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Hacioglu A, Karaca Z, Uysal S, Ozkaya HM, Kadioglu P, Selcukbiricik OS, Gul N, Yarman S, Koksalan D, Selek A, Canturk Z, Cetinarslan B, Corapcioglu D, Sahin M, Sah Unal FT, Babayeva A, Akturk M, Ciftci S, Piskinpasa H, Dokmetas HS, Dokmetas M, Sahin O, Eraydın A, Fenkci S, Ozturk S, Akarsu E, Omma T, Erkan B, Burhan S, Pehlivan Koroglu E, Saygili F, Kilic Kan E, Atmaca A, Elbuken G, Alphan Uc Z, Gorar S, Hekimsoy Z, Pekkolay Z, Bostan H, Bayram F, Yorulmaz G, Sener SY, Turan K, Celik O, Dogruel H, Ertorer E, Turhan Iyidir O, Topaloglu O, Cansu GB, Unluhizarci K, Kelestimur F. Evaluation and follow-up of patients diagnosed with hypophysitis: a cohort study. Eur J Endocrinol 2024; 191:312-322. [PMID: 39186535 DOI: 10.1093/ejendo/lvae101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/31/2024] [Accepted: 08/21/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVE Primary hypophysitis might be challenging to diagnose, and there is a lack of evidence regarding optimal treatment strategies due to rarity of the disease. We aim to investigate the clinical features and compare the outcomes of different management strategies of primary hypophysitis in a large group of patients recruited on a nationwide basis. DESIGN A retrospective observational study. METHODS The demographic, clinical, and radiologic features and follow-up data were collected in study protocol templates and analyzed. RESULTS One hundred and thirteen patients (78.8% female, median age: 36 years) were included. Lymphocytic (46.7%) and granulomatous hypophysitis (35.6%) were the prevailing subtypes out of 45 patients diagnosed after pathologic investigations. Headache (75.8%) was the most common symptom, and central hypogonadism (49.5%) was the most common hormone insufficiency. Of the patients, 52.2% were clinically observed without interventions, 18.6% were started on glucocorticoid therapy, and 29.2% underwent surgery at presentation. Headache, suprasellar extension, and chiasmal compression were more common among glucocorticoid-treated patients than who were observed. Cox regression analysis revealed higher hormonal and radiologic improvement rates in the glucocorticoid-treated group than observation group (hazard ratio, 4.60; 95% CI, 1.62-12.84 and HR, 3.1; 95% CI, 1.40-6.68, respectively). The main indication for surgery was the inability to exclude a pituitary adenoma in the presence of compression symptoms, with a recurrence rate of 9%. CONCLUSION The rate of spontaneous improvement might justify observation in mild cases. Glucocorticoids proved superior to observation in terms of hormonal and radiologic improvements. Surgery may not be curative and might be considered in indeterminate, treatment-resistant, or severe cases.
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Affiliation(s)
- Aysa Hacioglu
- Department of Endocrinology, Erciyes University Medical School, Kayseri 38039, Türkiye
| | - Zuleyha Karaca
- Department of Endocrinology, Erciyes University Medical School, Kayseri 38039, Türkiye
| | - Serhat Uysal
- Department of Endocrinology, Cerrahpasa University Medical School-Cerrahpasa, Istanbul 34098, Türkiye
| | - Hande Mefkure Ozkaya
- Department of Endocrinology, Cerrahpasa University Medical School-Cerrahpasa, Istanbul 34098, Türkiye
| | - Pınar Kadioglu
- Department of Endocrinology, Cerrahpasa University Medical School-Cerrahpasa, Istanbul 34098, Türkiye
| | | | - Nurdan Gul
- Department of Endocrinology, Istanbul University Medical School, Istanbul 34093, Türkiye
| | - Sema Yarman
- Department of Endocrinology, Istanbul University Medical School, Istanbul 34093, Türkiye
| | - Damla Koksalan
- Department of Endocrinology, Kocaeli University Medical School, Kocaeli 41001, Türkiye
| | - Alev Selek
- Department of Endocrinology, Kocaeli University Medical School, Kocaeli 41001, Türkiye
| | - Zeynep Canturk
- Department of Endocrinology, Kocaeli University Medical School, Kocaeli 41001, Türkiye
| | - Berrin Cetinarslan
- Department of Endocrinology, Kocaeli University Medical School, Kocaeli 41001, Türkiye
| | - Demet Corapcioglu
- Department of Endocrinology, Ankara University Medical School, Ankara 06230, Türkiye
| | - Mustafa Sahin
- Department of Endocrinology, Ankara University Medical School, Ankara 06230, Türkiye
| | - Fatma Tugce Sah Unal
- Department of Endocrinology, Ankara University Medical School, Ankara 06230, Türkiye
| | - Afruz Babayeva
- Department of Endocrinology, Gazi University Medical School, Ankara 06500, Türkiye
| | - Mujde Akturk
- Department of Endocrinology, Gazi University Medical School, Ankara 06500, Türkiye
| | - Sema Ciftci
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul 34180, Türkiye
| | - Hamide Piskinpasa
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul 34180, Türkiye
| | - Hatice Sebile Dokmetas
- Department of Endocrinology, Cemil Tascıoglu City Hospital, University of Health Sciences, Istanbul 34384, Türkiye
| | - Meric Dokmetas
- Department of Internal Medicine, Istanbul Medipol University Medical School, Istanbul 34214, Türkiye
| | - Onur Sahin
- Department of Internal Medicine, Istanbul Medipol University Medical School, Istanbul 34214, Türkiye
| | - Ayten Eraydın
- Department of Endocrinology, Pamukkale University Medical School, Denizli 20070, Türkiye
| | - Semin Fenkci
- Department of Endocrinology, Pamukkale University Medical School, Denizli 20070, Türkiye
| | - Sadettin Ozturk
- Department of Endocrinology, Gaziantep University Medical School, Gaziantep 27070, Türkiye
| | - Ersin Akarsu
- Department of Endocrinology, Gaziantep University Medical School, Gaziantep 27070, Türkiye
| | - Tulay Omma
- Department of Endocrinology, Ankara Training and Research Hospital, University of Health Sciences, Ankara 06230, Türkiye
| | - Buruc Erkan
- Department of Endocrinology, Basaksehir Cam and Sakura City Hospital, University of Health Sciences, Istanbul 34480, Türkiye
| | - Sebnem Burhan
- Department of Endocrinology, Basaksehir Cam and Sakura City Hospital, University of Health Sciences, Istanbul 34480, Türkiye
| | | | - Fusun Saygili
- Department of Endocrinology, Ege University Medical School, Izmir 35100, Türkiye
| | - Elif Kilic Kan
- Department of Endocrinology, Ondokuz Mayis University Medical School, Samsun 55200, Türkiye
| | - Aysegul Atmaca
- Department of Endocrinology, Ondokuz Mayis University Medical School, Samsun 55200, Türkiye
| | - Gulsah Elbuken
- Department of Endocrinology, Tekirdag Namik Kemal University Medical School, Tekirdag 59100, Türkiye
| | - Ziynet Alphan Uc
- Department of Endocrinology, Usak Research and Training Hospital, Usak 64100, Türkiye
| | - Suheyla Gorar
- Department of Endocrinology, Antalya Training and Research Hospital, Antalya 07100, Türkiye
| | - Zeliha Hekimsoy
- Department of Endocrinology, Celal Bayar University Medical School, Manisa 45030, Türkiye
| | - Zafer Pekkolay
- Department of Endocrinology, Dicle University Medical School, Diyarbakir 21280, Türkiye
| | - Hayri Bostan
- Department of Endocrinology, Diskapi Yildirim Beyazit Training and Research Hospital, University of Health Sciences, Ankara 06110, Türkiye
| | - Fahri Bayram
- Department of Endocrinology, Erciyes University Medical School, Kayseri 38039, Türkiye
| | - Goknur Yorulmaz
- Department of Endocrinology, Osmangazi University Medical School, Eskisehir 26040, Türkiye
| | - Selcuk Yusuf Sener
- Department of Endocrinology, Maltepe Medical Park Hospital, Istanbul 34846, Türkiye
| | - Kubra Turan
- Department of Endocrinology, Yildirim Beyazit University Medical School, Ankara 06800, Türkiye
| | - Ozlem Celik
- Department of Endocrinology, Acibadem University Medical School, Istanbul 34750, Türkiye
| | - Hakan Dogruel
- Department of Endocrinology, Akdeniz University Medical School, Antalya 07070, Türkiye
| | - Eda Ertorer
- Department of Endocrinology, Baskent University Medical School, Adana Hospital, Adana 01250, Türkiye
| | - Ozlem Turhan Iyidir
- Department of Endocrinology, Baskent University Medical School, Ankara Hospital, Ankara 06490, Türkiye
| | - Omercan Topaloglu
- Department of Endocrinology, Bulent Ecevit University Medical School, Zonguldak 67630, Türkiye
| | - Guven Baris Cansu
- Department of Endocrinology, Kutahya Health Science University, Kutahya 43100, Türkiye
| | - Kursad Unluhizarci
- Department of Endocrinology, Erciyes University Medical School, Kayseri 38039, Türkiye
| | - Fahrettin Kelestimur
- Department of Endocrinology, Yeditepe University Medical School, Istanbul 34718, Türkiye
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Khaleghi M, Finger G, Wu KC, Munjal V, Ghalib L, Kobalka P, Blakaj D, Dibs K, Carrau R, Prevedello D. Successful treatment of medically and surgically refractory lymphocytic hypophysitis with fractionated stereotactic radiotherapy: a single-center experience and systematic literature review. Pituitary 2024; 27:213-229. [PMID: 38270722 DOI: 10.1007/s11102-023-01367-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE To explore the potential role of focused radiotherapy in managing the lymphocytic hypophysitis (LH) refractory to medical therapy and surgery. METHOD A systematic literature review was conducted following PRISMA guidelines to identify the studies on radiation treatment for hypophysitis, along with the experience in our institution. RESULTS The study included eight patients, three from our institution and five from existing literature. The age at presentation ranged from 37 to 75 years old, with a median age of 58. The presenting symptoms involved headache in seven patients and diplopia in two patients. Pre-radiation visual field defects were noticed in four patients. All patients exhibited variable degrees of hypopituitarism before radiation, with oral corticosteroids being the initial medical treatment. Immunosuppressive therapy was attempted in two patients prior to radiation. Seven patients had a history of transsphenoidal surgery with a histologically confirmed LH. Three patients underwent stereotactic radiosurgery (SRS), while the remaining received FSRT, with a mean irradiation volume of 2.2 cm3. A single-session total dose of 12 -15 Gy was administered in the SRS group. In the FSRT group, doses ranged from 24 to 30 Gy with a median dose of 25 Gy, delivered in 2 Gy fractions. Four patients achieved a resolution of visual field defects, while another two patients demonstrated improvement in their associated focal neurologic deficits. No change in pre-existing endocrine status was shown after radiation, except in one patient. Clinical response was achieved in seven patients after a single course of radiation, while one patient required the second course. Six patients remained stable on low-dose glucocorticoid during at least a 12-month follow-up period, and one discontinued it entirely without experiencing relapse. Three patients demonstrated a complete radiologic response, while the remaining showed a partial radiologic response. CONCLUSIONS Focused radiation, including FSRT, can play a role in symptomatic relief, effective mass shrinkage, and minimizing radiation exposure to critical surrounding structures in patients with refractory LH. However, further research efforts are necessary to better clarify its effects and optimal dose planning.
