Adenoma of a hypophysis is the tumoral formation of good-quality character proceeding from ferruterous fabric of a forward share of a hypophysis. Clinically adenoma of a hypophysis is characterized by an oftalmo-neurologic syndrome (a headache, glazodvigatelny violations, doubling, narrowing of fields of vision) and an endocrine and exchange syndrome at which depending on a type of adenoma of a hypophysis giantism and an akromegaliya can be observed, , violation of sexual function, a giperkortitsizm, hypo - or , a gipogonadizm. The diagnosis "hypophysis adenoma" is established on the basis of data of a X-ray analysis and KT of the Turkish saddle, MRT and angiography of a brain, hormonal researches and ophthalmologic inspection. Hypophysis adenoma by beam influence, a radio surgical method, and also by transnasal or transkranialny removal is treated.
settles down in a pole of the Turkish saddle on the basis of a skull. It has 2 shares: forward and back. Hypophysis adenoma -hypophysis tumor
, originating in fabrics of its forward share. It produces 6 hormones regulating function of endocrine glands: (TTG), (STG), , Prolactinum, and adrenokortikotropny hormone (AKTG). On statistical data adenoma of a hypophysis makes about 10% of all intra cranial tumors which are found in neurologic practice. Most often adenoma of a hypophysis arises at middle-aged persons (30-40 years).
The etiology and pathogenesis of adenoma of a hypophysis in modern medicine remain a subject of researches. It is considered that the new growth can arise at influence of such provocative factors as craniocereberal injuries, neuroinfections (tuberculosis, neurosyphilis, a brucellosis, poliomyelitis, encephalitis, meningitis, brain abscess, cerebral malaria, etc.), adverse effects on a fruit during its pre-natal development. It is lately noted that hypophysis adenoma at women is connected with prolonged use of medicines of oral contraception.
Researches showed that in certain cases adenoma of a hypophysis results from the increased hypothalamic stimulation of a hypophysis which is reaction to primary decrease in hormonal activity of peripheral endocrine glands. The similar mechanism of developing of adenoma can be observed, for example, at primary gipogonadizm and a hypothyroidism.
The clinical neurology subdivides hypophysis adenomas into two big groups: gormonalno inactive and gormonalno active. Adenoma of a hypophysis of the first group has no ability to produce hormones and therefore remains under the authority of only neurology. Adenoma of a hypophysis of the second group, like hypophysis tissues, produces hypophysial hormones and is also a studying subject for endocrinology. Depending on sekretiruyemy hormones gormonalno active adenomas of a hypophysis are classified on: somatotropny (somatotropinoma), prolaktinovy (prolaktinoma), kortikotropny (kortikotropinoma), tireotropny (tireotropinoma), gonadotropny (gonadotropinoma).
Depending on the size adenoma of a hypophysis can belong to microadenomas — the tumors with a diameter up to 2 cm or macroadenomas having diameter more than 2 cm.
Hypophysis adenoma symptoms
Clinically adenoma of a hypophysis is shown by a complex of the oftalmo-neurologic symptoms connected with pressure of the growing tumor upon the intra cranial structures located in the field of the Turkish saddle. If adenoma of a hypophysis is gormonalno active, then in her clinical picture to the forefront there can be an endocrine and exchange syndrome. At the same time changes in a condition of the patient are often connected not with the hyperproduction of tropny hypophysial hormone, and with activation of a target organ which it affects. Manifestations of an endocrine and exchange syndrome directly depend on the nature of a tumor. On the other hand, adenoma of a hypophysis can be followed by symptoms of a pangipopituitarizm which develops due to destruction of tissues of hypophysis the growing tumor.
Oftalmo-nevrologichesky symptoms by which hypophysis adenoma is followed in many respects depend on the direction and prevalence of its growth. As a rule, the headache, change of fields of vision, a diplopiya and glazodvigatelny violations concern to them. The headache is caused by pressure which adenoma of a hypophysis puts upon the Turkish saddle. It has stupid character, does not depend on position of a body and is not followed by nausea. The patients having hypophysis adenoma often complain that they not always manage to kill a headache by means of analgetics. The headache accompanying hypophysis adenoma is usually localized in frontal and temporal areas, and also behind an eye-socket. Perhaps sharp strengthening of a headache which is connected or with hemorrhage in tumor fabric, or with its intensive growth.
Restriction of fields of vision is caused by a sdavleniye the growing adenoma of the optic chiasm which is in area of the Turkish saddle under a hypophysis. It is long the existing adenoma of a hypophysis can lead to development of an atrophy of an optic nerve. If adenoma of a hypophysis grows in the side direction, then over time it squeezes branches III, IV, VI and V cranial nerves. Violation of glazodvigatelny function results (oftalmoplegiya) and doubling (diplopiya). Decrease in visual acuity is possible. If adenoma of a hypophysis sprouts a bottom of the Turkish saddle and extends to a trellised or wedge-shaped bosom, then the patient has a nose congestion imitating clinic of sinusitis or tumors of a nose. Growth of adenoma of a hypophysis up causes damage of structures of a hypothalamus and can lead to development of violations of consciousness.
