Transsphenoidal Pituitary Resection Research Articles

Pituitary Adenoma Prevalence and Characteristics of Omani Patients: A Single Center Experience.

To estimate the incidence of pituitary adenomas (PA) in adult Omani patients and describe its epidemiological, clinical, and radiological characteristics. In this longitudinal, descriptive study, we reviewed the records of all PA patients from January 2015 to January 2020 who presented at the endocrinology facilities at Sultan Qaboos University Hospital, Muscat. The participants comprised of 112 Omani patients with PA. The incidence of PA among all adult patients at Sultan Qaboos University Hospital (inpatient and outpatient) over five years (2015-2020) was 0.23%. The cohort had a mean age of 41.0±15.0 years. Of the 112 patients included in this study, 79 (70.5%) were women. Nearly half (51; 45.5%) of adenomas were prolactinomas while 46 (41.1%) were non-functioning adenomas, and seven (6.3%) were growth hormone-secreting adenomas while six (5.4%) were adrenocorticotropic hormone secreting adenomas. Headache was present in 67 (59.8%) patients, followed by visual field defects (40; 35.7%), galactorrhea (26; 23.2%), and fatigue (19; 17.0%). The majority of women (45/79; 57.0%) presented with menstrual cycle abnormalities. Radiological appearances were nearly equally distributed between micro- and macroadenomas. Most cases (58/112; 52.0%) of PA were treated medically by cabergoline, octreotide, and replacement therapies such as hydrocortisone and thyroxin, 38 (33.9%) were treated surgically (mainly by trans-sphenoidal pituitary resection), and the remaining 10 (8.9%) cases were subjected to radiotherapy. Medical treatment combined with surgery was employed for 15 (13.4%) patients. In our investigation, PA was primarily prevalent among Omani female patients, and the most common subtype of pituitary tumors was prolactinomas. The most common presentation symptom was headaches; most female patients had menstrual irregularities. Medical treatment was the primary approach for the applicable types of PAs, while surgery and radiotherapy were found to be secondary and tertiary treatment options, respectively.

THU021 Mysterious Resolution Of Cushing’s Disease

Abstract Disclosure: D.R. Whiteman: None. T. Hoang: None. V. Del Signore: None. P.V. Shah: None. Cushing’s disease is a unique problem to the endocrinologist. Clinical acumen is needed to guide correct therapy. We describe a case of Cushing’s disease in a young reproductive female with abnormal menses and obesity. Post-operative surgical pathology did not confirm her disease, but her menses normalized and biochemical evidence of disease did not persist. Case Presentation: A 24 year old female presented with irregular menses since menarche. She had 2-3 menstrual cycles per year prior to oral contraceptive pills (OCPs). She stopped OCPs and failed to conceive for > 1 year. Other symptoms included chronic fatigue, increased weight gain, abdominal striae, and hirsutism on her chin, arms, abdomen, and nipples. Prior evaluation showed positive progesterone withdrawal. Endocrine work-up included low dose 1mg dexamethasone suppression (LDST), total testosterone, FSH, LH, estradiol, sex hormone binding globulin, 17-hydroxyprogesterone, DHEA-sulfate, IGF-1, TSH, free T4, prolactin, and hemoglobin A1c. Work-up only positive for LDST: cortisol of 3.8 ug/dL. Additional screening tests included: 24 hour urine cortisol collection of 32 ug/24hr but volume not reported and late-night salivary cortisol (LNSC) of >0.1 ug/dL. Three more LNSC tests resulted as 0.212, 0.739, and 0.154 ug/dl. Confirmatory testing with 8mg Dexamethasone suppression test was positive: cortisol of 0.4 ug/dL. ACTH was 21.6 pg/mL, consistent with ACTH dependent disease. A pituitary MRI with and without contrast was negative for pituitary adenoma. Next, she completed inferior petrosal sinus sampling (IPSS) that lateralized to the left sella. Her central to peripheral ACTH ratio was > 2 and lateralized to the left with a ratio > 1.4. She had transsphenoidal pituitary resection and postoperative cortisol initially dropped to 5.5 ug/dL, but increased to 13.3 ug/dL prior to discharge. No glucocorticoid replacement required. Surgical pathology demonstrated non-neoplastic pituitary tissue with no pathologic change. Post-operative IPSS revealed all cortisol levels < 2.0 ug/dL. Two post-operative AM cortisol measurements were 5.4 ug/dL and 10.8 ug/dL suggestive of no remission. Interestingly, 2 months post-operatively repeat screening tests were negative: LDST cortisol of 0.6 ug/dL, salivary cortisol <0.010 ug/dL, and 24 hour urine cortisol 18 ug/24 hour. Furthermore, menses returned post-operatively. Discussion: Missing a diagnosis of Cushing’s disease results in increased morbidity. The diagnostic process can be both complex and invasive. Localization of the adenoma and resection are needed for cure. Standard practice dictates confirmation with pathology and biochemical remission. Interestingly, initial cortisol levels did not suggest remission, but later biochemical testing ruled out ongoing Cushing’s disease. Due to inadequate tissue data, true etiology of disease and remission remains a mystery. Presentation: Thursday, June 15, 2023

