Correlation between Pituitary Insufficiency and Magnetic Resonance Imaging Finding in Non-Functioning Pituitary Adenomas

Hyun Min Kim; Cheol Ryong Ku; Eun Young Lee; Woo Kyung Lee; Jung Soo Lim; Sena Hwang; Mi Jung Lee; Seung Ku Lee; Sun Ho Kim; Eun Jig Lee

doi:10.3803/EnM.2010.25.4.310

Journal List > Endocrinol Metab > v.25(4) > 1085846

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Kim, Ku, Lee, Lee, Lim, Hwang, Lee, Lee, Kim, and Lee: Correlation between Pituitary Insufficiency and Magnetic Resonance Imaging Finding in Non-Functioning Pituitary Adenomas

Original Article

Endocrinol Metab 2010;25(4):310-315.

Published online: 12 December 2010

DOI: https://doi.org/10.3803/EnM.2010.25.4.310

Correlation between Pituitary Insufficiency and Magnetic Resonance Imaging Finding in Non-Functioning Pituitary Adenomas

Hyun Min Kim¹, Cheol Ryong Ku¹, Eun Young Lee¹, Woo Kyung Lee¹, Jung Soo Lim¹, Sena Hwang¹, Mi Jung Lee¹, Seung Ku Lee⁴, Sun Ho Kim^2,^3,⁵, Eun Jig Lee^1,^2,³

^¹Department of Endocrinology, Yonsei University College of Medicine, Seoul, Korea

^²Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea

^³Pituitary Tumor Clinic, Yonsei University College of Medicine, Seoul, Korea

^⁴Departments of Radiology, Yonsei University College of Medicine, Seoul, Korea

^⁵Neurosurgery, Yonsei University College of Medicine, Seoul, Korea

Corresponding author: Eun Jig Lee Department of Endocrinology, Yonsei University College of Medicine 262 Seongsan-no, Seodaemun-gu, Seoul 120-752, Korea Tel: +82-2-2228-1983, Fax: +82-2-393-6884, E-mail: ejlee423@yuhs.ac

Received 25 June 2010 Accepted 12 September 2010

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Non-functioning pituitary adenomas (NFPAs) are characterized by the absence of clinical and biochemical evidence of pituitary hormone hypersecretion, and these tumors constitute approximately one third of all the tumors of the anterior pituitary. Recently, hormonal deficiencies have gradually evolved to become the leading presenting signs and symptoms in patients with NF-PAs. We investigated pituitary hormonal insufficiencies according to the magnetic resonance imaging (MRI) findings in patients with NFPA.

Methods

We evaluated the patients who were newly diagnosed with NFPA from 1997 through 2009. Among them, we analyzed 387 patients who were tested for their combined pituitary function and who underwent MRI. The severity of the hypopituitarism was determined by the number of deficient axes of the pituitary hormones. On the MRI study, the maximal diameter of the tumor, Hardy's classification, the thickness of the pituitary gland and the presence of stalk compression were evaluated.

Results

The mean age was 46.85 ± 12.93 years (range: 15–86) and 186 patients (48.1%) were male. As assessed on MRI, the tumor diameter was 27.87 ± 9.93 mm, the thickness of the normal pituitary gland was 1.42 ± 2.07 mm and stalk compression was observed in 201 patients (51.9%). Hypopituitarism was observed in 333 patients (86.0%). Deficiency for each pituitary hormone was most severe in the patients with Hardy type IIIA. Hypopituitarism was severe in the older age patients (P = 0.001) and the patients with a bigger tumor size (P < 0.001) and the presence of stalk compression (P < 0.001). However, the patients who had a thicker pituitary gland showed less severe hypopituitarism (P < 0.001). Multivariate analysis showed that age, tumor diameter and the thickness of pituitary gland were important determinants for pituitary deficiency (P = 0.004, P < 0.001, P = 0.022, respectively).

Conclusion

The results suggest that the hormonal deficiencies in patient with NFPA were correlated with the MRI findings, and especially the tumor diameter and preservation of the pituitary gland.

Go to :

Keywords: Non-functioning pituitary adenomas, Hypopituitarism, Magnetic resonance imaging

References

1. Asa SL, Ezzat S. The pathogenesis of pituitary tumours. Nat Rev Cancer. 2:836–849. 2002.

2. Cheol Ryong Ku, Eun Jig Lee. Treatment and prognosis of nonfunctioning pituitary adenomas. Asia-Pacific Journal of Endocrinology, Epub,. 2010.

3. Cury ML, Fernandes JC, Machado HR, Elias LL, Moreira AC, Castro M. Non-functioning pituitary adenomas: clinical feature, laboratorial and imaging assessment, therapeutic management and outcome. Arq Bras Endocrinol Metabol. 53:31–39. 2009.

