Study of management strategies in ACTH secreting pituitary microadenoma of Cushing disease

Background: Pituitary Microadenomas can be defined as small lesions less than 1 cm in the pituitary and detected as incidentalomas. Partial development or late development around puberty leads to maldevelopment of secondary sexual characteristics due to pituitary adenomas. Clinically this may manifest as secondary amenorrhoea and may lead to hyperprolactinaemia, galactorrhoea and Amenorrhoea. ACTH secreting micro adenomas of the Pituitary Gland is a clinical entity where the role of surgery is contemplated. This study attempted to explore the management options and strategies for pituitary microadenomas. The aim of the study: To highlight the characteristics of Cushing’s disease and discuss the management strategies including trans-sphenoidal surgery to treat ACTH secreting pituitary microadenomas. Materials and methods: This was a non-randomised prospective observational study involving all adrenal tumors from 2007-2017 in Madras Medical College, Chennai. Two adrenocortical adenomas M.S. Senthil Kumar, Rajan Ganesan, A. Nithyanandham, V. Kannan, T. Suresh Babu, K. Prabhakaran. Study of management strategies in ACTH secreting pituitary microadenoma of Cushing’s disease. IAIM, 2019; 6(3): 253-258. Page 254 with virilising features were ruled out and 8 ACTH secreting Cushing's disease with microadenomas were identified. 3 Patients with ACTH secreting microadenomas of Cushing's disease underwent surgery whereas 3 underwent medical treatment based on which this paper attempted to discuss management strategies for Cushings disease. Results: ACTH levels were measurable with an average of 136.71pg/ml (normal 7.2-63.3 pg/ml) Corticotrophin releasing hormone test was planned to evaluate an exaggerated response of serum cortisol consistent with pituitary disease. It was not carried out and inferior petrosal sampling also was not done. Biochemical evaluation confirmed pituitary dependent Cushing’s disease. MRI revealed a prominent circumscribed lesion suggestive of a Pituitary Micro Adenoma in All 6 Cases. Conclusion: Pituitary micro adenomas are operable and in Cushing’s disease offer an effective cure. The outcome is good with minimal complications, but surgeons must have a thorough knowledge of the surrounding anatomy and potential complications.

A patient with Cushing disease lateralizing a pituitary adenoma by inferior petrosal sinus sampling using desmopressin: a case report

A 14-year-old girl was referred for evaluation of the etiology of Cushing syndrome. During the previous 2 years, she had experienced weight gain, secondary amenorrhea, growth retardation, and back pain. Random serum cortisol level, 24-hour urinary free cortisol excretion, and overnight and low-dose dexamethasone suppression tests suggested Cushing syndrome. Midnight adrenocorticotropic hormone (ACTH) level and high-dose dexamethasone suppression test confirmed Cushing disease. Pituitary magnetic resonance imaging was suspicious for microadenoma. To eliminate ectopic ACTH syndrome, and lateralize the pituitary tumor, inferior petrosal sinus sampling (IPSS) was performed by desmopressin use to stimulate ACTH. Finally, the patient was diagnosed with Cushing disease due to ACTH-secreting pituitary microadenoma, lateralized to the left side; subsequently underwent transsphenoidal surgery. Here we report a case of a 14-year-old girl diagnosed with Cushing disease with a pituitary tumor lateralized by IPSS using desmopressin, which is very rare in pediatric Cushing disease.

A TSH-secreting pituitary microadenoma diagnosed with inferior petrosal sinus sampling: Case report / 대한내과학회지

Thyroid stimulating hormone (TSH)-secreting pituitary adenomas are rare tumors of the pituitary gland and represent 1~2% of all pituitary adenomas. A TSH-secreting pituitary adenoma shows as a normal or elevated thyrotropin level in a hyperthyroid patient. We present a 32-year-old woman who was diagnosed with a TSH-secreting pituitary microadenoma. She had a high free T4, with a normal TSH and alpha-subunit. Bilateral inferior petrosal sinus sampling (IPSS) was done to confirm the alpha-subunit secreting adenoma, and the concentration of the alpha-subunit was high on the tumor side. The pituitary microadenoma was removed, and her TSH and free T4 levels decreased to normal. IPSS may help give an accurate diagnosis in the patient with a normal alpha-subunit.