FRI311 GnRH Agonist Induced Pituitary Apoplexy In A Patient With Gonadotropinoma

Abstract Disclosure: I. Madahar: None. S. Khan: None. L. Hergenroeder: None. B. Skaff: None. A. Haider: None. Introduction: GnRH therapy is commonly employed in patients with advanced prostate cancer. It acts as an agonist that binds to pituitary GnRH receptors. It acts via desensitization, downregulating FSH and LH production, and ultimately decreasing testicular steroidogenesis. Initial administration leads to transient stimulation of the pituitary which leads to elevated FSH and LH levels and increased production of estrogen and testosterone with eventual downregulation of the overall pathway. Case description: 80-year-old male with a past history of atrial fibrillation and OA was diagnosed with prostate cancer. Prostate adenocarcinoma Gleason score 7 (4+3) grade 3 was diagnosed by needle core biopsy five months prior to presentation. CT chest, abdomen, pelvis, and bone scan did not show evidence of metastatic disease. A week prior to starting Lupron therapy he was started on bicalutamide therapy. He received a dose of leuprolide (Elligard) as part of his chemoradiation therapy for his cancer. The patient went golfing after the treatment and within four hours he started noticing headaches and retroorbital pain. Headaches were sharp in quality, intensity 9 out of 10, and associated with nausea and vomiting. He later developed right-sided ptosis and double vision which progressively worsened after the next few hours. An initial CT scan of the head showed an enlarging pituitary mass which was followed MRI of the brain with and without contrast showed an enlarged pituitary mass and right cavernous sinus effacement of the optic chiasm. Anterior pituitary hormone functions were ordered, and the patient was started on stress-dose steroids. Transsphenoidal pituitary resection was done which the patient tolerated well pathology showed pituitary adenoma with pituitary apoplexy and the immunoprofile was compatible with gonadotroph adenoma. The adenoma cells were positive for synaptophysin, cam 5.2, GATA3, and FSH. A repeat MRI of the Sella three months after surgery showed a 9 mm nodule in the right aspect of the Sella. Anterior pituitary hormone levels done prior to surgery showed an IGF- 1 level of 204 ng/ml (Z score 1.5 SD). TSH and free T4 were in the normal range. Hydrocortisone was tapered and stopped 6 weeks after transsphenoidal surgery. Discussion: Lupron levels reach maximum concentration four hours after intramuscular administration. Initial pituitary stimulation by leuprolide administration causes the increased metabolic activity of the underlying adenoma which outgrows its blood supply, thus developing ischemic necrosis and subsequent hemorrhage. The majority of pituitary apoplexy develops in patients with previous undiagnosed pituitary adenomas. Should patients get central imaging to screen for pituitary macroadenoma before Lupron treatments to prevent this potentially life-threatening complication? Presentation: Friday, June 16, 2023

FRI064 The Role Of GLP-1 Receptor Agonists In The Treatment Of Pituitary And Hypothalamic Tumor Induced Obesity

Abstract Disclosure: C.S. Botero Suarez: None. D. Broutin: None. H. Yau: None. Introduction: Glucagon-like peptide-1 receptor agonists (GLP1-RA) act by stimulating the GLP-1 receptor resulting in a reduction in food intake, increased energy expenditure, and improved glycemic control. The role of GLP1-RA in pituitary/suprasellar tumors causing hyperphagia and hypothalamic obesity is yet unknown. We present a case of a patient with a large non-functional pituitary mass resulting in severe hyperphagia and hypothalamic obesity. A trial of GLP-1RA showed significant improvement of hyperphagia. Case Description: A 30-year-old African American male is seen in the Endocrinology clinic. He was recently diagnosed with a non-functional pituitary mass 2 months prior, after a presentation of hyperphagia, significant weight gain, and altered personality changes causing significant social distress. He underwent transsphenoidal pituitary resection which resulted in postoperative hypopituitarism. His physical exam showed normal vital signs, a weight of 185 lbs, and a BMI of 25. His medications included hydrocortisone total of 15 mg daily, desmopressin 0.1mg daily, levothyroxine 137mcg daily, and risperidone 1mg daily. A brain MRI showed postoperative changes depicted by a T1 hyperintensity within the sella as well as T2 hyperintensity of the chiasm and hypothalamus indicating edema and a mass effect. Based on his presentation of marked hyperphagia and rapid weight gain with suggestive imaging, the clinical diagnosis of hypothalamic obesity was made. Further follow-up revealed a rapid weight gain of 45 lbs in 2 months, a worsening glycemic control, and a HbA1C of 7.2% compared to a HbA1C of 5.4% in his prior visit. Lab work showed a TSH of 0.017 mlU/mL, fT4 of 1.4ng/dL, prolactin 3.94 ng/mL, alpha subunit of 0.1 ng/mL (reference 0.1-0.5 ng/mL), ACTH of 15 pg/mL, morning cortisol of < 3 ug/dL. Given the significant metabolic consequences of his marked hyperphagia, related weight gain, and new onset of diabetes, the patient was started on semaglutide 0.5mg weekly and later up-titrated to 1mg weekly. There was marked improvement of hyperphagia, and his weight remained neutral at the 3-month follow-up. Discussion: Hyperphagia is a rare presentation of sellar and suprasellar tumors and can lead to hypothalamic obesity. Tumors can affect the arcuate nucleus of the hypothalamus, which is a key regulator of energy homeostasis and is regulated by orexigenic (AgRP/NPY) and anorexigenic neurons (POMC/CART). GLP-1R agonists, have shown to cause significant weight loss due to decreased gastric emptying and stimulating POMC/CART neurons, but they also inhibit neuropeptide Y (NPY) and agouti-related peptide (AgRP), leading to reduced hunger, energy intake, and food cravings. Although the clinical role of GLP1-RA in pituitary tumors with significant hyperphagia is unknown, we believe early initiation can help avoid a rapid progression of obesity and glycemic deterioration. Presentation: Friday, June 16, 2023

SAT347 Surprising Turn Of Events In A Patient With Weight Gain: Simultaneous Diagnosis Of Macroprolactinoma And Polycystic Ovary Syndrome