4. Milker-Zabel S, Debus J, Thilmann C, Schlegel W, Wannenmacher M. Fractionated stereotactically guided radiotherapy and radiosurgery in the treatment of functional and nonfunctional adenomas of the pituitary gland. Int J Radiat Oncol Biol Phys. 50:1279–1286. 2001.

5. Nomikos P, Ladar C, Fahlbusch R, Buchfelder M. Impact of primary surgery on pituitary function in patients with non-functioning pituitary ade-nomas – a study on 721 patients. Acta Neurochir (Wien). 146:27–35. 2004.

6. Lee EJ, Ahn JY, Noh T, Kim SH, Kim TS, Kim SH. Tumor tissue identification in the pseudocapsule of pituitary adenoma: should the pseudocapsule be removed for total resection of pituitary adenoma? Neurosurgery. 64:62–69. 2009.

7. Melmed S, Kleinberg D. Anterior pituitary. In: Kronenberg H, Williams RH eds. Williams textbook of endocrinology. 11th ed. pp.240–242. Philadelphia, Elsevier Saunders,. 2008.

8. Melmed S, Jameson JL. Disorders of the anterior pituitary and hypothalamus. In: Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J eds. Harrison's principles of internal medicine. 17th ed. pp.2195–2216. New York, McGraw-Hill Medical,. 2008.

9. Mohr G, Hardy J, Comtois R, Beauregard H. Surgical management of giant pituitary adenomas. Can J Neurol Sci. 17:62–66. 1990.

10. Lee SC, Senior BA. Endoscopic skull base surgery. Clin Exp Otorhinolaryngol. 1:53–62. 2008.

11. Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM. Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg. 108:715–728. 2008.

12. Kassam AB, Prevedello DM, Thomas A, Gardner P, Mintz A, Snyderman C, Carrau R. Endoscopic endonasal pituitary transposition for a transdor-sum sellae approach to the interpeduncular cistern. Neurosurgery. 62:57–72. 2008.

13. Kato K, Saeki N, Yamaura A. Morphological changes on MR imaging of the normal pituitary gland related to age and sex: main emphasis on pu-bescent females. J Clin Neurosci. 9:53–56. 2002.

14. Arafah BM, Kailani SH, Nekl KE, Gold RS, Selman WR. Immediate recovery of pituitary function after transsphenoidal resection of pituitary macroadenomas. J Clin Endocrinol Metab. 79:348–354. 1994.

15. Arafah BM. Reversible hypopituitarism in patients with large nonfunctioning pituitary adenomas. J Clin Endocrinol Metab. 62:1173–1179. 1986.

16. Arafah BM, Prunty D, Ybarra J, Hlavin ML, Selman WR. The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headaches in patients with pituitary adenomas. J Clin Endocrinol Metab. 85:1789–1793. 2000.

17. Wichers-Rother M, Hoven S, Kristof RA, Bliesener N, Stoffel-Wagner B. Non-functioning pituitary adenomas: endocrinological and clinical outcome after transsphenoidal and transcranial surgery. Exp Clin Endocrinol Diabetes. 112:323–327. 2004s.

18. Dekkers OM, Pereira AM, Roelfsema F, Voormolen JH, Neelis KJ, Schroi-jen MA, Smit JW, Romijn JA. Observation alone after transsphenoidal surgery for nonfunctioning pituitary macroadenoma. J Clin Endocrinol Metab. 91:1796–1801. 2006.

19. Dekkers OM, Pereira AM, Romijn JA. Treatment and follow-up of clinically nonfunctioning pituitary macroadenomas. J Clin Endocrinol Metab. 93:3717–3726. 2008.

20. Karavitaki N, Thanabalasingham G, Shore HC, Trifanescu R, Ansorge O, Meston N, Turner HE, Wass JA. Do the limits of serum prolactin in dis-connection hyperprolactinaemia need re-definition? A study of 226 patients with histologically verified non-functioning pituitary macroadenoma. Clin Endocrinol (Oxf). 65:524–529. 2006.

21. Bevan JS, Burke CW, Esiri MM, Adams CB. Misinterpretation of prolactin levels leading to management errors in patients with sellar enlargement. Am J Med. 82:29–32. 1987.

22. Korbonits M, Carlsen E. Recent clinical and pathophysiological advances in non-functioning pituitary adenomas. Horm Res. 71:123–130. 2009.

Go to :

Fig. 1.

Measurement of the tumor size as a maximal diameter in coronal plane.

undefined

Fig. 2.

(A) An example case of normal stalk morphology. (B) An example case of stalk deviation; The stalk attachment of the pituitary gland deviated from the midline to the right side (dotted line). (C) An example case of stalk compression; Normal stalk morphology are not seen.

undefined

Fig. 3.

Measurement sites of the pituitary gland. (A) Maximal height were measured in coronal plane. (B) Maximal height were measured in sagittal plane.

undefined

Table 1.

