Full text of DOI:10.1007/BF03343820

J. Endocrinol. Invest. 24: 92-97, 2001
Pituitary adenomas in childhood and adolescence.
Clinical analysis of 10 cases
E. De Menis*, A. Visentin**, D. Billeci***, P. Tramontin*, S. Agostini**, E. Marton***,
and N. Conte*
*I Medical Division, **Department of Pediatrics, ***Division of Neurosurgery, Regional Hospital,
Treviso, Italy
ABSTRACT. Pituitary adenomas in childhood and
adolescence constitute 2-6% of all operated pitu-
itary adenomas. We report the clinical features,
treatment and follow-up of 10 pediatric patients
affected by pituitary adenomas. All patients un-
derwent clinical evaluation, endocrine tests, mag-
netic resonance imaging and visual field assess-
ment. Follow-up ranged from 8 to 132 months (me-
dian 52.6). All patients were older than 10 years of
age; 60% were males. In 50% the initial complaints
were headache and/or visual impairment, all except
one had clear evidence of endocrine dysfunction.
Ninety percent were macroadenomas. According
to hormone measurements and immunostaining
50% were prolactinomas, 20% were pure GH-se-
creting and 30% were non-functioning adenomas.
Prolactinomas in two females were successfully
treated with cabergoline. The other patients un-
derwent surgery: three prolactinomas are still being
treated with dopamine agonists and a GH-secreting
adenoma is being treated with octreotide LAR and
cabergoline. Two patients were also treated with
conventional radiotherapy. Treatments were com-
pletely successful in 50% of patients: these have
normal hormone secretion, full pubertal develop-
ment, no significant tumor mass and normal visual
field. Hypersecretion of prolactin persists in two
cases; partial or complete hypopituitarism is pre-
sent in four, relevant tumor remnant in another four
and impairment of visual field is present in two cas-
es. In conclusion, pediatric adenomas occur mostly
in pubertal age, are prevalently macroadenomas
and clinically functioning. Medical therapy should
be preferred for secreting adenomas, but in some
cases, notably prolactinomas in males, surgery and
eventual radiotherapy may be needed.
(J. Endocrinol. Invest. 24: 92-97, 2001)
©2001, Editrice Kurtis
INTRODUCTION
MATERIALS AND METHODS
Pituitary adenomas rarely occur in childhood and
adolescence (1-6). Most data are based on case re-
ports and only a few series of importance have
been reported. Furthermore, different definitions
of pediatric age and criteria of cure have been used
which, in addition to incomplete follow-up, make
this topic of pediatric endocrinology far from re-
solved (7). We report the clinical features, man-
agement and outcome of 10 pediatric patients with
pituitary adenomas.
The files of all patients admitted to our hospital for
pituitary adenomas since 1989 were searched. Ten
patients were considered pediatric cases: all sub-
jects were 18 years old or less at diagnosis with the
exception of one patient affected by acromegaly/-
gigantism. Assessment of clinical history, physical
examination (including pubertal staging according
to Tanner) and complete evaluation of hypothala-
mic-pituitary function were carried out in all pa-
tients. Hormonal status was assessed in the basal
state with dynamic tests when appropriate, gener-
ally according to standard protocols (8). Hormone
measurements were made using commercial ra-
dioimmunologic Kits: IGF-I was measured by an
immunoradiometric assay after ethanol extraction
and the values compared with normal references
after adjustment for age.
Key-words: Pituitary adenomas, adolescence, prolactinomas, gigantism,
octreotide.
Correspondence: Dr. Ernesto De Menis, I Divisione Medica, Ospedale
Regionale, P.zza Ospedale, 31100 Treviso, Italy.
Pituitary imaging was performed by magnetic reso-
nance before and after contrast. All patients under-
went complete ophthalmologic evaluation, includ-
E-mail: edemenis@ulss.tv.it
Accepted August 9, 2000.
92

Pituitary adenomas in children
RESULTS
ing visual field measurement by Goldman-Friedman
or computerized perimetry. All operations, except
in patient 6, were performed by the same surgeon
(D.B.). Tumor specimens were stained with specific
antibodies against GH, PRL, ACTH, LH, FSH, TSH.