Abstract Disclosure: A.N. Keskinkilic: None. D. Sistla: None. Background: The differential diagnoses of excess weight gain are broad and endocrinopathies constitute a small proportion of these etiologies. A pattern of associated symptoms, classical exam findings and hormonal testing can signal some endocrine causes. However, diagnosis can still be challenging due to overlapping clinical and biochemical features and concurrent presentations of endocrine disorders. Here, we present a diagnostically challenging rare case of a young female with weight gain who had simultaneous diagnosis of macroprolactinoma and PCOS. Clinical Case: A 34-year-old healthy female presented with one year of weight gain despite lifestyle changes. She also reported headaches, acne, hirsutism, stretch marks, excessive sweating, and had 10 years of amenorrhea while on oral contraceptives (OCs). Labs revealed mildly low free T4 of 0.72 ng/dl (n: 0.70-1.48 ng/dl) and significantly elevated prolactin (PRL) of 259.8 ng/ml (n: 1.2-29.9 ng/ml); normal FSH, LH, GH, IGF, TSH, ACTH, 1 mg dexamethasone suppression test, and 24-hour urinary cortisol. HbA1c, lipid panel, plasma metanephrine and androgen levels were normal. MRI pituitary revealed a 2.1 x 1.9 x 1.5 cm macroadenoma with mild compression to the optic chiasm. A low dose levothyroxine and cabergoline 0.25 mg twice weekly was started with dose increment to 0.5 mg twice weekly. At 6-month follow-up, PRL decreased to 30 ng/ml. Repeat MRI showed a decrease in size of the pituitary adenoma (1.5 x 1.4 x 1.3 cm). However, she could not tolerate cabergoline due to persistent headaches and depression. Hence, she elected to undergo transsphenoidal pituitary resection. Tumor pathology showed sparsely granulated lactotroph adenoma. Post op PRL level normalized, and MRI showed radiological cure of the adenoma. Headaches improved but amenorrhea persisted despite discontinuation of OCs for 6 months. Progesterone challenge tests resulted in withdrawal bleed suggesting anovulation. Repeat work-up ruled out nonclassical CAH, Cushing’s, and androgen-secreting tumors. However, subsequent pelvic ultrasound confirmed polycystic ovarian morphology, suggesting PCOS. The patient preferred to avoid OCs and could not tolerate metformin. She elected progesterone IUD placement for endometrial protection in combination with lifestyle changes with notable improvement in her symptoms. Conclusion: PCOS is a diagnosis of exclusion. Thorough evaluation of symptoms like weight gain, amenorrhea, clinical hyperandrogenism is recommended to rule out serious pathology like prolactinoma. Dual diagnosis of PCOS and macroprolactinoma is rare and should be suspected if menstrual abnormalities persist even after treatment of hyperprolactinemia. Presentation: Saturday, June 17, 2023

Safety of withholding perioperative steroids for patients with pituitary resection with an intact hypothalamus-pituitary-adrenal axis: A meta-analysis of randomized clinical trials

IntroductionSeveral observational studies have evaluated the effects of pre-operative steroids (STER) for transsphenoidal pituitary removal in patients with an intact hypothalamus-pituitary-adrenal axis. However, a consensus built upon randomized studies has not been previously performed. PurposeTo comprehensively evaluate the clinical effects of patients receiving STER when compared to those not receiving steroids (NOSTER) in transsphenoidal pituitary resection, a meta-analysis of randomized clinical trials (RCT) was conducted. MethodsA systematic review of the literature of RCTs comparing STER and NOSTER was performed in accordance with the PRISMA guidelines. Databases, including PUBMED, Cochrane Library, Web of Science, and Embase were queried. The primary outcomes were adrenal insufficiency (AI) and diabetes insipidus (DI) post-operatively. ResultsA total of 4 final studies were included, in which 530 total patients were analyzed. The meta-analysis suggested that there was no significant difference between STER and NOSTER groups post-operatively related to transient AI (RR= 0.83, 95% CI [0.51–1.35], p = 0.45; I² = 52%), permanent AI (RR= 0.97, 95% CI [0.41–2.31], p = 0.95; I² = 0%), and permanent DI (RR= 0.62, 95% CI [0.16–2.33], p = 0.48; I² = 0%). Nevertheless, STER group had significantly lower rates of transient DI (RR= 0.60, 95% CI [0.38–0.95], p = 0.03; I² = 5%), and post-op hyponatremia (RR = 0.49, 95% CI [0.28–0.87], p = 0.02; I² = 0%). ConclusionThis study demonstrates evidence from RCTs that patients receiving pre-operative STER are both safe and effective pre-operatively for resection of pituitary adenomas with an intact hypothalamus-pituitary-adrenal axis.

A Case Report of Pituitary Apoplexy and Acute Ischemic Stroke (P2-5.004)

<h3>Objective:</h3> N/A <h3>Background:</h3> Pituitary apoplexy is a medical emergency resulting from acute hemorrhage or infarction of the pituitary gland. Symptoms include headache, diplopia, visual impairment, and encephalopathy. We present a diagnostically challenging case of pituitary apoplexy in a patient who presented with fever, headache, diplopia, cerebrospinal fluid showing neutrophilic pleocytosis with elevated protein, and neuroimaging showing a left basal ganglia infarct with diffuse cerebral vasospasm. <h3>Design/Methods:</h3> A 46 year old post-menopausal female exhibiting a two day prodrome of severe headaches, nausea, and double vision. She presented to the emergency department febrile (104.6 F), disoriented, with a left lateral rectus palsy and mild right hemiparesis. MRI brain revealed an enhancing suprasellar lesion extending into the sphenoid sinuses and left cavernous sinus with optic chiasm effacement. Diffusion weighted imaging showed evidence of a left recurrent artery of Heubner infarct. Intracranial CT angiography revealed anterior circulation vasospasm. Cerebrospinal fluid resulted in 300 nucleated cells with neutrophilic predominance and elevated protein (121 mg/dL). Her presentation and workup was concerning for an intracranial abscess versus pituitary apoplexy. The patient underwent transsphenoidal pituitary resection, confirming a macroadenoma and pituitary apoplexy. As her CSF infectious work up and biopsy cultures remained negative, the results were suggestive of sterile inflammation and her antibiotics were discontinued. Following surgical intervention and on six month follow up, the patient remained at her baseline functional status without deficits. <h3>Results:</h3> N/A <h3>Conclusions:</h3> Pituitary macroadenomas have varying severity of presentations. Pituitary apoplexy should be considered in a patient with altered sensorium, severe headache, and cranial nerve deficits. Cerebral infarcts can result from mechanical compression from mass effect or arterial vasospasm secondary to vasoactive substances released from necrotic and hemorrhagic pituitary tumor. Prompt diagnosis and early intervention can reduce mortality and morbidity and is critical for successful patient outcomes. <b>Disclosure:</b> Dr. Sandhu has nothing to disclose. Dr. Saini has nothing to disclose. Dr. Liang has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Abbvie.

