The idea for this book developed as an outcome of a multidisciplinary sym- posium entitled "Pituitary Adenoma Update" that was held at Tufts-New En- gland Medical Center in April 1977. The purpose of that symposium was to put together our current knowledge of the cause of pituitary tumors and discuss the diagnostic evaluation and management that was now appropriate, in light of the rapid advances that had taken place so recently in this area. Those of our colleagues who had presented papers at the symposium, as well as a number of others, were invited to contribute to this volume, which should serve as a presentation of the "state of the art" on all aspects of pitu- itary tumors. We felt that such a book would be of value to endocrinologists, neurosurgeons, neuroradiologists, and pathologists who are involved in the investigation or care of patients with pituitary disorders. For a number of reasons, a review of pituitary adenomas seems particu- larly timely. Rapid advances have taken place coincidentally in the fields of neurosurgery, neuroendocrinology, neuroradiology, neuropathology, and neuropharmacology.
Seven major developments in these areas have occurred independently and almost simultaneously that have virtually revolutionized our approach to pituitary adenomas.
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Springer Science+Business Media
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234 black & white illustrations, biography
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978-0-306-40382-8 (9780306403828)
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Schweitzer Klassifikation
I. Pathophysiology of Pituitary Tumors.- 1 Anatomical and Physiological Basis of Hypothalamic-Pituitary Regulation.- 1. Anatomical Overview.- 2. The Neurohypophysis.- 2.1. Anatomy.- 2.2. Hormone Synthesis, Transport, and Secretion.- 2.3. Physiological Regulation of Neurohypophyseal Hormone Release.- 3. The Median Eminence and Tuberohypophyseal Neurons.- 3.1. Anatomy.- 3.2. The Portal Vessel-Chemotransmitter Hypothesis and Hypophysiotropic Hormones.- 4. Regulation of Secretion of the Tuberohypophyseal Neurons: Neuropharmacology of Hypothalamic Regulation.- 4.1. Neurotransmitter Regulation of Hypophysiotropic Neurons.- 4.2. Endocrine Significance of Neuropeptides.- 5. Interaction of the Hypothalamic-Pituitary Unit with Feedback Control by Target-Gland Secretions.- References.- 2 Etiology of Pituitary Adenomas.- 1. Introduction.- 2. Insights into The Pathogenesis of Adenoma Based on Embryological Considerations.- 3. Pituitary Adenomas Arising Due to Prolonged Hormonal Stimulation or Loss of Normal Negative-Feedback Control.- 3.1. Estrogen Effects.- 3.2. Response to Loss of Negative-Feedback Control.- 4. Role of the Hypothalamus in Pathogenesis and Manifestations of Pituitary Adenomas.- 4.1. Physiological Responses in Patients with Pituitary Hypersecretion: Acromegaly.- 4.2. ACTH-Secreting Adenomas.- 4.3. Prolactin-Secreting Tumors.- References.- 3 The Pathology of Pituitary Adenomas.- 1. Traditional Concepts.- 2. Modern Techniques and Their Limitations.- 2.1. Electron Microscopy.- 2.2. Immunological Staining.- 3. Electron Microscopy of Pituitary Adenomas.- 3.1. Somatotropic (Growth Hormone-Producing) Adenomas.- 3.2. Prolactinomas.- 3.3. Mixed Prolactin- and Growth-Hormone-Producing Tumors.- 3.4. Corticotropic Adenomas.- 3.5. Thyrotropic Adenomas.- 3.6. Gonadotropic Adenomas.- 3.7. Acidophilic Stem-Cell Adenomas.- 3.8. Oncocytomas.- 4. Additional Features.- 4.1. Amyloid Production.- 4.2. Hemorrhage and Infarction.- 4.3. Carcinoma of the Pituitary Gland.- 5. Incidence of the Various Types of Pituitary Adenomas.