Pituitary radiotherapy was performed using a 6 MV
linear accelerator to deliver a dose of 4500 cGy via
three fields in 25 fractions with the aid of comput-
erized tomography for targeting. Clinical examina-
tion, hormonal measurements and ophthalmologic
evaluation were performed at least every six months
and M.R. was repeated at least yearly.
The results are shown in Table 1 (prolactinomas) and
Table 2 (non prolactinomas). Six patients were males
(60%). Age at diagnosis ranged from 11 to 19 years
(median 16.5). Mean delay from onset of symptoms
and diagnosis was 17 months (range 2-48). Follow-up
ranged from 8 to 132 months (median 52.6).
Symptoms that primarily led to medical attention
were visual defects and/or headache in five patients
(50%), primary amenorrhea in two (20%), secondary
amenorrhea in one (10%) and acromegaly/gigan-
tism in two other cases (20%). At diagnosis clinical
Table 1 - Clinical features, hormonal status, treatment and follow-up of pediatric prolactinomas.
Case
Sex
1
F
2
F
3
M
4
M
5
M
Age at onset of symptoms
and diagnosis (yr)
13 16
16 17
14 15
11 11
16 18
Follow-up
(months)
51
8
60
38
11
Presenting
complaints
Primary
amenorrhea,
galactorrhea
Secondary
amenorrhea
Visual defects
Visual defects
Visual defects,
headache
Other clinical
findings
Galactorrhea
Compulsive
behavior,
epilepsy
Short stature
G1P2
Gynecomastia
Pubertal stage (Tanner)
Visual field
B3P2
B5P5
G3P4
G3P3
Normal
Reduced
bitemporal
field
Right temporal
hemianopsia,
visual loss of
the left field
Bitemporal
hemianopsia
Bitemporal
hemianopsia
Magnetic resonance
Adenoma with
sovrasellar
extension (18 mm)
Adenoma
(13 mm)
Giant adenoma
(98 mm)
Adenoma with
sovrasellar
Adenoma with
sovrasellar
extension (33 mm) extension (22 mm)
Hormonal findings
Surgery
PRL 254 ng/ml
PRL 105 ng/ml
PRL 9400 ng/ml
PRL 787 ng/ml
PRL 2130 ng/ml
TSP
Combined TC
and TSP
TSP: two
operations
Immunostaining
Radiotherapy
PRL
PRL
PRL
Conventional
external
Current treatment
Long-term results
Cabergoline
1.5 mg/week
Cabergoline
3 mg/week
Bromocriptine
20 mg/day,
C, D, Te, T4
Bromocriptine
15 mg/day,
hrGH
Cabergoline
0.5 mg/day
PRL 21 ng/ml,
marked tumor
shrinkage (4 mm),
normal visual field,
B5P5, normal menses
PRL 2 ng/ml,
marked tumor
shrinkage (6 mm),
normal visual field, right quadrantopsia
normal menses
PRL 142 ng/ml,
marked reduction
of tumor mass,
PRL 199 ng/ml,
persistent tumor
mass (20 mm),
worsening of
the bilateral
hemianopsia, G1P2
PRL 10 ng/ml,
significant tumor
shrinkage (6 mm),
improved visual
field, G4P4
and improved
vision of the
left eye, G5P5
C: cortone acetate, D: desmopressin, hrGH: human recombinant GH, T4: L-thyroxine, TC: transcranial surgery, Te: testosterone enanthate, TSP: transsphe-
noidal surgery.
93

E. De Menis, A. Visentin, D. Billeci, et al.
Table 2 - Clinical features, hormonal status, treatment and follow-up of pediatric pituitary GH-secreting and non-functioning adenomas.