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Affiliation(s)
- Mehdi Khaleghi
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Guilherme Finger
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kyle C Wu
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vikas Munjal
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Luma Ghalib
- Department of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Peter Kobalka
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Dukagjin Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ricardo Carrau
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Vakharia JD, Muhammed M, Remba-Shapiro I, Marsiglia M, Hadaway N, Chwalisz BK, Nachtigall LB. A novel approach to hypophysitis: outcomes using non-glucocorticoid immunosuppressive therapy. Eur J Endocrinol 2023; 189:309-317. [PMID: 37602514 PMCID: PMC10473830 DOI: 10.1093/ejendo/lvad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/08/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVE To determine pituitary function before and after nonglucocorticoid immunosuppressive therapy (NGIT) in subjects with hypophysitis and evaluate their clinical and radiologic outcomes. DESIGN Retrospective, longitudinal study. METHODS We reviewed a large database, selected subjects with hypophysitis treated with NGIT, and collected information on the duration of therapy, and clinical, hormonal, and radiologic outcomes. RESULTS Twelve subjects met the inclusion criteria. Five subjects had primary hypophysitis (PH), while seven had secondary hypophysitis (SH) due to an underlying systemic inflammatory disease. Mean age ± SD was 48.0 ± 15.7 years and 40.9 ± 13.0 years, for PH and SH, respectively. The majority were female (PH 60% and SH 86%). BMI ± SD at presentation was 25.2 ± 2.5 kg/m2 and 26.8 ± 6.7 kg/m2 for PH and SH, respectively. The most common symptom at presentation was fatigue (75%). All PH subjects (100%) and 2 (28.6%) SH subjects had polyuria/polydipsia. There was a significant decrease in mean pituitary stalk thickness after NGIT (P = .0051) (mean duration 16.5 ± 4.8 months). New hormone loss or recovery occurred rarely. Mycophenolate mofetil was the most used NGIT: adverse effects prompted discontinuation in 2 out of 7 subjects. CONCLUSIONS Subjects with hypophysitis receiving NGIT had stable or improved brain/pituitary magnetic resonance imaging findings with a significant decrease in pituitary stalk thickness. NGITs did not improve anterior pituitary function. Our findings suggest that NGIT may be considered as an alternative therapy for patients with hypophysitis who require immunosuppression.
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Affiliation(s)
- Janaki D Vakharia
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Maged Muhammed
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ilan Remba-Shapiro
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcela Marsiglia
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114-2696, United States
| | - Natalia Hadaway
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Bart K Chwalisz
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114-2696, United States
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114-2696, United States
| | - Lisa B Nachtigall
- Neuroendocrine Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Iglesias P, Biagetti B, Guerrero-Pérez F, Vicente A, Cordido F, Díez JJ. Executive summary of the consensus document on hypophysitis of the Neuroendocrinology Area of Knowledge of the Spanish Society of Endocrinology and Nutrition. ENDOCRINOL DIAB NUTR 2023; 70 Suppl 1:116-125. [PMID: 36894450 DOI: 10.1016/j.endien.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/14/2023] [Indexed: 03/09/2023]
Abstract
The term hypophysitis is used to designate a heterogeneous group of pituitary conditions characterized by the presence of inflammatory infiltration of the adenohypophysis, neurohypophysis, or both. Although hypophysitis are rare disorders, the most common in clinical practice is lymphocytic hypophysitis, a primary hypophysitis characterized by lymphocytic infiltration, which predominantly affects women. Other forms of primary hypophysitis are associated with different autoimmune diseases. Hypophysitis can also be secondary to other disorders such as sellar and parasellar diseases, systemic diseases, paraneoplastic syndromes, infections, and drugs, including immune checkpoint inhibitors. The diagnostic evaluation should always include pituitary function tests and other analytical tests based on the suspected diagnosis. Pituitary magnetic resonance imaging is the investigation of choice for the morphological assessment of hypophysitis. Glucocorticoids are the mainstay of treatment for most symptomatic hypophysitis.
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Affiliation(s)
- Pedro Iglesias
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Majadahonda, Madrid, Spain; Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Betina Biagetti
- Servicio de Endocrinología y Nutrición, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Fernando Guerrero-Pérez
- Servicio de Endocrinología y Nutrición, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Almudena Vicente
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Toledo, Toledo, Spain
| | - Fernando Cordido
- Servicio de Endocrinología y Nutrición, Complexo Hospitalario Universitario de A Coruña, Universidad de A Coruña, A Coruña, Spain
| | - Juan J Díez
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Majadahonda, Madrid, Spain; Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
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Honegger J, Giese S, Nasi-Kordhishti I, Donegan DM. Pregnancy-related hypophysitis revisited. Eur J Endocrinol 2023; 188:6992197. [PMID: 36655394 DOI: 10.1093/ejendo/lvad003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/17/2022] [Accepted: 01/12/2023] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The aim of the study is to assess the distinguishing features of pregnancy-related hypophysitis (PR-Hy) compared to non-pregnancy autoimmune hypophysitis and to evaluate the changing therapeutic approaches and outcomes in PR-Hy over time. DESIGN Retrospective analysis of all published cases with PR-Hy and 6 own cases. METHODS A PubMed search was performed and abstracts screened for publications with information on cases with PR-Hy from which full-text review was performed. Clinical features, diagnostic findings, and outcome in relation to treatment modalities in PR-Hy were assessed. RESULTS One hundred and forty-eight cases with PR-Hy were identified. PR-Hy was significantly delimited from non-PR-Hy by the frequent occurrence of the chiasmal syndrome (50% vs 13%, P < .0001), higher rate of intrasellar origin (94% vs 74%, P = .0005), lower rate of pituitary stalk involvement (39% vs 86%, P < .0001), and low rate of diabetes insipidus (12% vs 54%, P < .0001). The role of surgery in PR-Hy decreased over time while noninvasive treatment modalities increased. The recurrence rate after high-dose glucocorticoid therapy (33%) was high and exceeded that of surgery (2%) and conservative management (2%). In contrast to initial reports on PR-Hy, recent literature regarding outcome of mother's and child's health was positive. The frequency of spontaneous preterm delivery was not increased. Recurrent PR-Hy in a subsequent pregnancy was reported in only two females. CONCLUSION PR-Hy has distinct features that delineate the disorder from non-PR-Hy. With increasing experience in diagnosis, availability of adequate replacement therapy, and improved treatment modalities, PR-Hy has lost its threat and the outcome is encouraging.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Sabrina Giese
- Department of Neurosurgery, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | | | - Diane Mary Donegan
- Division of Endocrinology, Indiana University, Indianapolis, IN, United States
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Iglesias P, Biagetti B, Guerrero-Pérez F, Vicente A, Cordido F, Díez JJ. Resumen ejecutivo del documento de consenso sobre hipofisitis del Área de Conocimiento de Neuroendocrinología de la Sociedad Española de Endocrinología y Nutrición. ENDOCRINOL DIAB NUTR 2023. [DOI: 10.1016/j.endinu.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Rabiei MM, Ebrahimzadeh K, Davoudi Z, Bidari Zerehpoosh F, Javandoust Gharehbagh F, Sedaghati R, Lotfollahi L, Kalhor F, Alavi Darazam I. A case of pituitary gland abscess associated with granulomatous hypophysitis. BMC Neurol 2023; 23:11. [PMID: 36631799 PMCID: PMC9835326 DOI: 10.1186/s12883-023-03060-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/24/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Granulomatous hypophysitis is a rare disease that presents with chronic inflammation of the pituitary gland. In this study, we reported a case of granulomatous hypophysitis associated with a pituitary abscess. CASE PRESENTATION A 39-year-old woman presented with a 2-year history of infertility. For the past six months, she has suffered from amenorrhea, decreased libido, headaches, and vertigo. She was referred to our hospital with a suspected diagnosis of nonfunctioning pituitary adenoma based on her presentation and brain MRI findings. She underwent trans-sphenoidal surgery (TSS). Direct observation during surgery revealed drainage of malodor pus and pituitary gland abscess. The histopathological evaluation also showed granulomatous hypophysitis and neutrophilic microabscess formation. The patient was initially treated with high doses of ceftriaxone (2 g twice daily) and metronidazole (500 mg (mg) four times per day). Also, the patient received cortisol replacement therapy after the operation. After obtaining the antibiogram and culture results, the treatment regimen was continued for 4 weeks postoperatively, followed by amoxicillin-clavulanate (500/125 mg three times daily) for a total duration of 12 weeks. CONCLUSION The patient recovered uneventfully and the postoperative MRI was normal without any remnant lesions.
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Affiliation(s)
- Mohammad Mahdi Rabiei
- grid.411600.2Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kaveh Ebrahimzadeh
- grid.411600.2Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Davoudi
- grid.411600.2Department of Endocrinology, Skull Base Research Center of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farahnaz Bidari Zerehpoosh
- grid.411600.2Department of Pathology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Javandoust Gharehbagh
- grid.411600.2Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Roghayeh Sedaghati
- grid.411600.2Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Legha Lotfollahi
- grid.411600.2Department of Nephrology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Kalhor
- grid.411600.2Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ilad Alavi Darazam
- grid.411600.2Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,grid.411600.2Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Konishi M, Maegawa Y, Tani M, Asakura T, Hayashi Y, Kakuta Y, Tsutahara K, Komori K, Takao T. A case of hypogonadtropic hypogonadism due to hypophysitis discovered by secondary male infertility. IJU Case Rep 2022; 6:51-53. [PMID: 36605681 PMCID: PMC9807335 DOI: 10.1002/iju5.12548] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction The main causes of secondary male infertility are varicocele and aging. It is rarely caused by adult-onset hypopituitarism. The onset of hypopituitarism is often due to brain tumors, trauma, surgery, or congenital disorders. Case presentation A 29-year-old man was admitted to the hospital with complaints of decreased libido and semen volume, which lasted for 4 months. He had no abnormalities in adolescence and has a 2-year-old child. Blood tests showed low luteinizing hormone and follicle-stimulating hormone, and semen tests showed azoospermia. Magnetic resonance imaging T1-weighted images showed swelling and enhancement effect of the pituitary gland, and lymphocytic hypophysitis was suspected. After an Insulin-thyroid-stimulating hormone releasing hormone-luteinizing hormone-releasing hormone test, a decrease in luteinizing hormone/follicle-stimulating hormone secretion was considered. We diagnosed hypogonadotropic hypogonadism due to lymphocytic hypophysitis. Currently, the patient is being treated with a hormone replacement therapy. Conclusion We experienced a case of hypogonadotropic hypogonadism due to lymphocytic hypophysitis discovered by secondary infertility.
