Pituitary+Gland

**10% to 25% of all diagnosed intracranial tumors ** * **Usually benign but associated with substantial morbidity ** * **The sex incidence is equal ** * **These tumors are rare in childhood ** * **Incidence increases with age ** * **Prolactin-producing are the most common type ** ||
 * Epidemiology: || [[image:pituitary.jpg width="225" height="225"]] ||< **Pituitary gland tumors: ** *

Postmenopausal women * **<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Women who had their first child before the age of 20 ** * <span style="background-color: transparent; color: #002060; display: block; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Genetic syndromes: <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Multiple endocrine neoplasia 1 (MENS1) ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Carney complex (CNC) ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-align: left; text-decoration: none; vertical-align: auto;">Isolated familial acromegaly [1,2] ** ||
 * Etiology: ||  ||< <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">The etiology of pituitary tumors is largely unknown. Increased risk factors include: ** *

<span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Headache ** * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Visual field deficits ** * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Oligomenorrhea or amenorrhea; reduced fertility ** * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Loss of libido; erectile dysfunction ** * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Centripetal fat distribution ** * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Neurophychiatric symptoms; dysmorphophobia ( ****<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">a fixation on an imaginary flaw in the physical appearance) ** * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Striae ** * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Proximal myopathy ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">The __<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: underline; vertical-align: auto;">three histological subtypes __<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;"> of the pituitary tumors are: * <span style="background-color: transparent; color: lime; display: block; font-family: Times New Roman; font-size: 16px; margin-top: 0in; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">__<span style="background-color: transparent; color: windowtext; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: underline; vertical-align: auto;">Chromophobe adenomas __ ****<span style="background-color: transparent; color: windowtext; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">- **<span style="background-color: transparent; color: windowtext; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;"> (most common) these tumors are associated with non function * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-top: 12pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">__<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: underline; vertical-align: auto;">Acidophillic adenomas __ **-<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">(responsible for the growth hormone or prolactin)- these types of tumors are associated with **<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">//<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Acromegaly // **<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">-(which is when the pituitary gland produces excess growth hormone(hGH). * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-top: 12pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">__<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: underline; vertical-align: auto;">Basophilic adenomas __ **-<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">(to much ACTH which is a thyroid stimulating hormone). Basophilic adenomas are associated with **<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">//<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Cushings disease // **<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">. <span style="background-color: transparent; color: #000000; font-family: Arial; font-size: 13px; text-decoration: none; vertical-align: auto;">ACTH <span style="background-color: transparent; color: lime; font-family: Arial; font-size: 13px; text-decoration: none; vertical-align: auto;">stimulates the production and release of cortisol, a stress hormone. Too much ACTH means too much cortisol. Cortisol is normally released during stressful situations. It controls the body's use of carbohydrates fats and proteins and also helps reduce the immune system's response to swelling (inflammation). <span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">[1][2] || [8] || Grade I: Normal sized sella (15x12mm) with asymmetry of the floor. Grade II: Enlarged sella with an intact floor Grade III: Localized erosion or destruction of the sellar floor Grade IV: Diffusely eroded or destroyed floor[1] Grade I: sella of normal size, but with asymmetry Grade II: enlarged sella, but with an intact floor Grade III : localized erosion or destruction of the sella floor Grade IV: diffusely eroded floor Type A: tumor bulges into the chiasmatic cistern Type B: tumor reaches the floor of the third ventricle Type C: more voluminous tumor, with extension into the third ventricle up to the formamen of Monro. Type D: extension into temporal or frontal fossa Pituitary Gland and surrounding anatomy [2] ||
 * Signs & Symptoms: || <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Signs and symptoms of pituitary tumors vary with each specific cell type. They can be caused by the growth of the tumor and/or by hormones the tumor makes. Some tumors do not cause symptoms while others cause the following: ** *
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Growth of hands and feet; jaw growth and prognathism **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Coarsening of facial features **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Osteoarthritis and arthralgia; osteopenia **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Excessive sweating **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Tremor **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Palpitations **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Hypogonadism **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Hyperdefecation **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Insomnia **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Weight loss **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Pituitary apoplexy (vomiting, visual field defects, ocular paresis, mental deterioration, hyponatremia and syncope) **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Hirsutism **<span style="background-color: transparent; color: black; font-family: 'Arial','sans-serif'; font-size: 16px; text-decoration: none; vertical-align: auto;"> ( **<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">a condition of unwanted, male-pattern hair growth in women ****<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">) **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Skin thinning; ability to easily bruise **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Snoring and obstructive sleep apnea **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Pituitary insufficiency (secondary gonadism) **
 * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Cushing’s syndrome [1] ** ||<   ||   ||
 * Diagnostic Procedures: || || * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">History and physical exam (including examination of eyes, visual and neurological exam) **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">MRI **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">CT Scan **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Labs (blood chemistry, testosterone or estrogen levels, 24- hour urine, high and low-dose dexamethasone suppression tests) **
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Biopsy with immunohistochemistry and light and electron microscopy1 ** ||
 * Histology: || General histology discussion: <span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Pituitary adenomas often don’t correlate with tumor behavior.
 * Histology: || General histology discussion: <span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Pituitary adenomas often don’t correlate with tumor behavior.
 * Lymph Node Drainage: || Pituitary adenomas are **__ histolocially benign __** and don’t spread through the lymphatics or the bloodstream. They do locally invade or compress adjacent structures. They can travel laterally into the cavernous sinus which presses on the cranial nerves III IV and VI causing extraocular muscular dysfunction and if the optic nerve is compressed it can lead to blindness. [8] ||
 * Metastatic Spread: || * The normal pituitary gland doesn’t have lymphatics, but lymphatic spread of the pituitary tumors can occur after the tumor has invaded the skull base.
 * Malignant pituitary tumors are usually spread by local invasion and the venous system, the cerebrospinal fluid (CSF) pathways , and the lymphatics.
 * The three most common routes of spread are: local invasion, venous system, CSF.
 * Distant mets are very rare.
 * **__Spread through the venous system:__** occurs initially through the cavernous sinus; posterior spread can then occur through the petrosal veins all the way to the jugular vein. Retrograde spread through the cortical draining veins may affect the superior sagittal sinus. Systemic spread through the bloodstream has shown mets to the liver lung kidneys, hear, bones, spine, scalp, and skull
 * **__ Spread by CSF pathways: __** may involve the supratentorial, infratentorial, or spinal compartments. In the supratentorial space, the tumor may spread to the interpeduncular fossa. Spread along the cortical hemispheric surface may lead to metastases in the frontal, temporal, parietal or occipital lobes. Spread to these. lobes seems to occur more often through CSF pathways than through the bloodstream. Subarachnoid spread in the infratentorial compartment leads to metastases in the cerebellopontine angle, in the ependymal lining of the fourth ventricle, and in the cerebellum.
 * **__ ACTH secreting pituitary carcinomas: __** have a higher frequency in systemic spread mainly to the liver compared to carcinomas of the pituitary.
 * Grading: || Pituitary tumors are classified by the endocrine function and anatomic extent. There isn’t a true staging system because they are benign. They are classified as microadenomas (<10mm) and macroadenomas(>10mm) They are classified into four grades depending on whether they invade the sella or not . It also puts the tumor into four categories for suprasellar extension . An imaging/surgical classification system developed by //__Hardy and Vezina__// separates tumors into microadenomas and macroadenomas: Grade 0: Intrapituitary microadenoma with normal sellar appearance
 * Washington and leavers version**
 * Staging: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Pituitary tumors are difficult to stage with the low rate of malignancies. [1] They are classified into four grades [2]: **


