Pituitary Tumors: A Comprehensive and Interdisciplinary Approach

Description

Pituitary Tumors: A Comprehensive and Interdisciplinary Approach provides the latest information on preclinical issues, diagnostic procedures, treatment options and post-treatment care for patients with pituitary tumors. The book includes basic and advanced knowledge for a broad audience, including physicians, endocrinologists, neurosurgeons, neuro-radiologists, neuro-ophthalmologists, neuro-pathologists, oncologists, radiotherapists and researchers who are investigating pituitary tumors. Readers will find the latest research surrounding progress on uncoding the molecular mechanisms involved in tumor genesis. In addition, standard treatment modalities, including surgery, medical treatment and radiosurgery are explored. Front Cover Pituitary Tumors: A Comprehensive and Interdisciplinary Approach Copyright Contents Contributors About the editors Foreword Preface Section I: Preclinical essentials Chapter 1: Physiology of pituitary hormones Introduction Hypothalamic-pituitary-adrenal axis Corticotropin-releasing hormone Proopiomelanocortin Adrenocorticotropic hormone Alpha-melanocyte stimulating hormone Gonadotropic axis Gonadotropin-releasing hormone Glycoprotein hormones Gonadotropins Luteinizing hormone Follicle-stimulating hormone Somatotropic axis Growth hormone-releasing hormone Ghrelin Somatostatin Growth hormone Insulin-like growth factors Thyrotropic axis Thyrotropin-releasing hormone Thyroid-stimulating hormone Lactotropic axis Prolactin Dopamine Hormones of the posterior pituitary Antidiuretic hormone Oxytocin Key points References Chapter 2: Principles of laboratory investigation for pituitary hormones Preanalytical aspects Patient-related factors Technical factors related to sampling Analytical aspects Analytical techniques (immunoassays and mass spectrometry) Standardization and harmonization of hormone measurements Quality control for hormone measurements Pitfalls Cross-reactions Interference by antibodies present in a sample Human antianimal antibodies Heterophilic antibodies Interference from biotin High-dose hook effect Complex formation Postanalytical aspects (interpretation) Reference intervals Confounders Key points References Chapter 3: Pathophysiology and genetics in pituitary tumors Introduction Pathophysiology Hypothalamic regulation Growth hormone-releasing hormone (GHRH) Corticotrophin-releasing hormone (CRH) Thyrotropin-releasing hormone (TRH) Gonadotrophin-releasing hormone (GnRH) Dopamine Somatostatin Peripheral negative feedback Glucocorticoids (GC) Thyroid hormones Sex hormones Genetics of pituitary tumorigenesis Pituitary tumors in syndromes McCune-Albright Carney complex MEN1 MEN2 MEN4 3PAs syndrome Familial-isolated pituitary adenomas (FIPA)-AIP X-linked acrogigantism (X-LAG) Other syndromes Sporadic pituitary tumors GNAS TP53 USP8 USP48 Other Conclusion Key points References Chapter 4: Pathophysiology and genetics in craniopharyngioma Introduction Genetic alterations in craniopharyngioma CTNNB1 mutations in ACP p.BRAF-V600E mutations in PCP Other genetic and epigenetic aberrations in craniopharyngioma Preclinical models of craniopharyngioma Genetically engineered mouse models of ACP Patient-derived xenografts Cell culture models Models of PCP Role of the clusters in ACP Senescence The molecular relationship between ACP and the developing tooth Developmental pathways activated in craniopharyngioma The MAPK pathway The sonic hedgehog pathway The TGFβ and BMP pathways The Hippo pathway Expression of inflammatory factors in ACP Angiogenesis Tumor recurrence Summary and future directions Key points Acknowledgments References Chapter 5: Anatomy of the pituitary region Introduction Nasal cavities Paranasal sinuses Frontal sinus Maxillary sinus Ethmoidal air cells Sphenoid sinus Skull base Sphenoid bone Hypothalamus Pituitary gland Microanatomy of the pituitary gland Diaphragma sellae Cavernous sinus Internal carotid artery and its branches Skull base segment of the internal carotid artery Cavernous segment of the internal carotid artery Supracavernous segment of the internal carotid artery Cisternal segment Cranial nerves I-VI Olfactory nerve (CN I) Optic nerve (CN II) Oculomotor nerve (CN III) Trochlear nerve (CN IV) Trigeminal nerve (CN V) Abducens nerve (CN VI) Key points References Section II: Neuroradiological and ophthalmological diagnosis in