Diagnostic Imaging Pathways - Pituitary Dysfunction or Mass (Suspected)
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This pathway provides guidance on the imaging of adult patients with suspected pituitary mass.
Date reviewed: July 2014
Date of next review: 2017/2018
Published: August 2014
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1a |  |
Pituitary Microadenoma Image 1a (T1 weighted), 1b and 1c (T2 weighted) (Magnetic Resonance Imaging): There is a lesion seen within the pituitary gland centred to the right of the midline which is of high signal intensity on the T2 weighted imaging and shows slightly reduced signal intensity compared with adjacent pituitary on the T1 weighted imaging. Overall, the lesion measures up to 6mm. The lateral aspect of the lesion is abutting the medial aspect of the cavernous segment of the right internal carotid artery. The superior aspect of the pituitary is directly adjacent to the inferior aspect of the optic chiasm. The appearances are consistent with a pituitary microadenoma. |
| 1b |  |
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| 1c |  |
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| 2a |  |
Pituitary Macroadenoma (Cushing's Disease) Image 2a and 2b (Magnetic Resonance Imaging): There is a 13mm right sided pituitary adenoma (arrows) causing deviation of the stalk to the left. Slight suprasellar extension is noted without impingement of the chiasm or optic nerves. |
| 2b |  |
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| 3a |  |
Pituitary Macroadenoma Image 3a and 3b: Post-mortem specimens showing a circumcribed nodular tumour arising from the anterior pituitary consistent with a macroadenoma. |
| 3b |  |
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| 3c |  |
Image 3c (H&E, x2.5) and 3d & 3e (H&E, x20): Histological sections demonstrating a circumscribed lesion composed of sheets of uniform polygonal cells with centrally placed nuclei and amphophilic cytoplasm. The features are consistent with a pituitary adenoma. |
| 3d |  |
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| 3e |  |
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Teaching Points
Teaching Points
- A pituitary mass or pituitary fossa dysfunction may present clinically in a number of ways such as hormonal deficiency/excess, visual changes or headache
- A detailed history, examination and biochemical screening is required in conjunction with imaging
- MRI (Magnetic Resonance Imaging) with intravenous gadolinium is the modality of choice. It is accurate in the depiction of the pituitary gland, infundibulum, optic chiasm, cavernous sinuses and neighbouring vascular structures
- If MRI is contra-indicated or unavailable, a CT (Computed Tomography) with contrast is an alternative
ct
Computed Tomography (CT) with IV Contrast
- Coronal CT with intravenous contrast and thin slices is the preferred imaging modality if MRI is unavailable or contraindicated, and can produce diagnostic images 1
- Superior to MRI in demonstration of bony erosion. 2,3 CT is also more sensitive than MRI in detecting calcification of soft tissues 4
- There has been promising results in the use of dual-energy CT in differentiating sellar meningiomas and pituitary adenomas. The MR appearances of these two lesions can often be difficult to differentiate and often there can be contraindications to the use of MRI 5
- Inferior to MRI for distinguishing the tumour from the optic chiasm, and in diagnosis of cavernous sinus invasion 3,6,7
- Advantages: relatively less expensive and widely available
- Disadvantages: exposure to ionising radiation
- Information for consumers on Computed Tomography (CT) InsideRadiology
mri
Magnetic Resonance Imaging (MRI)
- Gadolinium enhanced MRI is the imaging modality of choice for investigation of suspected pituitary fossa lesion 6,8-10
- The use of MRI pre operatively is well established, accuracy between pre operative imaging findings and surgical findings was high in this study 11
- Subtle microadenomas can be difficult to detect and a dynamic contrast enhanced study is often used to assist diagnosis 1,12
