Pituitary Tumors Treatment & Management

  • Author: Jorge C Kattah, MD; Chief Editor: Robert A Egan, MD   more...
 
Updated: Aug 15, 2011
 

Medical Care

  • Prolactinomas: The majority of these lesions respond to dopamine receptor agonists. Improvement in visual field abnormalities, resolution of symptoms associated with hyperprolactinemia, and visible diminution of the actual mass can result with treatment.
  • Acromegaly: Somatostatin analogues (octreotide) can be helpful in the treatment of increased postoperative levels of GH. In some cases, the tumor may shrink modestly. Gallstones are a frequent complication of somatostatin-analogue therapy. Dopamine agonists also have been used.
  • Replacement therapy for decreased or absent hormones should be instituted as needed.
  • All hormone-based treatment should be directed by a consulting endocrinologist.
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Surgical Care

  • Transsphenoidal surgery
    • Transsphenoidal microscopic surgery is the most frequent surgical approach for the resection of pituitary tumors. With larger lesions, a transfrontal approach may become necessary to decompress the visual pathways.
    • Minimally invasive endoscopic surgery using a 4-mm endoscope through a nostril is a possibility in selective cases.
    • Open low-field intraoperative MRI monitoring for transsphenoidal surgical resection is gaining acceptance to monitor the precise extent of tumor resection.
    • Null cell tumors and gonadotrophinomas are best treated with transsphenoidal surgery.
    • The main complication after transsphenoidal surgery (from the endocrine standpoint) is hypopituitarism.
    • Low- and high-field intraoperative monitoring is used to minimize resectable tumor.[7]
  • Prolactinomas
    • Microprolactinomas: Transsphenoidal resection of the tumor offers a chance for a cure without the need for long-standing dopamine agonist therapy; however, many patients choose dopaminergic therapy.
    • Macroadenomas that secrete prolactin are best treated with dopamine agonists.
  • Acromegaly
    • Transsphenoidal surgery decreases GH levels to less than 5 mcg/L in 60% of cases.
    • Normal pulsatile secretion of GH is not always regained, and 20% of patients continue to have increased GH levels in response to TRH.
    • Radiotherapy is an alternative, although GH levels may not decrease for 2-4 years.
    • Elevated GH levels may be treated with somatostatin analogues and dopamine agonists, if tolerated.
  • Cushing disease
    • Transsphenoidal tumor resection is the first line of treatment in patients with basophilic adenomas of the pituitary gland. It is curative in 80% of cases.
    • Pituitary irradiation is required in the remaining cases to prevent the development of Nelson syndrome.
    • In children, pituitary irradiation and adrenalectomy are highly effective.
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Consultations

  • The treatment team should consist of any or all of the following specialists: ophthalmologist or neuro-ophthalmologist, neuroradiologist, endocrinologist, gynecologist, neurosurgeon, neuropathologist, and radiation medicine specialist.
  • Different specialists may be involved as indicated by the patient's specific symptoms.
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Diet

  • Dietary factors are important in patients with acromegaly or Cushing disease.
  • Patients with hypothyroidism, hypoadrenalism, or hypopituitarism have specific dietary needs.
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Activity

  • Activities of daily living (ADLs) generally are not restricted in these patients.
  • Exercise tolerance may be limited in some cases.
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Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Jorge C Kattah, MD  Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, and New York Academy of Sciences

Disclosure: Biogen Honoraria Consulting; Bayer Corporation Honoraria Consulting

Specialty Editor Board

Frederick M Vincent Sr, MD  Clinical Professor, Department of Neurology and Ophthalmology, Michigan State University Colleges of Human and Osteopathic Medicine

Frederick M Vincent Sr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Legal Medicine, American College of Physicians, and Michigan State Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert A Egan, MD  Director of Neuro-Ophthalmology, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, and Oregon Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Robert A Egan, MD  Director of Neuro-Ophthalmology, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, and Oregon Medical Association

Disclosure: Nothing to disclose.

References

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This is a characteristic bitemporal hemianopic visual field defect.
This contrast-enhanced coronal MRI was obtained in a patient who complained of visual loss.
This visual field was plotted using a Goldman perimeter (ie, kinetic perimetry). It was obtained from a patient who reported visual loss and had a normal endocrine workup. The dark areas correspond to the impaired peripheral visual field. This visual field defect is consistent with an intrasellar lesion.
Coronal T1 precontrast MRI A (left panel), B postcontrast (middle panel) and T2 (right panel) showing a sellar mass causing obvious left and upward displacement of the optic chiasm. The mass is a histologically proven pituitary macroadenoma, which presented initially with a large cystic subfrontal extension that was successfully resected in April of 2006. This patient has been observed closely for 2.5 years and despite obvious mass effect, he has no visual complaints and the neuro-ophthalmologic evaluation is normal. Although infrequent, clinicians should be aware of this possibility. Close follow-up is required.
 
 
 
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