- 6. Frozen-Section Diagnosis of Pituitary Adenomas.- References.- II. Clinical Features of Pituitary Tumors.- 4 Galactorrhea Syndromes.- 1. Introduction.- 2. Materials and Methods.- 2.1. Patients.- 2.2. Anatomical Evaluation of the Pituitary Fossa.- 2.3. Endocrinological Evaluation of Galactorrhea Patients.- 2.4. Assay Procedures.- 3. Results.- 3.1. Categories of Galactorrhea Patients.- 3.2. Clinical Evaluation of Patients with Galactorrhea: Etiological Associations and Patient Complaints.- 3.3. Prolactin Secretion in Patients with Galactorrhea.- 3.4. Gonadotropic Function in Patients with Galactorrhea.- 3.5. Growth Hormone, Adrenocorticotropin, and Antidiuretic Hormone Function in Patients with Galactorrhea.- 4. Discussion.- 5. Roentgenographic Study.- 6. Endocrine Evaluation in Differential Diagnosis.- 7. Natural History of Adenomas.- 8. Conclusions.- References.- 5 Prolactin-Secreting Adenomas in the Male.- 1. Introduction.- 2. Results.- 2.1. Males with Prolactin-Secreting Tumors.- 2.2. Males with Nonsecreting Tumors.- 3. Discussion.- 4. Conclusion.- References.- 6 Growth-Hormone-Secreting Pituitary Adenomas.- 1. Introduction.- 2. Pathogenesis of Acromegaly.- 3. Pathology of Acromegaly.- 4. Clinical Features of Acromegaly.- 4.1. Acral Changes.- 4.2. Headaches.- 4.3. Neuromuscular Changes.- 4.4. Skeletal and Bony Changes.- 4.5. Other Organs.- 5 Effects of Acromegaly on Other Endocrine Functions.- 6. Diagnosis of Acromegaly.- 7. Treatment of Acromegaly.- 8. Associated Tumors.- 9. Causes of Acromegaly Other Than a Pituitary Adenoma.- 10. Differential Diagnosis.- 11. Prognosis in Acromegaly.- 12. Summary.- References.- 7 ACTH-Secreting Adenomas.- 1. Introduction.- 2. Regulation of ACTH Secretion.- 3. Relationship of ACTH to ?-Lipotropin and the Endorphins.- 4. Clinical Features of Cushing's Syndrome.- 5. Laboratory Diagnosis of Cushing's Disease.- 6. Pathogenesis of Cushing's Disease.- 7. Therapy of Cushing's Disease.- 8. Management of Patients Undergoing Ablative Therapy.- 9. Conclusions.- References.- 8 Thyrotropin- and Gonadotropin-Secreting Pituitary Adenomas.- 1. Introduction.- 2. TSH-Secreting Pituitary Adenomas.- 2.1. Primary Hypothyroidism.- 2.2. Primary Hypothalamic-Pituitary Disease.- 2.3. Pituitary Hyperthyroidism ("TSH Toxicosis").- 2.4. Summary.- 3. FSH- and LH-Secreting Pituitary Adenomas.- 3.1. Adenomas Associated with Chronic Hypogonadism.- 3.2. Primary Pituitary Adenomas That Secrete Gonadotropins.- 3.3. Summary.- References.- 9 Nonsecreting Adenomas.- 1. Introduction.- 2. Prevalence.- 3. Presentation.- 4. Differential Diagnosis.- 5. Evaluation.- 6. Therapy.- 7. Summary.- References.- 10 Sellar and Parasellar Lesions Mimicking Adenoma.- 1. Introduction.- 2. Symptoms and Signs of Parasellar and Intrasellar Nonpituitary Lesions.- 3. Radiological Presentation of Intrasellar and Parasellar Nonpituitary Lesions.- 4. Specific Lesions of the Parasellar Region.- 4.1. Craniopharyngioma.- 4.2. Suprasellar and Intrasellar Cysts.- 4.3. Rathke's Cleft Cyst.- 4.4. Arachnoid Cyst.- 4.5. Chordoma.- 4.6. Suprasellar Germinoma (Atypical Teratoma, Ectopic Pinealoma).- 4.7. Dermoid and Epidermoid Tumors.- 4.8. Optic Nerve Glioma.- 4.9. Hypothalamic Glioma.- 4.10. Microglioma.- 4.11. Parasellar Meningioma.- 4.12. Pituitary Metastases.- 5. Miscellaneous Tumors.- 6. Aneurysms.- 7. Pituitary Abscess.- 8. Granulomatous and Infectious Diseases.- 8.1. Tuberculosis.- 8.2. Sarcoid.- 8.3. Histiocytosis X.- 9. Other Infectious Diseases.- 10. Sphenoid Sinus Mucoceles.- 11. Empty Sella.- References.- III. Clinical Evaluation of Pituitary Tumors.- 11 Diagnostic Tests for the Evaluation of Pituitary Tumors.- 1. Introduction.- 2. Regulation of Pituitary Secretion.