pituitary tumors Chapter 6: Morphological imaging including imaging anatomy Introduction Magnetic resonance imaging Technical background MR sequences Imaging anatomy of the sellar region Sagittal view Coronal view Dynamic series Interpretation of cyst content on MRI MR imaging of adenoma MR imaging of microadenomas MR imaging of macroadenomas Computed tomography (CT) Imaging technique Digital subtraction angiography Arterial examination Inferior petrosal sinus sampling (IPSS) Key points References Chapter 7: Functional imaging Introduction Somatotroph adenomas Corticotroph adenomas Lactotroph adenomas Gonadotroph/nonfunctioning adenomas Thyrotroph adenomas Nonadenomatous pituitary lesions Conclusions Key points References Chapter 8: Neuroophthalmological diagnosis Introduction Neuroophthalmological examination techniques History Neuroophthalmological routine examination Macroscopic inspection and Brückner test Pupil examination and swinging flashlight test Ocular motility testing Visual acuity testing Visual field testing Confrontation perimetry Kinetic perimetry Static automated perimetry Morphological studies Ophthalmoscopy Optic coherence tomography (OCT) Electrophysiological studies Typical neuroophthalmological signs of pituitary tumors Visual field loss Visual acuity loss Ocular motility disorders Vertical nystagmus Neuroophthalmological symptoms of chiasmal visual loss Key points References Section III: Endocrinological diagnosis and replacement therapy for hypopituitarism and diabetes insipidus in pituitary t ... Chapter 9: Endocrinological diagnosis and replacement therapy for hypopituitarism Introduction Historical prospective Clinical symptoms and signs The patients with hypopituitarism Acute onset Insidious onset Epidemiology Etiology of hypopituitarism Endocrine evaluation and replacement therapies ACTH deficiency Diagnosis Hormonal replacement therapy Adrenal crisis TSH deficiency Diagnosis Management Gonadotropin deficiency and fertility Diagnosis Management Fertility GH deficiency Diagnosis Management Hormone-hormone interaction Limitation with current replacement strategy Hypopituitarism during pregnancy Summary Key points References Chapter 10: Endocrinological diagnosis and replacement therapy for diabetes insipidus Prevalence and definition of the polyuria polydipsia syndrome Causes of central diabetes insipidus Acquired central diabetes insipidus Hereditary central diabetes insipidus Idiopathic central diabetes insipidus Osmorecptor dyfunction or adipsic diabetes insipidus Diagnosis Clinical manifestations Radiological findings Differential diagnosis The indirect water deprivation test The direct test with AVP measurement The direct test with Copeptin measurement Replacement therapy Correction of body water deficits Specific replacement therapy Specific therapy in adipsic diabetes insipidus Quality of life with appropriate therapy Key points References Chapter 11: The role of nurses in supporting self-management for patients with hypopituitarism Introduction Hormone replacement therapy in hypopituitarism Polypharmacy in hypopituitarism and the need for self-management The remit of nurses in the care of patients with hypopituitarism The nursing process framework in supporting patient self-management Assessment and nursing diagnosis Planning Implementation Evaluation Improving adherence to pituitary replacement therapy Understanding factors that influence adherence to medication Nonadherence to medication in patients with hypopituitarism Strategies to improve adherence to pituitary replacement therapy Patient education approaches in supporting self-management Education approaches for patients with adrenal insufficiency Conclusion Key points References Section IV: Endocrinological diagnosis and medical treatment in functioning pituitary adenomas Chapter 12: Prolactinomas: Diagnosis and medical treatment Introduction Epidemiology Clinical presentation Diagnosis Other etiologies of hyperprolactinemia Medical treatment Resistant prolactinomas Adverse effects of dopamine agonists Children and adolescents Giant prolactinomas Cystic prolactinomas Pasireotide Temozolomide Conclusions Key points References Chapter 13: Endocrinological diagnosis in acromegaly Physiology of the hypothalamic-pituitary-somatotropic axis Regulation of GH secretion Secretion pattern Influencing factors Epidemiology Incidence and prevalence Mortality Etiology Pituitary