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Transcript of The 'incidentaloma' of the pituitary gland. Is ... · ditorial Assistants: Mary Cannon, Kemberly...

  • JAMA The Journal of the American Medical Association

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    May 23/30,1990, Vol 263, No. 20 To promote the science and art of medicine and the betterment of the public health.

    Original Contributions Value of the Ventilation/Perfusion Scan in Acute Pulmonary Embolism 2753 The PIOPED Investigators, Bethesda, Md

    Methods Used to Quit Smoking in the United States .. .2760 M. C. Fiore, Madison, Wis; T. E. Novotny, J. P. Pierce, G. A. Giovino, Rockville, Md; E. J. Hatziandreu, Washington, DC; P. A. Newcomb, TS. Surawicz, Madison, Wis; R. M. Davis, Rockville, Md

    Exercise Training Combined With Antihypertensive Drug Therapy .................... ...2766 Μ. H. Kelemen, Columbia, Md; Μ. B. Effron, Baltimore, Md; S. A. Valenti, Columbia, Md; K. J. Stewart, Baltimore, Md

    The 'Incidentaloma' of the Pituitary Gland 2772 M. Reincke, B. Allolio, Cologne, West Germany; W. Saeger, Hamburg, West Germany; J. Menzel, W. Winkelmann, Cologne, West Germany

    Special Communications The Cystic Fibrosis Gene: Medical and Social Implications for Heterozygote Detection ......2777 B. S. Wilfond, N. Fost, Madison, Wis

    Who Profits From Tobacco Sales to Children? .2784 J. R. DiFranza, Rtchburg, Mass; J. B. Tye, Springfield, Mass

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    2709

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    2710 JAMA, May 23/30,1990-Vol 263, No. 20

  • Martin Reincke, MD; Bruno Allolio, MD; Wolfgang Saeger, MD; Jürgen Menzel, MD; Werner Winkelmann, MD

    The 'Incidentaloma' of the Pituitary Gland Is Neurosurgery Required?

    We describe a series of 18 patients with an intrasellar mass incidentally discov-ered by computed tomography or magnetic resonance imaging. The average size of the mass was 13 mm, with a range from 5 to 25 mm. Initial ophthalmologic examination revealed bitemporal hemianopia in 2 patients. Results of routine endocrine testing showed partial hypopituitarism in 5 patients and growth hor-mone hypersecretion without signs and symptoms of acromegaly in 1 patient. Four patients underwent neurosurgery. Histologically, one chondroid chordoma and three pituitary adenomas were found. In the remaining 14 patients treated conservatively, repeated computed tomography and magnetic resonance imag-ing revealed no significant change in tumor size at the time of follow-up (median, 22 months). Our results suggest that the "incidentaloma" of the pituitary gland is a benign condition that does not necessarily require neurosurgical intervention.

    {JAMA. 1990;263:2772-2776)

    I N 1936, Costello1 reported in his inves-tigation entitled "Subclinical Adenomas of the Pituitary Gland" that in a series of 1000 pituitary glands obtained from un-selected autopsies pituitary adenomas occurred with the remarkable frequen-cy of 22.5%. The tumors were unassoci-ated with clinical signs or obvious hor-monal abnormalities and remained undiagnosed during the subjects' life-time.

    Costello's investigation has been cited in numerous publications. The

    From the Department of Medicine II, University of Cologne, Krankenhaus Merheim, West Germany (Drs Reincke and Allolio and Prof Dr Winkelmann); Depart-ment of Pathology, Marienkrankenhaus Hamburg, West Germany (Prof Dr Saeger); Department of Neuro-surgery, Krankenhaus Merheim, Cologne, West Ger-many (Prof Dr Menzel).

