Pituitary adenomas are the third most common intracranial tumor and arise from the pituitary gland
Surgical removal via the endoscopic endonasal approach is the treatment of choice for most patient with a symptomatic pituitary adenoma (with the exception of prolactinomas). Given major technical advances over the last two decades in high-definition endoscopy, surgical navigation techniques and more effective skull base closure methods, pituitary surgery is safer than ever in experienced hands.
At the Pacific Pituitary Disorders Center, we have one of the world’s largest experiences in endoscopic endonasal transsphenoidal surgery for all types of pituitary adenomas including acromegaly, Cushing’s disease, prolactinomas, non-functional adenomas, pituitary apoplexy and residual or recurrent adenomas.
By incorporating leading edge technology and instrumentation with proven surgical experience of over 2,000 endonasal surgeries, our pituitary tumor specialists led by neurosurgeons Dr. Daniel Kelly, Garni Barkhoudarian and Walavan Sivakumar, and ENT/Otolaryngologist Dr. Chester Griffiths, make pituitary surgery safer, less invasive and more effective.
What is a pituitary adenoma?
Pituitary adenomas arise from the pituitary gland and are by far the most common growth associated with the gland; they account for 15% of primary brain tumors and are the third most common intracranial tumor after meningiomas and gliomas. The great majority (over 90%) of pituitary adenomas are benign slow growing tumors, approximately 5-10% are somewhat more aggressive (atypical) and less than 1% qualify as pituitary carcinoma.
From autopsy studies and MRIs of normal individuals, it is known that 10-20% of the general population has a pituitary adenoma. Most of these tumors remain small and do not cause significant harm or symptoms; however many do progress and grow to cause hormonal and neurological problems.
Types of Pituitary Adenomas
Pituitary adenomas are classified by size and whether they produce pituitary hormones; microadenomas are less than 1 cm in diameter and macroadenomas are over 1 cm in diameter.
Adenomas that make excess hormones (endocrine-active adenomas) include prolactin-secreting adenomas known as prolactinomas, adrenocorticotropic hormone (ACTH) secreting adenomas causing Cushing’s disease, growth hormone (GH) secreting adenomas causing acromegaly, and thyroid stimulating hormone (TSH) secreting adenomas causing hyperthyroidism.
Adenomas that do not make excess hormones are called endocrine-inactive or Non-Functional Adenomas. Most adenomas are not genetically inherited; cases of familial pituitary tumors are rare. Multiple Endocrine Neoplasia (MEN) type I accounts for less than 5% of cases of pituitary adenomas. This autosomal dominant condition is characterized by multiple and sometimes simultaneous tumors of the pituitary, pancreas and parathyroid glands. Pituitary adenomas develop in 25% of patients with MEN I.
What are the symptoms of a pituitary adenoma?
Pituitary adenomas may cause problems because of hormonal hypersecretion, pituitary hormonal failure, vision loss, headaches and/or bleeding into the tumor (apoplexy).
The three most common hormonally active adenomas are prolactinomas, GH-secreting tumors causing acromegaly, and ACTH-secreting tumors causing Cushing’s disease. Thyroid stimulating hormone (TSH) tumors are relatively rare.
Pituitary hormonal deficiency (Hypopitutiarism)
(Hypopituitarism) This problem typically occurs only in larger tumors (macroadenomas) and results from compression and damage to the normal pituitary gland from the enlarging adenoma.
Manifestations may include:
- Hypogonadism – sexual dysfunction, loss of libido, and impotence
- Hypothyroidism – fatigue, weakness, weight gain, coarse dry hair and dry skin, cold intolerance, depression
- Adrenal insufficiency – fatigue, weakness, loss of appetite, dizziness, nausea and vomiting
- Growth failure – in children and adolescents
- Hyperprolactinemia – due to “stalk effect”. This is seen in diseases within or near the pituitary gland and stalk. Interfering with the delivery of dopamine, a neuron-transmitter, from the hypothalamus to the prolactin secreting cells of the pituitary gland), which can result in hypogonadism and its associated problems. Rarely posterior pituitary gland damage occurs with diabetes insipidus, which is caused by the inability of the kidneys to conserve water, leading to frequent urination and thirst. Learn more about hypopituitarism
Larger pituitary macroadenomas often cause loss of visual acuity or peripheral vision (termed bitemporal hemianopsia) from pressure on the optic nerves and optic chiasm which is directly above the pituitary gland. Larger macroadenomas especially those that have hemorrhaged (apoplexy) may also cause double vision.
Patients with macroadenomas often have frontal, forehead and temporal area headaches. Pituitary adenoma removal often results in headache resolution.
