A 32-year-old female comes to the physician's office for a follow-up visit. She was recently brought to the emergency department due to head trauma, and the head CT scan performed at that time revealed an abnormal sella. She does not have any significant medical problems. She is currently not on any medications. Her menstrual cycles are regular. She is sexually active with one partner. She does not have any children. Her family history is insignificant. She does not smoke cigarettes or drink alcohol. Her physical examination is unremarkable. Prolactin, IGF-1, LH, FSH, TSH, and free T4 are within normal limits. Her plasma cortisol is normally suppressed after the administration of 1 mg of dexamethasone. MRI of the pituitary region shows a 5-mm hypo-intense lesion within the pituitary gland, whose architecture is not distorted. The rest of the brain appears normal. What is the next best step in the management of this patient?

Question

A 32-year-old female comes to the physician's office for a follow-up visit.  She was recently brought to the emergency department due to head trauma, and the head CT scan performed at that time revealed an abnormal sella.  She does not have any significant medical problems.  She is currently not on any medications.  Her menstrual cycles are regular.  She is sexually active with one partner.  She does not have any children.  Her family history is insignificant.  She does not smoke cigarettes or drink alcohol.  Her physical examination is unremarkable.  Prolactin, IGF-1, LH, FSH, TSH, and free T4 are within normal limits.  Her plasma cortisol is normally suppressed after the administration of 1 mg of dexamethasone.  MRI of the pituitary region shows a 5-mm hypo-intense lesion within the pituitary gland, whose architecture is not distorted.  The rest of the brain appears normal.  What is the next best step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The vignette describes the classic presentation of pituitary incidentaloma. Incidental pituitary tumors are very common and are usually innocuous. Majority of these tumors tend to remain very small. This patient has a small tumor and does not have clinical or laboratory evidence of any pituitary abnormalities or dysfunction. She can be safely followed with periodic assessment of the pituitary gland with MRI. (Choice A)Cosyntropin test is usually used in the evaluation of patients with adrenal insufficiency. (Choice C)Plasma ACTH levels are measured when the screening test for Cushing's syndrome (overnight dexamethasone suppression test) is positive. This patient has normal overnight dexamethasone suppression test. ACTH levels are always interpreted with simultaneous measurements of plasma cortisol. (Choice D)This patient does not require transphenoidal resection of the pituitary adenoma because she does not have any clinical features of hormonal dysfunction or any compressive symptoms. (Choice E)This patient clinically appears to be eucortisolemic. She does not need therapy with hydrocortisone. Educational Objective: Incidentally discovered small lesions in the sellar region are very common. Patients with a small mass or lesion without any hormonal dysfunction can be safely followed by periodic assessment of the pituitary gland with MRI.

A 32-Year-Old Female Comes to the Physician's Office for a Follow-Up Visit