Management Of Pituitary Tumors Research Articles

Multidisciplinary Team Care in Pituitary Tumours.

The optimal care for patients with pituitary tumours is best provided in a multidisciplinary and collaborative environment, which requires the contribution of multiple medical specialties working together. The benefits and advantages of the pituitary multidisciplinary team (MDT) are broad, and all relevant international consensus and guidelines in the field recommend that patients with pituitary tumours should always be managed in a MDT. Endocrinologists and neurosurgeons are normally the leading specialties within the pituitary MDT, supported by many other specialties with significant contributions to the diagnosis and management of pituitary tumours, including neuropathology, neuroradiology, neuro-ophthalmology, and otorhinolaryngology, among others. Here, we review the literature concerning the concepts of Pituitary MDT/Pituitary Tumour Centre of Excellence (PTCOE) in terms of their mission, goals, benefits, structure, proposed models of function, and barriers, and we also provide the views of different specialists involved in our Pituitary MDT.

Impulse Control Disorders in Patients with Pituitary Tumors Treated with Dopamine Agonists: A Systematic Review

The increased prevalence of Impulse Control Disorders (ICDs) in dopamine agonist (DA) treated patients with Parkinson's disease is well described. Despite the frequent use of DAs in the management of pituitary tumors, the relationship between DAs and prevalence of ICDs in patients with pituitary tumours is unclear. To establish the prevalence of ICDs in patients with prolactinoma or acromegaly and determine whether prevalence differs in those on DAs to those treated without. Systematic review of the literature (registered a priori) reporting prevalence of ICDs in patients with prolactinoma or acromegaly (conducted June 2023). A narrative synthesis describing prevalence of ICDs according to assessment method was performed. Prevalence comparisons between patients with prolactinoma or acromegaly treated with DAs, to patients treated without, were summarised. Studies were largely retrospective, observational and heterogenous, with few patients with prolactinoma and acromegaly treated without DA. Prevalence of ICDs varied between 0-60% in patients with prolactinoma, and from 5-23% in studies with at least five patients with acromegaly. In most studies comparing DA exposed to non-DA exposed cases, DA use was not associated with ICDs. Reported prevalence of ICDs in patients with prolactinoma and acromegaly varies considerably. Given ICDs were reported to be highly prevalent in some studies, clinicians should be mindful of these potentially serious disorders. ICD screening tools validated for use in patients with pituitary tumors combined with prospective studies including appropriate controls, are necessary to accurately establish prevalence of ICDs and true impact of DAs in their development.

Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: Clinical recommendations on the perioperative management of pituitary tumors

Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7%–14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.

Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: clinical recommendations on the perioperative management of pituitary tumors

Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7–14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.

Combined endoscopic-microscopic trans-nasal trans-sphenoidal approach for pituitary adenomas

Objective. To obtain evidence that the use of endoscopy along with a microscope in the surgical management of pituitary tumours improves intraoperative visualization and significantly impacts operative outcomes in the trans-nasal approach. Material and methods. Each patient underwent endonasal transsphenoidal microscopic tumour resection. The procedure was modified by the use of intrasellar endoscopy as an adjunctive imaging modality. Following complete microscopic resection of tumour, rigid 0° and 30° 4.0-mm endoscopes were used to conduct a final survey of the sellar and parasellar spaces. Residual tumour fragments identified during this endoscopic examination were removed. Results. In 50 patients with pituitary macroadenomas, the rigid 30 ° angled rigid endoscope was found to be highly beneficial. Hidden areas could be visualized and tumour residues were detected. In the majority of the patients with detected tumour residues, adenomatous remnants were safely removed by meticulous endoscopic dissection under optimum visual control after the main part of the tumour had been removed with the operating microscope. Conclusions. Endoscopy provides distinct advantages over microscopy in imaging intrasellar and parasellar structures during pituitary tumour resection which are often missed by microscopy alone.

In Memoriam: Hamit Ziya Gökalp, 1929 to 2022.

In Memoriam: Hamit Ziya Gökalp, 1929 to 2022.

How I do it: endoscopic endonasal chiasmopexy for optic chiasm prolapse.

Prolapse of the optic system into an empty sella is an unusual complication of the management of pituitary tumors. We described the technical nuances for an endoscopic endonasal chiasmopexy, the indications for the procedure, and the caveats on the diagnosis of optic chiasm prolapse. The endoscopic endonasal chiasmopexy provides a direct route to lift the optic system. In most cases, the procedure may be achieved extradurally, protecting the chiasm from manipulation and postoperative fibrosis.

