Difference between revisions of "Pituitary gland"

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**Classically: visual field defects (bitemporal hemianopsia).
**Classically: visual field defects (bitemporal hemianopsia).
**Others (increased intracranial pressure): headache, nausea, vomiting.
**Others (increased intracranial pressure): headache, nausea, vomiting.
Notes:
*May be part of [[multiple endocrine neoplasia]] I.
**3Ps: '''p'''ituitary adenoma, [[parathyroid|'''p'''arathyroid]] adenoma, [[pancreas|'''p'''ancreatic]] neuroendocrine tumours.


Classification:
Classification:
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Notes:
Notes:
*May be classified by what they secrete.  ''Cushing disease'' is due to pituitary gland hypersecretion of ACTH (due to a pituitary adenoma ''or'' CRH hypersecretion from the hypothalamus).<ref name=Ref_PBoD8_1148>{{Ref PBoD8|1148}}</ref>  [[Cushing syndrome]] is hypercortisolism ''not'' due to pituitary gland pathology.
*May be classified by what they secrete.  ''Cushing disease'' is due to pituitary gland hypersecretion of ACTH (due to a pituitary adenoma ''or'' CRH hypersecretion from the hypothalamus).<ref name=Ref_PBoD8_1148>{{Ref PBoD8|1148}}</ref>  [[Cushing syndrome]] is hypercortisolism ''not'' due to pituitary gland pathology.
====Familial pituitary adenomas====
A pituitary adenoma may be part of a familial syndrome:<ref name=pmid19564887>{{Cite journal  | last1 = Elston | first1 = MS. | last2 = McDonald | first2 = KL. | last3 = Clifton-Bligh | first3 = RJ. | last4 = Robinson | first4 = BG. | title = Familial pituitary tumor syndromes. | journal = Nat Rev Endocrinol | volume = 5 | issue = 8 | pages = 453-61 | month = Aug | year = 2009 | doi = 10.1038/nrendo.2009.126 | PMID = 19564887 }}</ref><ref name=Ref_PCPBoD8|554>{{Ref PCPBoD8|554}}</ref>
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Syndrome
! Gene
! Notes
|-
| [[Multiple endocrine neoplasia]] I
| MEN1
| characterized by the 3 Ps: '''p'''ituitary adenoma, [[parathyroid adenoma|'''p'''arathyroid adenoma]], [[pancreatic neuroendocrine tumour|'''p'''ancreatic neuroendocrine tumour]]
|-
| MEN-1-like syndrome
| CDKN1B<ref name=omim600778>{{OMIM|600778}}</ref>
| known as ''Multiple endocrine neoplasia IV''<ref name=omim600778>{{OMIM|600778}}</ref>
|-
| [[Carney syndrome]]
| PRKAR1A
|
|-
|
| AIP
| classically GH-producing adenoma - lead to acromegaly
|}


===Microscopic===
===Microscopic===

Revision as of 13:54, 23 May 2012

The pituitary gland is known as the master gland.

Divisions:[1]

  • Anterior pituitary (AKA adenohypophysis).
  • Posterior pituitary (AKA neurohypophysis, neural pituitary).

Function

Anterior

Hormones:[2]

  • Growth hormone (GH).
  • Luteinizing hormone (LH)
  • Follicle-stimulating hormone (FSH)
  • Thyroid stimulating hormone (TSH)
  • Adrenocorticotropic hormone (ACTH)
  • Prolactin (PRL)

Mnemonic: "Go Look For The Adenoma Please" = GH, LH, FSH, TSH, ACTH, PRL.

Posterior

Hormones:[2]

  • Oxytocin.
  • Antidiuretic hormone (ADH).

Anatomy and histology

Anatomy

Basic anatomy (simplified):[3]

  • Anterior:
    • Pars distalis.
    • Pars intermedia.
  • Posterior:
    • Pars nervosa.

Embryological origin:[3]

  • Anterior - Rathke's pouch (roof of mouth).
  • Posterior - diencephalon (ventral aspect).

Images:

Histology

Anterior

  • Acidophils (40% of cells) = red or orange.
    • GH, PRL.
  • Basophils (10% of cells) = basophilic (light blue).
    • TSH, LH, FSH, ACTH.
  • Chromophobes (50% of cells) = amphophilic (purplish/grey).

