ACTH Secreting Pituitary Adenoma. Neurosurgical view

Cushing's disease fom the neurosurgical view

1. Cushing’s Disease Mohamed W Samir, MD Prof. of Neurosurgery Ain Shams University Cairo, Egypt

2. ILOs Differentiate between Cushing's syndrome, pseudo-Cushing’s syndrome, and Cushing’s disease Discuss pathology of pituitary tumors Discuss the clinical presentation of Cushing’s disease Describe the different diagnostic work up for a patient with suspected Cushing’s syndrome Create a list for the D.D. of a sellar -suprasellar mass Discuss hormonal management in pituitary tumors Discuss the different treatment protocol for Cushing's disease Discuss in details endoscopic approach for a pituitary micro adenoma 3/1/2025 2 Pituitary Neoplasms

3. Definitions Cushing syndrome: It is a clinical syndrome result from excess cortisol secretion from adrenal. It may be ACTH non dependent (E.g. from tumors within the adrenal gland), or ACTH dependent (E.g. from ACTH produced lesions as lung cancer, or from a pituitary tumors). Cushingoid' features: Patients with features identical to Cushing's syndrome typically, are occurring as side effects of cortisone-related medications, such as prednisone and prednisolone. Cushing disease: It is a specific type of Cushing syndrome which is ACTH dependent & ACTH is secreted from a pituitary tumor. 3/2/2025 Pituitary Neoplasms 3

4. 3/1/2025 4 Review Embryology & Anatomy

5. Introduction: Embryology 3/1/2025 5 Pituitary Neoplasms the 5 th week of gestation the 7 th week of gestation the 9 th week of gestation Up to the 29 th week of gestation for different cells formations

6. Introduction: Anatomy Posterior lobe: 1) Pars posterior 2) Infundibulum 3) Median eminence 3/1/2025 6 Pituitary Neoplasms Anterior Lobe: 1) Pars tuberalis 2) Pars intermedia 3) Pars distalis (anterior)

7. 3/1/2025 7 Review Histology

8. Introduction: Histology Chromophobe : Non secretor ?? TSH & Gonadotropins Acidophil: PRL & GH Basophil : ACTH, Chromophobic to basophilic Gonadotropins & TSH 3/1/2025 8 Pituitary Neoplasms Mucoid wedge

9. Pituitary Transcription Factors 3/2/2025 Pituitary Neoplasms 9 Estrogen receptor alpha (ER-α) cooperates with Pit-1 to enhance PRL secretion

10. 3/1/2025 10 Review Physiology

11. Physiology 3/1/2025 Pituitary Neoplasms 11

12. Physiology 3/1/2025 Pituitary Neoplasms 12

13. Physiology Anterior Pituitary Posterior Pituitary Oxytocin ADH Testosterone Estradiol FSH & LH Growth Hormone ACTH Cortisol TSH T 3 T 4 Prolactin IGF-1 3/1/2025 13 Pituitary Neoplasms

14. Introduction: Physiology 3/1/2025 14 Pituitary Neoplasms

15. 3/1/2025 15

16. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis 3/3/2025 Pituitary Neoplasms 16

17. Pathology of Pituitary Tumors 5 th Edition (2022) of WHO Classifications of Endocrine Tumors 5th Edition (2021) of the Central Nervous System WHO Classification 3/1/2025 Pituitary Neoplasms 17

18. Tumors of Sellar Region Pituitary tumors: PitNET /pituitary adenoma Metastatic PitNET Tumors of post. Pituitary: Pituicytoma Pituitary blastoma Neuronal & Paraneuronal tumors Gangliocytoma & mixed gangliocytoma-pituitary adenoma Neurocytoma Paraganglioma Neuroblastoma Pituitary glioma Germ cell tumors: Germinoma 3/2/2025 Pituitary Neoplasms 18 Craniopharyngiomas: Papillary craniopharyngioma Adamantinomatous craniopharyngiom Mesenchymal tumors: Meningioma Schwannoma Chordoma Solitary fibrous tumor/ hemangiopericytoma Others Hematological tumors: Lymphoma Secondary tumors: Metastatic carcinoma

19. Sellar Lesions Other Than Neoplasm 1) Inflammatory Lesions Abscess Acute hypophysitis Amyloidosis Infections (bacterial, viral, fungal, parasitic) Lymphocytic hypophysitis 2) Granulomatous Lesions Granulomatous hypophysitis Tuberculosis Sarcoidosis Syphilis Xanthomatous hypophysitis 3) Cysts Arachnoid cyst Dermoid cyst Epidermoid cyst Rathke’s cleft cyst 4) Other Empty sella syndrome 3/3/2025 Pituitary Neoplasms 19

20. Pituitary Tumors in WHO Classification of CNS Tumors 3/2/2025 Pituitary Neoplasms 20 Revised 4 th 2016 WHO Classification of Tumors of the Central Nervous System 5th Edition (2021) of the Central Nervous System WHO Classification

