Table 6.

Key points in diagnosis, management and follow-up of pituitary apoplexy in patients with prostate cancer treated with GnRH agonist therapy^a

1. Suspected pituitary apoplexy (acute severe headache), perform thorough history and physical and look for neuro-ophthalmic symptoms

2. Assess vital signs and fluid status. Urgent biochemical assessment with full blood count, coagulation studies (requirement for surgical management), urea and electrolytes (hyponatremia in 40% patients), liver function test and detailed endocrine assessment (IGF1, GH, Prolactin, TSH, Free T4, LH, FSH, ACTH, cortisol, and testosterone; as baseline and to rule out hypopituitarism, which occurs in 50–80% patients.) If possible, laboratory work up should be done prior to administration of steroids.)

3. Urgent steroid and fluid replacement should be considered for hemodynamic instability

4. Urgent MRI or dedicated pituitary CT if MRI is contraindicated to confirm diagnosis

5. Evaluation by multidisciplinary team including endocrinologist, ophthalmologist and neurosurgeons after confirmation of diagnosis. Consideration of surgical vs conservative management based on clinical status, patient and physician decision

6. Rechallenge of ADT with GnRH analogues not recommended in conservatively managed patients. May consider GnRH antagonists or orchiectomy

7. Follow-up endocrine evaluation and formal ophthalmologic evaluation should be considered at 4–8 weeks following PA. Long-term follow-up with annual biochemical assessment of pituitary function should also be considered

^aAdapted from UK guidelines for the management of pituitary apoplexy (Rajasekaran et al. 2011)