Notes:

  • The cellular product (i.e. hormone produced) is not strictly correlated with the cell type.[4]
  • The cells can be typed using IHC; somatotrophs (GH), lactotrophs (PRL), corticotrophs (ACTH), thyrotrophs (TSH), gonadotrophs (FSH, LH).[5]

Posterior

Features:[4]

  • Herring bodies - key feature.
    • Eosinophilic axonal dilations filled with lysosomes and neurosecretory granules.
  • Less cellular.
    • Usually more cellular in perivascular location.

Image: Herring bodies (ouhsc.edu).

DDx for stellar lesions

Pituitary necrosis

  • Rare.

Causes of pituitary necrosis

  • Sheehan syndrome - secondary to blood loss in childbirth.[6]
  • Syphilis (fetal-maternal transmission).[7]
  • Mollaret's meningitis - very rare.[8] (???)
  • Spontaneous necrosis of pituitary tumours - case reports.[9]

Images:

Specific entities

Pituitary adenoma

General

  • Clinical:[10]
    • Classically: visual field defects (bitemporal hemianopsia).
    • Others (increased intracranial pressure): headache, nausea, vomiting.

Classification:

  1. Microadenoma <= 1 cm.
  2. Macroadenoma > 1 cm.

Notes:

  • May be classified by what they secrete. Cushing disease is due to pituitary gland hypersecretion of ACTH (due to a pituitary adenoma or CRH hypersecretion from the hypothalamus).[11] Cushing syndrome is hypercortisolism not due to pituitary gland pathology.

Familial pituitary adenomas

A pituitary adenoma may be part of a familial syndrome:[12][13]

Syndrome Gene Notes
Multiple endocrine neoplasia I MEN1 characterized by the 3 Ps: pituitary adenoma, parathyroid adenoma, pancreatic neuroendocrine tumour
MEN-1-like syndrome CDKN1B[14] known as Multiple endocrine neoplasia IV[14]
Carney syndrome PRKAR1A
AIP classically GH-producing adenoma - lead to acromegaly

Microscopic

Features:[15]

  • Loss of fibrous stroma.
    • The cells of a normal (anterior) pituitary are nested.

Notes:

  • Smears very well.[16]

Images:

Stains

  • Reticulin - loss of reticulin between tumour cells.

IHC

  • LH.
  • FSH.
  • TSH.
  • GH.
  • Prolactin.
  • ACTH - Cushing disease.

Rathke cleft cyst

General

  • Benign counterpart of craniopharyngioma.
  • Arises from intermediate lobe of pituitary gland (pars intermedia of pituitary gland).

Radiology:

  • Typically no calcifications.[17]

Radiologic DDx:[17]

Microscopic

Features:

  • Lined by a layer of cuboidal or columnar epithelial with cilia.
  • +/-Goblet cells.[18]
  • +/-Squamous metaplasia ~ may be several layers thick.
  • Cholesterol clefts may be seen in association with rupture.[20]

Images:

Craniopharyngioma

General

  • Develop from remains of Rathke's pouch or squamous epithelial cell rests.[21]

Comes in two flavours:[21]

  • Adamantinomatous type.
    • Adults and children.
  • Squamous papillary type.
    • Adults individuals.[22]
    • Usually solid.

Radiology:[21]

  • Calcified - adamantinomatous type only.
  • Solid & cystic.

Microscopic

Adamantinomatous

Features (adamantinomatous):[23]

  • Well-circumscribed (or pseudoinvasive border).
  • Multicystic.
  • Small-to-medium sized cells with moderate amount of basophilic cytoplasm.
  • Bland nuclei (with occ. small nucleoli).
  • "Wet" keratin - nests of whorled keratin.
  • Calcifications (non-psammomatous).

Images:

Papillary

Features (papillary):[24]

  • Non-keratinized squamous epithelium (without nuclear atypia).
  • Fibrovascular cores (required for papillary).

Notes:

  • +/-Cilia (rare).
  • +/-Goblet cell-like formations (rare).

Image:

Autoimmune hypophysitis

General

Features:[26]

  • Rare.
  • Autoantigens are unknown.
  • May be misdiagnosed as a nonsecreting adenoma.

