Literature

Clinical Pearls & Morning Reports


By Carla Rothaus

Published March 4, 2020

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What are some of the clinical features of acromegaly? 

Pituitary adenomas account for approximately 15% of intracranial tumors. Read the NEJM Review Article here.

Clinical Pearls

Q: What is the most common secretory tumor of the pituitary?

A: Prolactinomas are the most common secretory tumor, accounting for up to 60% of all pituitary adenomas and more than 75% of pituitary adenomas in women. Microprolactinomas, which have a female:male ratio of 20:1, are usually stable and slow-growing, with continued growth after diagnosis in less than 15% of cases.

Q: Are all types of prolactinomas more common in women than in men?

A: Most patients with a pituitary mass and a serum prolactin level exceeding 150 ng per milliliter (reference range, <20) are found to have a prolactinoma. A prolactin level of more than 250 ng per milliliter is usually diagnostic of a macroprolactinoma, and the tumor mass usually correlates with the serum prolactin level. Large prolactinomas (>10 mm in diameter) that are aggressive account for less than 5% of tumors and are characterized by very high prolactin levels (>1000 ng per milliliter) and a male:female ratio of 9:1. In a study involving 45 men and 51 women with prolactinomas, the tumors in the men were larger than those in the women (mean [±SD] diameter 26±2 mm vs. 10±1 mm) and grew more aggressively, with a mean serum prolactin level of 2789±572 ng per milliliter in men versus 292±74 ng per milliliter in women.

Morning Report Questions

Q: What are some of the clinical features of acromegaly?

A: Approximately 70% of patients with acromegaly have an invasive macroadenoma at diagnosis. Coexisting conditions include headache and insidious acral and soft-tissue changes. The diagnosis of acromegaly can be delayed by a mean of approximately 10 years after the onset of symptoms. Patients may first seek dental, orthopedic, rheumatologic, or cardiac care. In one study, approximately 20% of 324 patients sought care because of an altered facial appearance, enlarged extremities, or both. Other features include increased shoe or ring size, voice deepening, the carpal tunnel syndrome, hyperhidrosis, and frontal-skull bossing and coarse oily skin. Prognathism leads to incisor separation and jaw malocclusion. Obstructive sleep apnea and excessive snoring are hallmarks of uncontrolled acromegaly. Arthropathy is reported in approximately 70% of patients, with polyarticular arthritis, osteophytosis, dorsal kyphosis, and vertebral fractures. Coexisting cardiovascular conditions include hypertension, arrhythmias, and left ventricular dysfunction, with an increased aortic-root diameter.

Q: What is the recommended initial therapy for Cushing’s disease caused by a corticotropin-secreting corticotroph adenoma?

A: Selective transsphenoidal adenomectomy is recommended as initial therapy for Cushing’s disease, with remission achieved in approximately 75% of patients and recurrence seen in approximately 10%. Although more radical surgery offers the potential for total adenoma resection, complication rates are higher and pituitary damage is more likely with total resection. Radiation therapy may control the disease, but the efficacy of this treatment is delayed for several years, and approximately 30% of patients have a relapse. Adrenalectomy may immediately reverse hypercortisolism. However, lifelong replacement of adrenal hormones is challenging. Adrenal-targeted medical therapy may offer clinical and biochemical improvement, but most studies of such treatment have not been rigorously controlled, and the results are often inconsistent.

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