21. Evolution of WHO Classification of Ant. Lobe Pituitary Tumors 3/2/2025 Pituitary Neoplasms 21

22. Evolution of WHO Classification of Post. Lobe Pituitary Tumors In 2017: Pituicytoma, Spindle cell oncocytoma (was considered as non endocrinal tumor of ant. Pituitary), Granular cell tumor, Sellar ependymoma. In 2021: A family of pituicyte tumors Traditional pituicytoma, The oncocytic form of pituicytoma (spindle cell oncocytoma), The granular cell form of pituicytoma (granular cell tumor), The ependymal type of pituicytoma ( sellar ependymoma). 3/2/2025 Pituitary Neoplasms 22

23. Pathology of Pituitary Tumors Similarity Abandoned the terminology “atypical adenoma” Terminology of subtypes according to pituitary cell lineage Difference Carcinoma # Metastatic PITNET 3/2/2025 Pituitary Neoplasms 23

24. Pathology of Pituitary Tumors Similarity About 40% are locally invasive and may not be surgically cured About 1% demonstrate an aggressive clinical behavior that may metastasize Some subtypes have high risk of recurrence Difference 3/2/2025 Pituitary Neoplasms 24 Invasion & ↑ proliferation, or rapid growth indicate high risk of recurrence

25. High Risk Pituitary Adenoma #Atypical Adenoma Any subtype with: ↑ cell proliferation by mitotic count and Ki-67 proliferative index Signs of invasive growth by MRI and/or histology. Five subtypes of PitNETs : 1) Sparsely granulated somatotroph adenoma, 2) Lactotroph adenoma in men, 3) Crooke’s cell adenoma, 4) Silent corticotroph adenoma, 5) The newly introduced plurihormonal Pit-1-positive adenoma. 3/2/2025 Pituitary Neoplasms 25

26. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

27. They arise within the pituitary gland from a monoclonal cellular origin Ectopic anterior pituitary tissue is found along the Rathke’s pouch in virtually all individuals but mostly inactive Genetic alterations: Epigenetic alterations: Activation of oncogenes causing inactivation of tumor suppressor genes, and alterations of transcription factors regulating cell growth and differentiation Cell of Origin & Pathogenesis 3/2/2025 27 Pituitary Neoplasms

28. Pituitary Transcription Factors 3/1/2025 Pituitary Neoplasms 28

29. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

30. Epidemiology Incidence: ~ 10-15 % of all intracranial tumors The 3 rd primary intracranial neoplasm in adult after glioma & meningioma Most common neoplasm of the sellar region Sex: Equal but ♀ more easily diagnosed Race: No Age: 3 rd -4 th decade Risk factors: MEN-1 syndrome (Werner’s syndrome): 3 Ps [ pituitary, pancreas, & parathyroid] 3/1/2025 30 Pituitary Neoplasms

31. Incidences Incidentloma : up to 20 % Clinically functioning adenomas: (~75%) Prolactinomas : Acromegaly: Cushing: Iatrogenic hypercortisolism outweighs the endogenous causes, Of the endogenous causes pituitary-mediated ACTH production accounts for up to 80% of cases of hypercortisolism, F ollowed by adrenals, unknown source, and ectopic ACTH production secondary to malignancies. Clinically non-functioning adenomas: (~25%) Secreting but clinically non manifested (Silent adenomas) Negative clinical features of hormonal excess & no excess serum hormones Some author put cases with negative clinical features of hormonal excess and mild elevation of serum hormones ??? Positive immunohistochemical stain for hormones Positive immunohistochemical stain for pituitary transcription factors Non secreting: negative for all 3/1/2025 Pituitary Neoplasms 31

32. Common Causes of Ectopic ACTH Secretion Small cell carcinoma of the lung in 50% Endocrine tumors of foregut origin in 35% Pheochromocytoma in 5% Ovarian tumors in 2% Others in 5% Thymic carcinoid Islet cell tumor Medullary carcinoma thyroid Bronchial carcinoid 3/3/2025 Pituitary Neoplasms 32

33. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

34. Macroscopic Features Site: Sella turcica Ectopic tissue Size: Microadenomas <10mm or Macroadenomas ≥10mm - 4 cm. Giant adenoma ˃ 4 cm. Number: Multiples are reported Character: Discrete, grayish yellow, soft mass 3/1/2025 34 Pituitary Neoplasms

35. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

36. Corticotroph Adenomas Densely granulated corticotroph adenoma Sparsely granulated corticotroph adenoma Crooke’s cell adenoma 3/3/2025 Pituitary Neoplasms 36

37. Microscopic Features Basophil: ++++++ Typical for densely granulated corticotroph adenomas Chromophobe: +++ Typical for sparsely granulated corticotroph adenoma Acidophil: + Typical for Crooke’s cell adenoma 3/1/2025 37 Pituitary Neoplasms

38. Crooke’s Cell Adenoma Massive hyaline changes in the cells. One of the subtyped that carry high risk for recurrence 3/3/2025 Pituitary Neoplasms 38 Hematoxylin eosin (H&E) staining

39. Corticotroph Adenomas Pituitary adenoma with : 3/1/2025 Pituitary Neoplasms 39 Densely granulated corticotroph adenoma ACTH Sparsely granulated corticotroph adenoma ACTH Crooke’s cell adenoma Positive immunohistochemistry staining for T pit transcription factors ++++++++++++++ +++++ +++++ Positive immunohistochemistry staining for ACTH ++++++++++++++ +++++ +++++ Basophilic Chromophobic Acidophilic Crooke’s cells