- Superior diagnostic accuracy compared to CT. 2,3,6,13-15
- Advantages
- Disadvantages: expensive and limited availability
- MRI shows an incidental pituitary fossa lesion in approximately 10% of normal individuals 18
- The majority of these are microadenomas with macroadenomas being far less common 19
- There is considerable variation in clinical practice in relation to incidental pituitary lesions and the optimal management strategy is uncertain 20
- Serial imaging has shown that most incidental pituitary adenomas do not increase in size 21,22
- Information for consumers on Magnetic Resonance Imaging (MRI) InsideRadiology
pit
Pituitary Fossa Mass
- There are a number of causes for a pituitary fossa mass including 23
- Pituitary adenoma
- Meningioma
- Metastasis
- Germ Cell Tumour
- Sarcoidosis
- Tuberculosis
- Pituitary Abscess
- Aneurysm
- Craniopharyngioma
- A pituitary fossa mass can present clinically in a number of ways including 24
- Deficiency of one of more pituitary hormones
- Hormone excess - most commonly prolactin
- Mass effects from an expanding lesion; e.g. bitemporal hemianopia
- Pituitary adenomas are the most common cause of a pituitary fossa mass they comprise between 10 -15 percent of all intracranial tumours and are the most common lesions arising in the sellar region. 1,8,25 Pituitary adenomas are also classified depending on the ability to secrete hormones, those secreting hormones are known as functional adenomas and those that do not are referred to as non-functional adenomas. 26 They may secrete prolactin, TSH, GH, ACTH or gonadotropins. 8-10 The most common pituitary adenomas are prolactinomas 27
- Metastatic disease to the pituitary has been reported in 26 percent of autopsy cases 28 with the most common causes being metastatic disease from breast followed by lung and thyroid 29,30
- Plain radiography is insensitive and nonspecific for evaluation of sellar pathology and is no longer used, however an enlarged or eroded sella may reflect a pituitary or parasellar lesion 8-10
- Pituitary microadenoma and even small pituitary macroadenomas are frequently associated with a normal sella size 8-10
- Pituitary adenomas can be classified radiologically in accordance with their size, microadenomas are classified as being <1cm and macroadenomas are classified as being ≥1cm 4
References
References
Date of literature search: June 2014
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Zee CS, Go JL, Kim PE, Mitchell D, Ahmadi J. Imaging of the pituitary and parasellar region. Neurosurg Clin N Am. 2003;14:55-80, vi. (Review article). View the reference
- Davis PC, Hoffman JC, Jr., Spencer T, Tindall GT, Braun IF. MR imaging of pituitary adenoma: CT, clinical, and surgical correlation. AJR Am J Roentgenol. 1987;148:797-802. (Level IV evidence). View the reference
- Lundin P, Bergstrom K, Thuomas KA, Lundberg PO, Muhr C. Comparison of MR imaging and CT in pituitary macroadenomas. Acta Radiol. 1991;32:189-96. (Level IV evidence). View the reference
- Mustafa OG, McGregor AM. Diagnosis of pituitary disease. Medicine. 2013;41:497-503. (Review article). View the reference
- Wu LM, Li YL, Yin YH, Hou GQ, Zhu R, Hua XL, et al. Usefulness of dual-energy computed tomography imaging in the differential diagnosis of sellar meningiomas and pituitary adenomas: preliminary report. PLoS One. 2014;9:e90658. (Level II/III evidence). View the reference
- Johnson MR, Hoare RD, Cox T, Dawson JM, Maccabe JJ, Llewelyn DE, et al. The evaluation of patients with a suspected pituitary microadenoma: computer tomography compared to magnetic resonance imaging. Clin Endocrinol (Oxf). 1992;36:335-8. (Level II evidence). View the reference
- Stein AL, Levenick MN, Kletzky OA. Computed tomography versus magnetic resonance imaging for the evaluation of suspected pituitary adenomas. Obstet Gynecol. 1989;73:996-9. (Level III evidence). View the reference
- FitzPatrick M, Tartaglino LM, Hollander MD, Zimmerman RA, Flanders AE. Imaging of sellar and parasellar pathology. Radiol Clin North Am. 1999;37:101-21, x. (Review article). View the reference