Case
Sex
6
M
7
M
8
F
9
F
10
M
Age at onset of symptoms
and diagnosis (yr)
17 19
17 18
14 18
11 12
14 15
Follow-up (months)
66
42
95
23
132
Presenting
complaints
Acromegaly,
gigantism
Acromegaly,
gigantism
Primary
amenorrhea
Visual defects,
headache
Visual defects,
headache
Other clinical
findings
Obesity
Pubertal stage (Tanner)
Visual field
G5P5
G5P5
B3P4
B3P4
G1P1
Normal
Normal
Normal
Left temporal
hemianopsia
Left temporal
hemianopsia
Magnetic resonance
Adenoma with
sovrasellar
extension (30 mm)
Adenoma (8 mm)
Adenoma (25 mm) Adenoma (12 mm)
Adenoma with
sovrasellar
extension (24 mm)
and cavernous
sinus invasion
Hormonal findings
Mean basal
GH 14 ng/ml,
IGF-I 640 ng/ml
Mean basal
GH 12 ng/ml,
IGF-I 1246 ng/ml
Testosterone 1.5
ng/ml; mean basal LH
4 and FSH 3 mU/ml,
reduced response
to GnRH
Normal
Complete
hypopituitarism
Surgery
TSP
TSP
TSP
TSP
TC
Immunostaining
Radiotherapy
Only GH
Only GH
Negative
Negative
Negative
Conventional
external
Current treatment
C, D, Te, T4
Otreotide LAR 30
mg/month and
cabergoline
C, Te, T4, hrGH
1.5 mg/week
Long-term results
GH<0.5 ng/ml
IGF-I 93 ng/ml,
empty sella, normal
visual field, P5G5
Mean GH 2.5 ng/ml No residual tumor,
6 mm residual
Intracavernousal
IGF-I 350 ng/ml,
no residual tumor,
normal visual
normal visual
field, B5P5,
normal menses
tumor, normal visual remnant, normal
field, B5P5,
normal menses
visual field,
P5G5
field, G5P5
C: cortone acetate, D: desmopressin, hrGH: human recombinant GH, T4: L-thyroxine, TC: transcranial surgery, Te: testosterone enanthate, TSP: transsphe-
noidal surgery.
evaluation disclosed that all patients but one (case
9) had signs and/or symptoms of endocrine dys-
function: delayed or arrested puberty (cases 1, 5,
8, 10) with galactorrhea or ginecomastia in three
patients (cases 1, 2, 5), acromegaly/gigantism in
two (cases 6, 7) and short stature in one (case 4);
patient 3 had a clear hypothalamic syndrome with
compulsive behavior and epilepsy.
Visual field was reduced in six cases (60%). Magnetic
resonance disclosed the adenoma in all patients and
the diameters were larger then 10 mm in all but one
(case 7). Sovrasellar extension was present in 6 sub-
jects, in particular patient 3 had a giant adenoma.
Adenomas were clinically functioning in 7 patients
(70%). Cases 1-5 had prolactin levels ranging from
105 to 9400 ng/ml and were classified as prolacti-
nomas. Cases 6 and 7 had mean basal GH of 14
and 12 ng/ml respectively, with paradoxic response
to a standard OGTT. Their IGF-I were 640 and 1246
ng/ml respectively (age-adjusted upper normal val-
ues 450 ng/ml) and prolactin levels were normal;
these adenomas were classified as pure GH-se-
creting. Patient 8 had inappropriately low levels of
gonadotropins and impaired responsiveness to
GnRH; patient 9 had normal basal and stimulated
hormone values and patient 10 showed complete
hypopituitarism. These three cases were considered
clinically non-functioning adenomas.
94

Pituitary adenomas in children
Prolactinomas
pubertal development, no significant tumor mass is
present and visual fields are intact. In the other pa-
tients hypersecretion of PRL still persists in 2 cases
(cases 3 and 4), partial or complete hypopituitarism
is present in 4 (cases 3, 4, 6, 10), relevant tumor rem-
nant is evident in 4 (cases 3, 4, 9, 10) and visual field
is impaired in 2 patients (cases 3, 4).
Cabergoline caused a quick improvement in the
two female patients (cases 1 and 2); prolactin levels
are normal, tumor shrinkage has been impressive
and visual fields are normal; their sexual character-
istics are fully expressed and they have regular
menses. In male patients the results of therapy were
less successful apart from case 5. In this patient
bromocriptine had not improved bilateral hemi-
anopsia, he was operated on and then treated with
cabergoline 0.5 mg/day: PRL is normal, the size of
the residual tumor has decreased and the visual
field has markedly improved. Patient 3 had a giant
prolactinoma; a transcranial-transsphenoidal oper-
ation was performed, followed by radiotherapy.
Complete hypopituitarism is present and, despite
bromocriptine 20 mg/day and a decrease in the tu-
mor size, PRL is 142 ng/ml and significant deran-
gement of visual field is still present. Patient 4 was
treated by transsphenoidal surgery followed by
bromocriptine with doses up to 20 mg/day and lat-
er cabergoline 3 mg/week, but PRL did not norma-
lize, the tumor went on growing and visual field
worsened so a second transsphenoidal operation
was performed. Despite bromocriptine 15 mg/day,
PRL levels keep increasing, a significant tumor rem-
nant is still present and visual field is worsening,
therefore radiotherapy has been scheduled.