40. Corticotroph Adenomas 3/1/2025 Pituitary Neoplasms 40 Histopathological Clinically Sparely granulated - Densely granulated Crooke’s cells Functioning Silent Those are high Risk Pituitary Adenoma

41. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

42. Immunohistochemistry I) For Transcription factors and other co-factors Pit-1 Estrogen receptor Tpit SF1 II) For pituitary hormones: Adrenocorticotropin Growth hormone (GH) Prolactin b-Thyrotropin b–Follicle-stimulating hormone b–Luteinizing hormone a-Subunit III) For proliferation: % MIB-1/Ki-67 proliferative index p53 IV) Others: keratin immunostaining Chromogranin 3/3/2025 Pituitary Neoplasms 42

43. Immunohistochemistry MIB index 3/3/2025 43 Pituitary Neoplasms High Risk Pituitary Adenoma: 1) Ki-67 (MiB-1) proliferation index of ≥ 3% Now no cut off value 2) Extensive nuclear staining for p53 protein Types of secretory granules: Up to 90% of pituitary adenoma has hormonal granules while only 70% have functionally active hormones

44. 3/3/2025 Pituitary Neoplasms 44 H&E staining ACTH stain H&E staining ACTH stain Densely granulated corticotroph adenoma Sparsely granulated corticotroph adenoma

45. Crooke’s Cell Adenoma Crooke’s cells: Massive hyaline changes in the cells. 3/3/2025 Pituitary Neoplasms 45 ACTH stain Periodic Acid-Schiff (PAS) stain Low molecular weight keratin (LMWK) immunostaining Hematoxylin eosin (H&E) staining

46. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

47. Genetic & Ultra Structures Features Differentiate densely Granulated from sparsely granulated adenomas: 3/1/2025 47 Pituitary Neoplasms

48. 3/3/2025 Pituitary Neoplasms 48

49. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

50. Microadenoma Diagnosing Criteria On T1: A focal low intensity area in the pituitary gland on T1-weighted images, Increased gland size more than 9-10 mm vertical height, Asymmetric convexity of the superior surface of the gland Deviation of the stalk to the opposite side On T1+c The signal intensity of the microadenoma is weaker compared with that of normal pituitary tissue Dynamic contrast-enhanced studies show late enhancement and late wash out 3/1/2025 Pituitary Neoplasms 50

51. Microadenoma Diagnosing Criteria 3/1/2025 Pituitary Neoplasms 51 Focal bulge Mild hyperintense in T2 Less enhancing than normal pituitary Deviated stalk Focal bulge Mild hyperintense in T2 Less enhancing than normal pituitary Chiasma

52. Dynamic Contrast-Enhanced MRI (DCE‑MRI) Before Post. Pit. Stalk Ant. Pit.

53. Dynamic Contrast-Enhanced MRI (DCE‑MRI) 3/1/2025 Pituitary Neoplasms 53 Early: as a filling defect in enhanced pituitary Late: enhanced adenoma

54. T1 Volumetric Spoiled Gradient SPGR Postcontrast MRI 3/1/2025 Pituitary Neoplasms 54

55. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

56. Pattern of Growth & Behavior Growth rate: Only up to 10% of microadenomas progress to macroadenomas if not treated. Spread: Invasion of dura , cavernous sinus and bone: Microscopic invasion occurs in up to 90 % Predisposing factors for invasion Increase tumor size: Increase MIB index ≥ 3% [No cut off value now] Tumor type: 5 types are recognized by WHO as high-risk types. Extra-cranial metastasis: In 0.2% of cases (then named pituitary carcinoma or PitNET ) 3/3/2025 56 Pituitary Neoplasms

57. Wilson’s Grading For Pituitary Growth Gr V CSF or Bl. spread 3/3/2025 57 Pituitary Neoplasms C S invasion Extradural Parasellar (ant., post., lat.) Above Monro 5 stages A→ E 6 Grades 0→ V Cistern Recess 3 rd

58. Wilson’s Grading For Pituitary Growth 3/3/2025 58 Pituitary Neoplasms

59. Microadenoma Grade 0 & I 3/3/2025 59 Pituitary Neoplasms

60. Intrasellar Macroadenoma : grade II-IV Grade II: Widening with No bony erosion Grade III: Focal erosion Grade IV: Diffuse erosion 3/3/2025 60 Pituitary Neoplasms

61. Suprasellar Macroadenoma Stages: Stage A Suprasellar cistern & not reaching the suprachiasmatic recess of 3 rd ventricle 3/3/2025 61 Pituitary Neoplasms

62. Suprasellar Macroadenoma Stages: Stage B Suprasellar cistern & reaching the suprachiasmatic recess of 3 rd ventricle (Chiasma is pushed upward) 3/3/2025 Pituitary Neoplasms 62

63. Suprasellar Macroadenoma Stages: Stage C Suprasellar cistern & reaching the 3 rd ventricle till foramen of Monro 3/3/2025 63 Pituitary Neoplasms

64. Suprasellar Macroadenoma Stages: Stage D Suprasellar cistern & extend beyond foramen of Monro Parasellar extension (without invasion of cavernous simus ) Beyond the foramen of Monro with lateral extensions with anterior extensions 3/3/2025 64 Pituitary Neoplasms