Microscopic

Features:[26]

  • Lymphocytic infiltration.

See also

References

  1. http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/histo.html
  2. 2.0 2.1 http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/P/Pituitary.html
  3. 3.0 3.1 URL: http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/histo_pit.html. Accessed on: 31 October 2010.
  4. 4.0 4.1 Perry, Arie; Brat, Daniel J. (2010). Practical Surgical Neuropathology: A Diagnostic Approach: A Volume in the Pattern Recognition series (1st ed.). Churchill Livingstone. pp. 26. ISBN 978-0443069826.
  5. Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1098-9. ISBN 978-1416031215.
  6. URL: http://www.mayoclinic.com/health/sheehans-syndrome/DS00889. Accessed on: 16 November 2010.
  7. URL: http://pediatrics.aappublications.org/cgi/content/full/104/1/e4. Accessed on: 16 November 2010.
  8. Dancer CM, Woods ML, Henderson RD, Robertson T, Mungomery M, Allworth A (July 2008). "Mollaret's meningitis and pituitary failure associated with a Rathke's cleft cyst". Intern Med J 38 (7): 609–11. doi:10.1111/j.1445-5994.2008.01709.x. PMID 18715308.
  9. Sachdev Y, Evered DC, Hall R (April 1976). "Spontaneous pituitary necrosis". Br Med J 1 (6015): 942. PMC 1639254. PMID 1268492. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1639254/pdf/brmedj00512-0028a.pdf.
  10. Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1100. ISBN 978-1416031215.
  11. Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1148. ISBN 978-1416031215.
  12. Elston, MS.; McDonald, KL.; Clifton-Bligh, RJ.; Robinson, BG. (Aug 2009). "Familial pituitary tumor syndromes.". Nat Rev Endocrinol 5 (8): 453-61. doi:10.1038/nrendo.2009.126. PMID 19564887.
  13. Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 554. ISBN 978-1416054542.
  14. 14.0 14.1 Online 'Mendelian Inheritance in Man' (OMIM) 600778
  15. Perry, Arie; Brat, Daniel J. (2010). Practical Surgical Neuropathology: A Diagnostic Approach: A Volume in the Pattern Recognition series (1st ed.). Churchill Livingstone. pp. 36. ISBN 978-0443069826.
  16. MUN. 24 November 2010.
  17. 17.0 17.1 URL: http://emedicine.medscape.com/article/343629-overview. Accessed on: 14 November 2010.
  18. URL: http://www.endotext.org/neuroendo/neuroendo3/neuroendo3.html. Accessed on: 27 May 2010.
  19. Perry, Arie; Brat, Daniel J. (2010). Practical Surgical Neuropathology: A Diagnostic Approach: A Volume in the Pattern Recognition series (1st ed.). Churchill Livingstone. pp. 408. ISBN 978-0443069826.
  20. URL: http://path.upmc.edu/cases/case177/dx.html. Accessed on: 8 January 2012.
  21. 21.0 21.1 21.2 Garnett, MR.; Puget, S.; Grill, J.; Sainte-Rose, C. (2007). "Craniopharyngioma.". Orphanet J Rare Dis 2: 18. doi:10.1186/1750-1172-2-18. PMID 17425791.
  22. Giangaspero, F.; Burger, PC.; Osborne, DR.; Stein, RB. (Jan 1984). "Suprasellar papillary squamous epithelioma ("papillary craniopharyngioma").". Am J Surg Pathol 8 (1): 57-64. PMID 6696166.
  23. Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 184. ISBN 978-0470519035.
  24. Perry, Arie; Brat, Daniel J. (2010). Practical Surgical Neuropathology: A Diagnostic Approach: A Volume in the Pattern Recognition series (1st ed.). Churchill Livingstone. pp. 406. ISBN 978-0443069826.
  25. URL: http://library.med.utah.edu/WebPath/jpeg4/ENDO115.jpg. Accessed on: 6 December 2010.
  26. 26.0 26.1 Tzou SC, Lupi I, Landek M, et al. (July 2008). "Autoimmune hypophysitis of SJL mice: clinical insights from a new animal model". Endocrinology 149 (7): 3461–9. doi:10.1210/en.2007-1692. PMC 2453094. PMID 18388197. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2453094/.

External links