Endocrinological aspects of pituitary adenoma surgery in Europe

Hormone-secreting adenomas are treated in many neurosurgical centers within Europe. The goal of the survey is to understand variance in practice management of pituitary tumors amongst neurosurgical centers. A list of departments performing pituitary surgery was created. The survey consisted of 58 questions. This study focuses on neurosurgical care of hormone-secreting adenomas. For analysis, the departments were divided into four subgroups: academic/non-academic, high-volume/low-volume, “mainly endoscopic/mainly microscopic practice” and geographical regions. Data from 254 departments from 34 countries were obtained. Most centers surgically treat 1–5 hormone-secreting adenomas per year. In prolactinomas this is the case in 194 centers, (76.4%), in GH-secreting adenomas: 133 centers, (52.4%), ACTH-secreting adenomas: 172 centers, (69.8%). Surgery as a primary treatment of prolactinomas is considered in 64 centers (25.2%). In 47 centers (18.8%), GH-secreting microadenomas are often treated pharmacologically first. Debulking surgery for an invasive GH-secreting adenoma in which hormonal remission is not a realistic goal of the surgery and the patient has no visual deficit surgery is always or mostly indicated in 156 centers (62.9%). Routine postoperative hydrocortisone replacement therapy is administered in 147 centers (58.6%). Our survey shows that in most centers, few hormone-secreting adenomas are treated per year. In about 25% of the centers, prolactinoma surgery may be regarded as first-line treatment; in about 20% of the centers, medical treatment is the first-line treatment for GH-secreting adenomas. Pretreatment for ACTH-secreting adenomas is routinely used in 21% of centers. This survey may serve as plea for neurosurgical care centralization of hormone-secreting adenomas.

Endocrinology in the time of COVID-19: Management of pituitary tumours

Patients with pituitary tumours, ensuing hormonal abnormalities and mass effects are usually followed in multidisciplinary pituitary clinics and can represent a management challenge even during the times of non-pandemic. The COVID-19 pandemic has put on hold routine medical care for hundreds of millions of patients around the globe, while many pituitary patients' evaluations cannot be delayed for too long. Furthermore, the majority of patients with pituitary tumours have co-morbidities potentially impacting the course and management of COVID-19 (e.g. hypopituitarism, diabetes mellitus, hypertension, obesity and cardiovascular disease). Here, we summarize some of the diagnostic and management dilemmas encountered, and provide guidance on safe and as effective as possible delivery of care in the COVID-19 era. We also attempt to address how pituitary services should be remodelled in the event of similar crises, while maintaining or even improving patient outcomes. Regular review of these recommendations and further adjustments are needed, depending on the evolution of the COVID-19 pandemic status. We consider that the utilization of successful models of pituitary multidisciplinary care implemented during the COVID-19 pandemic should continue after the crisis is over by using the valuable and exceptional experience gained during these challenging times.

Introduction. Management of pituitary tumors: 2020 and beyond

Introduction. Management of pituitary tumors: 2020 and beyond

Pediatric pituitary adenomas.

Pediatric pituitary adenomas are a rare medical entity that makes up a small portion of intracranial tumors in children and adolescents. Although benign, the majority of these lesions are secreting functional tumors with the potential for physiological sequela that can profoundly affect a child's development. In this review, we discuss the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to treat these tumors. The management of pituitary tumors requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver comprehensive care.

Physicians' awareness of gadolinium retention and MRI timing practices in the longitudinal management of pituitary tumors: a "Pituitary Society" survey.

In view of mounting attention related to possible brain retention of gadolinium-based contrast agents (GBCAs) in patients with normal renal function, our purpose was to detail results from a survey of pituitary experts to assess: 1) the timing interval and frequency of pituitary magnetic resonance imaging (MRI) following surgical and/or medical and/or radiation therapy of pituitary tumors, 2) awareness of the types of GBCAs used and their possible safety issues. The Pituitary Society Education Committee composed a survey with 12 multiple choice questions, 8 of which specifically addressed the time interval and frequency of MRI in the longitudinal management of pituitary tumors. The survey was distributed at two meetings; the International Pituitary Neurosurgeons Society conference in San Diego, CA, on February 18th, 2018, and the Pituitary Society Membership and Career Development Forum, Chicago, IL on March 18th, 2018. There is consensus among pituitary endocrinologists and neurosurgeons that long-term repeated imaging is recommended in most pituitary tumors, although the precise strategy of timing varied depending on the specialist group and the specific clinical context of the adenoma. The data also suggest that International Pituitary Neurosurgeons Society neurosurgeons, as well as Pituitary Society neuroendocrinologists, are sometimes unaware of which contrast agents are used by their institution, and many are also unaware that evidence of long-term brain retention has been reported with the use of GBCAs in patients with normal function. International pituitary endocrinologists and pituitary neurosurgeons experts suggest ongoing MRIs for the management of pituitary tumors; strategies vary based on clinical context, but also on individual experience and practice.