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Affiliation(s)
| | - Yoko Maegawa
- Department of UrologyOsaka General Medical CenterOsakaJapan
| | - Masaru Tani
- Department of UrologyOsaka General Medical CenterOsakaJapan
| | | | - Yujiro Hayashi
- Department of UrologyOsaka General Medical CenterOsakaJapan
| | - Yoichi Kakuta
- Department of UrologyOsaka General Medical CenterOsakaJapan
| | | | | | - Tetsuya Takao
- Department of UrologyOsaka General Medical CenterOsakaJapan
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Thomas J, Jain A, Chong H. Lymphocytic Hypophysitis in a Patient With Suspected Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). Cureus 2022; 14:e30178. [PMID: 36397915 PMCID: PMC9648682 DOI: 10.7759/cureus.30178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
Abstract
Lymphocytic hypophysitis (LH) is a rare, autoimmune condition that presents with a range of symptoms that must garner the attention of medical practitioners. Clinically, it is characterized by symptoms of a compressive sellar mass with varying degrees of hypopituitarism due to chronic inflammatory infiltrate of the pituitary gland. It is often seen in women in their third trimester or postpartum and is associated with other autoimmune phenomena. Our case report describes a 73-year-old female with a past medical history of hypothyroidism and hypertension, who presented with continued intermittent dizziness, fatigue, and mild subjective hearing loss for the past several months. She was referred to the emergency department due to a sodium level of 119 and was initially diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH). The patient was treated accordingly; however, she failed to show signs of improvement. Due to her clinical presentation, imaging studies, and laboratory results, the patient was suspected to have LH, which was confirmed with the improvement of her symptoms after treatment with steroids. Because of the rare occurrence and possible atypical presentation of LH, this case illustrates the importance of maintaining a high index of clinical suspicion when diagnosing a patient with an unknown cause of hyponatremia, especially in patients with coexisting autoimmune disorders.
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Wright K, Kim H, Hill T, Lee M, Orillac C, Mogar N, Pacione D, Agrawal N. Preoperative differentiation of hypophysitis and pituitary adenomas using a novel clinicoradiologic scoring system. Pituitary 2022; 25:602-614. [PMID: 35622211 DOI: 10.1007/s11102-022-01232-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE Hypophysitis can clinically and radiologically mimic other nonfunctioning masses of the sella turcica, complicating preoperative diagnosis. While sellar masses may be treated surgically, hypophysitis is often treated medically, so differentiating between them facilitates optimal management. The objective of our study was to develop a scoring system for the preoperative diagnosis of hypophysitis. METHODS A thorough literature review identified published hypophysitis cases, which were compared to a retrospective group of non-functioning pituitary adenomas (NFA) from our institution. A preoperative hypophysitis scoring system was developed and internally validated. RESULTS Fifty-six pathologically confirmed hypophysitis cases were identified in the literature. After excluding individual cases with missing values, 18 hypophysitis cases were compared to an age- and sex-matched control group of 56 NFAs. Diabetes insipidus (DI) (p < 0.001), infundibular thickening (p < 0.001), absence of cavernous sinus invasion (CSI) (p < 0.001), relation to pregnancy (p = 0.002), and absence of visual symptoms (p = 0.007) were significantly associated with hypophysitis. Stepwise logistic regression identified DI and infundibular thickening as positive predictors of hypophysitis. CSI and visual symptoms were negative predictors. A 6-point hypophysitis-risk scoring system was derived: + 2 for DI, + 2 for absence of CSI, + 1 for infundibular thickening, + 1 for absence of visual symptoms. Scores ≥ 3 supported a diagnosis of hypophysitis (AUC 0.96, sensitivity 100%, specificity 75%). The scoring system identified 100% of hypophysitis cases at our institution with an estimated 24.7% false-positive rate. CONCLUSIONS The proposed scoring system may aid preoperative diagnosis of hypophysitis, preventing unnecessary surgery in these patients.
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Affiliation(s)
- Kyla Wright
- NYU Grossman School of Medicine, NYU Langone Health, 1st Ave, New York, NY, 10016, USA
| | - Hyon Kim
- Division of Endocrinology, Metabolism and Nutrition, Rutgers-Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ, 0890, USA
| | - Travis Hill
- Department of Neurosurgery, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Matthew Lee
- Department of Radiology, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Cordelia Orillac
- Department of Neurosurgery, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Nikita Mogar
- Department of Medicine, NYU Grossman School of Medicine, 550 1st Avenue, New York, NY, 10016, USA
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, 530 1st Ave Skirball Suite 8R, New York, NY, 10016, USA
| | - Nidhi Agrawal
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA.
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Donegan D, Saeed Z, Delivanis DA, Murad MH, Honegger J, Amereller F, Oguz SH, Erickson D, Bancos I. Outcomes of Initial Management Strategies in Patients With Autoimmune Lymphocytic Hypophysitis: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2022; 107:1170-1190. [PMID: 35137155 PMCID: PMC8947799 DOI: 10.1210/clinem/dgab839] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT Lymphocytic hypophysitis (LyHy) is characterized by inflammation of the pituitary and or neuroinfundibulum and is uncommon. Treatment options include observation, high-dose glucocorticoids (HD-GCs) or surgery. Optimal first-line management strategy, however, remains unknown. OBJECTIVE This work aimed to assess response to first-line treatment options (observation, HD-GCs, or surgery) of clinically relevant outcomes (symptomatic, hormonal, and radiographic improvement) among patients with LyHy. METHODS A systematic review was conducted in 6 databases through 2020. Meta-analysis was conducted when feasible using a random-effects model. RESULTS We included 33 studies reporting on 591 patients (423 women, 72%) with LyHy. Improvement/resolution of anterior pituitary dysfunction was highest when HD-GCs was first-line treatment. Surgery was associated with the greatest proportion of patients who had regression on imaging. Subgroup analysis comparing HD-GCs to observation showed the odds of anterior pituitary hormone recovery (OR 3.41; 95% CI, 1.68-6.94) or radiographic regression (OR 3.13; 95% CI, 1.54-6.36) were higher with HD-GCs, but so was the need for additional forms of treatment (OR 4.37; 95% CI, 1.70-11.22). No statistically significant difference was seen in recovery of diabetes insipidus (OR 0.9; 95% CI, 0.26-3.10). Certainty in these estimates was very low. CONCLUSION Observation and use of HD-GCs both are successful first-line management strategies in LyHy. Although use of HD-GCs was associated with increased recovery of anterior pituitary hormone deficit, it also was associated with greater likelihood of additional treatment after withdrawal. Optimal dosing and duration of HD-GCs remains unknown.
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Affiliation(s)
- Diane Donegan
- Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana 46206, USA
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
- Correspondence: D. Donegan, MB, BCh, BAO, Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, 1120 W. Michigan St, CL 459, Indianapolis, IN 46206, USA.
| | - Zeb Saeed
- Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, Indiana 46206, USA
| | - Danae A Delivanis
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | - Juergen Honegger
- Department of Neurosurgery, University of Tübingen, 72076 Tübingen, Germany
| | - Felix Amereller
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, 80336 Munich, Germany
| | - Seda Hanife Oguz
- Department of Endocrinology and Metabolism, Hacettepe University Medical School, 06230 Ankara, Turkey
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
- I. Bancos, MD, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN 55905, USA.
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Warmbier J, Lüdecke DK, Flitsch J, Buchfelder M, Fahlbusch R, Knappe UJ, Kreutzer J, Buslei R, Bergmann M, Heppner F, Glatzel M, Saeger W. Typing of inflammatory lesions of the pituitary. Pituitary 2022; 25:131-142. [PMID: 34463941 PMCID: PMC8821060 DOI: 10.1007/s11102-021-01180-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 11/17/2022]
Abstract
Inflammatory pituitary lesions account for 1.8% of all specimens from the German Pituitary Tumor Registry. They occure in 0.5% of the autoptical specimens and in 2.2% of the surgical cases. Women are significantly more often affected than men and are often younger when first diagnosed. In general, primary and secondary inflammation can be distinguished, with secondary types occurring more frequently (75.1%) than idiopathic inflammatory lesions (15.4%). In primary inflammation, the lymphocytic type is more common (88.5%) than the granulomatous type of hypophysitis (11.5%). The most common causes of secondary inflammation are Rathke's cleft cysts (48.6%), followed by tumors (17.4%) such as the craniopharyngioma (9.1%), adenoma (5.5%) or germinoma (2.0%). More causes are tumor-like lesions (7.1%) such as xanthogranuloma (3.5%) or Langerhans histiocytosis (3.5%), abscesses (5.5%), generalized infections (5.1%), spreaded inflammations (4.7%) and previous surgeries (4.0%). In 1.6% of all specimens the reason for the inflammation remains unclear. The described classification of hypophysitis is important for specific treatment planning after surgery.
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Affiliation(s)
- J. Warmbier
- grid.13648.380000 0001 2180 3484Institute of Neuropathology of the University of Hamburg, UKE, 20246 Hamburg, Germany
| | - D. K. Lüdecke
- grid.13648.380000 0001 2180 3484Clinic of Neurosurgery of the University of Hamburg, UKE, 20246 Hamburg, Germany
| | - J. Flitsch
- grid.13648.380000 0001 2180 3484Clinic of Neurosurgery of the University of Hamburg, UKE, 20246 Hamburg, Germany
| | - M. Buchfelder
- grid.5330.50000 0001 2107 3311Clinic of Neurosurgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany
| | - R. Fahlbusch
- grid.419379.10000 0000 9724 1951International Neuroscience Institute (INI), Rudolf-Pichelmayr-Str. 4, 30625 Hannover, Germany
| | - U. J. Knappe
- grid.5570.70000 0004 0490 981XDepartment of Neurosurgery, Johannes-Wesling-Klinikum Minden, Ruhr-University Bochum (RUB), 32429 Minden, Germany
| | - J. Kreutzer
- Praxis for Neurosurgery, 90941 Nuremberg, Germany
| | - R. Buslei
- grid.419802.60000 0001 0617 3250Institute of Pathology, SozialStiftung Bamberg, 96049 Bamberg, Germany
| | - M. Bergmann
- grid.419807.30000 0004 0636 7065Institute of Neuropathology, Klinikum Bremen-Mitte, 28205 Bremen, Germany
| | - F. Heppner
- grid.6363.00000 0001 2218 4662Institute of Neuropathology of the Humboldt University of Berlin, Charitè, 10117 Berlin, Germany
| | - M. Glatzel
- grid.13648.380000 0001 2180 3484Institute of Neuropathology of the University of Hamburg, UKE, 20246 Hamburg, Germany
| | - W. Saeger
- grid.13648.380000 0001 2180 3484Institute of Neuropathology of the University of Hamburg, UKE, 20246 Hamburg, Germany
- grid.13648.380000 0001 2180 3484Institutes of Pathology and Neuropathology of the University of Hamburg, UKE, Martinistraße 52, 20246 Hamburg, Germany
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Moszczyńska E, Kunecka K, Baszyńska-Wilk M, Perek-Polnik M, Majak D, Grajkowska `W. Pituitary Stalk Thickening: Causes and Consequences. The Children's Memorial Health Institute Experience and Literature Review. Front Endocrinol (Lausanne) 2022; 13:868558. [PMID: 35669693 PMCID: PMC9163297 DOI: 10.3389/fendo.2022.868558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pituitary stalk thickening (PST) is a rare abnormality in the pediatric population. Its etiology is heterogeneous. The aim of the study was to identify important clinical, radiological and endocrinological manifestations of patients with PST and follow the course of the disease. MATERIALS AND METHODS It is a study conducted in 23 patients (13 boys) with PST with/without central diabetes insipidus (CDI) diagnosed between 1990 and 2020 at Children's Memorial Health Institute (CMHI) in Warsaw, Poland. We analyzed demographic data, clinical signs and symptoms, radiological findings, tumor markers, hormonal results, treatment protocols and outcomes. RESULTS The median age at the diagnosis of PST was 9.68 years (IQR: 7.21-12.33). The median time from the onset of the symptoms to the diagnosis was 2.17 years (IQR: 1.12-3.54). The most common initially reported manifestations were polydipsia, polyuria and nocturia (82.6%); most of the patients (56.5%) also presented decreased growth velocity. Hormonal evaluation at the onset of PST revealed: CDI (91.3%), growth hormone deficiency (GHD) (56.5%), hyperprolactinemia (39%), central hypothyroidism (34.8%), adrenal insufficiency (9%), precocious puberty (8.7%). The majority of the patients were diagnosed with germinoma (seventeen patients - 73.9%, one of them with teratoma and germinoma). Langerhans cell histiocytosis (LCH) was identified in three patients (multisystem LCH in two patients, and unifocal LCH in one patient). A single case of atypical teratoid rhabdoid tumor, suspected low-grade glioma (LGG) and lymphocytic infundibuloneurohypophysitis (LINH). The overall survival rate during the observational period was 87.0%. CONCLUSIONS The pituitary infundibulum presents a diagnostic imaging challenge because of its small size and protean spectrum of disease processes. Germinoma should be suspected in all children with PST, especially with CDI, even when neurological and ophthalmological symptoms are absent.