65. Suprasellar Macroadenoma Stages: Stage E Intracavernous extension 3/3/2025 65 Pituitary Neoplasms

66. Knosp’s Grading For C S Invasion Grade 0 3/3/2025 66 Pituitary Neoplasms Grades of CS invasion 0-4 Grades of CS invasion 0-4

67. Knosp’s Grading For C S Invasion Grade 1 3/3/2025 67 Pituitary Neoplasms Grades of CS invasion 0-4

68. Knosp’s Grading For C S Invasion Grade 2 3/3/2025 68 Pituitary Neoplasms Grades of CS invasion 0-4

69. Knosp’s Grading For C S Invasion Grade 3 Without encased carotid 3/3/2025 69 Pituitary Neoplasms Grades of CS invasion 0-4

70. Knosp’s Grading For C S Invasion Grade 4 With encased carotid 3/3/2025 70 Pituitary Neoplasms Grades of CS invasion 0-4

71. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

72. WHO Classification 3/3/2025 72 Pituitary Neoplasms

73. Tumor Coding ICD-O: 8272/1 – pituitary adenoma 8272/3 - pituitary carcinoma, NOS ICD-11: 2F9A & XH94U0 - neoplasms of unknown behavior of endocrine glands & pituitary adenoma, NOS

74. Pathology 1) Cell of origin & pathogenesis 2) Epidemiology 3) Macroscopic features 4) Microscopic features 5) Immunohistochemistry 6) Genetic & Ultra structures features 7) Radiological features 8) Pattern of growth & Spread 9) Staging & behavior 10) Prognosis

75. Prognosis Recurrence: Recurrence rates as high as 20% have been reported after apparent complete surgical resection. Patient' s factors: Gigantism worse than acromegaly Previous treatment # DE novo Tumor’ s factors: Size of tumor Type of tumor: Preoperative hormonal level Invasive MIB index ≥ 3% Management’ s factors: 3/3/2025 75 Pituitary Neoplasms 1) Sparsely granulated somatotroph adenoma, 2) Lactotroph adenoma in men, 3) Crooke’s cell adenoma, 4) Silent corticotroph adenoma, 5) The newly introduced plurihormonal Pit-1-positive adenoma.

76. Clinical Presentation

77. Definitions Cushing syndrome: It is a clinical syndrome result from excess cortisol secretion from adrenal. It may be ACTH non dependent (E.g. from tumors within the adrenal gland), or ACTH dependent (E.g. from ACTH produced lesions as lung cancer, or from a pituitary tumors). Cushing disease: It is a specific type of Cushing syndrome which is ACTH dependent & ACTH is secreted from a pituitary tumor. Cushingoid' features = Pseudocushing : Patients with features identical to Cushing's syndrome typically, are occurring as side effects of cortisone-related medications, such as prednisone and prednisolone. 3/4/2025 Pituitary Neoplasms 77

78. States of Glucocorticoid Excess ACTH-dependent States a. Pituitary Adenoma (Cushing’s Disease) 90-95% b. Ectopic ACTH Syndrome ACTH-independent States a. Adrenal adenoma b. Adrenal carcinoma Pseudo-Cushing Disorders a. Depression b. Alcoholism

79. Pseudo-Cushing States Underlying etiology Uncontrolled diabetes: In a study of 190 patients with type 2 diabetes, 63 subjects (33%) had high cortisol concentrations.  Depression Obesity Physical stress Polycystic ovarian syndrome (PCOS) Chronic alcoholism Pathogenesis: Chronic stimulation of hypothalamic pituitary axis Clinically: Fewer clinical features than CS Laboratory: Lesser degree of hypercortisolism ± Preserved circadian rhythm of cortisol

80. Pathogenesis of Clinical Feature Hypercotisolism Moon-face buffalo hump truncal obesity Violaceous striae Hepatic gl. Production Insulin resistance Glucose intolerance Water & electrocytes metabolism Proximal muscle weakness Dependent edema Hypertension Hypokalemic metabolic alkalosis Lipid mobilization Lipid catabolism Lipid redistribution ↑Protein catabolism

81. Cushing Syndrome

82. Investigations

83. Investigations Laboratory: Specific: Preoperative: Imaging: CT: brain, neck, chest, & abdomen MRI: PET scan Neurophysiological: EEG: NCS & EMG: Others:

84. Laboratory Diagnosis of Cushing Is it Hypercortisolism state or not? Is it Cushing or pseudo-Cushing’s syndrome? Is it ACTH dependent or not? If not ACTH dependent, is it adrenal adenoma or carcinoma? If ACTH dependent, is it pituitary ACTH (Cushing disease = CD) or ectopic ACTH If it is of pituitary source, is the adenoma visualized on MRI (standard protocol, Dynamic Contrast-Enhanced MRI (DCE‑MRI), & Volumetric Spoiled Gradient SPGR Postcontrast MRI)? If not visualized in MRI, what is the result of ?IPSS 3/2/2025 84 Pituitary Neoplasms

85. Laboratory Work up For Diagnosis of CS Endocrinologist: Is it pseudo-Cushing, Cushing syndrome, Cushing disease? If it is Cushing syndrome, is it ACTH-dependent or independent? If it is ACTH-dependent Cushing disease, is it of pituitary source or not? Neurological surgeon: In ACTH-dependent Cushing disease and ectopic causes for ACTH, where in pituitary is the microadenoma? MRI brain: Standard MRI brain Dynamic Contrast-Enhanced MRI (DCE‑MRI) T1 Volumetric Spoiled Gradient SPGR Postcontrast MRI Inferior Petrosal Sinus Sampling (IPSS) 3/2/2025 Pituitary Neoplasms 85