adenoma Genetic causes Familial isolated pituitary adenoma (FIPA) X-linked acrogigantism (X-LAG) Multiple endocrine neoplasia type 1 and 4 (MEN-1 and MEN-4) Carney complex (CNC) Familial paraganglioma/pheochromocytoma syndrome McCune-Albright syndrome (MCA) Other causes Signs and symptoms Tumor compression symptoms Afflictions of the skeletal system and soft tissue Metabolic complications Organ manifestations Psychopathology Diagnosis Biochemical evaluation IGF-I GH Pitfalls of biochemical assessment Imaging Assessment of comorbidities Assessment of pituitary function Screening for organ manifestations Burden of disease and health care cost Summary Key points References Chapter 14: Medical treatment in acromegaly Introduction Therapeutic goals Biochemical outcomes Tumor shrinkage and clinical end points Treatment options First-generation SRLs Mechanism of action and available molecules Biochemical outcomes Tumor shrinkage Clinical end points Nonclassical indications: First-line treatment Nonclassical indications: Presurgical treatment Definition of resistance to SRLs Second-generation SRLs (pasireotide) Mechanism of action Biochemical outcomes Tumor shrinkage Clinical end points Dopamine agonists (DA) Mechanism of action and available molecules Biochemical outcomes Tumor shrinkage Clinical end points GH receptor antagonist (pegvisomant) Mechanism of action Biochemical outcomes Tumor effects Clinical end points Combination therapies Perspectives SRLs GH antagonists Estrogens and selective estrogen receptor modulators (SERMs) Conclusions Key points References Chapter 15: The diagnosis of Cushing's disease Clinical diagnosis Biochemical diagnosis Biochemical screening Biochemical differential diagnosis Bilateral inferior petrosal sinus sampling (BIPSS) Imaging Pituitary Adrenal Ectopic secretion Conclusions Key points References Chapter 16: Medical management of Cushing's disease Introduction Adrenal-directed therapy Ketoconazole Metyrapone Etomidate Mitotane Mifepristone Pituitary-directed therapy Cabergoline Pasireotide Emerging treatment Osilodrostat Levoketoconazole ALD1613 Relacorilant (CORT125134) Medical management of Cushing's disease in pregnancy Monitoring Combination therapy Severe hypercortisolemia and psychosis Key points Acknowledgments References Chapter 17: Endocrinological diagnosis and treatment of TSH-secreting pituitary adenomas Introduction Epidemiology Pathophysiology and etiologic forms Pure TSPA Mixed adenoma TSPA associated with genetic syndromes Extrapituitary TSPA TSH-secreting carcinoma Clinical features and diagnosis Clinical features Biochemical profile: Static testing Biochemical profile: Dynamic testing Neuroimaging Functional imaging and other diagnostic approaches Summary of the TSPA diagnostic algorithm Treatment Surgical treatment Medical treatment Radiotherapy Other treatments Prognosis and long-term evaluation Conclusions Key points References Section V: Surgical treatment of pituitary tumors Chapter 18: Microscopic transsphenoidal surgery General aspects Patient positioning Surgical technique The perinasal-paraseptal route The sublabial incision The direct endonasal approach Sphenoidotomy and exposure of the sellar floor Opening the sella and tumor resection Reconstruction of sellar floor and closure Postoperative management Key points References Chapter 19: Endoscopic transsphenoidal surgery: Including a brief history of transsphenoidal surgery Historical perspective of (endoscopic) transsphenoidal surgery Invention of endoscopy Evolution of endoscopic transsphenoidal surgery Surgical aspects Preoperative planning Endoscopic endonasal surgery for pituitary tumors The nasal phase The sphenoid phase The sellar phase Closure and reconstruction techniques Surgical pearls and pitfalls Endoscopic surgery for recurrent adenomas Comparison of the surgical results using the endoscopic and microsurgical technique Further developments Key points References Chapter 20: Risks of transsphenoidal surgery Introduction Patient selection, approach selection, and surgeon experience Surgical setup and technology adjuncts for endoscopic pituitary surgery Nasal approach and sphenoidotomy Sellar exposure and carotid artery localization Postoperative gland dysfunction, cranial nerve neuropathies, and bleeding Skull base reconstruction Postoperative surveillance Minor complications Key points References Chapter 21: Ophthalmologic outcome of