- 3. Basal Levels of Pituitary Hormones.- 4. Tests of Anterior Pituitary Secretion.- 4.1. Growth Hormone (GH).- 4.2. Prolactin (PRL).- 4.3. Adrenocorticotroph (ACTH).- 4.4. TSH Secretion.- 4.5. Gonadotropin (LH and FSH) Secretion.- 5. Special Tests of Hypothalamic-Pituitary Function.- 5.1. Cerebrospinal Fluid (CSF) Pituitary Hormone Levels.- 5.2. Measurement of Glycoprotein Fragments in Biological Fluids.- 5.3. Sleep EEG Studies.- 5.4. Prednisone-TRH Reserve Test.- 5.5. Cytochemical Bioassays of Polypeptide Hormones.- 5.6. Gel Chromatography and Radioreceptor Assays.- 6. Posterior Pituitary Function.- 7. Summary and Conclusion.- References.- 12 Pituitary Hormone Concentrations in Cerebrospinal Fluid in Patients with Pituitary Tumors.- 1. Introduction.- 2. Factors that Regulate the Presence of Anterior Pituitary Hormones in the Cerebrospinal Fluid.- 2.1. Molecular Weight.- 2.2. Retrograde Transport from Pituitary to Brain.- 2.3. Pituitary Tumors and Cerebrospinal Fluid Secretion.- 2.4. Other Factors That Might Affect Anterior Pituitary Hormones in the Cerebrospinal Fluid.- 3. Functional Role of Anterior Pituitary Hormones in the Cerebrospinal Fluid.- 4. Specific Hormones in the Cerebrospinal Fluid.- 4.1. Growth Hormone.- 4.2. ACTH.- 4.3. Prolactin.- 4.4. Thyroid-Stimulating Hormone.- 4.5. Luteinizing Hormone and Follicle-Stimulating Hormone.- 4.6. ?-Lipotropin and "-Melanocyte-Stimulating Hormone".- 5. Extrapituitary Sources of Pituitary Hormones.- 6. Conclusions.- References.- 13 Ophthalmological Evaluation of Pituitary Adenomas.- 1. Visual Involvement in Pituitary Adenomas.- 2. Visual-Field Testing.- 2.1. Visual Criteria in the Management of Pituitary Adenomas.- 2.2. Visual Evoked Potentials (VEPs).- 3. Chiasmal Syndromes.- 3.1. Relationships of the Chiasm.- 3.2. Axonal Arrangement in the Anterior Visual Pathways.- 4. Patterns of Visual Loss.- 4.1. Bitemporal.- 4.2. Bitemporal Hemianopic Scotomata.- 4.3. Monocular Visual-Field Defects.- 4.4. Binasal Field Loss.- 5. Causes of Bitemporal Hemianopia Other Than Chiasmal Lesions.- 6. Sensory Phenomena Associated with Chiasmal Compression.- 7. Ophthalmoscopy in Pituitary Adenomas.- 8. Ocular Motor Involvement in Pituitary Adenomas.- 8.1. See-Saw Nystagmus.- 9. Pituitary Apoplexy and Its Variants.- 10. Summary.- 11. Appendix: Perimetric Techniques.- 11.1. Color Visual Fields.- References.- 14 The Radiology of Pituitary Adenomas-An Update.- 1. Introduction.- 2. Plain Films of the Sella Turcica.- 3. Tomography of the Sella Turcica.- 4. Radiological Investigation of Patients with Suspected Prolactinomas.- 4.1. Value of Tomography.- 4.2. Value of Computed Tomography.- 4.3. Value of Pneumoencephalography.- 5. Radiological Investigation of Patients with Tumors Other Than Prolactinomas.- 5.1. Value Angiography.- 5.2. Differential Diagnosis of Pituitary Adenomas.- References.- IV. Treatment of Pituitary Tumors.- 15 Medical Therapy of Pituitary Tumors.- 1. Introduction.- 2. Growth Hormone and Acromegaly.- 2.1. Dopamine Agonists.- 2.2. Serotonin Antagonists.- 2.3. Medroxyprogesterone Acetate.- 2.4. Estrogens.- 2.5. Other Agents.- 3. Cushing's Disease.- 3.1. Antiserotonin Agents.- 3.2. Bromocriptine.- 3.3. Adrenolytic Therapy.- 4. Prolactin Hypersecretion.- 4.1. Bromocriptine.- 4.2. Other Drugs.- 5. Conclusions.- References.- 16 General Considerations in the Surgical Treatment of Pituitary Tumors.- 1. Historical Background.- 2. Indications.- 2.1. Nonfunctional Tumors.- 2.2. Functional Tumors.- 2.3. Pituitary Apoplexy.- 2.4. Uncertain Diagnosis.- 2.5. Treatment Failures.- 2.6. Cerebrospinal Fluid Leaks.- 3. Goals of Surgery.- 3.1. Cushing's Disease.- 3.2. Nelson's Disease.