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Affiliation(s)
- Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Karolina Kunecka
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Marta Baszyńska-Wilk
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute, Warsaw, Poland
- *Correspondence: Marta Baszyńska-Wilk,
| | - Marta Perek-Polnik
- Department of Oncology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Dorota Majak
- Department of Diagnostic Imaging, The Children’s Memorial Health Institute, Warsaw, Poland
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Langlois F, Varlamov EV, Fleseriu M. Hypophysitis, the Growing Spectrum of a Rare Pituitary Disease. J Clin Endocrinol Metab 2022; 107:10-28. [PMID: 34528683 PMCID: PMC8684465 DOI: 10.1210/clinem/dgab672] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Indexed: 01/13/2023]
Abstract
Hypophysitis is defined as inflammation of the pituitary gland that is primary or secondary to a local or systemic process. Differential diagnosis is broad (including primary tumors, metastases, and lympho-proliferative diseases) and multifaceted. Patients with hypophysitis typically present with headaches, some degree of anterior and/or posterior pituitary dysfunction, and enlargement of pituitary gland and/or stalk, as determined by imaging. Most hypophysitis causes are autoimmune, but other etiologies include inflammation secondary to sellar tumors or cysts, systemic diseases, and infection or drug-induced causes. Novel pathologies such as immunoglobulin G4-related hypophysitis, immunotherapy-induced hypophysitis, and paraneoplastic pituitary-directed autoimmunity are also included in a growing spectrum of this rare pituitary disease. Typical magnetic resonance imaging reveals stalk thickening and homogenous enlargement of the pituitary gland; however, imaging is not always specific. Diagnosis can be challenging, and ultimately, only a pituitary biopsy can confirm hypophysitis type and rule out other etiologies. A presumptive diagnosis can be made often without biopsy. Detailed history and clinical examination are essential, notably for signs of underlying etiology with systemic manifestations. Hormone replacement and, in selected cases, careful observation is advised with imaging follow-up. High-dose glucocorticoids are initiated mainly to help reduce mass effect. A response may be observed in all auto-immune etiologies, as well as in lymphoproliferative diseases, and, as such, should not be used for differential diagnosis. Surgery may be necessary in some cases to relieve mass effect and allow a definite diagnosis. Immunosuppressive therapy and radiation are sometimes also necessary in resistant cases.
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Affiliation(s)
- Fabienne Langlois
- Department of Medicine, Division of Endocrinology, Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Elena V Varlamov
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Maria Fleseriu
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
- Correspondence: Maria Fleseriu, MD, Oregon Health & Science University, Mail Code CH8N, 3303 S Bond Ave, Portland, Oregon 97239, USA.
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Kruse M, Olesen TB, Markovic L, Glintborg D, Andersen MS. Recurrent autoimmune hypophysitis treated with rituximab: a case report. J Med Case Rep 2021; 15:591. [PMID: 34906226 PMCID: PMC8672614 DOI: 10.1186/s13256-021-03146-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/08/2021] [Indexed: 12/22/2022] Open
Abstract
Background Autoimmune hypophysitis is a rare condition that often results in enlargement of the pituitary gland and hypopituitarism due to inflammatory infiltration. Management of autoimmune hypophysitis can include long-term hormonal replacement and close control of the inflammatory pituitary mass. Mass-related symptoms in patients with autoimmune hypophysitis are treated with anti-inflammatory therapy, surgery, and/or radiotherapy. Case presentation We present a 25-year-old White man with visual field defects of the right eye, headache, and weight loss. Magnetic resonance imaging showed a sellar mass, and the patient underwent transcranial surgery. Histopathology revealed autoimmune hypophysitis with predominantly CD20 positive B-cell infiltration. Progression of visual field defects necessitated postoperatively anti-inflammatory treatment with prednisolone. Azathioprine was initiated under gradual tapering of prednisolone with stable conditions at first, but relapse followed after dose reduction. Therefore, rituximab treatment was initiated, which resulted in regression of the pituitary mass. Rituximab treatment was discontinued after 25 months. The patient has continuously been in remission for 4 years after rituximab treatment was stopped. Conclusion This case illustrates that rituximab might be an effective alternative treatment in B-cell predominant autoimmune hypophysitis.
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Affiliation(s)
- Maria Kruse
- Department of Internal Medicine, Hospital of Littlebelt, Kolding, Denmark
| | | | - Ljubo Markovic
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Dorte Glintborg
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
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Abstract
PURPOSE To present a case series of primary and immunotherapy-related secondary hypophysitis. METHODS A single-center retrospective chart review was performed at the University of British Columbia, Vancouver, Canada. Eleven cases of primary hypophysitis and 2 cases of immunotherapy-related secondary hypophysitis were included. Of the 11 primary cases, 6 were diagnosed clinically without biopsy. RESULTS In primary hypophysitis, headache was the most common presenting symptom (6/11; 55%) and stalk enlargement the prevailing radiologic sign (8/11; 73%). Central adrenal insufficiency (4/11; 36%), central hypothyroidism (4/11; 36%), and central diabetes insipidus (CDI) (4/11; 36%) were the most common pituitary deficiencies at presentation. Initial management included surgery (4/11; 36%), supraphysiologic steroids (2/11; 18%), or observation (6/11; 55%). Outcomes assessed included radiologic improvement (8/9; 89%), improvement in mass symptoms (4/7; 57%), anterior pituitary recovery (1/7; 14%), and CDI recovery (0/4; 0%). In immunotherapy-related hypophysitis either under observation or supraphysiologic steroid therapy, the inflammatory mass resolved and pituitary dysfunction persisted. CONCLUSIONS In primary hypophysitis, the inflammatory pituitary mass typically resolves and hypopituitarism persists. In the absence of severe or progressive neurologic deficits, a presumptive clinical diagnosis and conservative medical management should be attempted. In the absence of severe features, immunotherapy-related hypophysitis may be managed effectively without the use of supraphysiologic steroids.
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Affiliation(s)
- Paul Atkins
- Department of Medicine, University of British Columbia , Vancouver, BC, Canada
| | - Ehud Ur
- Department of Medicine, University of British Columbia , Vancouver, BC, Canada
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Agarwal A, Bathla G. Parasellar T2 dark sign on magnetic resonance imaging to differentiate lymphocytic hypophysitis from pituitary adenoma. Surg Neurol Int 2020; 11:239. [PMID: 32874742 PMCID: PMC7451168 DOI: 10.25259/sni_338_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/03/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Pituitary adenomas are the most common sellar masses in adults with magnetic resonance imaging (MRI) being the imaging modality of choice. Inflammatory pituitary lesions such as lymphocytic hypophysitis (LH) can mimic pituitary macroadenoma on imaging and are often misdiagnosed as such. Although the imaging appearance on most of the sequences on MRI has similar findings, LH has a characteristic dark signal on T2 images (called dark T2 sign) which can be very helpful to reliably differentiate the two conditions. Case Description: A 68-year-old woman diagnosed with a “pituitary mass” on the MR study done at an outside facility was referred to our neurosurgery department. The case was discussed at our multidisciplinary tumor board, where the possibility of an inflammatory condition mimicking tumor was considered, given the very dark signal on T2-weighted sequences. Transsphenoidal endoscopic biopsy revealed a firm rubbery mass, which histopathology demonstrated fibrous connective tissue with inflammatory cells consistent with LH. Conclusion: Dark T2 signal on MR imaging can be very helpful in demarcating inflammatory pituitary conditions like LH from pituitary macroadenomas.
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Affiliation(s)
- Amit Agarwal
- Department of Radiology, University Texas Southwestern, Dallas, Texas, United States
| | - Girish Bathla
- Department of Radiology, University of Iowa, Iowa City, Iowa, United States
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Amereller F, Küppers AM, Schilbach K, Schopohl J, Störmann S. Clinical Characteristics of Primary Hypophysitis - A Single-Centre Series of 60 Cases. Exp Clin Endocrinol Diabetes 2020; 129:234-240. [PMID: 32770534 DOI: 10.1055/a-1163-7304] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Clinical data on primary hypophysitis are still scarce. Especially non-surgical cases are underreported. We sought to analyse clinical characteristics of primary hypophysitis, particularly in clinically diagnosed patients. DESIGN Retrospective single centre study in 60 patients with primary hypophysitis. METHODS Symptoms, MRI, histopathological findings, treatment and outcomes were analysed in 12 histopathologically and 48 clinically diagnosed patients. Diagnostic criteria for clinical diagnosis were: a) MRI findings compatible with primary hypophysitis; b) course of disease excluding other differential diagnoses. Mean duration of follow-up was 69 months. RESULTS Female sex was predominant (73%). Fatigue (52%), headache (38%) and diabetes insipidus (38%) were the most frequent symptoms. 42% had a concomitant autoimmune disease. The corticotropic, thyrotropic, gonadotropic, somatotropic axis was impaired in 67%, 57%, 52%, 20%, respectively. Men had a higher number of impaired hormone axes (p=0.022) with the gonadotropic axis being affected more frequently in men (p=0.001). Infundibular thickening (56%) and space occupying lesions (46%) were typical MRI findings. Pituitary size was frequently enlarged at presentation (37%) but diminished during observation (p=0.029). Histopathologically and clinically diagnosed cases did not differ. CONCLUSIONS The cohort of clinically diagnosed patients did not differ from our histopathologically diagnosed patients or from published cohorts with predominantly surgical patients. Thus, diagnosis of primary hypophysitis using clinical criteria seems feasible.