Diagnostic Value of Magnetic Resonance Imaging Examination for Pituitary Hypertension Complicated with Pituitary Microadenoma / 广州中医药大学学报

Objective To investigate the relationship between the secondary hypertension and pituitary microadenoma,and to explore the diagnostic value of magnetic resonance imaging(MRI) examination for pituitary microadenoma.Methods We analyzed the clinical information,laboratory examination results and imaging data in 21 hypertension patients complicated with pituitary microadenoma.Results The manifestations of the 21 patients were as follows:(1) The onset of hypertension was in young age,complicated with headache;(2) The results of 24-hour ambulatory blood pressure monitor(24h ABPM) showed the disappearance of circadian rhythm of blood pressure,and obvious increase of systolic/diastolic blood pressure;(3) The antihypertensive effect of antihypertensive drugs was not satisfactory;(4) Of adenohypophyseal hormones,adrenocorticotrophic hormone(ACTH) level in most patients and prolactin(PRL) level in a few patients were higher than the normal level,and the other hormones levels were normal;(5) The results of MRI examination presented adrenal cortical hyperplasia,adrenal adenoma and chromaffin tumor in some patients.(6) The results of MRI examination showed pituitary microadenoma in all of the patients.Conclusion For those middle-aged and young hypertension patients on whom antihypertensive effect of drugs is poor,MRI examination for adrenal gland and pituitary gland should be taken as the routine examination.MRI examination is the optimal imaging method for pituitary microadenoma,and supply evidence for the syndrome differentiation and treatment of pituitary microadenoma.

The Results of Transsphenoidal Microsurgery for Pituitary Microadenama in Cushing's Disease / 대한내과학회지

BACKGROUND: Cushing's disease is a hypercortisolic state attributable to hypersecretion of ACTH at pituitary gland Most of these diseases are due to pituitary microadenoma. Selective removal of adenoma by transsphenoidal microsurgery is the treatment of choice for Cushing's disease. We evaluated 25 cases to analyze results of transsphenoidal microsurgery and to identify prognostic factors that may predict successful outcome. METHODS: From 1989 to 1995, 25 patients were diagnosed as having Cushing's disease in Seoul National University Hospital. They were underwent pituitary microsurgery and confirmed to have pituitary microadenoma radiologically and pathologically. About these patients. retrospective evaluation was done. RESULTS: The patients consist of 21 females and 4 males and the age was ranged from 23 to 49 years. 19 patients (76%) were judged as immediate remission. The preoperative clinical, hormonal, and radiological characteristics of the remission and failure groups were similiar The patients who were immediate remission were followed from 3 months to 72 months. 3 patients had recurrences(15.8%) at 4, 8, 49 months after operation. The pre and postoperative clinical, hormonal, and radiological characteristics of the long-term remission and recurrence groups were similiar. We could not find any predictable factors of surgical outcome. CONCLUSION: The first line trearment of Cushing's disease is transsphenoidal microsurgery. However considering relative late and high rate of recurrence of Cushing's disease following curative surgery, careful longterm follow up is mandatory.

A Case of True Precocious Puberty Associated with Pituitary Microadenoma Treated with LHRH Agonist / 대한내분비학회지

Recently Brain CT and MRI have greatly contributed to the discovery of intracranial tumors including cysts which cause precocious puberty. Among many precocious pubetry patients that had previously been diagnosed as idopathic, a number of cases turn out the true precocious puberty caused by intracranial lesion.Authors experienced a case of true precocious puberty in a seven year old female whose vaginal bleeding appeared at age of five and she also had breast enlargement on admission. Pituitary microadenoma was found on her brain MRI and the microadenoma turned to be nonfunctional on hormonal tests.Following three does of decapety1-CR(LHRH Agonist), the vaginal bleeding was ceased and the deceleration of breast enlargement was noted. Her growth velocity was also affected but the further observation for final height would be warranted.

Thyrotropin-secreting pituitary microadenoma

We present a 45-yr-old male with clinical signs and symptoms of mild hyperthyroidism, high serum levels of T3, T4, and FT4 as well as serum TSH concentration. The elevated alpha-subunit level and alpha-subunit/TSH molar ratio were also observed. These findings indicated the presence of hyperthyroidism due to inappropriate secretion of TSH, whose neoplastic origin was documented by nuclear magnetic resonance scan showing a 0. 6 cm pituitary adenoma. Selective pituitary adenomectomy was completely successful; alpha-subunit, TSH, T3, T 4, and FT4 normalized, and euthyroidism was restored. Light microscopic immunohistochemistry showed that the adenoma was composed of TSH-secreting cells

A Case of Persistent Cushing's Syndrome

A case of persistent Cushing's syndrome in a 25 year-old male is presented. Inspite of bilateral total adrenalectomy twice during two years, there was no clinical improvement. Adrenal scanning revealed no adrenal remnants. ACTH secreting pituitary microadenoma is demonstrated by computed tomographic brain scan and hormonal studies. Selective transsphenoidal microadenomectomy results in clinical and endocrinological improvement.

A Case of Persistent Cushing's Syndrome

A case of persistent Cushing's syndrome in a 25 year-old male is presented. Inspite of bilateral total adrenalectomy twice during two years, there was no clinical improvement. Adrenal scanning revealed no adrenal remnants. ACTH secreting pituitary microadenoma is demonstrated by computed tomographic brain scan and hormonal studies. Selective transsphenoidal microadenomectomy results in clinical and endocrinological improvement.