Stereotactic radiation therapy for the treatment of functional pituitary adenomas associated with feline acromegaly.

BackgroundConventional fractionated radiotherapy has been shown to be partially effective for management of pituitary tumors in cats that cause acromegaly and diabetes mellitus (DM), but, the efficacy and safety of stereotactic radiation therapy (SRT) as a treatment for acromegalic cats has not been described.HypothesisStereotactic radiation therapy is an effective and safe treatment for controlling acromegaly associated with pituitary adenomas in cats. Additionally, SRT‐treated acromegalic cats with DM will experience a decrease in insulin requirements after radiation therapy.AnimalsFifty‐three client‐owned cats referred to Colorado State University for SRT to treat pituitary tumors causing poorly controlled DM secondary to acromegaly.MethodsRetrospective study of cats treated for acromegaly with SRT between 2008 and 2016 at Colorado State University. Diagnosis of acromegaly was based on history, physical examination, laboratory results, and cross‐sectional imaging of the pituitary. Signalment, radiation protocol, insulin requirements over time, adverse effects, and survival were recorded.ResultsMedian survival time was 1072 days. Of the 41 cats for which insulin dosage information was available, 95% (39/41) experienced a decrease in required insulin dose, with 32% (13/41) achieving diabetic remission. Remission was permanent in 62% (8/13) and temporary in 38% (5/13) cats. Median duration to lowest insulin dose was 9.5 months. Of the treated cats, 14% developed hypothyroidism and required supplementation after SRT.ConclusionsStereotactic radiation therapy is safe and effective for treating cats with acromegaly. Cats treated with SRT have improved survival time and control of their DM when compared to previously reported patients treated with non‐SRT.

Recent Progress in the Medical Therapy of Pituitary Tumors

Management of pituitary tumors is multidisciplinary, with medical therapy playing an increasingly important role. With the exception of prolactin-secreting tumors, surgery is still considered the first-line treatment for the majority of pituitary adenomas. However, medical/pharmacological therapy plays an important role in controlling hormone-producing pituitary adenomas, especially for patients with acromegaly and Cushing disease (CD). In the case of non-functioning pituitary adenomas (NFAs), pharmacological therapy plays a minor role, the main objective of which is to reduce tumor growth, but this role requires further studies. For pituitary carcinomas and atypical adenomas, medical therapy, including chemotherapy, acts as an adjuvant to surgery and radiation therapy, which is often required to control these aggressive tumors. In the last decade, knowledge about the pathophysiological mechanisms of various pituitary adenomas has increased, thus novel medical therapies that target specific pathways implicated in tumor synthesis and hormonal over secretion are now available. Advancement in patient selection and determination of prognostic factors has also helped to individualize therapy for patients with pituitary tumors. Improvements in biochemical and “tumor mass” disease control can positively affect patient quality of life, comorbidities and overall survival. In this review, the medical armamentarium for treating CD, acromegaly, prolactinomas, NFA, and carcinomas/aggressive atypical adenomas will be presented. Pharmacological therapies, including doses, mode of administration, efficacy, adverse effects, and use in special circumstances are provided. Medical therapies currently under clinical investigation are also briefly discussed.

Natural history of the anterior visual pathway after surgical decompression in patients with pituitary tumors

Introduction: Visual dysfunction is one of the primary indications for surgical management of pituitary tumors with the goal of terminating the progressive decline in vision. Unfortunately, it is difficult to predict how successful surgical decompression will be in these patients. The purpose of this study was to assess the structural changes seen in the anterior visual pathway after pituitary tumor resection. Methods: 13 patients (7F) underwent endoscopic tumor resection for pituitary macroadenoma. Each patient underwent a full ophthalmologic assessment including optical coherence tomography (OCT) preoperatively and postoperatively at 3-6months and 9-12months. Post-surgical changes in the retinal nerve fiber layer thickness (RNFLT) for each eye (N=26) were compared in cases with normal preoperative RNFLT (greater than 80 μm) versus those with abnormally thinned RNFLT (less than 80 μm). Results: For 9 cases with thinned RNFLT preoperatively (mean=70.1 μm±8.5), there was a significant decline in RNFLT at 3-6 months follow-up (mean change= −3.8 μm;p=0.002), which did not recover even at 9-12months after surgery (mean=67.6 μm±12.7). Contrastingly, eyes with normal RNFLT preoperatively (mean=89.7 μm±9.4) did not show significant postoperative thinning (mean change= −1.9 μm). Conclusion: Even after a complete surgical decompression, there are ongoing structural changes in the anterior visual pathway in patients with compressive neuropathy. There may be a point of no return where surgical decompression may not prevent further structural degeneration.

