Endoscopic pituitary surgery
The gold standard in pituitary surgery is transsphenoidal endoscopic approach. The NeuroHope team is trained in one of the largest pituitary surgery centers in Europe, the Foch Hospital – Paris, the center where the endoscope for pituitary surgery was introduced for the first time by the French neurosurgeon Guiot. In addition to tumors of pituitary origin, many other neurosurgical pathologies can be addressed through trans-nasal endoscopic techniques.
Pituitary adenomas
Pituitary adenomas – are benign tumors that develop in the pituitary endocrine gland, a structure located at the base of the brain that secretes key hormones of the endocrine system. A part of the adenomas produce endocrine diseases through an exaggerated secretion of a certain type of hormone: Cushing disease, acromegaly etc. Other part of the adenomas are non-secreting, but, the large ones can compress the optic nerves affecting vision.
Pituitary adenomas are benign tumors that develop in the pituitary gland, located at the base of the brain, an endocrine gland, secreting key hormones of the endocrine system. Adenomas can develop from secretory cells of the hypophysis and are called functional adenomas. The control of the hormone secretion is thus lost and hypersecretion is responsible for harmful effects on the body, depending on the type of hormone secreted.
There are adenomas that develop from nonsecretory cells that, due to compression, can lead to hypofunction of the gland. They are called nonfunctional adenomas. Any adenoma, if it is very large, can compress the optic chiasma and optic nerves, leading to visual field and visual acuity damage. Treatment options are surgical excision or hormonal control with drugs. In some cases, observation is an option.
Not all adenomas are symptomatic. Functional adenomas can cause signs and symptoms and are related to the hypersecretion of the hormone they produce.
For nonfunctional adenomas, the signs and symptoms are related to their growth, thus to the compression of the surrounding structures – the optic nerves, the chiasm, the normal pituitary tissue (the pituitary gland).
Depending on the size, adenomas are classified into microadenomas with a diameter of less than 1 cm and macroadenomas, those with a diameter of more than 1 cm.
Signs and symptoms related to tumor volume:
• headache
• Impairment of visual field and visual acuity
Signs and symptoms related to reduced hormonal secretion:
• nausea and vomiting
• weakness
• Feeling cold
• disturbances of menstrual periods
• Increasing the amount of urine output
• Increase or decrease of weight
Signs and symptoms related to the specific type of hormone secreted
ACTH secretory adenomas – corticotropic (adenocorticotropic hormone). This hormone stimulates the adrenal glands to produce the hormone called cortisol. If the adrenal glands secrete too much cortisol, Cushing’s syndrome occurs.
Signs of Cushing’s Syndrome can be:
• Accumulation of abdominal and shoulder fat
• The “full moon” face
• Thinning of upper and lower limbs
• Increased blood pressure
• diabetes
• acne
• osteoporosis
• decreased bone strength
• irritation, anxiety, depression
• bruises, etc
GH secreting adenomas – somatotropic (growth hormone). The disease caused by these is called acromegaly in adults and gigantism in children.
Signs and symptoms of acromegaly can be:
• enlargement of facial structures – large lips, prominent chin, enlarged cheekbones, enlarged frontal sinuses, enlarged tongue
• growth of hands and feet – growth of the shoe size
• excessive sweating
• diabetes
• heart problems – cardiac hypertrophy
• Joint problems – arthrosis, pain, enlargement
• Orthodontic problems – with teeth alignment
• Increased hairiness
The signs and symptoms of gigantism are increasing height and weight too fast in children. If treatment does not occur the child keeps growing up.
Prolactin-secreting adenomas (prolactinomas) – may decrease the level of sex hormones (estrogens in women and testosterone in men).
Signs and Symptoms in Women:
• irregular menstrual periods, uncommon or absent
• discharge of breast milk secretions
Signs and symptoms in men
• Erection problems
• decreased sperm production
• decreased libido
• breast enlargement (gynecomastia)
TSH secreting adenomas (thyreotropic) – increased TSH secretion leads to hyperfunction of the thyroid gland with increased secretion of thyroxine. Hyperthyroidism speeds up metabolism and is responsible for signs and symptoms such as:
• Weight loss
• tachycardia
• irritability, nervousness
• excessive sweating, etc
Causes of pituitary adenoma are unknown. Rarely, there are families where pituitary adenomas occur in several generations. An example is MEN 1 (multiple endocrine neoplasms), a genetic disease that can lead to adenomas.