Interpretation of combined pituitary function test

Test	Blood sampling (min)	Hormone	Normal response
Insulin tolerance test	0, 30, 60, 90, 120	GH	Peak GH > 3 ng/mL
(RI, 0.1 U/kg i.v.)		Cortisol	Peak cortisol > 180 ng/mL or increase by 70 ng/mL
		ACTH	Response decision by cortisol response
TRH stimulation test	0, 15, 30, 60, 120	PRL	2 ng/mL < baseline PRL < 15 ng/mL, and peak PRL > 200% of baseline
(500 μ g i.v.)		TSH	Peak TSH > basal TSH + 5 μ IU/mL and free thyroxine in normal range
LHRH stimulation test	0, 15, 30, 60, 120	FSH	Peak FSH > basal FSH + 2 mIU/mL, elevated baseline in postmenopausal women
(100 μ g i.v.)		LH	Peak LH > basal LH + 10 mIU/mL, elevated baseline in postmenopausal women

Nadir glucose should be less than 40 mg/dL in nondiabetics or less than 50% of basal level in diabetics for appropriate stress induction. GH, growth hormone; ACTH, adrenocorticotropic hormone; i.v., intravenously; PRL, prolactin; TSH, thyroid-stimulating hormone; TRH, thyrotropin-releasing hormone; FSH, follicle-stimulating hormone; LH, luteinizing hormone; LHRH, luteinizing hormone-releasing hormone; RI, regular insulin.

Table 2.

Baseline characteristics of 387 patients

Characteristics	Value
No. of patients	387
Mean age (years)	46.85 ± 12.93 (15–86)
Male (%)	186 (48.1%)
Pituitary function
Pituitary insufficiency (%)	333 (86.0%)
GH	273 (70.5%)
LH/FSH	242 (62.5%)
ACTH	184 (47.5%)
TSH	182 (47.0%)
PRL	76 (19.6%)
Hyperprolactinemia	188 (48.6%)
MRI findings
Tumor diameter (mm)	27.87 ± 9.93 (5.35–60.31)
Thickness of pituitary gland (mm)	1.42 ± 2.07 (0–11.68)
Presence of stalk compression (%)
Normal stalk morphology	40 (10.3%)
Stalk deviation	146 (37.7%)
Stalk compression	201 (51.9%)
Hardy's classification (%)
I	21 (5.4%)
II	58 (15.0%)
IIIA	101 (26.1%)
IIIB	153 (39.5%)
IV	54 (14.0%)

GH, growth hormone; FSH, follicle-stimulating hormone; LH, luteinizing hormone; ACTH, adrenocorticotropic hormone; TSH, thyroid-stimulating hormone; PRL, prolactin.

Table 3.

Pituitary insufficiency in different age groups

Age	Number of patients	Number of deficient hormone
< 20	4	1.75 ± 2.06
20 – 29	44	1.93 ± 1.60
30 – 39	66	2.33 ± 1.53
40 – 49	101	2.29 ± 1.46
50 – 59	107	2.69 ± 1.53
60 – 69	52	2.73 ± 1.49
≥ 70	13	3.85 ± 1.57^*

^* P < 0.05, P values were calculated by one-way ANOVA.

Table 4.

Pituitary Insufficiency depending on Tumor Size and Hardy's Classification

		Number of patients	Number of deficient hormone
Tumor size	< 10 mm	9	0.44 ± 0.52
	10 – 20 mm	72	1.35 ± 1.42
	20 – 30 mm	154	2.51 ± 1.53^**
	30 – 40 mm	101	3.03 ± 1.29^**
	40 – 50 mm	42	3.12 ± 1.23^**
	≥ 50 mm	9	3.56 ± 1.33^**
Hardy's classification	I II IIIA	21 58 101	1.19 ± 1.60 1.74 ± 1.58 2.88 ± 1.43^**
	IIIB	153	2.65 ± 1.51^**
	IV	54	2.48 ± 1.35^*

^* P < 0.05,

^** P < 0.001, P values were calculated by one-way ANOVA.

Table 5.

Pituitary insufficiency depending on pituitary gland thickness an stalk morphology

		Number of patients	Number of deficient hormone
Thickness of	≥ 5 mm	29	1.21 ± 1.55
pituitary gland	< 5 mm	120	2.11 ± 1.57^*
	Not seen	238	2.81 ± 1.45^*
Presence of stalk	Normal stalk	40	1.18 ± 1.41
compression	Stalk deviation	146	2.29 ± 1.59^*
	Stalk compression	201	2.87 ± 1.38^*

^* P < 0.001, P values were calculated by one-way ANOVA.

Table 6.

Multiple linear regression for variables independently associated with impaired pituitary function

Variable	Number of deficient hormone
Variable	Coefficient	P-value
Age (years)	0.016	0.004
Tumor size (mm)	0.045	< 0.001
Thickness of pituitary gland (mm)	–0.108	0.022
Presence of stalk compression	0.167	0.288
Hardy's classification	–0.118	0.149

TOOLS

Similar articles