Why do I need to have surgery for my pituitary tumor?
Pituitary adenomas (benign glandular tumors) arise from the pituitary gland itself.
There are two kinds: secretory (meaning that they give off hormones) and non-secretory (meaning that they don’t).
- Secretory tumors cause endocrine system problems by releasing excess hormones into your bloodstream. .
- Non-secretory tumors can cause vision problems by growing so large they press on your optic nerves, which can lead to a loss of peripheral vision.
Surgery is helpful for both kinds of pituitary tumors.
I have been told that I have a prolactinoma; can surgery help?
The most common type of secretory pituitary tumor is called a prolactinoma. It produces a hormone called prolactin, which stimulates the breast to produce milk. Excess prolactin in the blood can lead to irregular or absent periods in women, decreased erections and libido in men and infertility or milk production in men or women.
However, there are excellent medications available to treat this disorder — and most patients with prolactinomas are treated by endocrinologists. If your tumor doesn’t respond to the medication or you have serious side effects, surgery may be an option.
Once your levels of prolactin are brought back to normal, your symptoms will typically go away.
I have been told that I have acromegaly; can surgery help?
Acromegaly (or gigantism if it occurs in a child) results from an excess production of growth hormone because of a pituitary tumor. The excess growth hormone stimulates growth of the body tissues, which can cause a number of problems.
The typical treatment for acromegaly is the surgical removal of the tumor.
I have been told that I have Cushing’s disease; can surgery help?
Cushing’s disease is caused by pituitary tumors that secrete a hormone called ACTH. Unregulated secretion of ACTH results in abnormally high levels of cortisol, a steroid hormone produced by the adrenal glands.
Surgical removal of these tumors can restore normal hormone production for most people.
How is the surgery performed?
Most pituitary tumors can be removed transsphenoidally, through the nose. We use a direct endoscopic transnasal approach, where an incision is made in the back wall of the nose and the sphenoid sinus is entered directly. It is a minimally invasive procedure in which your surgeon uses a flexible endoscope to remove the pituitary tumor. With this direct approach, we rarely need to use bulky post-operative nasal packing.
How do you see the tumor?
Surgeons at the University of Washington/Harborview Medical Center use a fiber optic endoscope, which provides a wide field of view, and gives us the ability to look around corners with angled scopes.
How is the tumor removed?
The tumor is often soft and can be removed quite easily. A combination of breaking the tumor into pieces and gentle suction can work to remove very large tumors (up to the size of a small orange).
Do all pituitary tumors require surgery?
No. A majority of tumors are microadenomas (less than 1 cm in diameter) and do not secrete hormones. These small tumors frequently do not cause symptoms, so we typically recommend a series of imaging studies to make sure your tumor isn’t growing.
Tumors which secrete high amounts of the hormone prolactin usually respond to medication with dopamine agonists like cabergoline or bromocriptine, making surgery unnecessary.
How should I choose a surgeon for my pituitary operation?
Studies clearly show that the success of pituitary surgery is directly related to the number of operations already performed by the neurosurgeon. A wide range of experience correlates with increased cure rates and fewer complications. Surgeons at major pituitary centers, such as the UW Medicine pituitary program hospitals, operate on patients with pituitary tumors weekly.
What are the risks of the surgery?
The most common risk is damage to the pituitary gland. Hypopituitarism (decreased hormone secretion) can be temporary or permanent. Patients with tumors greater than 1 cm experience hypopituitarism 5%–10% of the time following their surgery. Hormone replacement can alleviate this condition.
Damage to the back part of the pituitary gland can produce a condition known as diabetes insipidus (DI), which can lead to frequent urination and excessive thirst. Permanent DI occurs 1-2% of the time after pituitary surgery. This can be controlled with medication in the form of a nasal spray or a pill.
Are there other more serious complications?
There are also some more severe complications that can occur in extremely rare circumstances.
- Damage to the carotid arteries leading to stroke or brain hemorrhage
- Loss of vision due to bleeding or damage to the optic nerves
- Cerebral spinal fluid leak, which can cause meningitis
The risk of all complications is higher with less experienced surgeons.
