0:01

Dr. Schupack, this is a 41 year old man,

0:03

and someone in a prior MRI and a prior report said

0:07

that there was an adenoma in this gland.

0:09

Now, this being a man,

0:10

we know that prolactin secreting adenomas are

0:13

more common in women by about five to one.

0:15

The growth hormone secreting ones more

0:17

common in men by about two to one.

0:19

And the ACTH type really important with

0:23

with a slight female predominance.

0:25

So does this patient have a microadinoma or an adenoma?

0:29

Well, this is one where some of the anatomy that Dr.

0:33

Pomerance presented comes in really handy.

0:36

Okay,

0:36

so the stars of the show are kind of like the anterior

0:40

lobe of the pituitary, the adeno hypothesis.

0:42

Here's your bright spot, the neuro hypothesis.

0:44

But there's actually a little zone in there

0:46

which was also mentioned by Dr.

0:48

Pomerance,

0:49

which is the pars intermedia just part of

0:51

the anterior gland. That's correct.

0:53

It's between the two posterior portion of

0:55

the anterior segment of the gland.

0:58

Okay,

0:58

so there's a little segment right in.

1:00

Here. And so when we're looking for an adenoma,

1:04

you really expect it to be sort of in the

1:06

anterior portion of the gland.

1:08

Sure.

1:08

So this lesion was being called an adenoma,

1:11

but it's really pretty far back,

1:13

right behind the infantibulum,

1:15

and actually right where you'd think the pars intermediate

1:18

would be. And then if you correlate on your images,

1:22

here's your T two. And so it's sort of cystic.

1:26

So I ended up thinking that this was probably a pars

1:31

intermediate cyst and that maybe the adenoma wasn't there.

1:34

And this patient actually does not

1:36

have endocrine disturbance. Okay.

1:38

The symptoms are something other than that.

1:40

Yeah, I read the history.

1:40

The history is kind of weird.

1:42

It really didn't point in any direction to a microadnoma.

1:45

Was, like,

1:45

headaches and memory loss and things of that nature.

1:49

Sorry. This is a Sagittal flare on the left,

1:52

and on the FLAIR, you can see the lesion is a little low.

1:55

On the T1, it's clearly low.

1:57

And on the axial T2, it is.

2:00

High in signal intensity.

2:02

You don't usually see untreated microadenomas

2:04

that are this bright.

2:05

So not only does the position go against a microadenoma,

2:10

the history goes against it, the gender goes against it,

2:13

and the T2 relaxivity goes against it.

2:15

Pituitary cyst or pars intermedia cyst is what it is.

2:18

So knowing where you are in the gland on that

2:20

anterior-posterior can be really important.

2:23

And knowing the segments of the gland where

2:25

things can come from is really helpful.

2:27

As part of your discussion touched on earlier, great.

2:30

So pars distalis, pars intermedia,

2:33

pars nervosa. Let's move on, shall we?