Background and recommendations

Question 1

RT dose for nonfunctional unresectable?

Answer 1

50.4 Gy at 1. Gy/fx

Question 2

What are the potential late compications of RT?

Answer 2

Blindness
Brain necrosis
Hypopituitarism

Question 3

What is the dose constraint with using SRS for the optic nerve?

Answer 3

8 Gy

Question 4

When can hormone normalization be expected after RT?

Answer 4

It can take months to years

Question 5

With conventional RT what is the dose tolerance for the optic nerves and chiasm?

Answer 5

54 Gy

Question 6

Fractionated RT dose for functional and non-functional tumors?

Answer 6

Functional: 54 Gy at 1.8 Gy/fx

Nonfunctional: 50.4 Gy at 1.8 Gy/fx

Question 7

What medication can be used for ACTH secreting pituitary tumors?

Answer 7

Ketoconazole

Question 8

When is fractionated RT recommended instead of SRS?

Answer 8

Tumor > 3 cm

Tumor 3 mm or less from the chiasm

Question 9

What agents are used for GH secreting tumors?

Answer 9

Somatostatin, octreotide, pegvisomant

Question 10

What dose will likely result in hypopituitarism?

Answer 10

40-45 Gy

Question 11

What are the typical doses for functional and nonfunctional tumors when using SRS?

Answer 11

Nonfunctional: 16 Gy
Functional: 20-25 Gy

Question 12

When is SRS best for pituitary adenomas?

Answer 12

Asymptomatic patient with microadeomas

Question 13

What is the expected local control for tumors treated with fractionated RT and SRS?

Answer 13

LC is over 90% for both treatment

Question 14

How long does it take medications to normalize prolactin levels in patients with prolactinomas?

Answer 14

1-2 months

Question 15

What is the treatment paradigm for prolactinomas?

Answer 15

Start with bromocriptine. 30% of patients can not tolerate it due to nausea, headache and fatigue.

Question 16

What needs to be done before RT?

Answer 16

Discontinue medications for functional adenomas before RT

Question 17

What are the hormone control rates after RT?

Answer 17

GH secretors: 80%
ACTH secretors: 50-80%
Prolactinomas: 30-40%

Question 18

What are the indications for RT?

Answer 18

1. Medically inoperable
2. Persistent hormone secretion after surgery
3. S/p only STR or decompression surgery
4. Recurrent tumor after surgery

Question 19

What are local control rates after transphenoidal surgery?

Answer 19

95%

Question 20

What are some poor prognostic factors for prolactinomas treated with surgery?

Answer 20

Size > 2 cm
High preop PL level
Older age
Longer duration of amenorrhea

Question 21

What are some poor prognostic factors for GH secreting tumors treated with surgery?

Answer 21

High preop GH and somatomedin C levels
Tumors > 1 cm
Extrasellar extension

Question 22

What type of surgery is needed for tumors that invade the cavernous sinus or frontal/temporal lobes?

Answer 22

Frontal craniotomy

Question 23

What is the likelihood of hormone normalization after surgery for a functional tumor?

Answer 23

Long term, only 30-40%

Question 24

Definition of picoadenoma, microadeonoma, macroadenoma?

Answer 24

Macro: > 1 cm
Micro: 0.3 to 1 cm
Pico: <0.3 cm

Question 25

What is cushing's syndrome?

Answer 25

``` Elevated cortisol (adrenal production or exogenous) Low ACTH ```

Question 26

What is cushing's disease?

Answer 26

High cortisol caused by high ACTH

Question 27

What is considered a normal level of PL after RT?

Answer 27

< 25 ng/mL

Question 28

What is the treatment paradigm for nonfunctional tumors?

Answer 28

1a. Surgery followed by observation or RT or 1b. RT alone

Question 29

What is the treatment for functional tumors?

Answer 29

1. Medications | 2. Surgery if progressive +/- RT

Question 30

What are the typical symptoms for patients with prolactinomas?

Answer 30

Galactorrhea, Amenorrhea, Decreased libido, infertility Levels: 20-25 or above

Question 31

Which cranial nerves are found in the cavernous sinus?

Answer 31

CN III-IV, V1-2 and VI

Question 32

What autosomal dominant syndrome is associated with pituitary adenomas?

Answer 32

MEN1 | Pituitary, parathyroid and pancreatic tumors

Question 33

What hormones are secreted by the pituitary and post pituitary adenoma?

Answer 33

Anterior: PL, GH, ACTH, TSH, LH, FSH Posterior: ADH, oxytocin

Question 34

What hormones are secreted by basophilic tumors?

Answer 34

ACTH, TSH, LH, FSH

Question 35

What hormones are secreted by acidophilic tumors?

Answer 35

GH, PL

Question 36

What are the most common functional tumors?

Answer 36

Prolactinoma 30% > GH 25% > ACTH 15%

Question 37

What are the most common tumors among men and the elderly?

Answer 37

Males and elderly: nonfunctioning or GH

Question 38

What are the most common tumors among women?

Answer 38

Prolactin and ACTH secreting tumors

Question 39

What percentage of tumors are functional vs. nonfunctional?

Answer 39

Functional: 75% Nonfunctional: 25%

Question 40

What are some heritable syndromes that predispose to pituitary tumors?

Answer 40

MEN1 and MEN2

Question 41

What is the histologic description of cells making up nonfunctional tumors?

Answer 41

Chromophobic

Question 42

What is the risk of endocrine dysfunction?

Answer 42

26% at UF