Effects of Low versus Intermediate Doses of Dexmedetomidine Infusion on Blood Loss, Hemodynamics, and Operative Time in Transsphenoidal Pituitary Tumor Removal: A Prospective Randomized Study

Abstract Background Dexmedetomidine, an alpha-2 agonist, has been widely used as an anesthetic adjunct for transsphenoidal pituitary resection. However, there is no consensus on the appropriate infusion dosage. This study aimed to compare the effects of low (0.2 mcg/kg/h) and intermediate (0.5 mcg/kg/h) dexmedetomidine infusions during anesthetic maintenance on blood loss, hemodynamics, and operating time. Methods A randomized controlled trial involving two centers was conducted. Between December 2015 and November 2019, 80 patients (40 in each group) who underwent elective transsphenoidal pituitary tumor resection were recruited. Dexmedetomidine was administered to group I at a loading dose of 0.5 mcg/kg, followed by 0.2 mcg/kg/h, and to group II at the same loading dose, followed by 0.5 mcg/kg/h. Comparative analyses were performed using the Student's t-test, repeated-measures analysis of variance, and Mann–Whitney U test; p-values &lt; 0.05 were considered statistically significant. Results Eighty patients were analyzed. Patient demographics were comparable. The difference in intraoperative blood loss between both groups (320 [220–525] vs. 250 [100-487] mL, p = 0.070) was not statistically significant. There were no differences in blood pressure or heart rate between the groups. In group II, the procedure took significantly less time (179 vs. 142 minutes, p = 0.018), with more episodes of transient hypotension (p = 0.034). Conclusion When maintaining anesthesia for transsphenoidal pituitary resection, dexmedetomidine infusions of 0.2 and 0.5 mcg/kg/h showed the same effect on blood loss and hemodynamics; however, significantly more episodes of transient hypotension and shorter operating times were noted with the latter.

Relevance of inferior petrosal sinus sampling in the diagnosis of Cushing's syndrome: a case report.

Non-specific signs and symptoms of Cushing's syndrome (CS) can pose a diagnostic challenge. We report the case of a man referred to the service of endocrinology for suspected CS. Hypercortisolism was confirmed on CS screening tests, whereas diagnostic tests confirmed the presence of adrenocorticotropin (ACTH) -dependent CS. The corticotropin-releasing hormone stimulation (CRH) test was performed to determine whether CS hadan endogenous or ectopic origin. Since the CRH and the magnetic resonance imaging (MRI) test were negative, IPSS was performed and suggested that CS was originated in the pituitary glands. Transsphenoidal pituitary resection was carried out. Histopathological analysis confirmed the cortitotrope origin of the tumor. The etiological study and differential diagnosis of CS are complex processes that involve a variety of biochemical and imaging tests. It is important that a sequence of biochemical screening and diagnostic tests is performed, along with studies for establishing the location of the lesion, to determine whether CS has an adrenal, pituitary or ectopic origin. Despite its good diagnostic performance, the results of biochemical tests may not be conclusive, especially in ACTH-dependent CS. In the case reported, the inconclusive results obtained in the CRH test rendered an invasive procedure (IPSS) necessary, which ultimately confirmed diagnosis.

PMON109 A Case of Non-functioning Pituitary Adenoma With Unexpectedly High Prolactin Level

Abstract Introduction Lactotroph or prolactin (PRL)-secreting adenomas account for approximately 45% of all pituitary adenomas. They are classified by size as microprolactinomas (&amp;lt;10 mm) and macroprolactinomas (≥10 mm). A giant prolactinoma is arbitrarily defined as an adenoma &amp;gt; 4 cm. PRL levels are often proportional to the size of tumor ranging from &amp;lt;200 ng/mL in adenomas smaller than 1 cm, 200 ng/mL to 1000 ng/mL in 1 cm to 2 cm adenomas and more than 1000 ng/ml in tumors larger than 2 cm. Nonfunctioning pituitary adenomas (NFPA) can cause mild increases in PRL levels due to pituitary stalk compression, however, levels more than 6 times the upper limit of normal have not been reported. We present a rare case of NFPA with significantly elevated prolactin levels Case: 42 yo female presented with headache and left eye blurry vision worsening over 2 years. MRI revealed a pituitary macroadenoma measuring 4.1×4.7×3cm with supra-sellar extension, mass effect including severe compression and displacement of the optic apparatus, and potential cavernous sinus invasion. Initial biochemical profile: TSH 1.01 (0.30–4.20 uU/mL), FT4 0.9 (0.6–1.5 ng/dL), AM ACTH of 20 (7.2-20 pg/ml), peak cortisol 18.8 mg/dl after cosyntropin stimulation, FSH 14.6 mIU/mL, LH 2.4 mIU/mL, IGF-1 71 (52-328 ng/mL) and prolactin 452 (&amp;lt;25.0 ng/mL), confirmed by dilution. PRL levels were concerning for prolactinoma but did not correlate with tumor size making giant prolactinoma an unlikely diagnosis. Yet, levels were higher than those expected from stalk compression. An interdisciplinary decision was made to proceed with operative management. The patient underwent trans-sphenoidal pituitary resection (TSPR). Tumor pathology showed sparsely granulated gonadotroph adenoma with weak LH expression and negative PRL staining, confirming NFPA. PRL level one-month post op was 33.2 ng/mL and vision is improved. Conclusion Medical treatment with dopamine agonists is first line treatment for any size prolactinoma with a high remission rate of 90% and prescribed before TSPR even in those with vision disturbance or neurologic symptoms. Giant NFPAs with compressive symptoms are best surgically managed.To our knowledge, this is the first report of significant PRL elevation due to stalk compression. Not only was the PRL higher than that previously associated with stalk compression, but also well above 250 ng/mL, which is typically diagnostic of prolactinoma. This case also highlights the importance of assessing the relationship between PRL level and tumor size to determine the correct course of management. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

RF13 | PMON83 Culture Negative Pituitary Abscesses: A Case Series

Abstract Introduction Pituitary abscesses are rare, representing less than 1% of pituitary lesions. Patients may present with pituitary hypofunction, headache, and/or vision changes, often without systemic or biochemical signs of infection, with diagnosis only made intraoperatively. Cases A 74-year-old man with history of diabetes and coronary artery disease presented with headache and left-eye ptosis. MRI revealed a 1.8 cm hypoenhancing cystic, hemorrhagic sellar mass extending into the left cavernous sinus. Pre-operative labs showed AM cortisol 1.1 ug/dL, testosterone 43 ng/dL (reference range 250-1100), FSH 15.3 mIU/mL, LH 4.5 mIU/mL consistent with adrenal insufficiency and hypogonadism. He underwent transsphenoidal pituitary resection (TSR) during which frank pus was demonstrated after incision into the dura overlying the pituitary. Surgical pathology showed necrosis and granulation-type reaction with acute inflammatory cell infiltrates. Gram stain and methenamine silver stains did not reveal definite micro-organisms while tissue bacterial cultures showed normal skin flora. He remained hemodynamically stable without fevers throughout the hospitalization and was discharged on empiric antibiotics and hydrocortisone. A 74-year-old female with history of a pituitary macroadenoma was admitted for worsening headaches. Labs were consistent with her known history of secondary adrenal insufficiency and hypogonadotropic hypogonadism. Repeat MRI showed characteristics suggestive of hemorrhage within a 1.8 cm intrasellar mass with inhomogeneous and peripheral enhancement after contrast. She underwent TSR and intraoperatively frank pus was encountered. Surgical pathology showed sinonasal mucosa with chronic inflammation. There was no growth in aerobic, fungal, or AFB cultures; anaerobic cultures grew rare commensal bacteria. She was discharged with a course of antibiotics and remains on hydrocortisone. A 42-year-old male presented with headache and was found to have a 2.5 cm sellar mass with rim enhancement elevating and compressing the optic chiasm on MRI. Labs were significant for AM cortisol 4.9 ug/dL and testosterone 8 ng/dL, FSH 0.4 mIU/mL, LH &amp;lt;0.2 mIU/mL consistent with adrenal insufficiency and hypogonadism. He underwent TSR and was found to have purulent debris in the sella. Pathology showed epithelial tissue fragments insufficient for diagnosis, and cultures grew few skin and oropharyngeal contaminants. He was discharged on hydrocortisone with a course of antibiotics. Conclusion We describe three patient cases presenting with headache and varying degrees of hypopituitarism, found to have purulent material emanating from the sella during transsphenoidal resection. None presented with clinical or biochemical systemic signs of infection. MRI imaging was variable, ranging from cystic, hemorrhagic features to peripheral enhancement. Surgical pathology and cultures were unrevealing for a definitive infectious source or other cystic lesion such as Rathke's cleft cyst. This case series demonstrates the potential nonspecific presentation of pituitary abscesses including negative cultures and pathology. It is important to keep this rare diagnosis in the differential for patients presenting with pituitary disease. Presentation: Sunday, June 12, 2022 12:30 p.m. - 12:35 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

PMON90 Pituitary Abscess, A rare cause of Hypopituitarism

Abstract Introduction Pituitary abscess is a rare condition, representing 0.2-0.6% of all pituitary lesions. The presentation can be non-specific, and imaging can mimic a pituitary adenoma, often making the diagnosis challenging. We present a case of a pituitary abscess from Staphylococcus epidermidis and Corynebacterium propinquum with resulting hypopituitarism and central diabetes insipidus (DI). Clinical case A 42-year-old man with a history of hypothyroidism secondary to thyroiditis presented to the emergency room with sudden onset headache, nausea, and emesis. There were associated symptoms of fatigue, weight loss, and sexual hypofunction for approximately six months. He did not have fever or leukocytosis. Brain MRI revealed a 2.5×1.8×1.6 cm sellar and suprasellar mass with rim enhancement and compression of the optic chiasm. Pre-operative pituitary hormonal evaluation showed central hypogonadism, growth hormone deficiency and secondary adrenal insufficiency: FSH 0.4 mIU/mL (n &amp;lt; 15mIU/mL), LH &amp;lt;0.2mIU/mL (n &amp;lt; 10 mIU/mL), AM Testosterone 8 ng/dL (n 250-1100 ng/dL), IGF-1 38 ng/ml (n 52-328 ng/mL), ACTH 5.6 pg/mL (n 7.2-63 pg/mL), AM cortisol 4.9 ug/mL (n 4-10 ug/dL). Prolactin was normal (14.7 ng/mL, n &amp;lt;15 ng/mL). TSH was elevated to 4.88 uU/mL (n 0.3-4.2 uU/mL) with a low FT4 of 0.5 ng/dL (n 0.6-1.5 ng/dL) on levothyroxine 75mcg daily. He was started on stress doses of hydrocortisone and underwent trans-sphenoidal pituitary resection. Intraoperative findings were significant for 3-5 mL of purulent debris in the sella suggestive of a pituitary abscess. He was started on Ceftriaxone, Metronidazole, and Vancomycin, with improvement in headache. Pituitary abscess cultures grew Staphylococcus epidermidis and Corynebacterium propinquum. Blood cultures were negative for any bacterial growth. Post-operative course was complicated by transient DI. The patient was discharged on Linezolid to complete six weeks of antibiotics, a physiological dose of hydrocortisone (20mg daily), and levothyroxine 88mcg daily. At outpatient Endocrine follow-up a month later, he was found to have a recurrence of DI and started on maintenance desmopressin with improvement in polyuria and polydipsia. Conclusion Pituitary abscesses are rare, life-threatening pituitary lesions. 70% of cases are primary pituitary abscesses, which develop in a previously healthy gland. Secondary pituitary abscesses arise within a pre-existing pituitary lesion and are less common. Clinical manifestations include headache, visual disturbance, and hypopituitarism. The diagnosis is challenging since classical signs of infection, such as fever and leukocytosis, are uncommon, and pre-operative radiological findings can be non-specific. The majority of cases are confirmed intra-operatively. Commonly isolated organisms are Gram-positive cocci (Staphylococcus and Streptococcus) and Gram-negative bacteria (Neisseria, Escherichia coli and Corynebacterium). This case highlights the importance of considering pituitary abscesses in the differential diagnosis of patients presenting with a sellar mass. Prompt recognition of a pituitary abscess will allow for rapid treatment with trans-sphenoidal evacuation, antibiotic therapy, and pituitary hormonal replacement when indicated. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Growth Hormone (GH) and Thyroid Stimulating Hormone (TSH) Co-Secreting Pituitary Macroadenoma

Background: TSH secreting pituitary adenomas are rare and accounts for 0.5-3% of all pituitary adenomas. Only 20-25% of those adenomas co-secrete other hormones like growth hormone or prolactin. Mixed GH and TSH secreting adenomas present with symptoms from tumor growth and features of both acromegaly and hyperthyroidism. Clinical Case: A 57 years old woman with a past medical history of chronic joint pains and bilateral knee swelling presented to her PCP with complaints of chronic fatigue. Evaluation revealed a normal TSH level and MNG and patient did not have any further work-up. She reported undergoing periodic knee arthrocentesis which gave her only temporary pain relief. Two years later, patient presented with complaints of unintentional weight loss, tremors and palpitations. She also reported enlargement in the size of hands, feet and forehead and no improvement in the knee swelling after multiple arthrocentesis. Lab evaluation revealed high free T4 2.31ng/dl (0.58-1.64), high free T3 6.44pg/ml (2.50-4.30), non-suppressed TSH 1.32mU/L (0.34-5.00), elevated IGF-1 415ng/ml (47-236), GH 7.76ng/ml (0.01-3.61) and prolactin 6.69ng/mL (2.74-26.72). Neck USG showed multiple nodules and 24hr radioactive iodine uptake scan showed increased uptake at 43%. 75gm OGTT showed non-suppression of GH level. MRI of brain showed 1.8 cm pituitary macroadenoma. Patient underwent transsphenoidal pituitary resection in January 2018 and the final pathology showed positive tumor staining for GH and TSH. Following surgery, patient reported improvement in symptoms. Lab work-up from October 2018 showed normal IGF 189 ng/ml (47-236), normal GH 0.35(0.01-3.61), Free T4 0.80(0.58-1.64), Free T3 2.41(2.50-4.30), TSH 0.06(0.34-5.00) and MRI from August 2020 showed no evidence of residual pituitary tumor. Conclusion: This is a rare case of a GH and TSH co-secreting pituitary macroadenoma. This case highlights the importance of considering acromegaly early in the differential diagnosis of patients presenting with chronic musculoskeletal symptoms and to pursue work up for central hyperthyroidism in a hyperthyroid patient presenting with a non-suppressed TSH level.

Occult Carcinoid Causes Cushing’s Syndrome

Introduction: Lung neuroendocrine tumors (NETs) are a common cause of ectopic ACTH-secretion. Only 3% of NETs cause Cushing’s syndrome1; the majority are small and may be radiographically occult. Additionally, the responses to dexamethasone, metyrapone, and oCRF can be indistinguishable from that observed in pituitary Cushing’s disease2. These challenges lead to misdiagnosis and unnecessary procedures. Case Description: 45-year-old male presented for resection of right-sided pulmonary carcinoid tumor. He was diagnosed with Cushing’s syndrome in 2011 when he experienced uncontrolled hypertension and excessive weight gain with elevations in cortisol and ACTH levels. He underwent transsphenoidal pituitary resection in May 2011 for a possible pituitary microadenoma. Post-operative worsening hypertension, weight gain, and striae led to bilateral adrenalectomy in November 2011, complicated by retroperitoneal hemorrhage and resuscitation-induced pulmonary edema. On chest CT in early 2012, an 8 mm incidental right pulmonary nodule was documented. 8 years later, chest imaging for mild COVID-19 infection again revealed a right-sided pulmonary nodule. He underwent CT-guided biopsy of the nodule in July 2020 with pathology demonstrating carcinoid histology. Right lower lobectomy was performed. Pre-operative ACTH was 1673 pg/mL (normal: 10-60 pg/mL) and post-operative ACTH was 16 pg/mL. The resected tumor stained positive for ACTH, confirming that carcinoid tumor was the source of Cushing’s for the past decade. Conclusion: The diagnosis of ectopic Cushing’s syndrome can be elusive, leading to surgeries with significant morbidity, as seen in our patient. In one retrospective review, 14% of patients with Cushing’s had transsphenoidal resection before they were diagnosed with an ectopic source3. Ectopic Cushing’s syndrome can be a challenging diagnosis to make and a multidisciplinary approach with close collaboration between endocrinologist, radiologist, surgeon and pathologist may increase the diagnosis accuracy. Citations: 1Kamp, K, Alwani, R A, Korpershoek, E, Franssen, G., de Herder, W W, & Feelders, R A. (2016). Prevalence and clinical features of the ectopic ACTH syndrome in patients with gastroenteropancreatic and thoracic neuroendocrine tumors, European Journal of Endocrinology, 174(3), 271-280. Retrieved Jan 15, 2021, from https://eje.bioscientifica.com/view/journals/eje/174/3/271.xml 2Malchoff CD, Orth DN, Abboud C, Carney JA, Pairolero PC, Carey RM. Ectopic ACTH syndrome caused by a bronchial carcinoid tumor responsive to dexamethasone, metyrapone, and corticotropin-releasing factor. The American Journal of Medicine. 1988;84(4):760-764. doi:10.1016/0002-9343(88)90116-7 3Ioannis Ilias, David J. Torpy, Karel Pacak, Nancy Mullen, Robert A. Wesley, Lynnette K. Nieman,Cushing’s Syndrome Due to Ectopic Corticotropin Secretion: Twenty Years’ Experience at theNational Institutes of Health, The Journal of Clinical Endocrinology & Metabolism, Volume 90, Issue8, 1 August 2005, Pages 4955–4962, https://doi.org/10.1210/jc.2004-2527

SAT-279 Crooke’s Cell Adenoma- an Aggressive Form of Cushing’s Disease

Introduction: Cushing’s disease is a condition of cortisol overproduction caused by an ACTH-producing tumor. Corticotroph cells surrounding an ACTH-producing tumor usually undergo Crooke’s hyaline change, where cytokeratin filaments accumulate in the cytoplasm in response to glucocorticoid excess. These changes are thought to be a mechanism of feedback inhibition and thus facilitate a suppression of ACTH. However, in a subtype of ACTH-secreting tumors known as Crooke’s cell adenomas (CCA), the ACTH-producing cells also undergo these hyaline changes. This would be expected to suppress hormone secretion but these cells are still able to release significant amounts of ACTH. Case presentation: A 32-year-old woman presented to the hospital after an episode of syncope. On head MRI, she was found to have a 2 cm sellar mass with optic chiasm compression. Labs showed low TSH, free FT4, T3, FSH, and LH. She was also pre-diabetic with an HgbA1c of 6.2%. Her baseline cortisol of 20.6 µg/dL did not suppress after 1 mg of dexamethasone. After receiving 4 mg of dexamethasone, her cortisol suppressed to 5.2 µg/dL. She was diagnosed with hypopituitarism except for cortisol and a likely ACTH-producing pituitary macroadenoma. She completed a transsphenoidal pituitary resection and pathology revealed Crooke’s hyaline changes with immunohistochemical stains positive for ACTH. The immunostain for the proliferation marker Ki67 showed a relatively low proliferation index. Her course was complicated by diabetes insipidus. She was ultimately discharged on 20 mg hydrocortisone each morning, 10 mg hydrocortisone each afternoon, desmopressin 0.05 µg daily, and levothyroxine 125 µg daily. Two weeks later, the patient was sent to the emergency room by her endocrinologist for hyperglycemia up to 288 mg/dL. She was also found to be newly diabetic with an HgbA1c of 6.5%. A fasting morning cortisol was collected during her admission and showed a cortisol level of <1.0 µg/dL, proving she was cured of Cushing’s disease. However, she will need close endocrinology follow up and MRI imaging of her pituitary for this aggressive type of pituitary adenoma. Discussion: We have come across an interesting case of a young woman who presented for syncope and was found to have a pituitary macroadenoma with pathology consistent with CCA. This type of ACTH-producing tumor is known for aggressive patterns including high rates of recurrence with rates of up to 60% reported in literature, persistent disease after surgery, malignant transformation, and metastases. Despite presentation and symptoms similar to those of other ACTH-producing adenomas, the dangerous pattern of Crooke’s cell adenomas necessitate long-term follow-up in affected patients.

Outcomes in Pediatric Transsphenoidal Pituitary Surgery Stratified by the Use of Image Guidance: An Analysis of the Kids' Inpatient Database from 1997 to 2016

Background To evaluate the utilization of image guidance technology for pediatric transsphenoidal pituitary resection (TSPR) and analyze the complication rates, length of stay (LOS), and total cost for such surgeries as function of time and utilization of image guidance. Methods The Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) was queried for all cases of TSPR between 1997 and 2016. Factors extracted included patient demographics, use of image guidance, LOS, total cost, and complications, including panhypopituitarism, diabetes insipidus (DI), cerebrospinal fluid (CSF) rhinorrhea, and cranial nerve (CN) III, IV, and VI palsies. Multivariate logistic regression was utilized to determine the odds ratio of developing panhypopituitarism, DI, CSF rhinorrhea, and CN palsies for image-guided versus nonimage-guided cases. A generalized linear model was used to determine the effect of image guidance on inflation-adjusted total cost and LOS. Results A total of 1,297 cases of TSPR were included in the KID over this time period. The majority were female, Caucasian, and older than 15 years. Utilization of image guidance has rapidly increased since 2006. Complication rates were comparable, but when controlling for other factors, the use of image guidance showed a lower risk of postoperative DI ( p = 0.05). The use of image guidance also resulted in a shorter LOS by 2.84 days ( p < 0.001) with no associated increase in total cost ( p = 0.663). Conclusion The use of imaging guidance for pediatric TSPR has precipitously increased in recent years, as it is cost-effective, decreases LOS, and may lead to lower complication rates, such as DI.

Immediate Use of Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea Following Transsphenoidal Pituitary Surgery: A Case Series

Patients who undergo transsphenoidal pituitary resection have an elevated risk of obstructive sleep apnea (OSA) yet their outcomes and the safety of continuous positive airway pressure (CPAP) remains unclear. Our study objective was to determine the incidence of complications related to the use of early positive airway pressure following pituitary resection. We retrospectively identified all patients who underwent endoscopic transsphenoidal pituitary tumor resection between January 1, 2005 and March 24, 2016 at our institution, including those with diagnosed or suspected OSA. We compared characteristics and postoperative complications of OSA patients who did and did not receive CPAP postoperatively. In total, 427 patients underwent transsphenoidal pituitary resection. Of these, 64 (15%) had OSA. Acromegaly was more common in patients with OSA (42% vs. 10%; P<0.001) but not Cushing Disease (19% vs. 16%; P=0.54). Hypoxia was more common in patients with OSA as compared to those without (14% vs. 5%; P<0.001) and one patient with OSA was reintubated compared with none in the control group (P=0.017). Eight patients had CPAP applied in the immediate postoperative period and the incidence of postoperative cerebrospinal fluid (CSF) leak, infection, and pneumocephalus was similar between OSA patients with and without CPAP. Our case series of patients with OSA who received CPAP immediately following transsphenoidal pituitary resection resulted in similar rates of surgical complications. Our results support further investigation to establish the safety of CPAP in this population.

The effects of dexmedetomidine and magnesium sulphate in adult patients undergoing endoscopic transnasal transsphenoidal resection of pituitary adenoma: A double-blind randomised study.

Background and Aim:Transnasal transsphenoidal resection of pituitary tumours is associated with blood loss and wide fluctuations in haemodynamic parameters. The aim of the present study was to compare the effect of dexmedetomidine and magnesium sulphate during the transsphenoidal resection of pituitary tumours.Methods:The study was a double-blind, randomised study and included 152 patients classified randomly into two groups: Group D: Dexmedetomidine was given as a loading dose 1 μg/kg over 10 min before induction followed by an infusion at 0.5 μg/kg/h during the surgery. Group M: Magnesium sulphate was given as loading dose of 50 mg/kg over 10 min followed by an infusion at 15 mg/kg/h during the surgery. The systolic, diastolic and mean arterial blood pressures, in addition to the amount of blood loss were measured at specific timepoints. Data were described in terms of mean ± standard deviation, median, frequencies, 95% confidence of interval of mean and percentages.Results:Mean bleeding score was lower in Group D than Group M (1.36 ± 0.48 vs. 3.05 ± 0.65, respectively; P = 0.002). Mean blood loss was lower in Group D (157.43 ± 48.79 ml vs.299.47 ± 77.28 ml in Group M; P < 0.001)Heart rate, mean arterial pressure, fentanyl requirements, end-tidal sevoflurane concentration, and extubation and emergence times were lower, while incidence of bradycardia and hypotension were higher in Group D.Conclusions:During transsphenoidal pituitary resection, dexmedetomidine, compared to magnesium, is associated with lower blood loss and better operating conditions but with more hypotension and bradycardia

Randomized trial for superiority of high field strength intra-operative magnetic resonance imaging guided resection in pituitary surgery

Till date there are no randomized trials to suggest the superiority of intra-operative magnetic resonance imaging (IOMRI) guided trans-sphenoidal pituitary resection over two dimensional fluoroscopic (2D-F) guided resections. We conducted this trial to establish the superiority of IOMRI in pituitary surgery. Primary objective was to compare extent of tumor resection between the two study arms. It was a prospective, randomized, outcome assessor and statistician blinded, two arm (A: IOMRI, n=25 and B: 2D-F, n=25), parallel group clinical trial. 4 patients from IOMRI group cross-over to 2D-F group and were consequently analyzed in latter group, based on modified intent to treat method. A total of 50 patients were enrolled till completion of trial (n=25 in each study arm). Demographic profile and baseline parameters were comparable among the two arms (p>0.05) except for higher number of endoscopic procedures and experienced neurosurgeons (>10years) in arm B (p=0.02, 0.002 respectively). Extent of resection was similar in both study arms (A, 94.9% vs B, 93.6%; p=0.78), despite adjusting for experience of operating surgeon and use of microscope/endoscope for surgical resection. We observed that use of IOMRI helped optimize the extent of resection in 5/20 patients (25%) for pituitary tumor resection in-group A. Present study failed to observe superiorty of IOMRI over conventional 2D-F guided resection in pituitary macroadenoma surgery. By use of this technology, younger surgeons could validate their results intra-operatively and hence could increase EOR without causing any increase in complications.

Reduction in Cutis Verticis Gyrata after Transsphenoidal Pituitary Resection of Growth Hormone–Secreting Adenoma

Aim Cutis verticis gyrata (CVG) describes a hypertrophy and folding of the skin that appears as gyration of the scalp. Secondary CVG is a common symptom of growth hormone (GH)–producing adenoma of the pituitary and an early sign of acromegaly. We hypothesized that surgical removal of a pituitary adenoma with a consecutive decrease in hormone levels will cause a reduction in gyration. Methods Imaging and laboratory examination of 10 patients (median age: 44 years) with GH-producing adenoma have been evaluated retrospectively. Surgical treatment consisted of endonasal transsphenoidal resection of the adenoma, followed by endocrinologic and radiographic follow-up. CVG was calculated as area under the curve of the scalp on preoperative coronal T1-weighted MRI, compared with postoperative follow-up imaging after 12 months (AUC, measured in cm2). In laboratory examination, the levels of insulin-like growth factor-1 (IGF-1) were analyzed accordingly as its levels are constant throughout the day. Results After 12 months, we found a statistically significant (p = 0.008) correlation between the decrease in IGF-1 levels (median: 219.00 ng/mL) and the reduction in CVG (median: 0.12 cm2). Conclusion Resection of GH-producing pituitary adenoma leads to a decrease in CVG in patients suffering from acromegaly, which is strongly related to the levels of IGF-1