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Affiliation(s)
- Felix Amereller
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Anna-Maria Küppers
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Katharina Schilbach
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Sylvère Störmann
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
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Gendreitzig P, Honegger J, Quinkler M. Granulomatous hypophysitis causing compression of the internal carotid arteries reversible with azathioprine and rituximab treatment. Pituitary 2020; 23:103-112. [PMID: 31748928 DOI: 10.1007/s11102-019-01005-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Compression of the internal carotid artery (ICA) in the cavernous sinus area is a rare event and is mostly associated with pituitary adenomas and meningiomas. Other causes of ICA compression are less well known. We present a rare case of granulomatous hypophysitis causing compression of the ICA, which was treated successfully with immune-suppressive agents. METHODS The electronic database MEDLINE (PubMed) was searched systematically and other cases with ICA compression were identified and analyzed. RESULTS A female patient with a history of two previous transsphenoidal operations for suspected pituitary adenoma and post-operative complete pituitary insufficiency presented with severe headaches, nausea, fatigue, and diplopia. Pituitary MRI scan suggested relapse of the pituitary lesion with atypical bilateral infiltration of cavernous sinuses and compression of ICAs. After histological reevaluation of her previous pituitary operations, granulomatous hypophysitis was diagnosed. Treatment was started with high doses of prednisolone. With decreasing doses of prednisolone, symptoms recurred, and azathioprine was started, followed by administration of rituximab resulting in clinical recovery and regression of ICA compression. Literature analysis disclosed 36 case reports with ICA compression in the cavernous sinus region (12 pituitary adenoma, 6 meningioma, 7 hypophysitis, 5 other tumors, and 4 other etiologies). Two cases of hypophysitis recovered completely; five cases improved only partly. CONCLUSION In the case of ICA compression, clinical signs, onset of symptoms, radiological findings and pituitary insufficiencies should be thoroughly evaluated, and hypophysitis should be considered as a possible cause. In our patient, treatment with azathioprine and, finally, rituximab was successful.
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Affiliation(s)
- Pauline Gendreitzig
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627, Berlin, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Marcus Quinkler
- Endocrinology in Charlottenburg, Stuttgarter Platz 1, 10627, Berlin, Germany.
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Caranci F, Leone G, Ponsiglione A, Muto M, Tortora F, Muto M, Cirillo S, Brunese L, Cerase A. Imaging findings in hypophysitis: a review. Radiol Med 2019; 125:319-328. [PMID: 31863360 DOI: 10.1007/s11547-019-01120-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/28/2019] [Indexed: 12/24/2022]
Abstract
Hypophysitis (HP) is a rare acute or chronic inflammatory condition of the pituitary gland. The greatest challenge in the management of HP is establishing a diagnosis through clinical criteria and non-invasive methods and predicting the patients' clinical outcome. The aim of this review is to describe the neuroradiological findings of this rare disease, providing some information regarding the possible differential diagnosis in order to avoid unnecessary surgery. Gadolinium-enhanced pituitary magnetic resonance imaging (MRI) is considered the neuroradiological investigation of choice. The features suggestive for HP include an enlarged triangular- or dumbbell-shaped gland with a thickened and not obviously deviated stalk, further supported by the absence of posterior pituitary bright spot on T1weighted images, particularly in patients presenting with diabetes insipidus. Contrast enhancement pattern is quite variable; dural enhancement has been reported in some cases after intravenous contrast administration. The characterization of the unusual sellar mass is not straightforward and generally results in a wide differential. HP should be primarily differentiated from pituitary adenomas (including pituitary apoplexy), from pituitary metastases, and from other sellar and parasellar tumors, e.g., craniopharyngiomas, germinomas, gliomas, lymphomas, meningiomas, pituicytomas, chordomas, teratomas, dermoids and epidermoids, Rathke's cleft cysts, and abscesses. In patients suspected for secondary forms related to systemic pathology, additional imaging is helpful in identifying other involved sites. Neuroradiologists need to know MRI appearance of this rare disease, as well as its typical symptoms and serological markers. A strict collaboration with endocrinologists and neurosurgeons is mandatory in order to reach a definitive diagnosis, allowing to promptly initiating an appropriate treatment.
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Affiliation(s)
- Ferdinando Caranci
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy.
| | - Giuseppe Leone
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Andrea Ponsiglione
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Massimo Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy.,Department of Neuroscience and Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Fabio Tortora
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Mario Muto
- Department of Neuroradiology, A.O.R.N. Cardarelli, Naples, Italy
| | - Sossio Cirillo
- Department of Precision Medicine, School of Medicine, "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco De Sanctis 1, 86100, Campobasso, Italy
| | - Alfonso Cerase
- Department of Neurological and Sensorineural Sciences, Azienda ospedaliero-universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
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21
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Romano A, Rigante D, Cipolla C. Autoimmune phenomena involving the pituitary gland in children: New developing data about diagnosis and treatment. Autoimmun Rev 2019; 18:102363. [PMID: 31401342 DOI: 10.1016/j.autrev.2019.102363] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 03/30/2019] [Indexed: 11/27/2022]
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22
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Korkmaz OP, Sahin S, Ozkaya HM, Apaydin T, Durmaz ES, Haliloglu O, Durcan E, Kadioglu P. Primary hypophysitis: Experience of a Single Tertiary Center. Exp Clin Endocrinol Diabetes 2019; 129:14-21. [PMID: 31234218 DOI: 10.1055/a-0919-4388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The authors review the clinical outcomes of patients with primary hypophysitis (PH). METHODS Patients with PH who were followed up between 2007 and 2018 at our clinic were evaluated. Clinical, endocrinologic, pathologic, radiologic findings and treatment modalities were assessed. RESULTS Seventeen patients with PH were assessed. The median follow-up was 24 (range, 6-84) months. Histologic confirmation was available in 8 patients (6 lymphocytic hypophysitis, 1 lymphocytic-granulomatous hypophysitis, 1 xanthomatous hypophysitis). None of the cases were diagnosed after pregnancy. Two patients had an autoimmune disease. The most commonly seen symptom was headache. The most common anterior pituitary deficiencies were hypocortisolemia and hypothyroidism. The radiologic findings of the patients at the time of diagnosis revealed various results including space-occupying lesion (41.2%), loss of posterior hypophysis bright spot (47.1%), pituitary stalk thickening (41.2%), uniform contrast enhancement (17.6%), partially empty sella (11.8%), optic chiasm compression (11.8%). The most frequent initial treatment modality was observation. Ten patients who were followed up conservatively had no endocrinologic deterioration; additional treatment was not needed in 8 of these 10 patients. The second most frequent initial treatment modality was pituitary surgery. Five patients received steroid treatment. We found serious adverse effects during steroid treatment in 3 of 5 (60%) patients; unilateral avascular necrosis of the femoral head (n=2), diabetes mellitus(n=1). CONCLUSION Correctly diagnosing PH and giving appropriate treatment is challenging. It is unclear whether active treatment with steroids improves clinical outcomes. The serious adverse effects of steroids are also taken into account. Observation, surgery and/or radiotherapy can be appropriate treatment modalities for selected patients.
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Affiliation(s)
- Ozge Polat Korkmaz
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Serdar Sahin
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Tugce Apaydin
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Emine Sebnem Durmaz
- Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University- Cerrahpasa, Istanbul, Turkey
| | - Ozlem Haliloglu
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Emre Durcan
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Pinar Kadioglu
- Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Division of Endocrinology, Metabolism and Diabetes, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Park HJ, Park SH, Kim JH, Kim YH. Idiopathic Granulomatous Hypophysitis with Rapid Onset: A Case Report. Brain Tumor Res Treat 2019; 7:57-61. [PMID: 31062534 PMCID: PMC6504759 DOI: 10.14791/btrt.2019.7.e22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/23/2018] [Accepted: 11/08/2018] [Indexed: 11/20/2022] Open
Abstract
Idiopathic granulomatous hypophysitis (IGH), a rare disease, requires differentiation from more common mass lesions of the sella such as pituitary adenoma, craniopharyngioma, Rathke's cleft cyst, or pituitary tuberculoma. IGH usually presents with an insidious onset of visual defects and headaches. On the other hand, rapid onset of neurologic and visual symptoms in an IGH patient is exceptionally rare. Here, we present a biopsy-proven case of IGH with rapid onset and satisfactory outcome after high dose steroid treatment.
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Affiliation(s)
- Hyun Joo Park
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Hye Park
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Pituitary Center, Seoul National University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Hwy Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Pituitary Center, Seoul National University College of Medicine, Seoul, Korea.
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24
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Gubbi S, Hannah-Shmouni F, Stratakis CA, Koch CA. Primary hypophysitis and other autoimmune disorders of the sellar and suprasellar regions. Rev Endocr Metab Disord 2018; 19:335-347. [PMID: 30547288 DOI: 10.1007/s11154-018-9480-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The pituitary gland and the hypothalamus can be affected by autoimmune-mediated structural and functional disruption. These autoimmune-mediated diseases occur more commonly in females and are often found during pregnancy or in the post-partum period. Autoimmune diseases can either affect parts of the pituitary or hypothalamus, or can involve both sellar and suprasellar structures. Most of these cases comprise primary hypophysitis (PRH). Over the years, there has been a tremendous increase in the number of reported PRH cases and related disorders, including hypophysitis induced by immune checkpoint inhibitors. With this increasing data, more light is being shed on the spectrum of clinical presentations, biochemical and imaging abnormalities of these disorders. Regardless, these disorders are still relatively rare. The clinical presentation can vary vastly, based on the type of pituitary cell or the area of the suprasellar region affected. The severity can range from clinically silent disease to progressive and rapid deterioration and death, likely due to unrecognized central adrenal insufficiency. Although biopsy remains a gold standard for diagnosing these disorders, the current standard of practice is biochemical assessment for hormonal deficiencies and imaging studies. In several instances, these disorders spontaneously resolve, but medical or surgical intervention might be necessary to treat symptomatic disease. Due to the subtlety and a vast spectrum of clinical manifestations which could often be asymptomatic, and the rarity of the occurrence of these diseases in clinical practice, the diagnosis can be easily missed which could potentially lead to substantial morbidity or mortality. Therefore, it is crucial to have a strong clinical suspicion and pursue timely biochemical and imaging studies to initiate prompt treatment. In this article, we review the various autoimmune conditions that affect the sellar and suprasellar structures, their diagnostic approach and management of these disorders.
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Affiliation(s)
- Sriram Gubbi
- Department of Endocrinology, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Fady Hannah-Shmouni
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA
| | - Constantine A Stratakis
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 20892, USA
| | - Christian A Koch
- Medicover GmbH, Berlin/Hannover, Germany.
- Carl von Ossietzky University, Oldenburg, Germany.
- Technical University of Dresden, Dresden, Germany.
- University of Louisville, Louisville, KY, USA.
- University of Tennessee Health Science Center, Memphis, TN, USA.
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25
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Joshi MN, Whitelaw BC, Carroll PV. MECHANISMS IN ENDOCRINOLOGY: Hypophysitis: diagnosis and treatment. Eur J Endocrinol 2018; 179:R151-R163. [PMID: 29880706 DOI: 10.1530/eje-17-0009] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/06/2018] [Indexed: 12/19/2022]
Abstract
Hypophysitis is a rare condition characterised by inflammation of the pituitary gland, usually resulting in hypopituitarism and pituitary enlargement. Pituitary inflammation can occur as a primary hypophysitis (most commonly lymphocytic, granulomatous or xanthomatous disease) or as secondary hypophysitis (as a result of systemic diseases, immunotherapy or alternative sella-based pathologies). Hypophysitis can be classified using anatomical, histopathological and aetiological criteria. Non-invasive diagnosis of hypophysitis remains elusive, and the use of currently available serum anti-pituitary antibodies are limited by low sensitivity and specificity. Newer serum markers such as anti-rabphilin 3A are yet to show consistent diagnostic value and are not yet commercially available. Traditionally considered a very rare condition, the recent recognition of IgG4-related disease and hypophysitis as a consequence of use of immune modulatory therapy has resulted in increased understanding of the pathophysiology of hypophysitis. Modern imaging techniques, histological classification and immune profiling are improving the accuracy of the diagnosis of the patient with hypophysitis. The objective of this review is to bring readers up-to-date with current understanding of conditions presenting as hypophysitis, focussing on recent advances and areas for future development. We describe the presenting features, investigation and diagnostic approach of the patient with likely hypophysitis, including existing conventional techniques and those in the research/development arena. Hypophysitis usually results in acute and persistent pituitary hormone deficiency requiring long-term replacement. Management of hypophysitis includes control of the inflammatory pituitary mass using a variety of treatment strategies including surgery and medical therapy. Glucocorticoids remain the mainstay of medical treatment but other immunosuppressive agents (e.g. azathioprine, rituximab) show benefit in some cases, but there is a need for controlled studies to inform practice.