    Reprint requests to Department of Medicine II, Kran-kenhaus Merheim, Ostmerheimer Str 200, 5000 Köln 91, West Germany (Dr Reincke).

    prevalence of subclinical pituitary ade-nomas has been reexamined by many subsequent investigators and was found to vary from 4.8% to 27% in unselected autopsy subjects.2 In most cases, these adenomas were small and could only be detected by microscopy. Adenomas vis-ible at the time of gross examination are detected less frequently. In the series of McComb et al,2 4 of 100 pituitary adeno-mas incidentally discovered at the time of autopsy were detected already by gross examination.

    During the last two decades, the in-troduction of radioimmunoassays, new radiological procedures, and microsur-gical techniques have allowed early di-agnosis and removal of small pituitary adenomas. However, even today, pitu-itary adenomas are a common incidental finding at the time of autopsy.3,4 With wider application of computed tomogra-

    phy (CT) and magnetic resonance imag-ing (MRI), pituitary masses will be de-tected incidentally during patients' lifetimes in increasing frequency. The diagnostic and therapeutic approach to patients with "incidentalomas" of the pituitary gland has not yet been estab-lished. We, therefore, present herein the findings of 18 patients with a sub-clinical pituitary mass incidentally dis-covered by CT or MRI.

    PATIENTS AND METHODS Since 1980, we studied 27 patients (21

    female and 6 male) with an intrasellar mass incidentally discovered by CT or MRI (incidentaloma), which was de-fined as follows: (1) the patient under-went CT scanning (or MRI) for evalua-tion of an unrelated disease, and (2) the patient did not complain of symptoms associated with a sellar mass (visual dis-turbance, symptoms of hypopituita-rism, or anterior pituitary hormone ex-cess). Headache as an isolated symptom was considered to be nonspecific i f the life profile of it was chronic, recurrent, and unassociated with other important signs. Patients with headache of in-creasing frequency and intensity were excluded. Patients with a primary para-sellar or suprasellar mass or with the empty-sella syndrome were not in-cluded in the study.

    Of the 27 patients with an incidenta-loma of the pituitary gland, 9 cases were excluded from this study for the follow-ing reasons: 6 patients were unavailable for follow-up, 1 patient had suspected

    2772 JAMA, May 23/30,1990-Vol 263, No. 20 'Incidentaloma'—Reincke et al

  • Table 1.—Clinical, Radiological, and Biochemical Characteristics of Four Patients With an 'Incidentaloma* of the Pituitary Gland That Required Neurosurgery*

    Maximum Patient/ Age, y/

    Sex Complaint

    (Reason for CT)

    Tumor Diameter,

    mm

    Endocrine Function Visual Acuity Patient/ Age, y/

    Sex Complaint

    (Reason for CT)

    Tumor Diameter,

    mm Surgery Preoperative Postoperative Preoperative Postoperative Histology Immunostaining 1/55/F Concussion 25 Transfrontal Hypopituitarism

    (LH, FSH) Hypopituitarism

    (C, TSH, LH, FSH) Bitemporal

    hemianopia Bitemporal

    hemianopia Chondroid

    chordoma 2/64/M Cerebrovascular

    disease 25 Transfrontal Hypopituitarism

    (LH, FSH) Hypopituitarism

    (C, TSH, LH, FSH) Bitemporal

    hemianopia Bitemporal

    hemianopia Chromophobic

    pituitary adenoma

    LHf, FSHt

    3/66/M Epilepsy 20 Transfrontal Normal Normal Normal Left hemianopia

    Oncocytic pituitary adenoma

    FSH}:, TSHt a-subunit§

    4/35/M Cervical myelopathy

    17 Transsphenoidal GH hypersecretion Normal Normal Normal Acidophilic pituitary adenoma

    GHt, PRLt.TSHt

    *CT indicates computed tomography; LH (luteinizing hormone), FSH (follicle-stimulating hormone), C (corticotropin), and TSH (thyrotropin [thyroid-stimulating hormone]), hormone deficiencies in patients with hypopituitarism; GH, growth hormone; and PRL, prolactin.

    tLess than 10% of tumor cells stained. ^Greater than 50% of tumor cells stained. §Ten percent to 50% of tumor cells stained.

    Table 2.—Clinical, Radiological, and Biochemical Data of 14 Patients With an 'Incidentaloma' of the Pituitary Gland Treated Conservatively*

    Patient/ Age, y/

    Sex Complaint

    (Reason for CT)

    Maximum Tumor Diameter, mm

    First CT Last CT Endocrine Function Follow-up,

    mo 5/65/F Concussion 22 25 Hypopituitarism (LH, FSH) 19 b/bö/M cerebrovascular disease 20 20 Normal 20 7/61/F Headache 16 15 Hypopituitarism (LH, FSH) 42 8/59/M Cluster headache 14 20 Normal 20 9/56/M Vertigo 14 14 Hypopituitarism (LH, FSH) 48

    10/32/F Psychiatric disorder 12 12 Normal 48 11/27/F Headache 11 11 Normal 17 12/15/F Epilepsy 9 9 Normal 29 13/19/F Concussion 8 8 Normal 12 14/22/F Syncope 8 4 Normal 14 15/24/F Headache 8 8 Normal 17 16/43/F Vertigo 8 8 Normal 24 17/37/F Psychiatric disorder 5 5 Normal 20 18/44/F Headache 5 9 Normal 96

    *CT indicates computed tomography; and LH (luteinizing hormone) and FSH (follicle-stimulating hormone), hormone deficiencies in patients with hypopituitarism.

    pituitary hyperplasia caused by prima-ry hypothyroidism, and 2 patients had normal CT scans at the time of follow-up, suggestive of artifacts that imitated a pituitary tumor in the initial scans.

    In the remaining 18 patients, com-plete medical histories were recorded and physical examinations given initial-ly and during follow-up. In addition, ophthalmologic examinations, including Goldman and computed perimetry, and routine pituitary function testing5 were performed. Assessment of the hormon-al status included determination of baseline (and stimulated) hormone con-centrations of plasma corticoptropin and serum Cortisol (corticoptropin-stim-ulation test, overnight metyrapone test, and since 1986 corticotropin-re-leasing hormone stimulation test), thyrotropin (thyroid-stimulating hor-mone), triiodothyronine and thyroxine

    (thyrotropin-releasing hormone stimu-lation test until 1988), prolactin (thyro-tropin-releasing hormone stimulation test), luteinizing hormone and follicle-stimulating hormone (gonadotropin-releasing hormone stimulation test), testosterone, growth hormone (GH), somatomedin C. α-Subunit was not measured. Follow-up studies were done every 12 months and earlier in patients with large tumors.

    Plasma corticotropin levels were determined by radioimmunoassay after extraction with microfine precipitated silica granules as described previously.6 Cortisol, prolactin, thyrotropin, triiodothyronine and thyroxine, luteinizing hormone, follicle-stimulating hormone, GH, and somatomedin C levels were measured by radioimmunoassay or im-munoradiometric assay with commercially available reagents.

    Sections of tumor tissue were examined by light microscopy using conventional and immunocytochemical techniques described previously.7 Using the peroxidase-antiperoxidase method on paraffin-embedded sections, the following commercial primary antibodies were tested: anticorticotropin, anti-GH, antiprolactin, antithyrotropin, anti-follicle-stimulating hormone, anti-luteinizing hormone, anti-ct-subunit.

    High-resolution CT of the pituitary fossa in 2-mm sections was performed after intravenous administration of contrast material with second- and third-generation scanning machines (Siemens Somatotom DR1 and DR2, Munich, Germany). Reformatting of multiple axial images was obtained in all patients; thin-section coronal scans were obtained in 10 patients.

    Since 1987, in addition to CT, magnetic resonance images in the coronal and sagittal views were obtained in eight patients at 1.0 Τ (Siemens Magentom LOT, Munich, Germany). Both T r and T2-weighted spin-echo pulse sequences were acquired before and after the administration of gadolinium-diethylene-triaminepentaacetic acid.

    RESULTS Clinical data of the patients are sum

    marized in Tables 1 and 2. In 17 patients, the pituitary mass was discovered by CT and in patient 4 by MRI. Patients' ages ranged from 15 to 68 years at the time of admission. The reasons for CT scanning (or MRI) were headache of chronic pattern (n = 3), cluster headache (n=l ) , cerebrovascular disease (n = 2), psychiatric disorders (n = 2X vertigo (n=2), epilepsy (n=2), concussion (n = 2), and other causes (n = 4). Al l female patients except for the postmenopausal women had regular menses. None of the male patients com-

    JAMA, May 23/30,1990-Vol 263, No. 20 'Incidentaloma'—Reincke et al 2773

  • Fig 1.—Initial coronal computed tomographic (CT) scan of patient 5 showing a large pituitary mass (maximum diameter, 22 mm) with suprasellar extension. The lesion was incidentally discovered by CT after head trauma and was completely asymptomatic.

    plained of loss of libido. On coronal CT scans, an intrasellar

    soft-tissue mass greater than 10 mm in maximum diameter was identified in 11 patients (range, 11 to 25 mm) (Fig 1). Enhancement characteristics were variable, with uniformly isodense lesions (5 patients), uniformly hypodense lesions (1 patient), and mixed-density lesions (5 patients) encountered relative to the adjacent cavernous sinus. Seven tumors extended into the suprasellar region. Magnetic resonance imaging was available in 6 of these patients. In 2 patients (patients 1 and 2) with bitemporal visual field defects, the chiasm could not be discerned from the tumor by MRI. Displacement of the optic nerve was noted in patient 3, who had normal visual acuity.

    In seven patients, pituitary gland CT scans showed a small lesion (diameter,

  • Incidentally Discovered Pituitary Mass

    Ophthalmologic Examination Pituitary Function Testing

    Abnormal Visual Fields and/or Hypopituitarism

    and/or Pituitary Hormone Excess

    I

    I Prolactinoma

    ι

    Treatment With Dopamine Agonist

    Normal Visual Fields Normal Pituitary Function

    Review Magnetic Resonance Imaging

    No Prolactinoma

    I Consider

    Neurosurgery

    Mass 1 cm

    I Repeat Magnetic Resonance

    Imaging, Ophthalmologic Examination and Pituitary Function Test

    After 72, 1, and 2 y

    ^ Tumor Growth Abnormal Visual Fields

    Hypopituitarism

    Consider Neurosurgery

    Fig 2.—Approach to the incidentally discovered noncystic mass.

    headache of recent onset or increasing frequency and intensity. In addition, Cohen et al8 reported in their large series of 100 patients with nonfunctioning pituitary adenomas that headache—the second most frequent symptom—was never observed as an isolated complaint; it was always accompanied by visual symptoms.

    The pituitary region can now be easily evaluated by means of high-resolution CT9 and MRI. 1 0 By CT, it is best demonstrated either directly on coronal scans or indirectly from data obtained in the axial plane and reformatted into coronal and sagittal images. The use of high-resolution CT scans for the diagnosis of pituitary tumors is well established. In the case of tumors greater than 10 mm in diameter, the mass will be easily demonstrated radiologically. However, in patients with suspected pituitary adenomas smaller than 10 mm, CT has been found to be of less value in localizing the lesion.1112

    Magnetic resonance imaging has been shown to be superior to CT in the evaluation of large pituitary tumors.1 0 1 3 I t is able to yield excellent anatomic presentations of the tumor and its immediate surroundings. The suprasellar exten

    sion of the tumor and the impinging of the optic apparatus and the third ventricle is more easily identified from MRI reconstructions than from CT images. In addition, MRI before and after administration of gadolinium-diethylene-triaminepentaacetic acid has been demonstrated to be more effective in the detection of microadenomas of the pituitary gland.14 Therefore, since 1987, MRI frequently has been used by us to confirm the presence of a pituitary tumor and to define the relationship of the lesion to the surrounding anatomic structures.

    Asymptomatic pituitary adenomas are a common incidental finding at the time of autopsy.1"4 Most reported series showed an incidence of approximately 20%.2 We believe that most of the inci-dentalomas in our patients represent slowly growing pituitary microadenomas and macroadenomas. No change in tumor size was noted in the majority of cases. This may be explained by the slow growth characteristics of pituitary adenoma cells,

    Patients with incidentalomas of the pituitary gland should be carefully monitored for anterior pituitary hormone excess, although the majority of pa

    tients have nonfunctional pituitary tumors. In the present study, only one patient with a GH-secreting adenoma had biochemical evidence of anterior pituitary hormone excess. No prolactin-secreting pituitary tumor was detected. Immunohistochemistry revealed a gonadotroph cell adenoma in one patient whereas gonadotropin levels were normal or low in all patients. However, gonadotroph cell adenomas cannot really be excluded on this basis since serum α-subunit was not measured in our patients.

    Nevertheless, subclinical masses may be caused by abnormalities other than microadenomas or macroadenomas. The differential diagnosis includes aneurysm, meningioma, and craniopharyngioma,15 pituitary hyperplasia,1 6 1 7 lymphoid adenohypophysitis,18,19 pars intermedia cysts,3 metastasis to the pituitary gland,3 , 2 0 , 2 2 infarcts of the pituitary gland,23 and abscesses.3

    Aneurysm, parasellar meningioma, and craniopharyngioma sometimes mimic the CT characteristics of pituitary tumors, especially the large pituitary adenomas with suprasellar extension. However, generally they present a characteristic constellation of findings

    JAMA, May 23/30,1990-Vol 263, No. 20 'Incidentaloma'—Reincke et al 2775

  • on CT scans and MRI, which allows the differential diagnosis.15

    I t is well known that in patients with suspected microadenomas, artifacts may mimic low-density lesions on CT.3 Earnest et al2 1 stated that a significant percentage of intrasellar low-density areas, visualized on reformatted images especially, represented artifacts associated with the bones of the skull base. We excluded two patients with normal CT scans at the time of follow-up from this study in whom probable artifacts initially imitated the findings of a true pituitary tumor.

    The therapeutic approach to patients with an incidentally discovered pituitary mass has not yet been established. We believe that it is rational to observe

    References

    1. Costello RT. Subclinical adenoma of the pituitary gland. Am J Pathol 1986;12:205-216. 2. McComb DJ, Ryan N, Horvath E , Kovacs K. Subclinical adenomas of the human pituitary: new light on old problems. Arch Patlvol Lab Med. 1983;107:488-491. 3. Chambers E F , Turski PA, LaMasters D, Newton TH. Regions of low density in the contrast-enhanced pituitary gland: normal and pathologic processes. Radiology. 1982;144:109-113. 4. Parent AD, Bebin J, Smith RR. Incidental pituitary adenomas. J Neurosurg. 1981;54:228-231. 5. Wilson JD, Foster DW, ed. Williams Textbook of Endocrinology. Philadelphia, Pa: WB Saunders Co; 1985. 6. Allolio B, Winkelmann W, Hipp FX. Effect of meclastine, an Hj-antihistamine, on plasma ACTH, in adrenal insufficiency. Acta Endocrinol (Co-penh). 1981;97:98-102. 7. Saeger W, Schmidt W. Classification and im-munohistology of clinically silent adenomas in postmortem pituitaries. In: Levy E , ed. Advances in Pathology. Elmsford, NY: Pergamon Press Inc; 1982;2:343-355. 8. Cohen AR, Cooper PR, Kupersmith MJ, Flamm E S , Ransohoff J. Visual recovery after transsphenoidal removal of pituitary adenomas. Neurosurgery. 1985;17:446-452.

