What are the next diagnostic steps for a 28-year-old female with normalized prolactin levels (previously elevated at 22.8, now decreased to 10) and elevated estrogen levels (513), presenting with a hypo-enhancing lesion in the pituitary gland and a partially empty sella (sella turcica) configuration on Magnetic Resonance Imaging (MRI)?

From the Guidelines

The next diagnostic steps for this 28-year-old female with a pituitary lesion and abnormal hormone levels should include a comprehensive endocrine evaluation and follow-up imaging. I recommend obtaining a complete pituitary hormone panel including TSH, free T4, ACTH, cortisol, FSH, LH, IGF-1, and repeat prolactin measurements 1. Dynamic testing should be considered, particularly a cortisol stimulation test to assess adrenal function, as hypofunction of other pituitary hormones caused by tumour mass compression or prolactin co-secretion has been noted in patients with somatotrophinomas 1. Formal visual field testing is essential to evaluate for any optic chiasm compression. A follow-up MRI with thin-slice pituitary protocol in 6-12 months would help monitor the lesion's stability, as MRI using high-resolution pituitary protocols is generally considered the gold standard for imaging the pituitary gland in cases of suspected hormone-secreting adenoma 1. Referral to both endocrinology and neurosurgery specialists is warranted for multidisciplinary management, as treatment of patients with pituitary adenomas is challenging due to the lack of high-quality evidence for treatment recommendations for this age group 1. The patient's prolactin levels have normalized (from 22.8 to 10), but the elevated estrogen level (513) and imaging findings of a hypoenhancing pituitary lesion with partially empty sella suggest possible pituitary dysfunction. The empty sella configuration may indicate previous subclinical pituitary apoplexy or primary empty sella syndrome, and these tests will help determine if this represents a functional pituitary adenoma, non-functioning adenoma, or another pituitary pathology, and will guide appropriate treatment decisions regarding medical therapy versus surgical intervention. Some key points to consider in the diagnostic workup include:

• The importance of clinical evaluation for associated syndromic causes of somatotrophinomas in patients with GH excess 1
• The need for biochemical screening for pituitary hormone excess in patients with certain syndromes, such as Carney complex, McCune–Albright syndrome, and MEN1 or MEN1-like disease 1
• The use of dynamic contrast-enhanced imaging of the pituitary to detect microadenoma 1
• The consideration of spoiled gradient-echo 3-D T1 sequence in the detection of hormone-secreting adenomas 1

From the Research

Diagnostic Considerations

The patient's normalized prolactin levels and elevated estrogen levels, along with the presence of a hypo-enhancing lesion in the pituitary gland and a partially empty sella configuration on MRI, require further diagnostic evaluation. The following steps should be considered:

• Measurement of insulin-like growth factor 1 (IGF-1) levels to rule out acromegaly, as suggested by 2
• Assessment of thyroid function to evaluate for potential thyroid-stimulating hormone (TSH)-secreting tumors, as mentioned in 3 and 4
• Consideration of other hormone levels, such as adrenocorticotropic hormone (ACTH), to evaluate for Cushing's disease, as discussed in 3 and 5

Imaging and Tumor Evaluation

• The patient's MRI results indicate a hypo-enhancing lesion in the pituitary gland, which may suggest a pituitary adenoma, as discussed in 3 and 6
• The partially empty sella configuration may be associated with various conditions, including pituitary adenomas, and requires further evaluation, as mentioned in 3

Treatment Options

• Depending on the diagnosis, treatment options may include medical therapy, such as dopamine agonists for prolactinomas, as discussed in 3, 6, and 5
• Transsphenoidal surgery may be considered for other types of pituitary adenomas, as mentioned in 3 and 5
• Radiation therapy may also be an option in certain cases, as discussed in 3 and 5

Further Evaluation

• The patient's elevated estrogen levels require further evaluation to determine the underlying cause, as discussed in 3 and 4
• A comprehensive endocrine evaluation, including assessment of other hormone levels, may be necessary to determine the underlying diagnosis and guide treatment, as suggested by 3, 5, and 2