Endocrine and exchange syndrome
Metabolic and endocrine violations are characteristic of the adenomas which are actively producing hormones. Clinical manifestations correspond to what type of hypophysial hormone is produced by a tumor. The following clinical options are possible:
- Somatotropinoma — the hypophysis adenoma producing STG at children is shown by giantism symptoms, at adults — an akromegaliya. Except characteristic changes of a skeleton, at patients diabetes and obesity, the increase in a thyroid gland (a diffusion or nodal craw) which is usually not followed by its functional violations can develop. The girsutizm, , the increased greasiness of skin and emergence on it of warts, papillomas and nevus is often observed. Development of the polyneuropathy which is followed by pains, paresteziya and decrease in sensitivity of peripheral departments of extremities is possible.
- Prolaktinoma — hypophysis adenoma, sekretiruyushchy Prolactinum. At women it is followed by violation of a menstrual cycle, galaktorey, amenorey and infertility. These symptoms can arise in a complex or be observed separately. About 30% of women from prolaktinomy have seborrhea, an acne, gipertrikhozy, moderately expressed obesity, an anorgazmiya. Men to the forefront usually have oftalmo-neurologic symptoms against the background of which it is observed , a ginekomastiya, impotence and decrease in a libido.
- Kortikotropinoma — the hypophysis adenoma developing AKTG comes to light practically in 100% of cases of a disease of Itsenko-Cushing. The tumor by classical symptoms of a giperkortitsizm, the strengthened pigmentation of skin as a result of the raised production along with AKTG and melanotsitostimuliruyushchy hormone is shown. Mental deviations are possible. Feature of this type of adenomas of a hypophysis is tendency to malignant transformation with the subsequent metastasis. Early development of serious endocrine violations promotes detection of a tumor before emergence of the oftalmo-neurologic symptoms connected with its increase.
- Tireotropinoma — hypophysis adenoma, sekretiruyushchy TTG. If it has primary character, then is shown by symptoms of a gipertireoz. If arises again, then the hypothyroidism is observed.
- Gonadotropinoma — the hypophysis adenoma producing gonadotropny hormones has nonspecific symptoms and comes to light generally on existence of typical oftalmo-neurologic symptomatology. In her clinical picture the gipogonadizm can be combined with the galaktorey, caused Prolactinum hyper secretion by the hypophysis tissues surrounding adenoma.
Patients at whom adenoma of a hypophysis is followed by the expressed oftalmo-neurologic syndrome, as a rule, ask for the help the neurologist or the ophthalmologist. Patients at whom adenoma of a hypophysis is shown by an endocrine and exchange syndrome more often come to reception to the endocrinologist. Anyway patients with suspicion of adenoma of a hypophysis have to be examined by all three experts.
For the purpose of visualization of adenoma carry out a X-ray analysis of the Turkish saddle which reveals bone signs: osteoporosis with destruction of a back of the Turkish saddle, a typical dvukonturnost of its bottom. In addition use a pnevmotsisternografiya which determines the shift of hiazmalny tanks from their normal situation. More exact data can be obtained during KT of a skull and MRT of a brain, KT of the Turkish saddle. However about 25-35% of adenomas of a hypophysis have so small size that their visualization does not work well even at modern opportunities of a tomography. If the weight of evidence suggests that adenoma of a hypophysis grows towards a kavernozny sine, appoint carrying out an angiography of a brain.
In diagnostics hormonal researches are important. Definition of concentration of hormones of a hypophysis in blood is made by a specific radiological method. Depending on symptomatology carry out also definition of the hormones produced by peripheral endocrine glands: cortisol, T3, T4, Prolactinum, estradiol, testosterone.
Ophthalmologic violations by which hypophysis adenoma is followed reveal at ophthalmologic survey, perimetry, visual acuity check. Make an oftalmoskopiya for an exception of diseases of eyes.
Treatment of adenoma of a hypophysis
Conservative treatment can be applied generally in the relation by Prolactinum of the small size. It is carried out by antagonists of Prolactinum, for example, bromkriptiny. At small adenomas application of beam ways of impact on a tumor is possible: gamma therapies, remote radiation or proton therapy, stereotaksichesky radio surgery — introduction of radioactive material directly in tumor fabric.
Patients at whom adenoma of a hypophysis has the big sizes and/or is followed by complications (hemorrhage, sight violation, formation of a cyst of a brain) have to undergo consultation of the neurosurgeon for consideration of a possibility of surgical treatment. Operation on removal of adenoma can be executed in the transnasal way with use of the endoscopic equipment. Macroadenomas are subject to removal in the transkranialny way — by cranial trepanation.
Adenoma of a hypophysis belongs to good-quality new growths, however at increase in the size it, as well as other tumors of a brain, the malignant current at the expense of a sdavleniye of the anatomic educations surrounding it accepts. The size of a tumor also caused a possibility of its full removal. Adenoma of a hypophysis with a diameter more than 2 cm is accompanied by probability of a postoperative recurrence which can take place within 5 years after removal.
The forecast of adenoma also depends on its look. So at mikrokortikotropinoma at 85% of patients the complete recovery of endocrine function after the carried-out surgical treatment is observed. At patients with somatotropinomy and prolaktinomy this indicator is much lower — 20-25%. According to some information on average after surgical treatment recovery is observed at 67% of patients, and the number of a recurrence makes about 12%. In certain cases at hemorrhage in adenoma there is a self-healing that is most often observed at prolaktinoma.