DISCUSSION
In childhood and adolescence pituitary adenomas
constitute 2.1-6% of adenomas removed by surgery
in all age groups (1-6). All our patients were older
than 10 years of age, confirming that most pituitary
adenomas in pediatric age occur in the pubertal
period (2, 4-6). Males accounted for 60% of our pa-
tients. A slightly higher prevalence of males (52-
60%) had been reported in a few series (2, 3, 9),
while others reported a higher prevalence (70-83%)
of females (4-6). The female/male ratio is higher for
prolactinomas, ranging from 1.6:1 to 4.8:1 (3, 5, 6,
10, 11) but perhaps less striking than in adults; in
GH and mixed GH/PRL tumors, female/male ratio is
lower ranging from 1:3 to 1:4.5 (3, 5, 6, 12); clini-
cally non-functioning adenomas are predominant-
ly male (6, 13).
Half our patients came to medical attention for tu-
mor mass symptoms, namely visual defects and
headache. It should be emphasized that clinical
evaluation at diagnosis disclosed that most of our
patients had unrecognized or misinterpreted en-
docrine dysfunctions, in particular 40% of the pa-
tients had inappropriate pubertal development for
their age: a more careful investigation of these en-
docrine signs would probably have allowed an ear-
lier diagnosis. The initial complaints of pediatric pa-
tients are generally reported to be endocrine symp-
toms or signs, particularly failure of growth or sex-
ual maturation (5, 6), but headache was present in
61% of patients in the series of Kane (5) and
headache and/or visual defects were the presenting
symptoms in half of 26 prolactinomas (11), too.
Perhaps in our series the large prevalence of symp-
toms due to tumor mass can be accounted for by
the fact that 90% were macroadenomas, sometimes
of great size. In pediatric age macroadenomas en-
compass 54-69% of prolactinomas (4-6, 10, 11), 50-
92% of GH/PRL-secreting tumors (3, 5, 6, 12) and
92-100% of clinically non-functioning adenomas (6,
13): this is in sharp contrast with ACTH-secreting
adenomas which are almost always microadenomas
(6, 14-16).
GH-secreting adenomas
Patient 6 was operated on by transsphenoidal
route, but the operation was complicated by in-
trasellar hemorrhage causing complete hypopitu-
itarism. No residual tumor is present, basal GH is
less than 0.5 ng/ml and IGF-I is 93 ng/ml. Patient
7 underwent selective transsphenoidal adenomec-
tomy. Despite no evidence of residual tumor, acro-
megaly was still active. He is currently treated with
octreotide LAR 30 mg/month and cabergoline 1.5
mg/week: GH is 2.5 ng/ml and IGF-I is normal.
Clinically non-functioning adenomas
Two patients (cases 8 and 9) were successfully op-
erated on by transsphenoidal approach: visual fields
are normal and they both have normal sexual de-
velopment with regular menses; no residual tumor
was evident after surgery but in case 9 an asymp-
tomatic recurrence was found 20 months later. Pa-
tient 10 was operated on by transcranial route, fol-
lowed by radiotherapy. The patient suffers from hy-
popituitarism, but his visual field is normal and a
small remnant in the cavernous sinus is unchanged.
Therefore, treatment was completely successful in
5 patients (cases 1, 2, 5, 7, 8) (50%): they now show
normal hormone secretion, have achieved complete
On the basis of clinical and immunohistochemical
characteristics 50% of our cases were PRL-secret-
ing, 20% pure GH-secreting and 30% non-func-
95

E. De Menis, A. Visentin, D. Billeci, et al.
tioning adenomas. Clinically functioning adenomas
are by far more frequent in all pediatric series.