transsphenoidal surgery Introduction Recovery of visual and oculomotor function Predictors of visual outcome Follow-up recommendations Baseline ophthalmologic examination Postsurgery ophthalmologic follow-up Recommended ophthalmological tests Key points References Chapter 22: Endocrinological outcome of transsphenoidal surgery in pituitary adenomas Introduction Cushing's disease Acromegaly Prolactinoma Pituitary stalk effect-related hyperprolactinemia Thyrotropin-producing adenoma Nonfunctioning pituitary (macro-)adenoma Large or giant pituitary adenoma Mixed cohorts Transsphenoidal pituitary surgery in special populations Children Elderly patients Endoscopic versus microscopic transsphenoidal surgery for pituitary adenomas Mono- versus binostril approach for endoscopic transsphenoidal neurosurgery Experience with transsphenoidal surgery Key points References Chapter 23: Extended transsphenoidal surgery Introduction Surgical implications of giant pituitary adenomas Indications of the extended endoscopic endonasal approach in the treatment of pituitary adenomas Preoperative evaluation Anatomical correlation and applied anatomy The extended endoscopic endonasal approach: Surgical tenets and description of the technique Limitations Complications associated with the technique How to avoid complications Key points Conflict of interest References Chapter 24: Transcranial surgery Historical perspectives Indications for transcranial surgery Preoperative preparation Operative techniques for transcranial approaches Pterional approach Orbitozygomatic approach Bifrontal approach Subfrontal approach Supraorbital keyhole approach via an eyebrow incision Subtemporal approach Conclusion Key points References Chapter 25: Video presentations of pituitary surgery Section VI: Histo-pathological classification of pituitary tumors Chapter 26: Pathology of pituitary adenoma Definition Epidemiology Etiology and (molecular) pathogenesis Classification GH-secreting (somatotroph) adenoma (PIT-1 positive) GH- and prolactin-secreting (mixed somatolactotroph) adenomas (PIT-1 positive) Prolactin-secreting (lactotroph) adenomas (PIT-1 positive) TSH-secreting (thyrotroph) adenomas (PIT-1 positive) Pit-1 positive hormone-negative adenomas ACTH-secreting (corticotroph) adenomas (T-PIT-positive) FSH/LH-secreting (gonadotroph) adenomas (SF-1 positive) Null cell adenomas (hormone- and transcription factor negative) Plurihormonal adenomas (PIT-1 or T-PIT or SF-1 positive) Aggressive adenomas Pituitary carcinomas Classification of Trouillas et al. (2015) PANCH (pituitary adenoma neuronal choristoma) PitNET (pituitary neuroendocrine tumor) instead of pituitary adenoma Key points References Chapter 27: Pathology of nonadenomatous pituitary tumors and tumor-like lesions Craniopharyngiomas Definition and basic data Adamantinomatous craniopharyngioma Papillary craniopharyngiomas Ultrastructure of craniopharyngiomas Immunohistochemistry of craniopharyngiomas Tumors of the neurohypophysis: TTF-1-positive spindle cell tumors Definition and general pathology Pituicytoma Spindle cell oncocytoma Granular cell tumor Other tumors of the sellar region Metastases in the pituitary Tumor-like lesions Rathkes cleft cysts Xanthogranuloma of the sellar region Key points References Section VII: Perioperative and postoperative management in patients with pituitary adenomas Chapter 28: Perioperative neurosurgical management Introduction Preoperative workup Preoperative imaging Laboratory data Blood products Informed consent Anesthesiological considerations for pituitary surgery Instrumentation Intraoperative glucocorticoid management Narcotics and analgesia Nasal packing and mucosal infiltration Trigeminocardiac reflex Obstructive sleep apnea Perioperative pain management Perioperative management of anticoagulation Cushing's disease (CD) Postoperative surgical order Postoperative level of care Perioperative glucocorticoid management Cushing's disease Secondary hypothyroidism Perioperative management of electrolyte and fluid balance Management of CSF leakage Postoperative imaging Otorhinolaryngological management after transsphenoidal surgery Postoperative recommendations after transsphenoidal surgery Checklist for discharge Key points References Chapter 29: Perioperative endocrinological management in patients with pituitary adenomas Introduction Central adrenal insufficiency Water balance disorders Diabetes insipidus