86. Step 1: Is it Hypercortisolism State or Not? Exclude exogenous glucocorticoid intake in the history. History of depression, severe obesity, or chronic alcoholism may suggest pseudo-CS (misinterpretation results) History of drugs as carbamazepine and phenytoin may cause false positive results Screening tests: Do one of them 1) 24-h urinary free cortisol (at least two 24-hour urinary free cortisol tests) 2) Late night salivary cortisol (at least 2 late-night salivary cortisol tests) 3) Overnight dexamethasone suppression test (ODS), 4) 2-day low-dose dexamethasone supp. test (LDDS), Confirmatory of screening 1) Repeat abnormal test + do one or two other tests 2) Midnight cortisol level 3) CRH stimulation test with a dexamethasone suppression test (LDDS- CRH stimulation) 3/2/2025 Pituitary Neoplasms 86

87. Step 1: Is it Hypercortisolism State or Not? 3/5/2025 Pituitary Neoplasms 87

88. 24 -Hour Urinary Free Cortisol (UFC) Time of sampling: Collection usually starts in the morning; the patient discards the first void and then collects all urine for the next 24 hours (including the first void the next morning) Pre requisites before sampling High fluid intake (more than 5 l/day) can falsely positive UFC results Reduced kidney function can falsely negative UFC results. Sampling methods: Urine collected in p lastic urine container containing 1g of boric acid per liter Storage/transport temperature: Refrigerated Cut off value Use the upper limit of normal range for the particular UFC assay as the cutoff criterion for a positive test in order to achieve high sensitivity Measurement of creatinine and urine volume and more than two UFC measurement often required Sensitivity ~90% & specificity ~ 96%

89. Midnight Salivary Cortisol Time of sampling: at 11 o’ clock at night on two separate nights Pre requisites before sampling Do not eat black liquorice for two weeks before sampling. Do not use prescription skin creams for one day before sampling. Avoid excessive exercise one day before sampling. Do not smoke for at least two hours before sampling. Do not brush your teeth, or eat and drink 30-60 minutes before sampling. Remove lipstick or lip balms 30 minutes prior to collection. You may rinse mouth thoroughly with water for 1-5 seconds. Wait 10 minutes before collecting the specimen to avoid contamination of the saliva by interfering substance Relax for approximately 1 hour before collection of saliva (high activity or excitement can raise your cortisol level). Sampling methods Do not touch the cotonoid by your hand Chew and roll the sponge in your mouth for 2 minutes Return the saturated swab to the inner tube Store your tube(s) in the fridge (not the freezer) till sending it to the lab. Next day

90. Midnight Salivary Cortisol Cut off value Variables along studies ≥ 1.45 ng/ml is diagnostic Sensitivity ~90% & specificity ~ 92%

91. Sleeping Midnight Cortisol Level Time of sampling: at midnight while patient is asleep Pre requisites before sampling Hospital admission days before sampling (to alleviate stress). Patient should be asleep Sampling methods: Sample should be taken within 2 minutes of waking Cut off value ≥ 1.45 μ g/dl is diagnostic Sensitivity ~100% & specificity ~ 20%

92. Overnight (Mini) Dexamethasone Suppression (ODS) Test Time of sampling: Administer 1 mg oral dexamethasone between 11 pm and midnight Test cortisol level between 8 am and 9 am the next morning Pre requisites before sampling: False positive with some drugs as phenytoin Sampling methods: Sampling between 8 am and 9 am the next morning Cut off value > than 1.8 μ g/dL suggesting Cushing’s syndrome Sensitivity 90% & specificity ~ 90%

93. Standard 2-day Low Dose Dexamethasone Suppression (LDDS) Test Time of sampling: Administer 0.5 mg dexamethasone orally every 6 Hours (9 am, 3 pm, 9 pm, and 3 am) for 48 Hours Measure cortisol level 6 hours (9 am) after the last dose. Pre requisites before sampling: False positive with some drugs as phenytoin Sampling methods: Measure cortisol level 6 hours (9 am) after the last dose Cut off value > 1.8 μ g/dL suggesting Cushing’s syndrome Sensitivity 90% & specificity ~ 97%

94. Intravenous Dexamethasone Suppression Test Time of sampling: A baseline morning serum cortisol (between 8 AM and 9 AM) is obtained . Repeat serum cortisol levels are measured at the end of the infusion (day 1) and 23-24 hours later (day 2) Pre requisites before sampling: Sampling methods: An infusion of intravenous dexamethasone at 1 mg/h for 4 to 7 hours  . Cut off value Cushing syndrome is diagnosed if the day 2 serum cortisol level is greater than 20% of the baseline value or greater than 4.7 mcg/dL (130 nmol/L) S ensitivity of 100% and specificity of 96% In pituitary ACTH dependent Cushing, the serum cortisol level at the end of the infusion on day 1 typically shows greater than 70% suppression from the baseline, followed by rebound hypercortisolism in 24 hours