How long does the operation take?
The procedure itself usually takes between one to three hours. After surgery, you will go to the recovery room for two to three hours , and will then be admitted to the hospital floor. There is usually no need to stay in an Intensive Care Unit. Most patients are discharged from the hospital in just one or two days.
How will I feel after the surgery?
You may have some bloody discharge from your nose. As long as this is a small amount of blood and does not become like a dripping faucet, this is normal. You will have a sinus headache and nasal congestion, which will gradually improve over a few weeks. You can take decongestants to help relieve these symptoms. It is also common to feel fatigued for two to three weeks after the surgery, but this gradually improves.
How long will I be out of work?
It depends on your line of work. Two to three weeks is a good estimate.
How will we know if the entire tumor has been removed?
If your tumor is a hormone-secreting adenoma (prolactinoma, Cushing's disease or acromegaly), the team will follow your hormone levels to determine whether you are cured. For non-secreting tumors MRI scans are used to determine the success of the operation.
It can be difficult to ensure complete resection of very large tumors that grow deep into the brain. Some centers, such as the UW Medicine Harborview Medical Center, have a special portable CT in the operating room, which is used by surgeons to see whether they have removed all of a large tumor.
Your doctor will have you undergo another MRI about six weeks after your surgery to determine if further therapy will be required
I have been told that I have a tumor that enters the cavernous sinus. What is that and am I a surgical candidate?
Pituitary tumors can also grow sideways into the cavernous sinus where the carotid artery and cranial nerves are located. The carotid artery delivers blood to the brain, while the nerves in this location control the movement of the eye and sensation to the eye and face. If you have a secreting tumor that invades but does not encase your carotid artery, we may be able to remove the tumor surgically. An angled endoscope enables us to see the tumor clearly, which helps with complete removal. This procedure requires special skill and extra bone removal over the carotid artery to be done safely and effectively.
What is the chance of being cured?
It largely depends upon the type, size and location of the tumor. Smaller, non-secretory tumors are much easier to cure than larger tumors. However, a large non-secretory tumor that has not grown into the bone or sinus can also typically be cured.
- It’s harder to cure a secreting tumor that has invaded the bone or the sinus.
- If the tumor has grown into an area where it is not possible or safe for the surgeon to operate, it may not be surgically curable.
- However, such tumors can often be surgically reduced in size so that they don’t impinge upon the optic nerves and pituitary gland, in order to protect your vision and hormonal function.
- Radiation treatment may be required to control further growth.
- The experience and expertise of your pituitary surgeon also matter greatly in these delicate surgical procedures.
What if some tumor is left behind after an attempt at surgical removal. Is radiation always required?
If the remaining tumor is surgically removable, your doctor may recommend an additional operation.
- If there is a substantial amount of a non-secretory tumor remaining after a successful transsphenoidal operation, radiation therapy can be used to halt further growth of the tumor.
- If only a small amount of tumor remains, your doctor may want to follow it through a series of MRIs and defer further therapy until there are signs of regrowth, which may not occur for years (or ever).
- If part of a secretory tumor (Cushing's disease, acromegaly, prolactinomas, TSH secreting tumors, lutenizing hormone secreting tumors) remains, your doctor may want to control the excess hormone secretion through medication. These medications, which are typically given under the supervision of an endocrinologist, can sometimes be used instead of, or in addition to, radiation therapy.
Who will take care of me in the hospital?
At a major pituitary center, such as the UW Medicine Pituitary program at Harborview Medical Center, a complete team of physicians will monitor your condition before, during and after your surgery. This team includes your neurosurgeon, a staff neuro-endocrinologist and the residents and fellows who work with them. The team will follow you until you can be returned to the care of your local endocrinologist and primary care physician.
- It’s important to follow through on endocrine testing after your surgery. These tests let your doctor know if you’re deficient in any of the hormones controlled by the pituitary gland, such as cortisol, thyroxine, estrogen/testosterone, growth hormone or vasopressin.