Syndrome of inappropriate antidiuretic hormone secretion Cerebral salt-wasting syndrome Assessment of remission in patients with hormone-secreting pituitary adenomas Cushing's disease Acromegaly Prolactinoma Conclusions Key points References Chapter 30: Perioperative and postoperative nursing care Institutional impact to care rendered Preoperative nursing care Patient education Preoperative nursing assessment Postoperative nursing considerations Patient monitoring and symptomatology management Vital signs Nasal discharge Epistaxis Intake and output Laboratory analysis Venous thromboembolism prophylaxis Infection CSF leak Lumbar drain care Symptom management Monitoring for endocrinologic dysfunction Adrenal insufficiency Diabetes insipidus Syndrome of inappropriate antidiuretic hormone Preparing for hospital discharge and follow up coordination Discharge instructions Symptom management Activity restrictions Postoperative follow-up Key points References Chapter 31: Postoperative endocrinological follow-up Introduction Assessment of anterior pituitary function after surgery (see Table 1) Hypothalamus-pituitary-adrenal (HPA) axis Hypothalamus-pituitary-thyroid axis Hypothalamus-pituitary-gonadal axis Growth hormone Prolactin Assessment of cure after surgery Acromegaly Cushing's disease Prolactinoma Concluding remarks Key points References Chapter 32: Pituitary magnetic resonance imaging use in the posttreatment follow-up of secreting pituitary adenomas Introduction Pituitary magnetic resonance imaging T1-weighted T2-weighted T2 echo gradient Gadolinium-based contrast agents 2017 WHO classification of pituitary tumors Postsurgical surveillance of pituitary tumors Surveillance during medical therapy Surveillance after radiotherapy/radiosurgery Acromegaly T2WI and acromegaly Cushing's disease T2WI in corticotrophinomas Prolactin-secreting tumors T2WI in prolactinoma Key points References Section VIII: Radiotherapy for pituitary adenomas Chapter 33: Fractionated radiotherapy for pituitary adenomas Introduction The evolution of radiation treatment of pituitary adenomas Treatment indication Treatment plan and application Conformal fractionated radiotherapy Stereotactic fractionated radiotherapy Intensity-modulated radiotherapy Photon- and proton-based treatment Follow-up Treatment outcomes Local control and biochemical stabilization Nonfunctional adenomas Prolactinomas Cushing's disease Acromegaly Overall survival Quality of life Radiotherapy-related toxicities Hypopituitarism Radiation-induced optic neuropathy Neurocognitive dysfunctions Carcinogenesis Other toxicities Hypofractionated stereotactic radiotherapy Key points References Chapter 34: Pituitary adenomas: Radiosurgery Background Efficacy on hormone hypersecretion Acromegaly Cushing's disease Prolactinoma Control of tumor growth Side effects Hypopituitarism Visual and oculomotor defects Rare adverse effects Secondary radiation-associated neoplasms Conclusions Key points References Section IX: Aggressive pituitary adenomas and carcinomas Chapter 35: Management of aggressive pituitary tumors Introduction Definition of an aggressive pituitary tumor Invasiveness Tumor growth Optimal standard medical treatment Diagnosis and follow-up of an aggressive pituitary tumor Pituitary carcinomas Role and limits of the neurosurgeon The dominant issue is how far into the parasellar space the surgeon can go Potential factors implicated in aggressiveness Conclusion Key points References Chapter 36: Medical treatment of aggressive pituitary tumors Introduction Chemotherapy Temozolomide Other forms of chemotherapy Off-label use of drugs licensed for other pituitary tumor entities Experimental therapies Potential of anti-VEGF therapy Treatment by mTOR inhibition Effects of tyrosine kinase inhibitors Therapy with cell-cycle inhibitors Use of checkpoint inhibitors Peptide receptor radionuclide therapy Conclusions Key points References Section X: Diagnosis, treatment and outcome in nonfunctioning pituitary tumors and lesions Chapter 37: Clinically nonfunctioning pituitary tumors Introduction Epidemiology Classification of clinically nonfunctioning pituitary tumors Steroidogenic factor 1 (SF-1) lineage-Gonadotropin expressing tumors T-box family member TBX19 (T-Pit) lineage-Silent corticotroph tumors Pituitary transcription factor 1 (Pit-1) lineage-Silent somatotroph, lactotroph, and thyrotroph tumors Null cell tumors Clinical