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THE PITUiTARY: SMALL GLAND, BIG EFFECT

From Washington University Physicians, written by Mary Jo Blackwood, RN, MPH, posted October 21, 2012

The size of a pea and located at the base of the brain behind the eyes, the pituitary gland is the command center for the body’s endocrine system, secreting nine different hormones, including prolactin, ACTH, thyroid, and sex hormones.

The pituitary gland is also prone to slow-growing non-cancerous tumors, called adenomas. These tumors, occurring in 10 percent to 15 percent of the general population, are frequently asymptomatic and may be discovered by accident during imaging, like an MRI, done for another reason.

Julie Silverstein, MD, a Washington University endocrinologist, is part of a team taking referrals from physicians for the multidisciplinary Pituitary Center. She evaluates the hormonal status of patients and manages the medical aspects of pituitary tumors.

“The initial evaluation of patients includes lab work to assess hormone levels, such as thyroid, ACTH, testosterone, growth hormone and others. Laboratory data in conjunction with the patient’s history, physical exam and imaging helps us answer three important questions: Is the tumor functionally active and making hormones? Is it causing hormone deficiency? Is it causing physical problems due to its size?”

Non-functioning tumors often have no effect until their size becomes significant, at which point, they may disrupt the hormone function of the gland or cause physical problems like headache and loss of vision, particularly peripheral vision. Some tumors, however, make hormones and cause symptoms related to excess hormone production. They are typed based on the hormone affected:
  •  Prolactinomas: Thirty percent of pituitary adenomas produce prolactin, the hormone that stimulates milk production in new mothers. They may cause nipple discharge, menstrual irregularities, infertility and low testosterone levels.
  • Corticotroph adenomas: Fifteen percent of pituitary adenomas produce ACTH and cause Cushing’s disease, a condition characterized by weight gain, thin skin with easy bruising, high blood pressure and high blood sugar.
  • Somatotroph adenomas: Another 15 percent of pituitary adenomas produce growth hormone and can cause acromegaly, characterized by enlargement of the jaw, hands and feet.
  • Thyrotroph adenomas: Tumors that are thyrotropin-secreting increase production of thyroid hormone and sometimes increased heart rate and other metabolic problems.
  • Gonadotroph adenomas: These tumors do not generally create hormone-related symptoms but tend to be larger tumors that cause headaches and visual disturbances.
Treatment of Pituitary Tumors

Asymptomatic small tumors generally require no treatment beyond periodic MRIs to monitor growth. Those that produce excess hormones, cause loss of vision or other symptoms may need treatment. In addition to overseeing the medical management of pituitary tumors, Dr. Silverstein treats patients in clinic prior to surgery and monitors the effects of treatment and hormone levels over time.

Medication: Some hormone-producing tumors can be medically treated. If the tumor causes hormonal deficiencies, those missing hormones can be replaced.

Radiation may be needed in some cases. The Gamma Knife delivers high-dose radiation to the tumor, sparing surrounding tissue. It can be used to decrease the size of the tumor, prevent further growth, and decrease the amount of excess hormone produced. Sometimes after Gamma Knife treatment, hormone deficiency can develop, so levels should be monitored.

Surgery: Most commonly, surgery to remove a pituitary tumor is done through a procedure called transsphenoidal resection. A neurosurgeon and ear, nose & throat (ENT) surgeon, often work as a team, to find access to the pituitary gland through the nose into the sphenoid sinus without external incisions.

Small, high-resolution endoscopic instruments and intra-operative MRI, available at Barnes-Jewish Hospital, allow surgeons more precision for greater patient safety. They remove only the tumor and try to preserve as much of the pituitary gland as possible.

The Washington University Pituitary Center

The Pituitary Center currently operates two times a week and has a rotating staff of endocrinologist Silverstein and one of five neurosurgeons, with patients seeing both the same day. Says Silverstein, “If they need to see an ENT surgeon, or have specialized testing that requires an interventional radiologist, we coordinate that.

We communicate with the referring physician and make sure all the care is handled as efficiently as possible for the patient.”

Physicians wishing to refer patients to the center may call 314-362-3577.

Pictured below are the physicians of the Washington University Pituitary Center. From left: Gregory Zipfel, MD; Albert Kim, MD, PhD; Julie Silverstein, MD; Ralph Dacey, Jr., MD; Michael Chicoine, MD; and Keith Rich, MD
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Copyright 2013 Washington University School of Medicine