Diagnosis and management of pituitary tumours in the elderly: a review based on personal experience and evidence of literature

Abstract

An increasing proportion of pituitary adenomas are recognized in the elderly, raising the question of their optimal diagnosis and management. Age-related endocrine changes and associated diseases may significantly modify the clinical presentation and hormonal evaluation of these patients. About 80% of pituitary adenomas in this age group are non-secreting, requiring careful differential diagnosis with non-adenomatous sellar lesions. In this group, visual deterioration and hypopituitarism remain the leading symptoms. Recognized secreting tumours are mainly GH-secreting, most of them intrasellar, followed by prolactinomas, which present as clinically non-secreting and are usually invasive. Cushing's disease appears as a very rare eventuality in the elderly. Optimal therapeutic management should aim to control the disease while preserving or improving patient's quality of life. Transsphenoidal surgery has proved to be an efficient and well-tolerated option for non-secreting adenomas with visual defects and intrasellar GH-secreting adenomas, being able to improve metabolic and cardiovascular complications of acromegaly even in this age group. In contrast, dopamine-agonist drugs can be proposed as a primary therapy for prolactinomas even in the presence of severe neurological complications. Because the use of radiotherapy is hampered by its delay of action and potential neurological side effects, its indications should be better defined in this age group. The clinical importance of hypopituitarism should not be underestimated, and thyroid-and adrenal-replacement therapy are mandatory in the presence of documented hormone deficiency, carefully avoiding overtreatment in order to limit possible side effects on the cardiovascular system and bone mineralization. Indications for GH-and sex steroid-replacement therapy still await age-specific guidelines.European Journal of Endocrinology 153 723-735

Clinical and laboratorial characterization and post-surgical follow-up of 87 patients with non-functioning pituitary macroadenomas

“…It has been reported that 80% of pituitary tumors in the elderly over 65 years of age are non-secreting 21 . In this sample, most of the patients were over 40 years of age (61.7%).…”

Thyroid Hormone Replacement for Central Hypothyroidism: A Randomized Controlled Trial Comparing Two Doses of Thyroxine (T4) with a Combination of T4 and Triiodothyronine

“…This suggests that T 4 dosage based on bw and aiming at fT4 in the upper reference range is superior to titration of T 4 T REATMENT OF hypopituitarism has improved over the last two decades, due to refined laboratory tests and availability of more physiological replacement regimens (1,2). However, it is a well-known clinical notion that quality of life remains impaired despite substitution therapy, including T 4 , hydrocortisone, sex hormones, and GH.…”

European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas

“…Most pituitary tumours in this age group are large, slowly growing invasive tumours (179,180). Low growth rate of tumour remnants is reported by some (in 21% of the patients despite subtotal and partial tumour resections), while other authors report progression rates comparable in elderly and young patients (178,179,180). There is no absolute contraindication to either radiotherapy or oncological drugs in the elderly.…”

“…Elderly Pituitary tumours in the elderly (patients older than 65 (176) are mostly clinically non-functioning (NFPA), although in general, they stain positive for gonadotroph hormones (177,178). Most pituitary tumours in this age group are large, slowly growing invasive tumours (179,180). Low growth rate of tumour remnants is reported by some (in 21% of the patients despite subtotal and partial tumour resections), while other authors report progression rates comparable in elderly and young patients (178,179,180).…”