presentation Incidentalomas Clinical characteristics according to lineage classification Gonadotroph adenomas Silent corticotroph adenomas Silent somatotroph adenomas Carcinomas Diagnosis Treatment and outcomes Natural history of untreated tumors Surgery Postoperative management Risk stratification Radiation therapy Conservative follow-up Medical treatment Dopamine agonists Somatostatin receptor ligands Other medications Conclusions Key points References Chapter 38: Childhood-onset craniopharyngiomas Introduction Epidemiology Pathology Tumor location Presenting clinical manifestations Imaging studies Treatment strategies Neurosurgery Irradiation Conventional external radiotherapy Proton beam therapy Stereotactic radiotherapy Radiosurgery Intracavitary β-irradiation Instillation of sclerosing substances for cystic recurrent tumors Treatment strategies and quality of life Risk factors and treatment for recurrences Long-term outcome and sequelae Morbidities Pituitary deficiencies Visual and neurological outcomes Hypothalamic dysfunction Obesity and eating disorders Physical activity and energy expenditure Autonomous nervous system Appetite regulation Pharmacological treatment of hypothalamic obesity Bariatric treatment of hypothalamic obesity Quality of life, neurocognitive outcome, and psychosocial functioning Cerebrovascular morbidity Second malignant neoplasms Survival and late mortality Questions and perspectives Surgical treatment strategies: Degree of resection Expertise Targeted therapies Key points Acknowledgments References Chapter 39: Adult craniopharyngiomas Introduction Epidemiology Pathogenetic background Histopathology Adamantinomatous craniopharyngioma Papillary craniopharyngioma Clinical presentation Diagnostic workup Cranial imaging techniques Magnetic resonance imaging Cranial computerized tomography (CT) Endocrinological testing Lumbar puncture for CSF examination Therapy Surgery Radiotherapy (RT) Novel target-directed therapy Prognosis Quality of life Key points References Chapter 40: Rathke's cleft cysts and arachnoid cysts Introduction Natural history Diagnosis and management Imaging Surgical techniques Conclusion Key points Conflicts of interest Disclosures References Chapter 41: Perisellar solid tumors Introduction Optic pathway gliomas Clinical symptoms Endocrinological findings Imaging Therapy and outcome Targeted therapy Hypothalamic hamartomas Clinical symptoms Imaging Treatment of precocious puberty Treatment of epilepsy Endoscopic disconnection Microscopic surgery Single-session radiosurgery Interstitial radiotherapy (brachytherapy) Thermocoagulation Intracranial germ cell tumors Clinical symptoms and endocrinological findings Imaging Treatment Outcome Targeted therapy Tumors of the posterior pituitary Clinical symptoms Endocrinological findings Imaging Treatment and outcome Targeted therapy Gangliocytomas and mixed gangliocytoma-pituitary adenomas Perisellar meningiomas Tuberculum sellae meningiomas Clinical symptoms Endocrinological findings Imaging Treatment Outcome Cavernous sinus meningiomas Clinical symptoms Endocrinological findings Imaging Treatment Outcome Diaphragma sellae meningiomas Intrasellar meningiomas Clinical symptoms Endocrinological findings Imaging Treatment Other perisellar meningiomas Role of somatostatin receptors in meningiomas Targeted therapy Clivus chordomas Clinical symptoms and endocrinological findings Imaging Treatment Outcome Targeted therapy Petroclival chondrosarcomas Clinical symptoms Imaging Treatment Outcome Targeted therapy Metastatic pituitary tumors Clinical symptoms Endocrinological findings Imaging Treatment Outcome Key points References Chapter 42: Inflammatory pituitary lesions Introduction Primary hypophysitis Epidemiology and pathology Clinical presentation and imaging features Nonendocrine symptoms Endocrine symptoms Autoantibodies Treatment and outcome Secondary hypophysitis Immune checkpoint inhibitor-induced hypophysitis Systemic, noninfectious granulomatous diseases Sarcoidosis Granulomatosis with polyangiitis (Wegener's granulomatosis) Langerhans cell histiocytosis Erdheim-Chester disease Rosai-Dorfman disease Sellar and parasellar diseases causing hypophysitis Germinoma Ruptured Rathke's cleft cyst Infectious diseases causing hypophysitis Pituitary tuberculosis Key points References Chapter 43: Vascular lesions and aneurysms Introduction Cavernous malformations of the