    the clinical course carefully in patients with normal visual acuity and normal pituitary function. Serial CT scans or MRI, pituitary function testing, and ophthalmologic examination should be performed depending on the size of the lesion (Fig 2). Magnetic resonance imaging may be useful to confirm the presence of the mass (especially in the case of small lesions), to define the boundaries of the tumor, and to characterize its relationship to normal gland and vascular, neural, and bony structures. I f the lesion shows no increase in size and endocrine and visual function remain intact, we recommend a conservative approach. However, in patients with tumor growth, loss of vision, or displacement of the optic apparatus shown

    9. Roppolo HMN, Latchaw R E , Meyer JD, Curtin HD. Normal pituitary gland, I: macroscopic anatom y - C T correlation. AJNR. 1983;4:927-935. 10. Kaufmann Β, Kaufman ΒΑ, Arafah BM, Roessmann U, Selman WR. Large pituitary gland adenomas evaluated with MRI. Neurosurgery, 1987;21:540-546. 11. Davis PC, Hoffman JC, Tindall GT, Braun IF. CT-surgical correlation in pituitary adenomas: evaluation in 113 patients. AJNR. 1985;6:711-716. 12. Saris SC, Patronas NJ, Doppmann J L , et al. Cushing's syndrome: pituitary CT scanning. Radiology. 1987;162:775-777. 13. Snow RB, Lavyne MH, Lee BCP, Morgello S, Patterson RH. Craniotomy versus transsphenoidal excision of large pituitary tumors: the usefulness of MRI in guiding the operative approach. Neurosurgery. 1986;19:59-64. 14. Dwyer AJ, Frank FA, Doppmann J L , et al. Pituitary adenomas in patients with Cushing's disease: initial experience with Gd-DTPA-enhanced MR imaging. Radiology. 1987;163:421-426. 15. Clark WC, Acker JD, Robertson J H , Eggers F, Muhlbauer MS. Reformatted sagittal images in the differential diagnosis of meningeomas and pituitary adenomas with suprasellar extension. Neurosurgery. 1986;18:555-558. 16. Floyd J L , Dorwart RH, Nelson MJ, Mueller

    on MRI or hypopituitarism or anterior pituitary hormone excess initially or at the time of follow-up, immediate neurosurgery is the treatment of choice.

    In conclusion, we describe a series of 18 patients with an incidentally detected sellar mass. These lesions seem to be heterogenous in origin, however, at least some of them represent slowly growing nonfunctional pituitary adenomas. Our preliminary results suggest that in most cases the incidentaloma of the pituitary gland is a benign condition that does not necessarily require neurosurgical intervention.

    Dedicated to Professor Doctor of Medicine Werner Kaufmann on the occasion of his 65th birthday.

    GL, DeVroede M. Pituitary hyperplasia secondary to thyroid failure: CT appearance. AJNR. 1984;5:469-471. 17. Mösli Ρ, Hedinger C. Noduläre Hyperplasie und Adenome des Hypophysenvorderlappens bei Hypothyreose. Acta Endocrinol (Copenh). 1968; 58:507-520. 18. Hungerford GD, Biggs PJ, Levine JH, Shelley E , Perot PL, Chambers JK. Lymphoid adenohypo-physitis with radiologic and clinical findings resem-bling a pituitary tumor. AJNR. 1982;3:444-446. 19. Ikeda H, Okudaira Y. Spontaneous regression of pituitary mass in temporal association with preg-nancy. Neuroradiology. 1987;29:488-492. 20. Kovacs K. Metastatic cancer of the pituitary gland. Oncology. 1973;27:533-542. 21. Earnest FIV, McCullough E C , Frank DA. Fact or artifact: an analysis of artifacts in high-resolution computed tomographic scanning of the sella. Radiology. 1981;140:109-113. 22. Gurling KJ, Scott GBD, Baron DN. Metastases in pituitary tissue removed at hypophysectomy in women with mammary carcinoma. Br J Cancer. 1957;11:519-522. 23. Kovacs K. Adenohypophysial necrosis in rou-tine autopsies. Endokrinologie. 1972;60:309-316.

    2776 JAMA, May 23/30,1990-Vol 263, No. 20 'Incidentaloma'—Reincke et al