Christine G. Yedinak

Significant headache improvement after transsphenoidal surgery in patients with small sellar lesions.

OBJECT Pituitary adenomas represent a large proportion of brain tumors that are increasing in incidence because of improved imaging techniques. Headache is the primary symptom in patients with large tumors (macroadenomas), but is also a symptom in patients with small tumors (microadenomas, tumors < 1.0 cm). The prevalence and optimal treatment of headaches associated with pituitary tumors is still unclear, particularly in cases of microadenoma. If conventional medical management fails, transsphenoidal surgery (TSS) may be considered as an alternative treatment for intractable headaches. METHODS The authors conducted a retrospective review of 512 patients who underwent TSS at Oregon Health & Science University between 2001 and 2007; patients with Cushing disease were excluded. The authors identified 41 patients with small pituitary tumors who underwent TSS, and retrospectively evaluated the resolution and/or treatment of headache. RESULTS Ninety percent of patients who presented with nonfunctioning microadenomas and Rathke cleft cysts experienced resolution or improvement in their headaches after TSS, and 56% of patients who presented with hyperfunctioning pituitary microadenomas had improvement in their headaches. There were no postoperative complications. CONCLUSIONS In this retrospective study, the authors demonstrate the efficacy of TSS in the treatment of intractable headaches in patients who present with pituitary microadenomas (nonsecreting and hypersecretory) and Rathke cleft cysts.

Polycystic ovarian syndrome and Cushing's syndrome: a persistent diagnostic quandary

OBJECTIVE To retrospectively review institutional records of female patients of reproductive age with Cushings disease (CD) and determine if and how many had been previously diagnosed as having solely polycystic ovarian syndrome (PCOS). To determine whether clinical patterns might be useful in identifying appropriate candidates for hypercortisolism screening in women suspected of PCOS. STUDY DESIGN The study included 50 patients with pathologically proven CD at Oregon Health & Science University, Northwest Pituitary Center between 2006 and 2011. Physical, clinical, and biochemical features for hypercortisolism were compared. RESULTS Of 50 patients with pathologically proven CD, 26 were women of reproductive age. Of these, half had previously been diagnosed with and treated initially solely for PCOS. Hirsutism and menstrual abnormalities were more common in the group with an initial PCOS diagnosis than in the group with an initial CD diagnosis. CONCLUSIONS Prolonged exposure to hypercortisolism has been linked with increased mortality and morbidity. Tests for hypercortisolism in all the PCOS cases we report led to an appropriate CD diagnosis. Future research should focus on when and which (if not all) women with suspected PCOS should be tested for hypercortisolism.

High prevalence of adrenal insufficiency at diagnosis and headache recovery in surgically resected Rathke’s cleft cysts—a large retrospective single center study

BackgroundRathke’s cleft cysts (RCC) are lesions that arise from Rathke’s pouch. Though frequently incidental, resulting symptoms in a minority of cases are indicators for surgical resection, which may prove beneficial.ObjectiveTo characterize a cohort of surgically-resected RCC cases at Oregon Health & Science University; tabulate associated hormonal imbalances and symptoms, possible symptom reversal with surgery, determine recurrence risk; identify predictors of recurrence and headache improvement.MethodElectronic records of all RCC resected cases (from 2006–2016; 11 years) were retrospectively reviewed. Patients had been evaluated by one neuroendocrinologist using a uniform protocol.ResultsA pathological RCC diagnosis was established in 73 of 814 (9%) surgical pituitary cases. The RCC cohort was 77% (n = 56/73) female, mean age was 39.5 ± 14.9 years at first surgery, and at presentation headache was reported in 88% and visual defects/diplopia in 18% of patients. Initial RCC maximum diameter was 1.3 ± 0.7 cm. The most frequent hormonal deficit was cortisol; 24% of patients had a new adrenal insufficiency (AI) diagnosis, however, 36% also had AI at 3 months post-operatively. Mean follow up was 4.0 ± 4.5 years. Two-thirds of patients (41/62) had headache improvement 3 months post-operatively. Post-operative imaging revealed no residual cyst in 58% (38/65). In those patients with no residual RCC, 29% had recurrence and 71% had long lasting cure. From the 42% (27/65) of patients with residual cyst on post-operative imaging; 59% (16/27) remained stable, 26% (7/27) progressed and 15% (4/27) regressed.ConclusionSymptomatic RCC present mostly in women, with a high proportion reporting headaches. Prevalence of AI at diagnosis is high. Surgery may not achieve adrenal axis recovery, but renders a high percentage of headache improvement. Approximately 25% of RCC will recur by 4 years postoperatively. Clinicians should cautiously screen patients with symptomatic RCC, regardless of lesion size for AI.

Dopamine agonist therapy induces significant recovery of HPA axis function in prolactinomas independent of tumor size: a large single center experience

AbstractOur objective was to compare prevalence and rates of recovery of hypothalamic–pituitary–adrenal axis dysfunction in prolactinoma patients before and after dopamine agonist therapy with nonfunctioning pituitary adenoma patients pre-transsphenoidal and post-transsphenoidal surgery. We retrospectively compared hypothalamic–pituitary–adrenal axis function in patients with prolactinomas naïve to dopamine agonist therapy with a cohort of nonfunctioning pituitary adenoma patients matched for gender and tumor size by classification (n = 57; 30 male/27 female; 27 microadenoma/30 macroadenoma). Patients with <52 weeks follow up, previous medical therapy, surgery, or radiation therapy were excluded. At baseline, there was no difference between groups for age, mean tumor size, or prevalence of adrenal insufficiency. Recovery from baseline adrenal insufficiency was demonstrated in patients with microprolactinomas and macroprolactinomas at a 52 week follow up (p  = 0.003 and p  = 0.004). These rates were similar to nonfunctioning pituitary adenoma patients after surgery. We show, in a large uniform study, that adrenal insufficiency significantly recovered after dopamine agonist treatment, independent of tumor size and gender in patients with prolactinomas naïve to therapy.

Idiopathic Granulomatous Hypophysitis Masquerading as a Pituitary Adenoma: Are There Reliable Diagnostic Criteria?

To review the clinical presentation of granulomatous hypophysitis (GrH) masquerading as a pituitary macroadenoma. To discuss the differential diagnosis of hypophysitis. To understand treatment options for GrH at initial presentation and recommendations for long-term management.

Acromegaly, Awareness Is Paramount for Early Diagnosis: Highlights of Diagnosis and Treatment Challenges

To highlight clinical features of acromegaly at presentation, to facilitate early diagnosis. To review the multi-modal approach in the management of acromegaly: surgical indications and medical treatment.

A Nontraumatic Hip Fracture in a Young Woman: Cushing’s Disease—Consequences of a Late Diagnosis and Treatment Highlights

To describe the late diagnosis of hypercortisolemia and associated severe clinical complications. To review the multimodal approach in the management of Cushing’s disease after failed transsphenoidal surgery: surgical re-exploration and the role of medical treatment.