Prolactinomas are the most frequent tumors, ac-
counting for about 50% of cases (5, 6, 17, 18);
ACTH-secreting adenomas are more frequent than
GH (pure and mixed) tumors, representing re-
spectively 29-50% vs 9-13% (3, 5, 6, 12) of surgi-
cally resected adenomas, in contrast with what ob-
served in adult patients. Non functioning adeno-
mas are very rare: the incidence is about 3-6% of all
pediatric pituitary adenomas (3, 6, 13, 18) and a
review of the literature in 1998 encompasses only
25 cases (13).
complete ablation of the tumor and control of hor-
monal hypersecretion without causing deficiency of
other hormones. In pediatric age an important ob-
jective is to guarantee a full sexual and linear de-
velopment. These aims were completely coupled
in 50% of our patients. In the other patients com-
plete tumor removal or normalization of hyper-
secretion was not achieved or was achieved at the
price of hypopituitarism; furthermore 2 patients still
have impairment of the visual field. In the series of
Mindermann et al. (6) only 10% of patients had tu-
mor recurrence, but data are lacking concerning fi-
nal sexual development and hypopituitarism. In the
Mayo Clinic series (5) 65% of microadenomas were
free of disease, but this fell to 33% for operated
macroadenomas without further treatment; fur-
thermore in 30% of patients hypopituitarism is pre-
sent. In the prolactinoma series of Colao et al. (11),
medical therapy had clearly better results in preser-
vation and restoration of the anterior pituitary func-
tions compared with surgery. As far as visual loss is
concerned Lee et al. (9) reported that pediatric pa-
tients are more severely affected than adults and
improvement after surgery occurs more rarely.
Review of the literature, availability of dopamine
agonists and somatostatin analogues, experience
derived from the present data suggest that the
treatment of choice for PRL and GH-secreting ade-
nomas in adolescence should be medical. In pro-
lactinomas cabergoline is probably the drug of
choice for its better tolerability, compliance and ef-
fectiveness. Nevertheless, we point out that some
patients, particularly males with prolactinomas, do
not invariably respond and a tumor may go on in-
creasing and subsequent transsphenoidal surgery
is needed. For clinically non-functioning adenomas
surgery is the best initial approach. The role of ra-
diotherapy is well established for pediatric Cu-
shing’s disease after unsuccessful surgery (21, 22),
but in the case of non-ACTH-secreting adenomas
we think that it should be used only for tumors
which go on growing despite medical and surgical
therapy. The close collaboration of pediatric and
adult endocrinologists, a neurosurgeon experi-
enced in transsphenoidal surgery and a radiother-
apist make up the team necessary to give the best
chance of successful long-term management of this
uncommon and intriguing pediatric disease.
Dopamine agonists are the treatment of choice for
prolactinomas in adults and are effective both in re-
ducing PRL levels and in tumor shrinkage also in
pediatric patients (10, 11, 19, 20). Recently in a multi-
center study Colao et al. (11) found that bromo-
criptine normalized PRL levels in 10/26 patients, fur-
thermore other 12 patients resistant or intolerant
to BCR normalized PRL levels with dopamine ago-
nists quinagolide and cabergoline. Dopaminergic
drugs alone were very effective in two female pa-
tients. Furthermore, cabergoline normalized PRL
levels and induced shrinkage of the residual tumor
in an operated patient. In the other two prolacti-
nomas dopamine agonists only partially controlled
PRL levels and tumor growth: both the patients
were males, confirming that prolactinomas in males
are more aggressive and less responsive than in fe-
males (3, 4, 18). The results of surgery in GH ade-
nomas in pediatric patients are not as good as for
adults (2, 3, 5, 12). Dyer et al. (3) reported that
surgery alone cures 12% of patients; somewhat bet-
ter results are those of Abe et al. (12) (40% of cure),
who used intra-operative GH measurements and
subsequent tumor exploration if indicated. Even if
GH tumors in pediatric age are more likely to be
locally invasive and aggressive than in adults, re-
sults are worse also for microadenomas (12). Soma-
tostatin analogues, particularly in the form of slow-
release formulations, are the drugs of choice for
GH-secreting tumors; there are very few data for
pediatric patients and in general octreotide has
been shown to have only limited effectiveness, for
istance Abe et al. (12) reported that 2 out of 4 pa-
tients responded to octreotide. We have found that
30 mg/month of octreotide LAR and 1.5 mg/week
of cabergoline normalized IGF-I levels. In three non-
functioning pituitary adenomas, operation was
completely successful in only one patient. Poor re-
sults have been reported by Artese et al. (18), but
in general the outcome of transnasal surgery does
not differ from that of adults (13).
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