Pituitary tumors are also known as pituitary adenomas. The pituitary gland is the most important endocrine gland in the body and secretes many hormones such as growth hormone, thyroid stimulating hormone, adrenocorticotropic hormone, gonadotropin, oxytocin, prolactin, melanocyte stimulating hormone, etc. It is also able to store anti-diuretic hormone secreted by hypothalamus. These hormones have very important roles in metabolism, growth, development and reproduction.
The normal pituitary gland is located at the base of the brain, and above the pituitary gland is the cross of the optic nerves on both sides responsible for vision.
The most common manifestations of pituitary tumor
1. Menopause and breast overflow: The longest manifestations in women of childbearing age are menstrual disorders and irregularity, cessation of menstruation, and milk overflow from the nipples (non-lactating).
2.Decreased vision and impaired visual field: The tumor enlarges and presses upward on the optic nerve, resulting in a gradual decrease in vision, which cannot be improved by wearing myopic or presbyopic glasses. The range of eyes seeing in front is reduced.
3.Headache: caused by tumor growth or bleeding pressure. The headache is mostly in the temple area, frontal area, behind the eye or nasal root.
Classification of pituitary tumor
Classification by diameter: micro adenoma (less than 1cm), large adenoma (1-3cm), giant adenoma (more than 3cm)
Classification according to the function of hormone secretion by tumor
a. Non-functional type.
Because the tumor does not secrete hormones, it is difficult to be detected at early stage, and is mostly detected only after it grows larger and presses the optic nerve. The tumor may manifest as vision loss, visual field defects and headache.
b. Prolactin type (abbreviated as PRL).
In women, it manifests as menopause and lactation, and infertility; in men, it manifests as impotence, decreased sexual function, and . Infertility.
c. Growth hormone (abbreviated GH).
In adults, it manifests as thickened hands and feet, larger shoe size, ugly face, thicker lips, etc. Due to the slow change, it often cannot be detected by oneself and is mostly discovered by friends, classmates or family members who have not seen each other for a long time. In children, it manifests as gigantism.
It can lead to diabetes and hypertension; due to joint deformation, it can lead to pain in joints all over the body and can be easily misdiagnosed as arthritis
d. Adrenocorticotropic hormone type (abbreviated ACTH).
Full-moon face, obesity above the waist, darkening of the skin, menstrual disorders, and easy weakness.
e. Thyrotropic hormone pituitary tumor (TSH) is uncommon: causes hyperthyroidism, weight loss, panic attacks, fear of heat, easy sweating, and emotional excitement
f. Gonadotropin pituitary tumors Uncommon
Invasion of peripheral structures: invasive (most commonly encircling the internal carotid artery, making total excision difficult, leading to ptosis, drooping eyelids and double vision), non-invasive
C. Pituitary tumor diagnosis
Magnetic resonance imaging of saddle area + enhancement: It is a necessary examination to understand the size of the tumor, whether it invades the surrounding structures, and to differentiate it from other tumors.
Endocrine hormone test: It is necessary to take blood test to know which hormone is secreted by the tumor, so as to facilitate the diagnosis and treatment plan.
Special tips.
1. The diagnosis and treatment of this disease must be made by experienced neurosurgeons!
2. The pituitary gland of adolescents and fertile women can be physiologically enlarged, and the “pituitary tumor” reported by MRI is not necessarily a pituitary tumor. Do not just operate or treat with radiotherapy.
3, pituitary hyperplasia can be manifested as “menopause, lactation, infertility, pituitary enlargement”, and blood test prolactin can also be increased or even significantly increased, which can easily be misdiagnosed as prolactin adenoma. I have encountered several cases where patients were misdiagnosed in several hospitals and almost operated on. In one case, a patient from Gushi, Henan Province, was correctly diagnosed and had already conceived and given birth.
IV. Pituitary tumor treatment
Drug therapy: It is mainly applied to prolactinoma, and most of them are effective. 90% of patients (both microadenoma and macroadenoma) can be treated with bromocriptine to control the prolactin level and reduce the size of the tumor (below). If bromocriptine is ineffective, carte blanche can be used (this drug is not available in China and can be purchased from Hong Kong or abroad)
Growth hormone type can also be treated with drugs, but the drugs are expensive and the effect is not as good as surgery, so surgery is preferred.
Surgical treatment: It is the main treatment method. It is suitable for all kinds of pituitary tumors except prolactin adenoma
Radiotherapy:Applicable to small amount of tumor residue after surgery; small adenoma that does not want to operate (the distance above the tumor is more than 4mm from the optic nerve, otherwise it is easy to cause visual impairment)
Observation: No surgery and no medication. It is suitable for patients with incidental pituitary adenomas, especially non-functional pituitary microadenomas, who only need regular MRI review to understand the changes of the tumor. Due to the biological characteristics of pituitary adenoma cells, some tumor cells do not grow to a certain extent, resulting in a so-called “quiescent tumor” in clinical practice.
Only if there are clear symptoms associated with pituitary adenoma or if there are signs of tumor enlargement during follow-up, treatment is needed. For some menopausal women with prolactin adenoma, they can also be followed up and observed, because the decrease of estrogen level can slow down the growth of tumor.
V. Surgical methods:
1. Transnasal approach surgery: It is suitable for most pituitary tumors that require surgery. The pituitary tumor is removed through the nostril, leaving no scar on the exterior and less trauma. The technology is very mature. Generally, neurosurgery can be performed in provincial tertiary hospitals, but for huge pituitary tumors, an experienced physician should perform the surgery.
(Special note: Transnasal approach pituitary tumor resection belongs to the New Agricultural Cooperative Medical Insurance for major diseases in Anhui Province, the patient only needs to pay 9300 RMB out of pocket, and the rest of the hospitalization cost is paid by medical insurance)
2.Transfrontal craniotomy: It is suitable for the few huge pituitary tumors that cannot be removed through the nose. The risk of trauma and surgery increases.
VI. Life-long follow-up
All pituitary tumor patients should be followed up for life.
Regular checkups (every 3-6 months, can be extended according to the condition as appropriate).
Examination content.
Saddle area MRI plain + enhancement; mandatory for all patients
Endocrine hormone tests: cortisol, thyroid function hormones (T3, T4, TSH) are mandatory for all patients. Prolactin (PRL), growth hormone (GH, IGF-1), adrenocorticotropic hormone (ACTH), etc. will be added depending on the condition.
Drug supplementation: In hypopituitarism, prednisone and levothyroxine (Eugenol) must be supplemented daily. Many patients with hypopituitarism stop their medication on their own because they are worried about the side effects of hormone medication. It is incorrect and very dangerous because the lack of hormones can lead to low resistance of the patient, and a common cold, diarrhea or minor surgery can lead to coma or even death. Patients with hypopituitarism must be supplemented because they cannot produce enough of their own hormones to maintain their physiological needs.
The following is a patient who was almost blind in both eyes due to a huge pituitary tumor (the right eye could only count fingers in front of the eyes and the left eye was blind), and underwent transnasal butterfly pituitary tumor resection in another tertiary hospital affiliated with a medical school, but only part of the tumor was removed, and after the surgery, only the vision in the right eye improved slightly, while the left eye remained blind and lightless. The vision of both eyes improved immediately, and the left eye could have light perception, and is continuing to recover.
(The above set of pictures shows the enhanced MRI before and after the first surgery in August 2015 at an outside hospital, showing that the tumor was only partially removed)
(The above set of images shows the enhanced MRI before and after the surgery at our hospital in December 2015, showing total tumor resection)
The following is a patient with a growth hormone pituitary tumor who had a total resection of the pituitary tumor through a nasal approach.