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Pituitary Tumors Treatment & Management

  • Author: Jorge C Kattah, MD; Chief Editor: Robert A Egan, MD  more...
 
Updated: Oct 26, 2015
 

Medical Care

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  • 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

Pituitary surgery has undergone quite an evolution since the days of Harvey Cushing’s research and his pioneering development of the sublabial and transcranial methods of accessing the sella. Besides the transsphenoidal/translabial approaches, an endoscopic transnasal approach has become an additional an increasingly favored option with a wider surgical field.

  • 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. A 2013 review examined the transnasal endoscopy approach for resection of giant adenomas with profound mass effect. In 54 cases, the lesions had the greatest diameters, measuring 4 cm; roughly 80% of them had visual-field defects. Near-total resection was achieved in 67% of cases, demonstrating efficacy of the approach in larger tumors. The endonasal approach was concluded to be effective, not only in tumor removal, but had limited complication rates. CSF leak, residual tumor, postoperative diabetes insipidus, and apoplexy in residual adenoma were listed as complications.
    • 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.[11]
  • 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.
    • Immediate postoperative biochemical remission of Cushing syndrome, evidenced by cortisol levels less than 2 micrograms/dL, was associated with sustained postoperative remission lasting 68.4 months. MRI evidence of a microadenoma was also a predictor of successful tumor resection via a transsphenoidal microsurgical approach.
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Consultations

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  • 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

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  • 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

See the list below:

  • Activities of daily living (ADLs) generally are not restricted in these patients.
  • Exercise tolerance may be limited in some cases.
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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, New York Academy of Sciences

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew J Tsung, MD Assistant Professor of Neurosurgery, University of Illinois College of Medicine at Peoria; Director, INI Brain Tumor Center, Director of Neurosurgery Research, Department of Neurosurgery, Illinois Neurological Institute; Physician Director, Intermediate Neuroscience Care Unit, OSF St Francis Medical Center; Attending Physician, Illinois Neurological Institute Physicians, LLC

Andrew J Tsung, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, Illinois State Medical Society, Society for Neuro-Oncology, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Joseph V Hanovnikian University of Illinois College of Medicine

Joseph V Hanovnikian is a member of the following medical societies: Illinois State Medical Society, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert A Egan, MD Director of Neuro-Ophthalmology and Stroke Service, 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, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec for speaking and teaching; Received honoraria from Teva for speaking and teaching.

Chief Editor

Robert A Egan, MD Director of Neuro-Ophthalmology and Stroke Service, 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, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec for speaking and teaching; Received honoraria from Teva for speaking and teaching.

Additional Contributors

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 Institute, American College of Legal Medicine, American College of Physicians

Disclosure: Nothing to disclose.

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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.
Axial, sagittal, and coronal MRI of the sellae in a patient with a severe headache, normal neuro-ophthalmologic examination, and no evidence of endocrine failure. A hyperintense mass is observed in the sella with suprasellar extension. This case illustrates the clinical spectrum of pituitary apoplexy. Transsphenoidal resection confirmed the diagnosis of pituitary apoplexy.
 
 
 
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