Update on Pituitary Surgery

Transsphenoidal surgery has an important role in the management of pituitary tumors and remains the primary treatment for most adenomas, with the exception of prolactinomas. This update will review the recent neurosurgical literature; modifications to the traditional microscopic approach, including the potential utility of endoscopy and intraoperative magnetic resonance imaging, are discussed. The value of experienced surgical judgment and expertise remains clear, over and above the possible advantages of current technology. Preliminary data on the relative cost-effectiveness of surgery vs. medical treatment suggest that surgical approaches compare favorably. It will be important to incorporate future technological advances in surgical technique with new medical therapies in a combined multidisciplinary approach for improved treatment algorithms.

Management of Giant Pituitary Tumors Affecting Vision in Nigeria

The management of pituitary tumors has evolved considerably in the past few decades. One of the indices for effective surgical outcome is the size of the tumor on presentation. Reports from west and central Africa have largely indicated late presentation with very large tumors. In the present study we examined this trend and the impact of late presentation on visual outcomes. This is a retrospective analysis of the patterns of visual presentation of giant pituitary tumors and the factors that influenced treatment outcomes. We analyzed 44 patients who presented with pituitary tumors extending into the suprasellar region during a five-year period. All patients had computerized tomography or magnetic resonance imaging confirmation of their tumor. About 43% of patients were referred from ophthalmologists. The main symptoms were impaired vision (100%) and visual field defect was present in 47.1%. Optic atrophy was found in 38 eyes (43.1%) and 30% of the patients were already blind on presentation. An additional 23% were functionally blind. Five patients had hydrocephalus from third ventricle obstruction. Of those who had surgery, five patients had additional radiotherapy. There were no perioperative deaths but there were two deaths during follow-up. Vision improved in 14 patients, was unchanged in nine and deteriorated in two. Tumors of the pituitary present late in developing countries resulting in increased morbidity. Intervention even at this stage results in visual improvement and efforts must be made to cascade this information to frontier health workers.

Management of Pituitary Tumors in Pregnancy

Successful pregnancy and delivery is dependent upon normal function of the pituitary gland. Benign tumors of the pituitary are relatively common and may interfere with normal pregnancy in a variety of ways. Symptoms related to pituitary tumors can include headache, fatigue, and visual loss. Some may present dramatically with pituitary tumor apoplexy, mimicking subarachnoid hemorrhage, meningitis, or myocardial infarction. In this article, the types of tumors likely to become symptomatic during pregnancy are reviewed. The various options of management are determined by the stage of pregnancy and whether there is visual loss or other signs of mass effect. Management options include close observation, medical therapy, or surgical removal of the tumor. Decision making for symptomatic adenomas during pregnancy is illustrated by two representative case reports.

Recent advances in pituitary tumor management

Advances in the neurosurgical management of pituitary tumors have included the refinement of surgical access and significant progress in navigation technology to help further reduce morbidity and improve outcome. Similarly, stereotactic radiosurgery has evolved to become an integral part in pituitary tumors not amenable to medical or surgical treatment. The evolution of minimally invasive surgery has evolved toward endoscopic versus microscopic trans-sphenoidal approaches for pituitary tumors. Debate exists regarding each approach, with advocates for both championing their cause. Stereotactic and fractional radiosurgery have been shown to be a safe and effective means of controlling tumor growth and ensuring hormonal stabilization, with longer-term data available for GammaKnife compared with CyberKnife. The advances in trans-sphenoidal surgical approaches, navigation technological improvements and the current results of stereotactic radiosurgery are discussed.

Management of pituitary tumors in pregnancy

Pituitary tumors, usually adenomas, account for about 10-15% of all intracranial tumors. Their treatment, which includes surgery, medicine or radiotherapy, either isolated or in combination, aims to halt tumor growth or achieve tumor shrinkage, as well as control hormone hypersecretion or ensure hormone replacement. Such approaches have made pregnancy possible for women with pituitary adenomas. Medical therapy with dopamine agonists is the treatment of choice for most patients with prolactinomas, with surgery reserved for individuals resistant to drugs. On the other hand, surgery before conception is indicated as a first-line approach in patients with acromegaly, Cushing disease or clinically nonfunctioning pituitary macroadenomas. In these patient populations, medical therapy with somatostatin analogues (acromegaly) or drugs that target the adrenal glands, such as metyrapone and ketoconazole (Cushing disease), should be reserved for those in whom surgery is unsuccessful or contraindicated.