- Naidich MJ, Russell EJ. Current approaches to imaging of the sellar region and pituitary. Endocrinol Metab Clin North Am. 1999;28:45-79, vi. (Review article). View the reference
- Swallow CE, Osborn AG. Imaging of sella and parasellar disease. Semin Ultrasound CT MR. 1998;19(3):257-71. (Review article). View the reference
- Cho CH, Barkhoudarian G, Hsu L, Bi WL, Zamani AA, Laws ER. Magnetic resonance imaging validation of pituitary gland compression and distortion by typical sellar pathology. J Neurosurg. 2013;119:1461-6. (Level III evidence). View the reference
- Kanou Y, Arita K, Kurisu K, Tomohide A, Iida K. Clinical implications of dynamic MRI for pituitary adenomas: clinical and histologic analysis. J Clin Neurosci. 2002;9:659-63. (Level II evidence). View the reference
- Nichols DA, Laws ER, Jr., Houser OW, Abboud CF. Comparison of magnetic resonance imaging and computed tomography in the preoperative evaluation of pituitary adenomas. Neurosurgery. 1988;22:380-5. (Level IV evidence). View the reference
- Guy RL, Benn JJ, Ayers AB, Bingham JB, Lowy C, Cox TC, et al. A comparison of CT and MRI in the assessment of the pituitary and parasellar region. Clin Radiol. 1991;43:156-61. (Level IV evidence). View the reference
- Kulkarni MV, Lee KF, McArdle CB, Yeakley JW, Haar FL. 1.5-T MR imaging of pituitary microadenomas: technical considerations and CT correlation. AJNR Am J Neuroradiol. 1988;9:5-11. (Level III evidence). View the reference
- Cottier JP, Destrieux C, Brunereau L, Bertrand P, Moreau L, Jan M, et al. Cavernous sinus invasion by pituitary adenoma: MR imaging. Radiology. 2000 215:463-9. (Level III evidence). View the reference
- Kucharczyk W, Davis DO, Kelly WM, Sze G, Norman D, Newton TH. Pituitary adenomas: high-resolution MR imaging at 1.5 T. Radiology. 1986;161:761-5. (Level III evidence). View the reference
- Hall WA, Luciano MG, Doppman JL, Patronas NJ, Oldfield EH. Pituitary magnetic resonance imaging in normal human volunteers: occult adenomas in the general population. Ann Intern Med. 1994;120:817-20. (Level II evidence). View the reference
- Molitch ME, Russell EJ. The pituitary "incidentaloma". Ann Intern Med. 1990;112:925-31. (Review article). View the reference
- Howlett TA, Como J, Aron DC. Management of pituitary incidentalomas. A survey of British and American endocrinologists. Endocrinol Metab Clin North Am. 2000;29:223-30, xi. (Level V evidence). View the reference
- Feldkamp J, Santen R, Harms E, Aulich A, Modder U, Scherbaum WA. Incidentally discovered pituitary lesions: high frequency of macroadenomas and hormone-secreting adenomas - results of a prospective study. Clin Endocrinol (Oxf). 1999;51:109-13. (Level II evidence). View the reference
- Donovan LE, Corenblum B. The natural history of the pituitary incidentaloma. Arch Intern Med. 1995;155:181-3. (Level II evidence). View the reference
- Connor SE, Penney CC. MRI in the differential diagnosis of a sellar mass. Clin Radiol. 2003;58:20-31. (Review article). View the reference
- Hurley DM, Ho KK. MJA Practice Essentials--Endocrinology. 9: Pituitary disease in adults. Med J Aust. 2004;180:419-25. (Review article). View the reference
- Rennert J, Doerfler A. Imaging of sellar and parasellar lesions. Clin Neurol Neurosurg. 2007;109:111-24. (Review article). View the reference
- Lucas JW, Zada G. Imaging of the pituitary and parasellar region. Semin Neurol. 2012;32:320-31. (Review article). View the reference
- Famini P, Maya MM, Melmed S. Pituitary magnetic resonance imaging for sellar and parasellar masses: ten-year experience in 2598 patients. J Clin Endocrinol Metab. 2011;96:1633-41. (Level I evidence). View the reference
- Morita A, Meyer FB, Laws ER, Jr. Symptomatic pituitary metastases. J Neurosurg. 1998;89:69-73. (Level II evidence). View the reference
- Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer. 1950;3:74-85. (Level I evidence). View the reference
- Pisaneschi M, Kapoor G. Imaging the sella and parasellar region. Neuroimaging Clin N Am. 2005;15:203-19. (Review article). View the reference
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Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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