- 3.3. Acromegaly.- 3.4. Prolactinomas.- 4. Surgery and Radiation.- 5. Choice of Surgical Approach.- 6. Interpretation of Surgical Results.- 7. Summary.- References.- 17 Anatomical Aspects of the Transseptal Approach to the Sphenoid Sinus.- 1. Introduction.- 2. The External Nose.- 2.1. Cosmetic Analysis.- 2.2. Influence of the Septum.- 3. The Nasal Cavity.- 3.1. Nostril.- 3.2. Valve.- 3.3. Nasal Atrium.- 3.4. Turbinates and Meati.- 3.5. Choana.- 3.6. Physiology of the Normal Nasal Airway.- 4. The Premaxilla.- 4.1. Nasal Spine and Premaxilla.- 4.2. Soft-Tissue Coverings.- 5. The Nasal Septum.- 5.1. Supporting Structures.- 5.2. Mucosa.- 5.3. Submucosal Tunnels.- 6. The Sphenoid Sinus.- 6.1. Rostrum, Floor, Face, and Ostia.- 6.2. Interior of the Sphenoid Sinus.- 6.3. Variations in Pneumatization.- 7. Conclusions.- References.- 18 Transsphenoidal Surgery for Pituitary Tumors.- 1. Introduction.- 2. Technique.- 3. Anatomical Pitfalls.- 3.1. Sphenoid Sinus.- 3.2. Sella Turcica.- 3.3. Intrasellar Contents.- 3.4. Discussion.- 4. Results.- 4.1. Nonfunctional Tumors.- 4.2. Prolactin-Secreting Tumors.- 4.3. ACTH-Secreting Tumors.- 4.4. Growth-Hormone-Secreting Tumors.- 5. Complications.- 6. Summary.- References.- 19 Transfrontal Surgery for Pituitary Tumors.- 1. Introduction.- 2. Anatomical Considerations.- 3. Surgical Techniques.- 4. Results.- 5. Summary.- References.- 20 Endocrine Management after Pituitary Surgery.- 1. Introduction.- 2. Pituitary-Adrenal Function.- 2.1. Postoperative Testing of the Hypothalamic-Pituitary-Adrenal Axis.- 2.2. Management of Chronic Secondary Adrenocortical Insufficiency.- 3. Disorders of Antidiuretic Hormone (ADH) Secretion.- 3.1. Diabetes Insipidus.- 3.2. Syndrome of Inappropriate ADH (SIADH).- 4. Hypothyroidism.- 4.1. Management of Chronic Central Hypothyroidism.- 5. Hypogonadism.- 6. Growth-Hormone Deficiency.- References.- 21 Conventional Radiotherapy and Pituitary Tumors.- 1. Introduction.- 2. Effects of Irradiation on Normal Hypothalamic-Pituitary Function.- 3. Pituitary Adenomas.- 3.1. Managment of Treatment.- 3.2. Radiotherapy.- 3.3. Results of Radiotherapy.- 3.4. Complications of Radiotherapy.- 4. Discussion.- 4.1. Comments on the Therapeutic Approach Based on the Proposed Staging System.- References.- 22 Radiosurgery Therapy for Pituitary Adenoma.- 1. Introduction.- 2. Epidemiology.- 3. Patients and Indications.- 4. "Informed Consent".- 5. "Cost-Effectiveness".- 6. Method.- 7. Procedures.- 7.1. Radiosurgical.- 7.2. Microsurgical.- 8. Results.- 8.1. Acromegaly.- 8.2. Cushing's Disease.- 8.3. Nelson's Syndrome.- 8.4. Prolactinemia.- 8.5. Nonfunctioning Adenomas.- 9. Radiographic Classification.- 10. Malignancy.- 11. Summary.- References.- 23 Overview of Pituitary Tumor Treatment.- 1. Introduction.- 2. Large Nonfunctioning Tumors.- 2.1. Radiation Treatment of Large Pituitary Tumors.- 2.2. Surgical Treatment of Large Pituitary Tumors.- 2.3. Considerations in the Choice of Therapy for Large Tumors.- 3. Acromegaly.- 3.1. Medical Treatment of Acromegaly.- 3.2. Radiation Treatment of Acromegaly.- 3.3. Surgical Treatment of Acromegaly.- 3.4. Considerations in the Choice of Therapy for Acromegaly.- 4. Prolactinomas.- 4.1. Medical Treatment of Prolactinomas.- 4.2. Radiation Treatment of Prolactinomas.- 4.3. Surgical Treatment of Prolactinomas.- 4.4. Considerations in the Choice of Therapy for Prolactinomas.- 5. Cushing's Disease.- 5.1. Medical Treatment of Cushing's Disease.- 5.2. Radiation Treatment of Cushing's Disease.- 5.3. Surgical Treatment of Cushing's Disease.- 5.4. Considerations in the Choice of Therapy for Cushing's Disease.- 6. Miscellaneous Tumors and Lesions.- 7. Summary.- References.
