PET-positive, clinically non-functioning pituitary macroadenoma (GALANT study): a randomised, multicentre, phase 3 trial with blinded outcome assessment

No established medical treatment options currently exist for patients with non-functioning pituitary macroadenoma (NFPMA). Somatostatin analogues may prevent tumour growth, but randomised controlled trials are lacking. Invivo somatostatin receptor assessment with 68Ga-DOTATATE PET could help in selecting patients for treatment. We aimed to determine the effect of the somatostatin analogue lanreotide on tumour size in patients with a 68Ga-DOTATATE PET-positive NFPMA. The GALANT study was an investigator-initiated, multicentre, randomised, double-blind, placebo-controlled, parallel-group, phase 3 trial with recruitment at three academic hospitals in the Netherlands. Adult patients with a suprasellar extending NFPMA, either surgery-naïve or postoperative remnant ≥10mm, were eligible for inclusion. Important exclusion criteria were previous sellar radiotherapy and use of dopamine receptor agonists. Somatostatin receptor expression in the NFPMA was determined through 68Ga-DOTATATE PET/CT, co-registered with MRI. A predefined sample of 44 patients with PET-positive NFPMA were randomly assigned (1:1) to lanreotide acetate 120mg or placebo, both administered as deep subcutaneous injections every 28 days for 72 weeks. Primary outcome was the change in cranio-caudal tumour diameter measured on pituitary MRI from baseline to end-of-treatment in the intention-to-treat population. Participants, investigators and outcome assessors were masked to treatment allocation. The trial is registered with the Netherlands Trial Registry, NL5136, and EudraCT, 2015-001234-22. Between Nov 3, 2015, and Dec 10, 2019, 49 patients were included in the study. Forty-four patients with a 68Ga-DOTATATE PET-positive NFPMA were randomly assigned to lanreotide (22 [50%]) or placebo (22 [50%]). Study treatment was completed in 13 (59%) lanreotide and 19 (86%) placebo participants. The mean (SD) change from baseline in cranio-caudal tumour diameter after treatment was+1·2 (2·5) mm with lanreotide and+1·3 (1·5) mm with placebo; adjusted mean difference versus placebo-0·1mm (95% CI-1·3 to 1·2, p=0·93). Adverse events occurred in 22 (100%, 147 events) lanreotide and 21 (95%, 94 events) placebo participants. Gastrointestinal complaints were most common, reported by 18 (82%) lanreotide and 8 (36%) placebo participants. There were no treatment-related serious adverse events. Compared with placebo, lanreotide treatment did not reduce tumour size or growth in patients with 68Ga-DOTATATE PET-positive NFPMA. Ipsen Farmaceutica BV.

Lanreotide in patients with a 68Ga-DOTATATE PET-positive, clinically non-functioning pituitary macroadenoma (GALANT study): A randomised, double-blind, placebo-controlled trial

Lanreotide in patients with a 68Ga-DOTATATE PET-positive, clinically non-functioning pituitary macroadenoma (GALANT study): A randomised, double-blind, placebo-controlled trial

Historic unveiling; ground breaking encounter of non-functioning pituitary macroadenoma coexisting with myasthenia gravis- debut case report

Historic unveiling; ground breaking encounter of non-functioning pituitary macroadenoma coexisting with myasthenia gravis- debut case report

Long-term outcomes of non-functioning pituitary macroadenomas following surgery

Long-term outcomes of non-functioning pituitary macroadenomas following surgery

SARS-Cov-2 Infection: A New Risk Factor for Pituitary Apoplexy?