 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Hardy and Vezina's Tumor Classification: **


 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Grade I=normal size sella with asymmetry **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Grade II=sella with intact floor and enlarged **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Grade III=sella floor destruction, localized erosion **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Grade IV=floor eroded diffusely **


 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Type A=Tumor bulges into chaismatic cistern **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Type B=Tumor extends to third ventricle floor **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Type C=Tumor becomes large in volume extending into third ventricle to the foramen of Monro **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Type D=Extends into frontal or temporal fossa ** ||
 * Radiation Side Effects: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif';">The side effects from pituitary radiation treatment are: swelling of the scalp, hair loss, and otitis. [1] ** ||
 * Prognosis: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif';">The cure rate after surgery is 70-90% for small adenomas. Overall, remission occurs in 80-86%, with a 10 year recurrence rate of 8-10%. [1] Radiation therapy alone has a 5 to 10 year survival rate of 85%. ** ||
 * Treatments: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Surgery: **


 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Surgery is often the only treatment for pituitary tumors. [1] Hormones bounce back to normal levels almost immediately after surgery, although function can be affected by nonfunctioning adenomas. [2] A transsphenoidal technique is used to remove the microadenomas and tumors with extension via the nose. The mortality rate for this technique is about 0.9%, a drastic increase from the 2-25% mortality rate of craniotomies, which was the technique pre-1970. **


