Patient had elevated prolactin levels (22.5 ng/ml; normal 3-18.6), as well as a slightly elevated estradiol level (15 pg/ml). An LRF stimulation test with Leuprolide acetate was ordered to rule out precocious puberty, and an MRI was ordered to rule out pituitary adenoma. A neurology/oncology clinic was consulted, and at the time the prolactin and estradiol levels had returned to normal. However, the alpha fetal protein levels were mildly elevated (11.5 ng/ml; normal 0-8.5 ng/ml).
The first MRI showed a pituitary mass of 7.5 x 4.8 x 4.3 mm in height, transverse, and AP views, respectively. By age 6, the adenoma has grown to 8 x 12 x 6, but has remained stable since. Imaging shows no anterior or posterior flattening of the pituitary gland.
â€˘ Pituitary microadenoma (intrasellar pituitary cyst)
â€˘ Rathkeâ€™s Cleft Cyst Remnant
â€˘ Precoccious puberty
Dx: Spurious hyperprolactinemia, intrasellar cyst
Dx Confirmed by: Normal LRF stimulation labs ruled out precocious puberty. CSF studies ruled out a germ cell tumor for the intrasellar cyst. No calcifications, which is common in craniopharyngioma, and the absence of a suprasellar lesion rule-out craniopharyngioma.
No treatment is needed if there is no adenoma An MRI every year is required to ensure no significant growth has occurred.
The initial concern in this young child was hyper-prolactinemia from a suprasellar mass causing the "stalk effect". - LINK -
However, the imaging did not show a suprasellar mass, and the prolactin elevation was minimal. Prolactin levels due to the stalk effect are usually lower than produced by a prolactinoma. However, the values from the stalk effect will still be significantly higher than just the slightly elevated prolactin levels this patient showed (Anywhere from
100ng/ml to under 250ng/ml verses the patients 23ng/ml).
After discussing this case with a pediatric endocrinologist, his top theory was the stress caused to the patient. It could be due to the child's environment at home, or the fact the she
just had about 10 immunization shots (1 year check-ups are the worst).
Lastly, regarding the DDX. I was looking into distinguishing the cysts from the adenoma. One thought I had was that the growth of the cyst would be slower than the adenoma presented.
Followup of the child, for early detection of any visual disturbance, will prevent loss of sight in the event that the lesion grows.
The pituitary gland plays a major role of our body. It is responsible for the release of many important hormones with receptors throughout the majority of our organs. Structurally, the adult pituitary gland spans 6.0 mm superior-inferior x 9.0 mm antero-posterior x 13.0 mm mediolaterally(1). It rests in a bony saddle called the sella turcica, and is surrounded laterally by the cavernous sinuses, superiorly by the optic chiasm, hypothalamus, and sphenoid sinuses. With all of the important structures located close to the sella turcica, it is surprising that an estimated 16.7% of our population has a pituitary adenoma, most of which go undiagnosed(2). Pituitary adenomas also make up 25% of all intracranial tumors(3).
Classically, pituitary adenomas were defined radiologically based on size and degree of infiltration of surrounding tissue. This classification led to the definitions of microadenomas and macroadenomas(4). More recently, pituitary adenomas could be further broken into multiple classification schemes including functional, histologic, immunohistochemical, ultrastructural, and clincopathic(3). Furthermore, pituitary adenomas present with three categories of pathology: excessive hormone production, insufficient pituitary function, and mass effects.
This patient showed up to a 12-month checkup with premature thelarche and increased hair (hypertrichosis) on the legs. Lab results showed a minor increase in prolactin levels, as well as estradiol. An MRI showed a mass measuring 7.5 mm x 4.8 mm x 4.3 mm in height, transverse view, and AP view, respectively. At this point, the tumor could be classified as a microadenoma. However, the prolactin levels were not significantly high enough to warn of a prolactin-secreting adenoma (prolactinoma), the most common of functional pituitary adenomas (1). Instead, the adenoma could have been pressing against the pituitary stalk, causing compression of the blood vessels supplying inhibitory dopamine from the hypothalamus, an event called the â€śstalk effectâ€ť(5). This was later ruled out when both prolactin and estradiol levels normalized. The temporary elevation of prolactin could have been due to stress, and the increased estradiol levels from breast-feeding. As it turns out, this pituitary microadenoma was non-functional, which accounts for 33% of all pituitary adenomas(1).
Treatment of pituitary adenomas are tailored the to patient, and can range from control of hormone secretion, preserving normal pituitary function, and controlling tumor growth to prevent mass effects. For this patient, tumor growth was visualized annually, and changes in vision or headaches (indicating mass effects) were monitored closely.
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