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Affiliation(s)
- Mamta N Joshi
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Benjamin C Whitelaw
- Department of Endocrinology, Kings College Hospital NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College Hospital London, London, UK
| | - Paul V Carroll
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences & Medicine, King's College Hospital London, London, UK
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26
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Faje AT, Lawrence D, Flaherty K, Freedman C, Fadden R, Rubin K, Cohen J, Sullivan RJ. High-dose glucocorticoids for the treatment of ipilimumab-induced hypophysitis is associated with reduced survival in patients with melanoma. Cancer 2018; 124:3706-3714. [PMID: 29975414 DOI: 10.1002/cncr.31629] [Citation(s) in RCA: 312] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/01/2018] [Accepted: 04/24/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND It remains unclear whether high doses of glucocorticoids have a negative impact on the efficacy of checkpoint inhibitors. To control for the potential association between immune-related adverse events (irAEs) and improved survival, this study examined a unique cohort of patients who had the same irAE treated with varying glucocorticoid doses. METHODS In total, 98 patients with melanoma who had ipilimumab-induced hypophysitis were identified retrospectively in the Partners Healthcare system using an automated electronic medical record query tool. Patients with melanoma who received ipilimumab at Massachusetts General Hospital without developing hypophysitis were listed in an actively maintained institutional patient database. Glucocorticoid doses for patients with hypophysitis were categorized as low dose (LD) or high dose (HD). Survival analyses were performed for patients who received ipilimumab monotherapy. RESULTS Both overall survival (OS) and the time to treatment failure were significantly longer in the LD group compared with the HD group (hazard ratio, 0.24; P = .002 and 0.28, P = .001, respectively). Median OS and the time to treatment failure were not reached in the LD group and were 23.3 and 14.5 months, respectively, in the HD group. All patients who had hypophysitis had improved OS compared with patients who did not have hypophysitis (median, 28.2 vs 9.5 months; P = .0003). This advantage was maintained in the HD group versus the nonhypophysitis group (P = .02). Radiologic and endocrinologic outcomes and symptom resolution did not differ in the LD group versus the HD group. CONCLUSIONS Among patients with melanoma who had ipilimumab-induced hypophysitis, those who received higher doses of glucocorticoids had reduced survival. This is the first study to demonstrate a potential negative effect of high glucocorticoid doses on the efficacy of checkpoint inhibitors after an irAE. These findings have potential implications for the management of other irAEs.
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Affiliation(s)
- Alexander T Faje
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Donald Lawrence
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Keith Flaherty
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Christine Freedman
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Riley Fadden
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Krista Rubin
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Justine Cohen
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan J Sullivan
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts
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27
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El Malik EFB, Manoranjan B, Ajani O, Zidan A. Hypophysitis Due to Paranasal Sinusitis: Neurosurgical Perspective from Developing World. World Neurosurg 2018; 115:162-165. [PMID: 29678705 DOI: 10.1016/j.wneu.2018.04.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Sinusitis is a common clinical condition, but sphenoid sinusitis is a less common form and even rarer is hypophysitis as a complication of the latter. Clinically, hypophysitis may mimic a pituitary neoplasm in presenting with mass effect and pituitary hormone dysfunction. CASE DESCRIPTION We present 5 cases of sinusitis-related hypophysitis treated at the Royal Care International Hospital in Khartoum, Sudan. Clinical symptoms at presentation included headache, fever, ptosis, ophthalmoplegia, and history of sinusitis with running nose (nasal discharge). None of the patients were immunocompromised or showed signs of meningitis. Laboratory tests indicated neutrophilia and elevated inflammatory indices, namely C-reactive protein and erythrocyte sedimentation rate. There was also a disturbance of the hypothalamic-pituitary hormone axis, particularly impaired cortisol level. Magnetic resonance imaging scans on all patients revealed swollen masses in the pituitary fossa and enhancement of the sellar region and paranasal sinuses, especially the sphenoid sinus. All cases were empirically treated with hydrocortisone and amoxicillin-clavulanate, resulting in reversal of symptoms. CONCLUSIONS Sinusitis is common in tropical regions where the climate is usually warm and often hot and dry. Here, the condition is considered a common incidental finding in magnetic resonance imaging examinations done for various indications. Hence it is not considered to be a serious health problem. Though our cohort of cases is small, we emphasize the importance of keeping a high index of suspicion for the diagnosis of hypophysitis in relevant case settings. This would help make an early diagnosis and ensure appropriate medical, perhaps nonsurgical, management.
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Affiliation(s)
| | - Branavan Manoranjan
- Department of Surgery, Michael G. DeGroote School of Medicine McMaster University, Hamilton, Ontario, Canada
| | - Olufemi Ajani
- Department of Surgery, Michael G. DeGroote School of Medicine McMaster University, Hamilton, Ontario, Canada
| | - Ahmed Zidan
- Department of Surgery, Royal Care International Hospital, Khartoum, Sudan
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28
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Youssef A, Ali R, Marouf M. Granulomatous hypophysitis in a postpartum patient: A case report. COGENT MEDICINE 2018. [DOI: 10.1080/2331205x.2018.1428034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Alexey Youssef
- Faculty of Medicine, Tishreen University, MED Research Team, Lattakia, Syria
| | - Rahaf Ali
- Faculty of Medicine, Tishreen University, MED Research Team, Lattakia, Syria
| | - Maya Marouf
- Faculty of Medicine, Tishreen University, MED Research Team, Lattakia, Syria
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29
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Joint approach based on clinical and imaging features to distinguish non-neoplastic from neoplastic pituitary stalk lesions. PLoS One 2017; 12:e0187989. [PMID: 29140989 PMCID: PMC5687750 DOI: 10.1371/journal.pone.0187989] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/30/2017] [Indexed: 02/06/2023] Open
Abstract
Purpose Distinguishing non-neoplastic pituitary stalk lesions (non-NPSLs) from neoplastic pituitary stalk lesions (NPSLs) is a major concern in guiding treatment for a thickened pituitary stalk. Our study aimed to aid provide preoperative diagnostic assistance by combining clinical and magnetic resonance imaging (MRI) findings to distinguish non-NPSLs from NPSLs. Materials and methods We recruited 158 patients with thickened pituitary stalk lesions visible on MRI. Laboratory findings included hypopituitarism, diabetes insipidus (DI), and hyperprolactinemia. MR images were assessed for anterior–posterior thickness (mm), diffuse pituitary stalk thickening, cystic changes, a high T1 signal, and glandular or extrasellar involvement. A diagnostic model was developed using a recursive partitioning logistic regression analysis. The model was validated in an independent dataset comprising 63 patients, and its diagnostic performance was compared with that of the original radiological reports. Results A univariate analysis found significant associations of DI (P = 0.006), absence of extrasellar involvement (P = 0.002), and lower stalk thickness (P = 0.031) with non-NPSLs. A diagnostic model was created using the following parameters (in order of priority): 1) lack of extrasellar involvement, 2) stalk thickness < 5.3 mm, and 3) presence of DI. The diagnostic performance (area under the curve; AUC) of this model in the independent set was 0.813, representing a significant improvement over the original radiological reports (AUC: 0.713, P = 0.029). Conclusion The joint diagnostic approach based on clinical and imaging-based factors robustly distinguished non-NPSLs from NPSLs. This approach could guide treatment strategies and prevent unnecessary surgery in patients with non-NPSL.
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30
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Wang S, Wang L, Yao Y, Feng F, Yang H, Liang Z, Deng K, You H, Sun J, Xing B, Jin Z, Wang R, Pan H, Zhu H. Primary lymphocytic hypophysitis: Clinical characteristics and treatment of 50 cases in a single centre in China over 18 years. Clin Endocrinol (Oxf) 2017; 87:177-184. [PMID: 28423475 DOI: 10.1111/cen.13354] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/28/2017] [Accepted: 04/12/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Primary lymphocytic hypophysitis (LYH) is rare, and it is often evaluated in a small case series. This study aimed to describe the diagnosis and treatment of primary LYH in a larger cohort. DESIGN A retrospective study of the diagnosis and treatment of primary LYH was conducted at Peking Union Medical College Hospital from 1999 to 2016. PATIENTS Fifty patients (28 histologically diagnosed and 22 clinically-diagnosed) were eligible for inclusion. MEASUREMENTS Clinical, endocrine, pathological and imaging findings; therapies and outcomes were assessed. Ordinal logistic regression analysis was used to evaluate the association between the clinical parameters and outcomes (eg, improvements in pituitary function, regression of lesion size on MRI and disease recurrence). RESULTS Central diabetes insipidus (CDI) (72.0%) was the most common endocrine dysfunction. Hypogonadotropic hypogonadism was the most frequently observed (60.0%) manifestation of anterior pituitary dysfunction; adrenal insufficiency was the third most common (26.0%) manifestation; and IGF-1 axis defects were the least frequent (22.0%). Thickening of the pituitary stalk was the most frequent (96.0%) imaging finding, and 78.0% of the patients exhibited both intrasellar and suprasellar expansion. Pharmacological dose of glucocorticoids was identified to be significantly associated with increased odds of anterior pituitary function improvement. No observed covariates were significantly associated with improvement of CDI and recurrence. CONCLUSION The sequence of anterior pituitary deficiencies in Chinese primary LYH patients was atypical (LH/FSH>TSH>ACTH>IGF-1 axis deficiency). A pharmacological dose of glucocorticoids was significantly associated with the improved anterior pituitary insufficiency.
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Affiliation(s)
- Shuchang Wang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Linjie Wang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng Feng
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongbo Yang
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhiyong Liang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Sun
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zimeng Jin
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Pan
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health and Family Planning Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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31
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Cerebral Vasospasm Following Transsphenoidal Hypophysectomy in the Treatment of Lymphocytic Hypophysitis. J Craniofac Surg 2017; 27:988-91. [PMID: 27244208 DOI: 10.1097/scs.0000000000002672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cerebral vasospasm following transsphenoidal hypophysectomy is an exceedingly rare but serious complication with high morbidity and mortality. The initial signs and symptoms of cerebral vasospasm following transsphenoidal hypophysectomy are changes in mental status, motor deficits, and speech difficulties. Symptomatic vasospasm is difficult to reverse despite treatment and often only resolves with time. Furthermore, most transsphenoidal hypophysectomy patients have been discharged before the onset of vasospasm, so when they do present it is often in a fulminant form and recalcitrant to available treatments.All previously reported patients of cerebral vasospasm following transsphenoidal hypophysectomy were status postresection of a pituitary macroadenoma. The authors report the first patient of vasospasm following transsphenoidal hypophysectomy in the treatment of lymphocytic hypophysitis; a rare inflammatory disorder characterized by lymphocytic infiltration of the pituitary gland causing destruction glandular tissue.