Bleeding (pituitary apoplexy)
This condition develops over hours to several days from hemorrhage and/or infarction of pituitary adenoma (typically a macroadenoma or a Rathke’s cleft cyst).
Symptoms may include:
- Visual loss
- Double vision
Most patients have undiagnosed hormone insufficiency prior to the apoplectic event. Pituitary apoplexy is best confirmed by MRI. A head CT will also show areas of bleeding or a mass in the sella in the majority of cases. Other conditions that can mimic pituitary apoplexy are a ruptured aneurysm, meningitis, a stroke, intracerebral hemorrhage and migraine headache.
The treatment for most patients with pituitary apoplexy is urgent endoscopic endonasal surgery and intravenous administration of the stress hormone cortisol.
How are pituitary adenomas diagnosed?
Pituitary adenomas are best diagnosed by imaging studies and hormonal testing.
The imaging study of choice is an MRI of the pituitary gland without and with gadolinium (a contrast agent). A brain MRI or CT scan will also reveal most pituitary macroadenomas but may not reveal smaller microadenomas.
In a minority of patients it may be difficult to distinguish an adenoma of the pituitary from other masses which may include:
- Rathke’s Cleft cyst
- Hypophysitis (pituitary inflammation)
- Glioma of the suprasellar region
- Metastatic tumor
Pituitary Hormonal Testing
Evaluation and interpretation of the pituitary gland function either for hormonal deficits or inappropriate hormonal secretion is performed in our center, under the supervision of our pituitary neuroendocrinologist Dr. Katherine Araque.
Our team recognizes that one size does not fit all. Consequently, pituitary hormonal testing is individualized to the needs of our patients.
Our center can be easily perform these types of blood level measurements:
- Serum cortisol
- Free T4
- Total T3 (thyroid function)
- LH (luteinizing hormone)
- FSH (follicle-stimulating hormone)
- Estradiol in women
- Free and total testosterone in men
- GH (growth hormone)
- IGF-1 (insulin-like growth factor)
Additionally, patients can have access to various diagnostic tools including radiologic images with selected pituitary protocols, noninvasive and invasive dynamic endocrinology testing.
Patients with visual complaints or those whose tumors that contact the optic nerves or optic chiasm should receive a full ophthalmological evaluation. An evaluation with our neuro-ophthalmologist, Dr. Howard Krauss, should include acuity (vision quality) testing of each eye and formal visual field testing to determine if there is loss of peripheral vision.
How are pituitary adenomas treated?
Endoscopic Endonasal Surgery
The first-line treatment for all pituitary adenomas except prolactinomas (as discussed below), as well as Rathke’s Cleft Cysts (RCCs) and most craniopharyngiomas is endoscopic endonasal transsphenoidal surgery. Because of improved tumor visualization and tumor removal rates, the endoscopic endonasal approach has become the preferred method for removal of pituitary adenomas, RCCs, as well as the great majority of craniopharyngiomas, clival chordomas and many midline meningiomas.
Surgical success rates (complete tumor removal and normalization of hormonal hypersecretion) are generally quite high (>80-90%) with smaller and non-invasive pituitary adenomas, but are lower for large or invasive macroadenomas (40-70%).
Major surgical complications such as vision loss, bleeding, stroke, cerebrospinal fluid leak and meningitis are low when performed by experienced endonasal transsphenoidal neurosurgeons who often work collaboratively with a Head & Neck surgeon. The success rates of surgery are described further in the sections below for specific tumor types.
A craniotomy (opening in the skull from above to reach the pituitary region) is required in less than 1% of patients who require surgery for a pituitary adenoma.
Medical & Radiation Therapies
See specific adenoma subtypes:
Hormone Replacement Therapy
Many patients with pituitary adenomas will develop varying degrees of hypopituitarism (pituitary gland deficiency) either as a result of the tumor impact on the gland or sometimes as a result of surgery or other treatments. While many patients can have some degree of gland recovery, many will ultimately require short-term or long-term hormone replacement therapy. Our highly experienced pituitary endocrinologists, Drs. Pejman Cohan and Katherine Araque can provide tailored hormone replacement therapy including for low testosterone, low estrogen, growth hormone deficiency, hypothyroidism, low cortisol (adrenal insufficiency) and diabetes insipidus (anti-diuretic hormone deficiency).
For prolactinomas that are typically treated with medical therapy, we have highly experienced endocrinologists to provide this therapy. For patients with adenomas that cannot be completely treated with surgery and/or medical therapy, our experienced radiation oncologists experts can deliver focused radiosurgery or radiotherapy to tumors, halting their growth.
We also have clinical trials available using novel medical therapies for patients with persistent acromegaly and Cushing’s disease who failed prior treatments.
Learn more about pituitary adenomas: