Pitfalls in pituitary diagnosis: peculiarities of three cases (original) (raw)
Related papers
Pituitary imaging is indicated for the evaluation of hyperprolactinemia
Fertility and Sterility, 2005
Objective: To evaluate the signs and symptoms associated with hyperprolactinemia and establish guidelines for a minimal serum PRL level for which pituitary imaging is indicated. Design: Retrospective study. Setting: Reproductive endocrinology clinic in a university hospital. Patient(s): One hundred four consecutive patients with hyperprolactinemia, mean age 30 Ϯ 6.5 (range 19 -44) years. Intervention(s): Classification of clinical symptoms, serum hormone measurements, and pituitary magnetic resonance imaging (MRI). Main Outcome Measure(s): Incidence of presenting symptoms, serum PRL levels, and pituitary tumor size. Result(s): Median (range) PRL value was 82.6 ng/mL (25-1,342). Reported symptoms from most to least common were infertility (48%), headaches (39%), oligoamenorrhea (29%), galactorrhea (24%), and visual changes (13%). Hypothyroidism was diagnosed in 2 of 104 (1.9%) patients. Of 86 patients who had pituitary imaging, 23 (26%) had normal findings and 63 (74%) had pituitary tumor; of these, 47 (55% of total imaged) had microadenomas and 16 (19% of total imaged) had macroadenomas. There was a statistically significant association between the tumor size and the PRL level. However, 11% of the patients with microadenomas had PRL levels Ͼ200 ng/mL, and 44% of the patients with macroadenomas had PRL levels between 25 and 200 ng/mL.
Clinical Endocrinology, 2006
Background The differentiation of a pituitary non-functioning macroadenoma from a macroprolactinoma is important for planning appropriate therapy. Serum PRL levels have been suggested as a useful diagnostic indicator. However, values between 2500 and 8000 mU / l are a grey area and are currently associated with diagnostic uncertainty. Objective We wished therefore, to investigate the serum PRL values in a large series of patients presenting with apparently non-functioning pituitary macroadenomas. Patients and methods All patients presenting to the Department of Endocrinology in Oxford with clinically non-functioning pituitary macroadenomas (later histologically verified) between 1990 and 2005 were studied. Information documented in the notes on the medications and on the presence of conditions capable of affecting the serum PRL levels at the time of blood sampling was also collected. Results Two hundred and twenty-six patients were identified (median age at diagnosis 55 years, range 18 -88 years; 146 males/80 females; 143 gonadotroph, 46 null cell, 25 plurihormonal and 12 silent ACTH adenomas). All tumours had suprasellar extension. At the time of blood sampling 41 subjects were taking medications capable of increasing serum PRL. Hyperprolactinaemia was found in 38·5% (87/226) of the patients. The median serum PRL values in the total group were 386 mU/ l (range 16-3257) (males: median 299 mU/ l, range 16 -1560; females: median 572 mU/ l, range 20 -3257) and in those not taking drugs capable of increasing serum PRL 363 mU/ l (range 16 -2565) (males: median 299 mU/ l, range 16 -1560; females: median 572 mU/ l, range 20 -2565). Serum PRL < 2000 mU/ l was found in 98·7% (223/226) of the total group and in 99·5% (184/185) of those not taking drugs. Among the three subjects with serum PRL > 2000 mU/ l, two were taking oestrogen preparations. Conclusions Based on a large series of histologically confirmed cases, serum PRL > 2000 mU/l is almost never encountered in nonfunctioning pituitary macroadenomas. Values above this limit in the presence of a macroadenoma should not be surrounded by diagnostic uncertainty (after acromegaly or Cushing's disease have been excluded); a prolactinoma is the most likely diagnosis and a dopamine agonist should be considered as the treatment of choice.
Nonfunctioning pituitary macroadenoma presenting with mild hyperprolactinemia and amenorrhea
Fertility and Sterility, 1999
Objective: To describe a patient with a clinically nonfunctioning pituitary macroadenoma who presented with mild hyperprolactinemia and amenorrhea. Design: Case report. Setting: Tertiary care medical facility. Patient(s): A 44-year-old woman with a 6-month history of amenorrhea. Intervention(s): Pituitary testing, magnetic resonance imaging of the sella turcica, and transsphenoidal surgery. Main Outcome Measure(s): Pituitary function testing, magnetic resonance imaging, and return of menstrual cycles. Result(s): Baseline laboratory data revealed a serum prolactin level of 34 ng/mL (normal range, 3-20 ng/mL), normal thyroid function test results, and an FSH level of 6.7 mIU/mL. A second fasting prolactin level was 48 ng/mL. Magnetic resonance imaging of the sella turcica revealed a pituitary macroadenoma measuring 1.4 ϫ 3.2 cm. Further testing of baseline pituitary function revealed normal findings. The patient underwent an uncomplicated transsphenoidal resection of the pituitary tumor and maintained normal pituitary function. Pathologic evaluation revealed a pituitary adenoma that stained positive for FSH and focally for the ␣ subunit. The adenoma stained negative for GH, prolactin, ACTH, LH, and TSH.
Prolactin-Producing Pituitary Adenoma Associated with Prolactin Cell Hyperplasia
Endocrine Pathology, 2002
A 24-yr-old woman with amenorrhea, galactorrhea, hyperprolactinemia, and sellar mass underwent transsphenoidal surgery. Histologic, immunohistochemical, and electron microscopic investigation revealed a well-differentiated, sparsely granulated prolactin (PRL) cell adenoma of the pituitary showing conclusive PRL immunoreactivity. In the nontumorous adenohypophysis PRL cell hyperplasia was noted. Marked differences were evident between the neoplastic and hyperplastic areas. The tumor consisted of sparsely granulated PRL cells immunoreactive only for PRL. As demonstrated by immunoelectron microscopy, the hyperplastic area comprised monohormonal sparsely granulated PRL cells as well as bihormonal mammosomatotrophs immunoreactive for both PRL and growth hormone. The MIB-1 index was higher whereas microvessel density was lower in the adenoma as compared with the hyperplastic area. In addition, the nontumorous area showed lymphocytic infiltration whereas inflammatory reaction was not seen in the adenoma. This case represents a rare association of a PRL cell adenoma and PRL cell hyperplasia. The fact that these two lesions were contiguous in the surgically removed material raises the possibility that hyperplasia can precede and transform into adenoma.
Diagnostic pitfalls of hyperprolactinemia: the importance of sequential pituitary imaging
BMC research notes, 2014
The purpose of this study is to confirm whether the serum prolactin cut-off value is definitive to distinguish prolactinoma and non-functioning pituitary adenoma with hyperprolactinemia. We retrospectively reviewed patients with non-functioning pituitary adenoma, including gonadotroph cell adenoma, null cell adenoma and prolactinoma who were surgically treated at Kohnan hospital between June 2005 and March 2012. The patients without endocrinological/neurological symptom and with the tumor larger than 40 mm in diameter were excluded. According to previously reported cut-off value of serum prolactin, mild hyperprolactinemia, which is considered non-definitive (border zone) concentration between prolactinoma and non-functioning pituitary adenoma, were defined as 90 - 200 ng/ml. Ninety-five prolactinoma patients and 212 patients with non-functioning pituitary adenoma were analyzed. The serum prolactin concentration, tumor size, and clinical characteristics were statistically compared. R...
Case Report: Secondary Amenorrhea with Hyperprolactinemia due to Pituitary Macroadenoma
Asian Journal of Health Research
Introduction: Secondary amenorrhea has a broad etiology, so each case must be studied in depth. One of the causes of secondary amenorrhea is a state of hyperprolactinemia caused by a mass in the anterior pituitary. Pituitary macroadenoma patients may be asymptomatic or have a hormone imbalance or mass impact symptoms. Tumors in asymptomatic patients might be identified during a routine head imaging examination for unrelated medical issues. Case Presentation: A 24-year-old unmarried woman with complaints of headache, blurred vision, and worsening for one year ago. The patient complained of not having menstruation in the past five years ago, with a history of previous normal menstruation. On physical examination, found breast and pubic Tanner stage 5. On laboratory examination, it was found FSH (2.21), Oestradiol (20.23), and Prolactin (1365.47). On an MRI of the head examination on April 14, 2021, a solid intrasellar mass of suspected pituitary macroadenoma was found with a size of ±...
Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas
Clinical …, 2006
Prolactinomas contain lactotrophs that secrete PRL, a process that is enhanced by oestrogen and inhibited by dopamine, which is synthesized by the hypothalamus and transported to the pituitary by portal vessels. Prolactinomas lead to hyperprolactinaemia, but drugs or situations that inhibit hypothalamic production of dopamine, its transport to the pituitary, or its effectiveness at dopaminergic receptors can also cause hyperprolactinaemia without prolactinoma. Therefore, hyperprolactinaemia does not invariably indicate concomitant prolactinoma. Although oestrogen stimulates prolactin secretion, there is no evidence linking oestrogen therapy
Pituitary hyperplasia: an uncommon presentation of a common disease
Endocrinology, Diabetes & Metabolism Case Reports, 2015
A 21-year-old woman presented with amenorrhea, bilateral galactorrhea and fatigue. Visual acuity and visual fields were normal. Laboratory examination demonstrated hyperprolactinemia. Magnetic resonance imaging (MRI) of the pituitary showed a 19!17!12-mm sellar mass with supra-and parasellar extension, causing compression of the pituitary stalk and optic chiasm. Further examinations confirmed mild hyperprolactinemia, strongly elevated TSH (O500 mU/l), low free thyroxine (FT 4), hypogonadotropic hypogonadism and secondary adrenal insufficiency. Hydrocortisone and L-T 4 replacement therapy was started. Three months later, the galactorrhea had disappeared, thyroid function was normalized and MRI revealed regression of the pituitary enlargement, confirming the diagnosis of pituitary hyperplasia (PH) due to primary hypothyroidism. Subsequently, the menstrual cycle returned and the hypocortisolism normalized. This case demonstrates that severe primary hypothyroidism may have an unusual presentation and should be considered in the differential diagnosis of pituitary enlargement associated with moderate hyperprolactinemia. Learning points: † One should always try to find one etiology as the common cause of all the clinical findings in a pathologic process. † Amenorrhea, galactorrhea and fatigue may be the only presenting clinical manifestations of primary hypothyroidism. † Not every patient with galactorrhea, hyperprolactinemia and a pituitary mass has a prolactinoma. † Primary hypothyroidism should always be considered in the differential diagnosis of hyperprolactinemia associated with pituitary enlargement and pituitary hormone(s) deficiency(ies). † When PH due to primary hypothyroidism is suspected, thyroid hormone replacement should be started and only regression of pituitary enlargement on MRI follow-up can confirm the diagnosis. † Examination of thyroid function in patients with a pituitary mass may avoid unnecessary surgery.
Acta Neuropathologica, 1991
Prolactin cell adenoma is the most frequently found lesion in surgically removed pituitaries of patients with hyperprolactinemia. However, in several instances, instead of prolactin cell adenoma, other lesions are encountered by morphological investigation. We report here the morphological findings in a patient with hyperprolactinemia who underwent transsphenoidal pituitary surgery for suspected prolactin cell adenoma. A morphological diagnosis of tumor could not be confirmed and massive diffuse prolactin cell hyperplasia was identified. The aim of this publication is to describe the lesion by histology, immunocytochemistry, electron microscopy, and in situ hybridization and to call attention to primary prolactin cell hyperplasia which can mimic prolactin cell adenoma.