 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">Radiation therapy: **


 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px;">Radiation therapy for pituitary tumors is somewhat controversial since these tumors can be treated definitively with surgery, although recurrence rate is high **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">without radiation. [1] Radiation therapy has been shown to reduce recurrence rates and control disease in patients that cannot have surgery, or chose not to. Patients will need post operative radiation treatment if the tumor could not be fully resected, or if other side effects from the tumor persist such as elevated hormone levels and trouble with vision. Radiation is also used to treat postoperative recurrences, or even to reirradiate recurrences in an area previously treated with radiation. [2] **

<span style="color: #e36c0a; font-family: 'Times New Roman','serif';"> || **<span style="color: #e46c0a; font-family: 'Times New Roman','serif'; font-size: 16px;">Figure 1. Field placement for arc rotation treatment. ** || >
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif';">A dose of 45-50 Gy at 1.8 Gy per day is used to treat Cushing’s disease, and doses of 50-54 Gy at 1.8 Gy per day are given to treat pituitary adenomas definitively, or post operatively. [1] Radiation treatment techniques often involve a supine patient set up with mask and chin tucked down in order to avoid dose to the eyes. The collimator may be turned to avoid the eyes as well, and dose is given through an anterior-posterior (AP) and 2 lateral fields with wedges, or multiple fields such as 5 or 7 depending on the clinic. Gamma Knife is also a popular technique to treat deep-seated tumors, as well as proton therapy, but not readily available at most clinics. **
 * TD5/5: || <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: 150%; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">TD 5/5 ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: 150%; text-align: left; text-decoration: none; text-indent: 0.5in; vertical-align: auto;">**<span style="background-color: transparent; color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">The TD 5/5 is the total dose delivered via a conventional radiation fractionation schema that will cause a minimum of 5% complication rate within 5 years. The TD 50/5 is the total dose delivered via a conventional fractionation schema that will cause a minimum of 50% complication rate within 5 years. These doses are known as normal tissue tolerance doses (NTTDs) The NTTDs are classified into mild to moderate and severe to fatal categories.<span style="background-color: transparent; color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">1 ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: 150%; text-align: left; text-decoration: none; text-indent: 0.5in; vertical-align: auto;">**<span style="background-color: transparent; color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">The volume of tissue being irradiated and the fractionation size directly affect NTTDs. Generally the whole organ can tolerate larger doses if the volume of the organ receiving dose is small. As volume increases tolerance decreases.<span style="background-color: transparent; color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"> 1  ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: 150%; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">The NTTDs of organs in the involved field according to mild to moderate and severe to fatal morbidity combined are demonstrated in Table 1. ** ||
 * 1) **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">REFERENCES: **
 * 2) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Pituitary Tumors Treatment (PDQ®). National Cancer Institute Web site. [] . Accessed May 30, 2011. **
 * 3) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Schoemaker M J, Swerdlow A J. Risk factors for Pituitary tumors: a case-control study. American Association for Cancer Research Journals Web site. [] . Accessed May 30, 2011. **
 * 4) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Chao KSC, Perez CA, Brady LW. Pituitary. In: Chao KSC, Perez CA, Brady LW, eds. //Radiation Oncology Management Decisions.// Philadelphia, PA: Lippincott Williams & Wilkins; 2002:223-233. **
 * 5) **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Washington, C.M. & Leaver, D. Overview of Radiobiology. In //Principles and Practice of Radiation Therapy.// 3rd ed. St. Louis, MO: Elsevier; 2010:80-82. **
 * 6) **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Perez C A, Halpern E C, Brady L W, Schmidt-Ullrich R K. Pituitary Cancer. In: //Principles and Practices of Radiation Oncology.// Philadelphia, PA. Lippincott Williams & Wilkins; 2008:778-796. **
 * 7) **<span style="background: white; color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Dasher BG, Vann AM. //Portal Design in Radiation Therapy//. 2nd edition. Philadelphia, PA: DWV Enterprises. 2006: 64-65. **
 * 8) **<span style="background: white; color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Elias, M. (n.d.) //Pituitary Adenomas//. CNS Clinic-Jordan website: available at: **[|**http://pituitaryadenomas.com/pituitarycarcinoma.htm**]**<span style="background: white; color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">. Accessed: June 1, 2011. **
 * 9) **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Washington CM, Leaver D. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby Elsevier; 2004: 638-644, 881-882, 912. **
 * 1) **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Washington CM, Leaver D. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby Elsevier; 2004: 638-644, 881-882, 912. **

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