• loss of vision
• permanent hormonal deficiency
• permanent disorders linked to hormone hypersecretion
• pituitary apoplexy – the sudden appearance of a tumor bleeding. It is accompanied by “the greatest headache I’ve had” and requires medical emergency treatment with corticosteroids and possibly surgically when visual problems or consciousness problems occur.
Frequently, pituitary adenomas are not diagnosed, as their signs and symptoms resemble those caused by other diseases.
The diagnosis of hypophyseal adenomas is based on:
• history taking (detailed discussion with the patient),
• blood and urine tests
• cerebral imaging with CT and / or MRI to determine the anatomy of the adenoma
• ophthalmologic exam – visual field and visual acuity,
• detailed endocrinological examination
Many pituitary adenomas do not require treatment. Wait and see is depending on type, size, impact on surrounding structures, age and your health.
Treatment is multidisciplinary, requiring a multidisciplinary team that offers the optimal treatment plan and helps you take the best decisions for your health.
Surgery
Surgery is necessary if it affects vision, or in the case of secretory tumors, when there are no medical therapeutic resources (corticotropic, tireotropic, somatotropic adenomas).
As a rule, surgery is minimally invasive, transnasal, transphenoidal with the aid of endoscopes. Our team has experience in this type of surgery, with the team being trained in the center with the largest volume of transnasal endoscopically treated pituitary adenomas in Europe (Foch Hospital, Paris – approximately 300 pituitary interventions per year).
Stereotactic radiosurgery (Gamma Knife or LINAC) is targeted, stereotactic radiation in a single session that does not require incisions. Radiation on tissues is minimal, thus reducing the risk of damage to these structures. This type of treatment is an option when structures such as the cavernous sinus are invaded and surgery is impossible without significant risks.
Conformational radiotherapy is a radiation therapy offered when the tumors are large and are in contact with radio-sensitive structures such as the optical nerves, and surgery is not an option or ablation is not complete. Radiotherapy requires many years to achieve its effect.
Drug treatment
Prolactinomas – are pituitary adenomas that are usually well controlled with drugs (cabergoline and bromocriptine). These drugs control prolactin secretion and decrease tumor volume.
Somatotrope adenomas (GH) – partially benefit from medical treatment when the surgical procedure did not succeed in tumor control. There are two groups of drugs – somatostatin analogues (may cause the decrease of hyperproduction of the hormone and tumor volume decrease) and pegvisomant (Somavert), a blocker of excess growth hormone in the body.
Substitution treatment
When there is a decrease in the production of pituitary hormones, substitution with hormones administered to the patient is necessary. Hormones such as cortisone and thyroxine are absolutely necessary for survival, but if they are properly substituted, the patient has an absolutely normal life.
Observation
If a tumor does not cause signs or symptoms, “wait and see” may be an option.
You have most likely been seen by your family doctor and an endocrinologist. If your doctor suspected you had a pituitary adenoma, he probably sent you to an endocrinologist and to a neurosurgeon. Here’s some information to help you prepare for a specialist consultation.
What can you do?
• Write any symptoms you have, including those that seem unrelated to the reason for your presentation
• Write any personal information, including any major stress or recent life changes • Make a list of all the drugs you are taking, including vitamins, dietary supplements or alternative medication
• You are advised to come with a family member or a friend, if possible. Sometimes it is difficult to remember all the information that is given to you during a consultation. So, your attendant can help you remember the information you provided during the consultation.
• Write the questions you would like to ask your doctor during the consultation. Prepare a list of questions to help you make the most of your time spent in consultation with your doctor.
For an adenoma, some questions that you can formulate include:
• What caused my problems?
• What other doctors do I need to see?
• What tests should I do?
• What is the best therapeutic attitude?
• What alternatives to this attitude exist?
• I have other health problems. How can they be managed together?
• Are there any restrictions imposed by my illness?
• Where can I get additional information from?
Do not hesitate to ask any other questions.
The stress you are undergoing knowing you have a tumor that can have a lot of negative effects on your health can be very important. Here are some suggestions that can help you manage this stress:
• the more you know about your affection, the better your choice of treatment
• a psychologist can help
• ask other patients who have had the same problems
• family and friends can help you move around over stressful periods
• look for support groups – online or in the area where you live