95. Dexamethasone-CRH test Time of sampling: Administer 0.5 mg dexamethasone orally every 6 Hours, starting at noon (12pm, 6pm, 12am, & 6am) for 48 Hours. The last dose is given at 6 A.M, 2 hours before the CRH test. 1 µg / kg of CRH is administered intravenously at 8 A.M . Sampling methods: Before CEH injection by 4 basal time points -15, -10, -5 and 0 minutes and After CRH injection at 5, 15, 30, 45 and 60 minutes after oCRH . Cut off value ≥ 1.4 μ g/dL at 15 minutes after CRH administration

96. Algorithm For Confirming Excessive Glucocorticoid Production 3/2/2025 Pituitary Neoplasms 96

97. Step 1: Is it Hypercortisolism State or Not? One of the Screening tests Positive Negative No hypercortisolism Mild or cyclic hypercortisolism state Cushing syndrome Pseudo-Cushing syndrome 1) Repeat abnormal test + do one or two other tests 2) Midnight cortisol level 3) LDDS- CRH stimulation test 1) 24-h urinary free cortisol (at least two 24-hour urinary free cortisol tests) 2) Late night salivary cortisol (at least 2 late-night salivary cortisol tests) 3) Overnight dexamethasone suppression test (ODS), 4) 2-day low-dose dexamethasone supp. test (LDDS), Pseudo Negative Pseudo Positive

98. Pseudo-Cushing Diagnosis Causes: Depression Alcohol induced Clinically: Asymptomatic Varying degrees of hypertension With or without hypokalemia Hyperandrogenism may exist (acne, hirsutism, oligomenorrhea and amenorrhea) No thinning of the skin, proximal myopathy, easy bruising, or early onset osteoporosis Biochemical pictures: Overlap with most of screening tests as basal UFCs, LDDST Best differentiation through: LDDS- CRH stimulation Preserved circadian rhythm of cortisol secretion 3/2/2025 Pituitary Neoplasms 98

99. Diagnosis: Is it ACTH Dependent or not? ACTH-Dependent Cushings Disease Ectopic ACTH Ectopic CRH Small cell & Non-small cell lung cancer Pancreatic tumors Neuroendocrine tumors including lung carcinoids, pheo-chromocytoma , and medullary thyroid cancer ACTH-Independent Adrenal Adenoma Adrenal Carcinoma Adrenal Hyperplasia Exogenous Steroids N.B.: Unilateral or bilateral adrenal enlargement is frequent in patients with an ACTH hypersecretion. N.B.: Pituitary may looks normal in MRI Ectopic ACTH source may present.

100. Step 2: Is it ACTH Dependent or not? More than one Late-afternoon (after 4 p.m.) plasma ACTH level Suppressed ACTH: < 5 pg /ml = ACTH non-dependent CS → abdominal imaging Elevated ACTH: >10 pg /ml is suggestive of ACTH-dependent → Pituitary imaging. Equivocal result: 5 - 10 pg /ml CRH stimulation test: ↑ plasma cortisol of ≥ 20%, plasma ACTH of ≥ 50% = ACTH dependent In ACTH non-dependent: → Ct abdomen & chest & PET scan In ACTH dependent: 3/5/2025 Pituitary Neoplasms 100

101. Corticotropin-Releasing Hormone (CRH) Test Time of sampling: ACTH and cortisol levels are measured before CRH injection and 15, 30, 45, 60, 90 and 120 minutes after injection. Sampling methods: 1 µg / kg ( or a total dose of 100 mg) of CRH is administered intravenously at 8 A.M . Cut off value ↑ plasma cortisol of ≥ 20%, plasma ACTH of ≥ 50% = ACTH dependent

102. Diagnosis: Is it ACTH Dependent or not? Cushing syndrome ACTH dependent ACTH non-dependent More than one Late-afternoon (after 4 p.m.) plasma ACTH level Abdominal imaging ACTH < 5 pg /ml = ACTH non-dependent ACTH >10 pg /ml is = ACTH dependent either pituitary or ectopic ACTH 5-10 pg /ml is = Equivocal CRH stimulation test ↑ plasma cortisol of ≥ 20%, plasma ACTH of ≥ 50% = ACTH dependent No ↑ plasma cortisol of ≥ 20%, plasma ACTH of ≥ 50% = ACTH non-dependent HDDST+ pituitary imaging

103. Step 3: Is it pituitary ACTH (Cushing disease = CD) or Ectopic ACTH ACTH >10 pg /ml is = ACTH dependent either pituitary or ectopic With pituitary source With ectopic source 8X X Suppressed by HDDS test Not Suppressed by HDDS test

104. Step 3: Is it pituitary ACTH (Cushing disease = CD) or Ectopic ACTH Do high dose dexamethasone suppression test (either the overnight form or the standard 2 days form) MRI pituitary 3/5/2025 Pituitary Neoplasms 104 + Both positive Pituitary ACTH Ectopic ACTH Both negative One positive & one negative IPSS ±

105. Overnight High Dose Dexamethasone Suppression (HDDS) Test Time of sampling: Baseline morning serum cortisol is measured Repeat serum cortisol levels are drawn the following morning, typically 8 AM - 9 AM Sampling methods: 8 mg is administered orally between 11 PM and midnight. Repeat serum cortisol levels are drawn the following morning, typically 8 AM - 9 AM. Cut off value Decrease of more than 50% in serum cortisol makes Cushing disease the likely source of adrenocorticotropic hormone-dependent Cushing syndrome

