00:01
How do we treat pituitary tumors?
Well, there's really two goals.
00:05
The first is to replace
hormone function.
00:08
The second is to definitively
treat the tumor.
00:11
And we're going to talk about
how we balance
each of those parts of treatment.
00:16
When we think about these tumors,
many are benign.
00:19
The vast majority are benign tumors
that may be observed
on serial imaging
and not grow at all
or for many years.
00:26
Observation is the treatment
that is recommended
for asymptomatic patients.
00:30
Patients who don't have
abnormal hormone testing
on laboratory evaluation,
or those with not concerning
without concerning
growth rate or growth pattern.
00:40
Lesions that are staying the same
on serial imaging.
00:45
There are times
when we need to consider surgery.
00:48
And typically we consider a
transsphenoidal hypophysectomy,
but we'll talk about some
of the other approaches to surgery.
00:54
And this should be considered
in patients who are symptomatic,
or for other indications that
we'll get into in just a minute.
01:00
And then the last tool
in our toolbox
to treat these patients is
hormonal replacement therapy,
or other types of
hormonal treatment.
01:07
And this is critical, given the
association of these tumors
with both increased hormone function
and reduced hormone function.
01:16
Let's talk a little bit more
about surgery.
01:18
What are the indications
for surgery
for a patient with
a pituitary lesion?
Well, the first is
symptomatic mass effect.
01:25
Big lesions that are
pushing on the brain
are not going to respond
to observation or hormonal therapy
and require a surgery.
01:33
Vision loss.
Vision is critical.
01:35
And in patients
who have lost vision,
they're not going to recover
that vision loss.
01:40
So it's important to recognize early
vision loss and intervene quickly,
for lesions that are
expanding into the optic chiasm
and resulting in vision loss.
01:50
The last is inability to achieve
hormonal stability.
01:54
In lesions that are initially
treated with hormonal therapy,
if we can't get that under control,
particularly for patients
who have the potential
for life threatening
hormonal dysfunction,
surgery is going to be
the treatment of choice.
02:05
There are many approaches
to surgery
and I don't need you to know
all of these
except to know that we can do
surgery in many different ways.
02:12
There is surgery
through the nose,
because what sits
at the end of the nose
is the area of the sella turcica,
right above the the
posterior nasal pharynx.
02:23
There's a pterional approach,
subfrontal approach, and others.
02:26
And that surgeon
is going to get to this area
in the safest way possible.
02:29
In certain situations,
surgery may not be safe
or a surgery is performed and
the tumor is incompletely resected.
02:37
In those situations, radiation can
be another treatment option.
02:41
We talked about
three types of radiation.
02:44
Focal radiation called
stereotactic radiosurgery.
02:47
Partial brain radiation,
and whole brain radiation.
02:50
And typically for tumors
in the pituitary region,
which again is in close proximity
to important vital structures
like the eye and vision.
02:59
We use focal radiation or
stereotactic radiosurgery.
03:02
This is an excellent treatment for
growing tumors that are symptomatic
that cannot be removed
with surgery
or where the tumor
is incompletely removed
after a surgery.
03:13
Now, let's talk about
hormonal therapy.
03:15
And this is the third arm
of our treatment approach.
03:17
Observation, surgery, may be
radiation, and hormonal therapy.
03:22
There are two reasons
to give hormonal therapy.
03:24
The first is if there's
inadequate hormone function
and we need to replace
hormone functioning
that isn't there.
03:31
And the second is hormonal treatment
to reduce tumor growth.
03:35
When we're thinking about promoting
or replacing hormone function,
it depends on the type of hormone
that is insufficient.
03:43
We think of using
prednisone and hydrocortisone
for insufficient corticosteroid or
steroids circulating steroid levels.
03:52
Levothyroxine is used to supplement
inadequate thyroid function.
03:56
Growth hormone is considered for
inadequate growth hormone function
particularly in young children
or adolescents
prior to bone closure.
04:04
Testosterone and estrogen
for men and women
requiring gonadotrophin
replacement.
04:11
And Desmopressin or DDAVP
particularly when
there is dysfunction
of the posterior pituitary gland,
and function
and maintaining fluid balance,
and dynamics.
04:23
We can also consider
hormonal therapy to treat the tumor
not just to replace a loss or
insufficient hormone production,
but to reduce and shrink tumor size.
04:32
And we consider this in tumors
that are hormone secreting.
04:36
Prolactinomas can be treated
with dopamine agonists
because dopamine neurons
inhibit the production of prolactin.
04:44
And for those tumors,
we consider agents
like bromocriptine and cabergoline
like for our patient
at the beginning of this lecture.
04:52
For growth hormone-secreting tumors,
we think of
octreotide or pegvisomant
as agents that can help treat
those tumors.
04:59
And for Cushing's disease
or tumors that secrete
too much ACTH,
one agent is pasireotide.
05:07
So hormonal treatment
is also an important arm
for managing pituitary tumors,
which is different from
some of the other brain tumors
that we've discussed.