Current Status of Diagnosis and Management for Functioning Pituitary Tumors

Thakkar, K., Sarathi, V., & Shah, N. S. (2020)

Introduction

Pituitary adenomas (PA) are non-metastasizing tumors of the anterior pituitary gland.
Prolactinoma, somatotropinoma, corticotropinoma, thyrotropinoma, and gonadotropinoma are the
different subtypes of PA based on the cell of origin or associated hormone hypersecretion. PAs are also
classified as either functional, which causes increased secretion of pituitary hormones, or nonfunctional,
which does not produce any hormone. Because of associated hyperpituitarism conditions, PAs are
associated with higher morbidity and mortality. Therefore, early diagnosis and treatment are important to
reduce these related health risks.

Treatment Strategies for Functioning Pituitary Tumors

The treatment of functioning pituitary tumors includes one or more of the following three
modalities: surgery, radiation therapy (RT), and medical therapy.

The first line of treatment for functioning PA (except prolactinomas) is trans-sphenoidal surgery
(TSS) and resection of adenoma since it can achieve faster control of hypersecretion of a hormone, rapid
decompression of surrounding vital structures, and not only short-term but also long-term remission than
other treatment modalities. Complications associated with TSS include hypopituitarism, transient or
permanent diabetes insipidus (DI), and hyponatremia as well as surgical complications such as a
cerebrospinal fluid leak, meningitis, injury to surrounding structures like carotid vessels, optic nerve, etc.,
Rates of success and complications improve significantly with experienced neurosurgeon and high-
volume centers.

For patients with persistent or recurrent disease after TSS, radiotherapy is considered a second- or
third-line treatment option. The action of RT on PA is slow, taking months to years to achieve hormonal
normalization, but it produces long-term hormonal and tumor control in the majority of patients.
Conventional and stereotactic fractionated RT (CRT and SRT) are delivered in small fractions of
approximately 180 to 200 cGy (45 to 50 Gy over 5-6 weeks), while stereotactic radiosurgery (SRS) is
delivered in 1-2 high dose fractions (15 to 25 Gy). The efficacy of both modes (CRT and SRS) appears to
be comparable, but normalization of hormonal hypersecretion is slightly faster with SRS. Stereotactic
radiosurgery is more convenient to patients as only 1-2 fractions are delivered. However, patients should
be carefully chosen for SRS because there is a higher risk of optic nerve injury if the tumor is close to the
optic chiasm. Furthermore, administering SRS to patients with unvisualized tumors on MRI (as in
Cushing's disease) is difficult and associated with a higher risk of recurrence. Complications associated
with RT include risk of hypopituitarism, slightly higher risk of stroke, neurocognitive impairment, and
very rarely, risk of second brain tumor. However, these can be minimized by using techniques of
conformation and stereotaxis to reduce exposure to normal brain structures.

Medical therapy is considered a primary treatment for prolactinomas, but an adjunctive therapy to
surgery and/or radiation therapy for other functional PA. Medical therapy is frequently administered for
an extended time and necessitates biochemical and radiologic monitoring to control hormone
hypersecretion and tumor growth, respectively. Aside from the drugs that are currently available, clinical
trials for some emerging medical therapies are currently underway, with the hope that they will be
available for use soon.

Personal Comment:

Since pituitary adenomas (PA) frequently cause hyperpituitarism, this article provides the
information to treat PA reducing the risk of the patient’s getting hypersecretion of hormones. It also aids
the healthcare team in considering the right mode of treatment of the patient with regards to the severity
of their condition. With the right modality or combination of modalities, the healthcare team can improve
the quality of care to the patient by enhancing their recovery while also preventing complications.
 As a future nurse, I have chosen this article because after knowing in our discussion that these
pituitary adenomas are the common cause of hyperpituitarism, I thought that focusing on the treatment of
these tumors will lower the risk of a patient. I also chose it because it shows that prevention is better than
cure. While treating the root of a disease, we are actually preventing the patient to get even sicker. As part
of the healthcare team, we should focus on what matters to our patients to promote better health and well-
being and stopping them from becoming ill.

After reading the article, I have learned about the different treatment modalities for pituitary
adenomas and their therapeutic effects on the patients. With this knowledge, I can use these pieces of
information, soon, in my clinical exposure and application as a tool to render quality nursing care,
specifically with those who have pituitary adenomas.

References:

Thakkar, K., Sarathi, V., & Shah, N. S. (2020). Current Status of Diagnosis and Management for
Functioning Pituitary Tumors: Part I. Neurology India, 68(7), 13-19.
https://doi.org/10.4103/0028-3886.287680