106. 2Ds High Dose Dexamethasone Suppression (HDDS) Test Time of sampling: Baseline morning serum cortisol is measured Repeat serum cortisol levels are checked 6 hours after the last dose of dexamethasone, typically at 9 AM on day 2 Sampling methods: Dexamethasone 2 mg is administered orally every 6 hours, typically at 9 AM, 3 PM, 9 PM, and 3 AM, for 2 days to complete a total dose of 16 mg over days 1 and 2. Repeat serum cortisol levels are checked 6 hours after the last dose of dexamethasone, typically at 9 AM on day 2. Cut off value A reduction in urinary-free cortisol or serum cortisol greater than 50% overnight during a 2-day high-dose dexamethasone suppression test makes Cushing disease the likely source of adrenocorticotropic hormone-dependent Cushing syndrome. At a cut-off value of 50% suppression, the high-dose dexamethasone suppression test provides a sensitivity and specificity of 60% to 100%, respectively

107. Intravenous Dexamethasone Suppression Test Time of sampling: A baseline morning serum cortisol (between 8 AM and 9 AM) is obtained . Repeat serum cortisol levels are measured at the end of the infusion (day 1) and 23-24 hours later (day 2) Pre requisites before sampling: Sampling methods: An infusion of intravenous dexamethasone at 1 mg/h for 4 to 7 hours  . Cut off value In pituitary ACTH dependent Cushing, the serum cortisol level at the end of the infusion on day 1 typically shows greater than 70% suppression from the baseline, followed by rebound hypercortisolism in 24 hours

108. Algorithm For Confirming Source of ACTH Both negatives Ectopic ACTH Pituitary

109. Bilateral Inferior Petrosal Sinus Sampling (BIPSS) Both negatives Ectopic ACTH Pituitary

110. Bilateral Inferior Petrosal Sinus Sampling (BIPSS) Indications: 1) Proven ACTH-dependent Cushing’s disease 2) ,,,,,,,,+ negative or equivocal MRI findings 3) To attempt to lateralize the site of a pituitary tumor to guide neurosurgical approaches 4) Persistence of Cushing’s syndrome after previous unsuccessful pituitary surgery, to ensure that the diagnosis of CD is correct. Diagnostic criteria for CD: ACTH basal ratio [ the concentration in the right or left inferior petrosal sinus to the concentration in the peripheral blood (IPS/P ratio)] of ≥ 2.0 or CRH stimulated ratio of ≥3.0 Overall sensitivity of 96% and specificity of 100% (although false positive responses have been documented Diagnostic criteria for lateralization of adenoma: Intersinus gradient ≥1.4 in basal conditions Sensitivity is in the range of 50–100% 3/1/2025 Pituitary Neoplasms 110

111. Differential Diagnosis

112. Differential Diagnosis Clinical D.D.: Radiological D.D.: Histopathological D.D.:

113. Differential Diagnosis Clinical differential diagnosis: Cushing and pseudo- cushing Radiological differential diagnosis: sellar /suprasellar lesions Hypophysis Pituitary abscess (V-I-T-A-M-I-N-C-D) Craniopharyngioma Rathkes cyst Tuberculum sella meningioma Histopathological differential diagnosis: Adenoma # High risk adenoma Subtypes of adenomas 3/1/2025 Pituitary Neoplasms 113

114. Management

115. Management Follow up: Pharmacological therapy: Minimal invasive procedures: Surgical therapy: Microsurgical: Endoscopic surgery: Radiation therapy: Conventional: Radiosurgery: Chemotherapy: Target therapy: Goals of Management Reduction/Elimination Of Tumor Mass Hormonal Cure Preservation Of Pituitary Function Prevention Of Recurrence

116. Treatment of Cushing’s Disease Follow up: Pharmacological therapy: Drugs Minimal invasive procedures: Surgical therapy: Microsurgical: Endoscopic surgery: Transsphenoidal microadenomectomy Bilateral total adrenolectomy Radiation therapy: Pituitary radiation Conventional: Radiosurgery: Chemotherapy: Target therapy: 3/2/2025 Pituitary Neoplasms 116

117. Pharmacological Management og CD Pharmacological management of the co-morbidity (hypertension, D.M…..) Pharmacological management of hypercortilism Adrenal steroidogenesis inhibitors Osilodrostat Metyrapone Ketoconazole (antifungal) Neuromodulatory treatment Dopamine agonists (cabergoline) Octreotide Glucocorticoid receptor antagonist (mifepristone) 3/6/2025 Pituitary Neoplasms 117

118. Ketoconazole 3/6/2025 Pituitary Neoplasms 118

119. 3/1/2025 Pituitary Neoplasms 119 Surgical Management

120. Surgical Management Indications: For associated hydrocephalus For tumor excision Procedures: Transphenoidal Approaches Endonasal , sub mucosal, trans- septal Endonasal , septal pushover Sublabial , endonasal , trans- septal Transcranial Approaches Pterional craniotomy Subfrontal craniotomy 3/1/2025 120 Pituitary Neoplasms