Pituitary apoplexy (PA) can arise from haemorrhage or ischaemia of pituitary tissue and is characterized by abrupt onset of headache, visual impairment and hypopituitarism. COVID-19 may be associated with various degrees of vascular complications and, recently, its relationship with PA has been suggested. Cases Presentation Case 1: A 64-year-old male with type 2 diabetes, hypertension and coronary heart disease was admitted to the ER, after several days of asymptomatic COVID-19 infection, with symptoms of PA of a known non-functioning pituitary macroadenoma. The hormonal panel was consistent with anterior panhypopituitarism and the sellar MRI showed haemorrhagic changes of macroadenoma tissue. Transsphenoidal resection of the pituitary lesion was carried out seven days after admission. Although a volumetric reduction of the lesion was apparent during follow-up, some degree of visual symptoms endured. Case 2: An 18-year-old, otherwise healthy, female presented to the ER with symptoms of PA of a recently-diagnosed non-functioning pituitary macroadenoma, after ten days of asymptomatic COVID-19 infection. Central hypocortisolism and hypothyroidism were diagnosed and, after six days, the lesion was surgically resected. At two months follow-up, clinical symptoms had completely resolved, and the hormonal panel was normal. Alongside known risk factors (hypertension, anticoagulation, pregnancy, surgery, etc.), COVID-19 infection might represent an emerging predisposing factor for PA onset. The two cases hereby presented are both significant: the first confirms the role of "classic" vascular predisposing factors for PA, while the second demonstrates that PA might arise also in young patients without known risk factors.

Coexisting Non-functioning Pituitary Macroadenoma and Sellar-Suprasellar Lipoma: A Case Report and Literature Review

Coexisting Non-functioning Pituitary Macroadenoma and Sellar-Suprasellar Lipoma: A Case Report and Literature Review

The Road To Retrograde Recovery

This month's column highlights a patient that was diagnosed with a non-functioning pituitary macroadenoma and underwent trans-sphenoidal resection.

Severe Headache and Fever Associated with a Non-functioning Pituitary Macroadenoma: a Case Report

Severe Headache and Fever Associated with a Non-functioning Pituitary Macroadenoma: a Case Report

The Natural History of Clinically Non-functioning Pituitary Macroadenomas (NFPAs) managed conservatively

The Natural History of Clinically Non-functioning Pituitary Macroadenomas (NFPAs) managed conservatively

Long-term outcomes of non-operated non-functioning pituitary macroadenomas - results from the UK NFPA consortium

Long-term outcomes of non-operated non-functioning pituitary macroadenomas - results from the UK NFPA consortium

Natural history and surgical outcome of incidentally discovered clinically nonfunctioning pituitary macroadenomas.

The incidental diagnosis of nonfunctioning pituitary macroadenomas (NFPMAs) is becoming more prevalent with the spread of modern brain imaging techniques. We sought to uncover new data about their natural history and surgical outcome. This is a retrospective single-center observational study. Among 210 patients seen for a NFPMA between 2010 and 2019, 70 (33%) were discovered incidentally (i-NFPMA). We analyzed outcomes in a total of 65 patients with available follow-up data. Mean age at diagnosis (± s.d.) was 60 ± 14 years and mean maximal diameter was 20.0 ± 7.3 mm. At diagnosis, 29 patients (45%) had pituitary hormone deficits (LH/FSH 41%, TSH 29%, ACTH 15%) and 12% had visual field deficits. 26 patients underwent initial surgery, while 12 had delayed surgery after initial surveillance. In the surveillance group, the risk of tumor growth was estimated at 10%/year. Patients with hormonal deficits at diagnosis experienced earlier growth at 24 months (P < 0.02). Overall, surgical resection of the i-NFPMA led to stable or improved endocrine function in 91% of patients, with only 6% postoperative permanent diabetes insipidus. Moreover, surgery was more effective in preserving intact endocrine function (10/12) than restoring altered endocrine function to normal (6/22, P = 0.03). About one-third of NFPMAs are now discovered incidentally and a significant subset may be responsible for unrecognized endocrine and visual deficits. Under surveillance the risk of further tumor growth is significant (10%/year) and seems to occur faster in patients already harboring an endocrine deficit. Early surgical removal before onset of endocrine deficits appears to lead to better endocrine outcome.