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32
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Tortosa F, Webb SM. Novel aspects in histopathology of the pituitary gland. ACTA ACUST UNITED AC 2017; 64:152-161. [PMID: 28440754 DOI: 10.1016/j.endinu.2016.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/01/2016] [Accepted: 10/03/2016] [Indexed: 11/16/2022]
Abstract
The sellar and parasellar region is a complex anatomical area in which several diseases may develop. The pituitary gland may be affected by a wide range of conditions having similar clinical characteristics. Diagnosis of these lesions requires a multidisciplinary approach including, in addition to clinical, laboratory, imaging, and surgical findings, histological diagnosis of pituitary adenomas to guide therapeutic management. As the result of development in recent years of new immunohistochemical techniques, histopathological classification has become more complex and wide, and not only continues to be the gold standard in diagnosis, but also has prognostic implications. The aim of this review is to provide a clear and simple update of the main concepts of histological diagnosis of the most common pituitary conditions, especially for professionals in direct contact with such diseases.
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Affiliation(s)
- Francisco Tortosa
- Servicio de Anatomía Patológica, CHLN, EPE - Hospital de Santa María, Lisboa, Portugal; Departamento de Medicina/Endocrinología, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Centro de Investigación Biomédica En Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, España.
| | - Susan M Webb
- Departamento de Medicina/Endocrinología, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Centro de Investigación Biomédica En Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, España
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Vallecillos FJT, Fernández SO. Histopathological features of post-mortem pituitaries: A retrospective analysis. Rev Assoc Med Bras (1992) 2017; 62:399-406. [PMID: 27656848 DOI: 10.1590/1806-9282.62.05.399] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/25/2015] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE As a result of the use of neuroimaging techniques, silent pituitary lesions are diagnosed more and more frequently; however, there are few published post-mortem studies about this gland. Incidence data of pituitary lesions are rare and in Portugal they are outdated or even non-existent. The aim of this study is to determine the prevalence of normal patterns and incidental post-mortem pituitary pathology at Centro Hospitalar Lisboa Norte, analyzing the associations with clinical data and assessing the clinical relevance of the findings. METHOD We reviewed retrospectively and histologically 167 pituitaries of a consecutive series of autopsies from the Department of Pathology of this centre. They were done between 2012 and 2014, and in all cases medical records were reviewed. The morphological patterns observed, were classified into three major groups: 1) Normal histological patterns and variants; 2) Infectious-inflammatory pathology, metabolic and vascular disorders; 3) Incidental primary proliferation and secondary to systemic diseases. RESULTS The subjects included in this study were of all age groups (from 1 day to 91 years old), 71 were female and 96 male. Fifty-seven of these glands didn't show any alteration; 51 showed colloid cysts arising from Rathke cleft; 44 presented hyperplasia in adenohypophysis and we identified 20 adenomas in 19 glands (immunohistochemically, eight PRL-producing and five ACTH-producing tumors), ten of which associated with obesity, 11 to hypertension and six to diabetes mellitus. There were two cases with metastasis. CONCLUSION Subclinical pathology in our country is similar to that seen in other parts of the world, but at older ages.
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Affiliation(s)
- Francisco José Tortosa Vallecillos
- MD, specialist in Pathological Anatomy - Department of Pathology, Centro Hospitalar Lisboa Norte, Lisboa. Lecturer, Faculdade de Medicina, Universidade de Lisboa. PhD Student at the Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Santiago Ortiz Fernández
- MD, specialist in Pathological Anatomy - Department of Pathology, Centro Hospitalar Lisboa Norte, Lisboa. Lecturer, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Somma T, Solari D, Beer-Furlan A, Guida L, Otto B, Prevedello D, Cavallo LM, Carrau R, Cappabianca P. Endoscopic Endonasal Management of Rare Sellar Lesions: Clinical and Surgical Experience of 78 Cases and Review of the Literature. World Neurosurg 2017; 100:369-380. [DOI: 10.1016/j.wneu.2016.11.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 11/10/2016] [Accepted: 11/12/2016] [Indexed: 12/28/2022]
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Clinical Interrogation for Unveiling an Isolated Hypophysitis Mimicking Pituitary Adenoma. World Neurosurg 2017; 99:735-744. [DOI: 10.1016/j.wneu.2016.07.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 01/29/2023]
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Tortosa F, Webb SM. Novel aspects in histopathology of the pituitary gland. ENDOCRINOLOGIA, DIABETES Y NUTRICION 2017; 64:152-161. [PMID: 28440754 DOI: 10.1016/j.endien.2017.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/01/2016] [Accepted: 10/03/2016] [Indexed: 05/23/2023]
Abstract
The sellar and parasellar region is a complex anatomical area in which several diseases may develop. The pituitary gland may be affected by a wide range of conditions having similar clinical characteristics. Diagnosis of these lesions requires a multidisciplinary approach including, in addition to clinical, laboratory, imaging, and surgical findings, histological diagnosis of pituitary adenomas to guide therapeutic management. As the result of development in recent years of new immunohistochemical techniques, histopathological classification has become more complex and wide, and not only continues to be the gold standard in diagnosis, but also has prognostic implications. The aim of this review is to provide a clear and simple update of the main concepts of histological diagnosis of the most common pituitary conditions, especially for professionals in direct contact with such diseases.
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Affiliation(s)
- Francisco Tortosa
- Servicio de Anatomía Patológica, CHLN, EPE - Hospital de Santa María, Lisboa, Portugal; Departamento de Medicina/Endocrinología, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Centro de Investigación Biomédica En Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, España.
| | - Susan M Webb
- Departamento de Medicina/Endocrinología, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Centro de Investigación Biomédica En Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Universitat Autònoma de Barcelona (UAB), Barcelona, España
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Kleinschmidt-DeMasters BK. Histological features of pituitary adenomas and sellar region masses. Curr Opin Endocrinol Diabetes Obes 2016; 23:476-484. [PMID: 27763894 DOI: 10.1097/med.0000000000000293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Most pituitary region masses are pituitary adenomas; however, when other sellar region masses are encountered by clinicians or pathologists, the differential diagnosis can be broad. This review will focus on updates for pituitary adenomas, as well as briefly discuss some of these other entities: Rathke cleft cyst, hypophysitis, craniopharyngioma, pituicytoma, and spindle cell oncocytoma. RECENT FINDINGS The use of new immunohistochemical (IHC) tools for assessing transcription factors, pituitary transcription factor-1, steroidogenic factor-1, and the not-yet-widely available Tpit IHC have provided insights into origin particularly of clinically silent and even hormone-negative pituitary adenomas. IHC for keratins coupled with use of E-cadherin IHC can serve to easily identify sparsely granulated growth hormone adenomas that behave more aggressively and may not respond well to some therapies. Thyroid transcription factor-1 IHC has shown common embryological lineage of pituicytoma, spindle cell oncocytoma, and granular cell tumor of neurohypophysis. SUMMARY IHC supplements classification of pituitary adenoma subtypes for clinicians and can confirm diagnosis of nonpituitary adenoma sellar region masses.
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The sellar and suprasellar region: A “hideaway” of rare lesions. Clinical aspects, imaging findings, surgical outcome and comparative analysis. Clin Neurol Neurosurg 2016; 149:154-65. [DOI: 10.1016/j.clineuro.2016.08.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/09/2016] [Accepted: 08/11/2016] [Indexed: 11/22/2022]
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Abstract
Hypophysitis is the acute or chronic inflammation of the pituitary gland. The spectrum of hypophysitis has expanded in recent years with the addition of two histologic subtypes and recognition as a complication of treatment with immune checkpoint inhibitors. Despite the increased number of published cases, the pathogenesis of hypophysitis is poorly understood, and treatment strategies are diverse and controversial. The diagnosis of hypophysitis generally requires histopathologic confirmation. The presentation and clinical course of hypophysitis varies. Hypophysitis can resolve spontaneously, relapse may occur, and some cases can be refractory to treatment.
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Affiliation(s)
- Alexander Faje
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA
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Guo S, Wang C, Zhang J, Tian Y, Wu Q. Diagnosis and management of tumor-like hypophysitis: A retrospective case series. Oncol Lett 2015; 11:1315-1320. [PMID: 26893737 PMCID: PMC4734295 DOI: 10.3892/ol.2015.4046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/03/2015] [Indexed: 01/08/2023] Open
Abstract
Tumor-like hypophysitis is an uncommon sellar condition that presents as inflammatory lesions on the structures of the pituitary gland. The diagnosis and management of hypophysitis poses a significant challenge, as its clinical manifestation and appearance in imaging studies are difficult to distinguish from that of pituitary tumors. The present retrospective study summarizes two rare cases of primary granulomatous hypophysitis, two cases of lymphocytic hypophysitis, and three cases in which a pathological diagnosis was not determined due to the use of hormone replacement therapy only. The mean age of the patients studied was 45.71±22.16 years, and the patients comprised two males and five females. The clinical signs of hypophysitis included headache, fever, gradual decrease in visual acuity, nausea and vomiting. Enhanced magnetic resonance imaging revealed sellar and pituitary stalk lesions, with iso- or hypodense signals on T1-weighted images. Transsphenoidal surgery was performed in three cases. It was challenging to diagnose hypophysitis due to the lack of any significant specific clinical signs. A transsphenoidal biopsy with fast-frozen pathology is able to diagnose hypophysitis. Glucocorticoid therapy may be a potential treatment for hypophysitis, as complete removal of pituitary masses may disable pituitary function.
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Affiliation(s)
- Songxue Guo
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China; Department of Burns, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Chaohui Wang
- Department of Neurosurgery, Ruian People's Hospital, Wenzhou, Zhejiang 325200, P.R. China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Yong Tian
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310005, P.R. China
| | - Qun Wu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
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Sellayah R, Gonzales M, Fourlanos S, King J. Lymphocytic hypophysitis in the elderly. J Clin Neurosci 2015; 22:1842-3. [DOI: 10.1016/j.jocn.2015.03.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022]
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Allix I, Rohmer V. Hypophysitis in 2014. ANNALES D'ENDOCRINOLOGIE 2015; 76:585-94. [DOI: 10.1016/j.ando.2015.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/07/2015] [Accepted: 08/04/2015] [Indexed: 12/24/2022]
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Abstract
PURPOSE The authors review their treatment experience and summarize clinical outcomes for patients with hypophysitis over the past 15 years. METHODS A retrospective analysis was conducted on patients with lymphocytic, granulomatous or IgG4-related hypophysitis treated from 1997 to 2014 at a single academic center. Patients' medical records were reviewed and binary logistic regression analysis was used to assess whether various clinical parameters were associated with improved outcomes including endocrine function, radiographic appearance and disease recurrence. RESULTS Twenty-one patients (13 women and 8 men) were identified with a median diagnosis age of 37.4 years. All but two patients (90%) were diagnosed histopathologically and the remaining two were diagnosed clinically with lymphocytic hypophysitis. 16 patients (76%) had lymphocytic hypophysitis, 3 (14%) had granulomatous hypophysitis, 1 (5%) had IgG4-related hypophysitis and 1 (5%) had mixed lymphocytic-granulomatous. Patients presented with various symptoms of expanding sellar mass with most common signs including headache (57%), polyuria/polydipsia (52%), vision changes (52%) and amenorrhea or decreased libido (48%). Pre-treatment endocrine evaluation revealed that 12 (57%) patients had complete anterior hypopituitarism, 11 patients (52%) had diabetes insipidus, ten patients (48%) had mild hyperprolactinemia and three patients (14%) had isolated endocrine axis deficiencies with partial gland function. We observed a broad diversity in pre-treatment imaging with common findings including uniform contrast enhancement (62%), thickened infundibulum (57%) and loss of hypophysis bright spot on T1 imaging (43%). Patients were treated with steroids and hormone supplementation as needed. 16 patients (76%) had recorded post-treatment MRI scans which revealed that half had radiographic improvement and half had stable or worsened post-treatment imaging. Only female gender was found to significantly predict improved odds of post-steroid radiographic improvement. For post-treatment endocrine evaluation, six patients (29%) did not have an evaluation on record, four patients (19%) had some improvement in at least one axis, seven patients (33%) had stable but non-worsened endocrine function and four patients (19%) had worsened endocrine function post-steroids. CONCLUSIONS Hypophysitis is an increasingly recognized diagnosis that can present with a broad array of radiographic and clinical features. Surgical biopsy can be helpful to make definitive diagnosis and may guide treatment decision-making.