optic pathways Imaging Treatment Outcomes Cavernous sinus hemangiomas Symptoms Imaging Treatment and outcomes Perisellar aneurysms Signs and symptoms Imaging Treatment for extradural aneurysms Treatment for intradural aneurysms Endocrinological sequelae of SAH Coexistence of intracranial aneurysm and pituitary adenoma Abnormal intrasellar arteries Persistent primitive trigeminal artery Transsellar communicating artery Key points References Section XI: Diagnosis and treatment of co-morbidities in pituitary tumors Chapter 44: Psychiatric disorders Introduction Hormone excess syndromes and psychiatric disorders Acromegaly Cushing's disease Prolactinomas Rare diseases of the hypothalamus/pituitary gland and psychiatric disorders Diagnosing and treating psychiatric disorders in pituitary tumors Conclusion Key points References Chapter 45: Metabolic disorders Introduction Growth hormone GH excess-Acromegaly GH deficiency ACTH/cortisol Cushing's disease Adrenocorticotropic insufficiency Glucocorticoid replacement therapy Prolactinomas Hypopituitarism Gonadotropin deficiency Thyrotropin deficiency Key points References Chapter 46: Osteoporosis and arthropathy in functioning pituitary tumors Introduction Part A Acromegaly Background Acromegalic arthropathy Pathophysiology Clinical picture Disease progression Diagnostic challenges Approach to an acromegalic patient with joint complaints Conclusion Bone disease in acromegaly Pathophysiology Clinical picture Disease course Monitoring and treatment Conclusion Part B Cushing's disease Background Skeletal fragility in Cushing's disease Pathophysiology Clinical picture Treatment of endogenous glucocorticoid-induced osteoporosis Avascular osteonecrosis Conclusion Joint disorders in Cushing's disease Part C Prolactinoma Background Skeletal fragility in PRL-oma patients Pathophysiology Clinical picture Management Conclusion Joint complaints in PRL-oma patients Part D TSH-producing adenoma Background Bone disease in TSH-oma patients Pathophysiology Clinical picture Management Conclusion Conclusion Key points Disclosure statement References Section XII: Special issues Chapter 47: Pituitary incidentaloma Definition Epidemiology Etiology Clinical features and differential diagnosis Visual field impairment Hormonal function deficit Hyperfunction Pituitary apoplexy Differential diagnosis Natural history of pituitary incidentalomas Evaluation Treatment Treatment for PIs due to pituitary adenomas Relative surgical indications for pituitary incidentalomas Drugs Pituitary incidentalomas in special clinical situations Pregnancy Pediatric patients Pituitary apoplexy RCC Follow-up For pituitary incidentalomas greater than 1-cm diameter For pituitary incidentalomas less than 1 cm Key points References Chapter 48: Pituitary apoplexy Definition The medical history of PA Epidemiology of PA Pathophysiology and risk factors of PA Clinical presentation of PA Imaging diagnostics Laboratory findings in PA Treatment of PA Long-term endocrinological outcome and follow-up recommendations Key points References Chapter 49: Management of pituitary tumors in pregnancy Introduction Prolactinomas Acromegaly Clinical manifestations during pregnancy Diagnosis during pregnancy Treatment during pregnancy Cushing's syndrome during pregnancy Clinical manifestations during pregnancy Diagnosis during pregnancy Treatment during pregnancy TSH secreting pituitary adenoma during pregnancy Clinically nonfunctioning pituitary adenoma Conclusions Key points References Chapter 50: Quality of life in pituitary tumors Introduction Quality of life in patients with adult growth hormone deficiency (AGHD) Quality of life in patients with acromegaly QoL in Cushing's syndrome QoL in hyperprolactinemia/prolactinomas QoL in NFPA Examples of patient perceptions on QoL Strategies for patients to improve QoL and pituitary disease perception Conclusions Key points References Chapter 51: Multidisciplinary team perspective: A model of care for patients with pituitary tumors Introduction Goals and benefits of pituitary multidisciplinary teams The structure of the pituitary multidisciplinary team Endocrinology Pituitary surgery Neuroradiology Neuro-ophthalmology Neuro-oncology Neuropathology Nursing Proposed model of function of pituitary multidisciplinary team Multidisciplinary team model as part of a Pituitary Tumor Center of Excellence Conclusions Key points References Index Back Cover