121. 3/1/2025 Pituitary Neoplasms 121 Endoscopic Approach For Pituitary Adenoma Review Presentations for Trans Sphenoidal Approach

122. Tips & trikes in Endoscopic Management for Cushimg ’ Disease Usually very small adenoma so sella not enlarged Neuronavigation Intraoperative vascular Doppler Drill Intraoperative fluorescent agents Surgical Management of MRI-Negative Cushing’s Gland exploration starting with lateral side with higher IPS result then if negative shift to other side Hemiresection of the pituitary gland 3/6/2025 Pituitary Neoplasms 122

123. Use of Fluorescent Agents 5-ALA: Used mainly for detecting tumor margins and residual disease Indocyanine green (ICG): Used mainly for detecting of blood vessels Fluorescein : Used mainly for detection tissue perfusion 3/6/2025 Pituitary Neoplasms 123

124. Post Operative Follow-up Neurological follow up Radiological follow up Hormonal follow up Acute removal of excess ACTH may induce Addisonian crises Due to excessive pituitary manipulation DI incidence may be more Due to hemi-resection of the pituitary gland post operative other hormonal deficiency may developed 3/6/2025 Pituitary Neoplasms 124

125. Post-Operative Endocrinal Evaluation In functional adenomas: To diagnose a hormonal cure To diagnose development of a new deficits in pituitary hormones In non functional adenomas: With pre operative hypopituitarism: To diagnose a recovery of pituitary function (~6%) With normal pituitary function (apart from stalk effect) To diagnose development of a new deficits in pituitary hormones (~ 15%) 3/1/2025 Pituitary Neoplasms 125

126. Post-Operative Endocrinal Evaluation for Hypo-Secretion Thyroid function: If on preoperative replacement → stop & examine 6-8 weeks later If not → examine 6-8 weeks later Adrenal function: Assessment for remission Monitor for signs of adrenal insufficiency (AI) Supraphysiological dose of hydrocortisone may be needed Diabetes Insipidus: 3/1/2025 Pituitary Neoplasms 126

127. 3/6/2025 Pituitary Neoplasms 127

128. 3/6/2025 Pituitary Neoplasms 128 Assessment For Remission

129. Steroid Replacement Therapy 3/6/2025 Pituitary Neoplasms 129

130. Monitoring For Post Operative hypopituitrism 3/6/2025 Pituitary Neoplasms 130

131. Post-operative Radiological Evaluation 3/1/2025 Pituitary Neoplasms 131

132. 3/1/2025 Pituitary Neoplasms 132 Radiation Therapy

133. Radiation Therapy Patients undergoing sellar radiation therapy are maintained on hydrocortisone 10 mg/d (½ tablet/day) during the course of radiation and 1-2 weeks thereafter Methods of radiation therapy: Conventional radiation: 40–50 Gy administered over 4–6 weeks (5 fractions /w) Stereotactic radiation: The usual dose for nonsecretory tumors is ≈ 16–18 Gy , and a higher dose is required for secretory tumor ≈ 25 Gy 3/1/2025 Pituitary Neoplasms 133 > 5 fractions

134. Radiotherapy 3/1/2025 Pituitary Neoplasms 134 The main radiosurgery technologies are: Photon stereotactic radiosurgery Leksell Gamma Knife uses cobalt-60 gamma rays Linear accelerator systems (LINAC) use high energy x-rays; the Novalis, TrueBeam or Cyberknife Proton stereotactic radiosurgery (charged particle radiosurgery) Beam therapy uses accelerated protons

135. Difference Between Photon & Proton Irradiation 3/1/2025 Pituitary Neoplasms 135 Gamma ray

136. Difference Between Gamma & LINAC Radiosurgery The key difference between gamma rays and X-rays is how they are produced. Gamma rays originate from the settling process of an excited nucleus of a radionuclide after it undergoes radioactive decay whereas X-rays are produced when electrons strike a target or when electrons rearrange within an atom. 3/1/2025 Pituitary Neoplasms 136

137. Difference Between Gamma & LINAC Radiosurgery Gamma knife LINAC accurate within 0.15 millimeters accurate within 1.10 millimeters Designed exclusively for brain surgery. Not designed exclusively for brain surgery A lightweight stereotactic frame is affixed to the head to provide rigid stabilization for maximum accuracy. Non-rigid immobilization reduces head movement by using a thermoplastic face mask that is shrink wrapped to the table during treatment. Treatment is delivered in one session. Single or multiple treatments, possibly over a period of several days. 3/1/2025 Pituitary Neoplasms 137

138. Radiotherapy Through one of two approaches Stereotactic radiosurgery (SRS): The application of a single large dose of radiation to a stereotactically localized target usually ≤ 3cm diameter with minimal radiation delivered to surrounding tissue. Single treatment Usually by Gamma knife Fractionated stereotactic radiotherapy (FSRT): It employs hypofractionated dosing (2–5 treatment fractions) The target can be larger Usually by LINAC 3/1/2025 138 Pituitary Neoplasms

139. Adverse Effects of Conventional Radiotherapy For Pituitary Adenomas Hypopituitarism : Up to 80% GH > LH/FSH > ACTH > TSH Second Brain Tumors: 2-3% at 20 years Stroke: Increased 2-Fold Cognitive Dysfunction: Rare 3/1/2025 139 Pituitary Neoplasms