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Affiliation(s)
- Brandon S Imber
- Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Ave. Room M779, San Francisco, CA, 94143, USA
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Honegger J, Schlaffer S, Menzel C, Droste M, Werner S, Elbelt U, Strasburger C, Störmann S, Küppers A, Streetz-van der Werf C, Deutschbein T, Stieg M, Rotermund R, Milian M, Petersenn S. Diagnosis of Primary Hypophysitis in Germany. J Clin Endocrinol Metab 2015; 100:3841-9. [PMID: 26262437 DOI: 10.1210/jc.2015-2152] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Representative data on diagnostic findings in primary hypophysitis (PrHy) are scarce. OBJECTIVE The objective of the study was to collate consistent data on clinical features in a large series of patients with PrHy. Another objective was to gain information on current practice in a diagnostic work-up. DESIGN The Pituitary Working Group of the German Society of Endocrinology conducted a nationwide retrospective cross-sectional cohort study in Germany. PATIENTS Seventy-six patients with PrHy were identified. MAIN OUTCOME MEASURES Clinical and endocrinological features were assessed. RESULTS Headache (50%) and increase in body mass (18%) were the most frequent nonendocrine symptoms. Hypophysitis was associated with pregnancy in only 11% of the female patients. Diabetes insipidus was found in 54% of the patients at presentation. Hypogonadotropic hypogonadism was the most frequent endocrine failure (62%), whereas GH deficiency was the least frequent (37%). With 86%, thickening of the pituitary stalk was the prevailing neuroradiological sign. Compared with surgical cases, the cases without histological confirmation presented more often with suprasellar lesions and had less severe nonendocrine symptoms. Granulomatous hypophysitis was associated with more severe clinical symptoms than lymphocytic hypophysitis. Examination of cerebrospinal fluid was predominantly performed in participating neurosurgical centers, whereas thyroid antibodies were almost exclusively assessed in endocrinological centers. CONCLUSION In contrast to the literature, hypogonadism was found to be the most frequent endocrine failure in PrHy. Weight gain was identified as a clinical sign of PrHy. In the majority of patients, PrHy can be reliably identified by characteristic clinical signs and symptoms, obviating histological confirmation. The diagnostic approach should be standardized in PrHy.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sven Schlaffer
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christa Menzel
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Michael Droste
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sandy Werner
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Ulf Elbelt
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christian Strasburger
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Sylvère Störmann
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Anna Küppers
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Christine Streetz-van der Werf
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Timo Deutschbein
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Mareike Stieg
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Monika Milian
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
| | - Stephan Petersenn
- Department of Neurosurgery (J.H., M.M.), University of Tuebingen, 72076 Tuebingen, Germany; Department of Neurosurgery (S.Sc., C.M.), University of Erlangen-Nuremberg, 91054 Erlangen, Germany; Endocrine Practice (M.D., S.W.), 26122 Oldenburg, Germany; Department of Endocrinology, Diabetes, and Nutrition (U.E., C.S.), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany; Department of Medicine IV (S.St., A.K.), Campus Innenstadt, University of Munich, 80336 Munich, Germany; Division of Endocrinology and Diabetes (C.S.v.d.W.), RWTH Aachen University, 52074 Aachen, Germany; Endocrine and Diabetes Unit (T.D.), Department of Medicine I, University Hospital Würzburg, 97080 Würzburg, Germany; Max Planck Institute of Psychiatry (M.S.), 80804 Munich, Germany; Department of Pituitary Surgery/Interdisciplinary Endocrinology (R.R.), UKE Hamburg, 20246 Hamburg, Germany; and ENDOC Center for Endocrine Tumors (S.P.), 20357 Hamburg, Germany
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Krause ML, Norgan A, Vella A, Beckman TJ, Warrington KJ. Concomitant giant cell arteritis and secondary adrenal insufficiency. Scand J Rheumatol 2015; 44:517-9. [PMID: 26169623 DOI: 10.3109/03009742.2015.1046913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- M L Krause
- a Division of Rheumatology , Department of Internal Medicine , Rochester , MN , USA
| | - A Norgan
- b Department of Anatomic and Clinical Pathology , Rochester , MN , USA
| | - A Vella
- c Division of Endocrinology , Department of Internal Medicine , Rochester , MN , USA
| | - T J Beckman
- d Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - K J Warrington
- a Division of Rheumatology , Department of Internal Medicine , Rochester , MN , USA
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Kleinschmidt-DeMasters BK, Lopes MBS, Prayson RA. An Algorithmic Approach to Sellar Region Masses. Arch Pathol Lab Med 2015; 139:356-72. [DOI: 10.5858/arpa.2014-0020-oa] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
Most sellar region masses (85%–90%) are pituitary adenomas; however, other neoplasms or even inflammatory or cystic nonneoplastic lesions may occasionally be encountered in this location. A practical, non–electron-microscopically based approach is essential for the daily practice of diagnosing and subclassifying adenomatous and nonadenomatous sellar region lesions.
Objective
To provide an algorithmic approach to sellar region masses for the pathologist and to formulate a cost-effective, limited panel of stains and immunostains that can be used in daily practice at most small to medium-sized centers.
Design
Pool collective experience of 3 neuropathologists practicing at academic medical centers with expertise in diagnosis and treatment of sellar region masses to craft a single-page algorithmic diagram and to liberally illustrate the range of lesions present in the sellar region.
Results
After formulating a differential diagnosis, the general pathologist can generate a confident final diagnosis of adenoma using 1 histochemical (reticulin) and 1 immunohistochemical (synaptophysin) stain, supplemented by 5 immunohistochemical stains (CAM5.2, follicle-stimulating hormone, growth hormone, prolactin, and adrenocorticotropic hormone), which provide subtyping of the adenoma in the overwhelming majority of examples. CAM5.2 and clinical information further help identify clinically aggressive variants such as sparsely granulated growth hormone adenomas and silent adrenocorticotropic hormone adenomas, respectively. MIB-1, thyroid transcription factor 1, and S-100 protein can be of further assistance in select cases where increased mitotic activity or possible nonadenomatous spindle cell lesions are suspected.
Conclusions
Adenomas, normal anterior or posterior gland, and nonadenomatous masses can be easily diagnosed in a nontertiary pathology laboratory setting.
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Affiliation(s)
- B. K. Kleinschmidt-DeMasters
- From the Departments of Pathology, Neurology, and Neurosurgery, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora (Dr Kleinschmidt-DeMasters)
- the Departments of Pathology and Neurosurgery, University of Virginia School of Medicine, Charlottesville (Dr Lopes)
- and the Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Prayson)
| | - M. B. S. Lopes
- From the Departments of Pathology, Neurology, and Neurosurgery, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora (Dr Kleinschmidt-DeMasters)
- the Departments of Pathology and Neurosurgery, University of Virginia School of Medicine, Charlottesville (Dr Lopes)
- and the Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Prayson)
| | - Richard A. Prayson
- From the Departments of Pathology, Neurology, and Neurosurgery, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora (Dr Kleinschmidt-DeMasters)
- the Departments of Pathology and Neurosurgery, University of Virginia School of Medicine, Charlottesville (Dr Lopes)
- and the Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Prayson)
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Abstract
In this article, an overview is presented of hypophysitis in terms of current clinical and experimental findings, with discussion of the anatomic and histopathologic classification of primary hypophysitis and factors associated with secondary hypophysitis. In addition, discusses the pathophysiology, clinical features, management, and prognosis associated with this disease are discussed.
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Affiliation(s)
- Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
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Park SM, Bae JC, Joung JY, Cho YY, Kim TH, Jin SM, Suh S, Hur KY, Kim KW. Clinical characteristics, management, and outcome of 22 cases of primary hypophysitis. Endocrinol Metab (Seoul) 2014; 29:470-8. [PMID: 25325267 PMCID: PMC4285029 DOI: 10.3803/enm.2014.29.4.470] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 04/17/2014] [Accepted: 04/29/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Primary hypophysitis causes varying degrees of endocrine dysfunction and mass effect. The natural course and best treatment have not been well established. METHODS Medical records of 22 patients who had been diagnosed with primary hypophysitis between January 2001 and March 2013 were retrospectively reviewed. Based on the anatomical location, we classified the cases as adenohypophysitis (AH), infundibuloneurohypophysitis (INH), and panhypophysitis (PH). Clinical presentation, endocrine function, pathologic findings, magnetic resonance imaging findings, and treatment courses were reviewed. RESULTS Among 22 patients with primary hypophysitis, 81.8% (18/22) had involvement of the posterior pituitary lobe. Two patients of the AH (2/3, 66.6%) and three patients of the PH (3/10, 30%) groups initially underwent surgical mass reduction. Five patients, including three of the PH (3/10, 33.3%) group and one from each of the AH (1/3, 33.3%) and INH (1/9, 11.1%) groups, initially received high-dose glucocorticoid treatment. Nearly all of the patients treated with surgery or high-dose steroid treatment (9/11, 82%) required continuous hormone replacement during the follow-up period. Twelve patients received no treatment for mass reduction due to the absence of acute symptoms and signs related to a compressive mass effect. Most of them (11/12, 92%) did not show disease progression, and three patients recovered partially from hormone deficiency. CONCLUSION Deficits of the posterior pituitary were the most common features in our cases of primary hypophysitis. Pituitary endocrine defects responded less favorably to glucocorticoid treatment and surgery. In the absence of symptoms related to mass effect and with the mild defect of endocrine function, it may not require treatment to reduce mass except hormone replacement.
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Affiliation(s)
- Sun Mi Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Cheol Bae
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ji Young Joung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Young Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hun Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Andong Sungso hospital, Andong, Korea
| | - Sang Man Jin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sunghwan Suh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dong-A Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Won Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea.
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Quoi de neuf dans les hypophysites ? Rev Med Interne 2014; 35:815-22. [DOI: 10.1016/j.revmed.2014.05.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 05/14/2014] [Accepted: 05/26/2014] [Indexed: 12/24/2022]
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