Magnetic resonance imagining MRI may be used to make images of the pituitary area using a computer and magnets during the surgery to help guide the surgeons. When the pituitary area is entered, the neurosurgeon removes the pituitary tumor in small pieces. When all parts of the tumor that can be reached have been removed, the endoscope is removed. Some packing may be placed in the nose to complete the operation.
You may need to stay in the hospital for a day or two. During this time, nurses will help you with any dressings and bathroom needs. You will be able to return to a normal diet as long as you are taking fluids well. You will be encouraged to get out of bed and walk as soon as you are able.
While in the hospital, you will be asked to help your nurses keep track of the amount of fluids you drink and your urine output to evaluate pituitary function. Health Home Treatments, Tests and Therapies. Reasons for endoscopic pituitary surgery Endoscopic pituitary surgery is done to remove certain types of tumors that start to grow in your pituitary gland: Hormone-secreting tumors. Risks of endoscopic pituitary surgery Endoscopic pituitary surgery is a safe type of surgery, but all surgical procedures carry some risk for reaction to anesthesia, bleeding, and infection.
Risks and complications that may occur with this type of surgery also include: CSF rhinorrhea. Before endoscopic pituitary surgery You may need to see an endocrinology specialist for an evaluation before surgery. During endoscopic pituitary surgery The actual surgery may take a few hours. These steps may take place: The ear, nose, and throat surgeon usually places the endoscope through the nose.
The thin bone of the sella is removed to expose the tough lining of the skull called the dura. The dura is opened to expose the tumor and pituitary gland. Step 4: remove the tumor Through a small hole in the sella, the tumor is removed by the neurosurgeon in pieces with long grasping instruments Fig.
The center of the tumor is cored out, allowing the tumor margins to fall inward so the surgeon can reach it. After all visible tumor is removed, the surgeon advances the endoscope into the sella to look and inspect for hidden tumor. Some tumors grow sideways into the cavernous sinus, a collection of veins. It may be difficult to completely remove this portion of the tumor without causing injury to the nerves and vessels. Any tumor left behind may be treated later with radiation.
At some hospitals, surgery can be performed in a special OR room equipped with an intraoperative MRI scanner. The patient can undergo an MRI during surgery. This technology enables more complete tumor removal and may reduce the need for a second operation [1].
Step 5: obtain fat graft optional After tumor is removed, the surgeon prepares to close the sella opening. If needed, a small 2cm skin incision is made in the abdomen to obtain a small piece of fat. The fat graft is used to fill the empty space left by the tumor removal. The abdominal incision is closed with sutures.
Step 6: close the sella opening The hole in the sella floor is replaced with bone graft from the septum Fig. Synthetic graft material is sometimes used when there is no suitable piece of septum or the patient has had previous surgery. Biologic glue is applied over the graft in the sphenoid sinus. This glue allows healing and prevents leaking of cerebrospinal fluid CSF from the brain into the sinus and nasal cavity. Soft, flexible splints may be placed in the nose along the septum to control bleeding and prevent swelling.
The splints also prevent adhesions from forming that may lead to chronic nasal congestion. After surgery you will be taken to the recovery room, where vital signs are monitored as you awake from anesthesia. Then you'll be transferred to a regular room or the intensive care unit ICU for observation and monitoring. You will be encouraged to get out of bed as soon as you are able sitting in a chair, walking. After surgery you may experience nasal congestion, nausea, and headache.
Medication can control these symptoms. An endocrinologist may see you the day after surgery to check that the pituitary gland is producing appropriate levels of hormones. If it is not, hormone-replacement medications may be given. If the doctor gave you a prescription medicine for pain, take it as prescribed. If you are not taking a prescription pain medicine, ask your doctor if you can take an over-the-counter medicine.
If you think your pain medicine is making you sick to your stomach: Take your medicine with meals unless your doctor has told you not to. Ask your doctor for a different pain medicine. If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics. If you have an incision on your belly, thigh, or head: Leave the tape on for a week or until it falls off.
Keep the area clean and dry. Change the bandage every 2 days, or if it gets wet or soiled. Do not take a bath or soak the incision in water for 2 weeks. After your doctor says it is okay to shower or bathe, gently wash the surgery area with warm, soapy water and pat it dry. For example, call if: You passed out lost consciousness. You have sudden chest pain and shortness of breath, or you cough up blood. You have severe trouble breathing.
It is hard to think, move, speak, or see. Your body is jerking or shaking. Call your doctor now or seek immediate medical care if: You have trouble thinking clearly.
You have a fever with a stiff neck or a severe headache. Your incision comes open, or you have pus or other fluid leaking from your incision. You have any sudden vision changes. You have new or worse headaches. You fall and hit your head. You are sleeping more than you are awake. You have pain that does not get better after you take pain medicine. You have a headache and you throw up. You have a lot of watery fluid leaking from your nose more than a slight runny nose.
You are urinating more than a pint of clear or light yellow urine every hour for at least 3 hours and you are more thirsty than usual. Current as of: March 31, Home About MyHealth. Include Images Large Print. Some patients have a better response to the combination of bromocriptine or cabergoline and octreotide Sandostatin, Somatuline , especially if the tumor makes too much of two hormones: growth hormone and prolactin.
Regardless of which regimen in used, these medications do not cure the disease; they control excessive growth hormone production by the tumor. Therefore, the medication s is effective only as long as it is taken regularly. Pegvisomant Somavert : This medication does not act directly on the pituitary tumor — it blocks the action of growth hormone at the liver to reduce production of IGF This medication is given as an injection under the skin self-administered once a day.
Bromocriptine: nausea, vomiting, dizziness, nasal stuffiness, constipation. Side effects are minimized by always taking the medication with food. Sandostatin LAR, Somatuline: when beginning treatment: loose stools, light-colored stools, occasional diarrhea and abdominal cramping.
This side effect usually lessens or disappears within 1 to 2 weeks. The gallstones may not cause a problem, but there is always a risk of developing problems. When beginning treatment with Sandostatin LAR, the recommendation is to first take the short acting preparation octreotide as an injection 3 times a day for a week in case side effects are too bothersome. If there are bothersome side effects, the long acting preparation, Sandostatin LAR, may not be suitable. In some centers and at U Va , the patient is given a single injection of the short-acting Sandostatin to make sure there are not side effects and then the patient is given an injection of long acting Sandostatin LAR later in the day.
Pegvisomant Somavert : Development of abnormal liver tests occurred in 2 of approximately patients treated with this drug. The tests returned to normal when the medication was stopped. The reason for this side effect is not known. It is recommended that liver tests be measured before beginning treatment and every month for the first 6 months of pegvisomant treatment and at regular intervals afterward I suggest every 6 months.
Enlargement of remaining tumor has occurred in a few patients; this means that regular MRI studies are necessary to detect this. Previous radiation treatment to the tumor appears to reduce the risk of tumor growth, but regular MRI scans are still necessary to make sure there is no growth.
In this situation, surgery to remove as much of the tumor as possible is usually the first treatment. This is particularly important if the tumor is close to the eye nerves optic chiasm or if the tumor is pressing on the optic chiasm causing loss of vision. If the patient cannot undergo surgery, medical treatment, preferably with a somatostatin drug Sandostatin LAR, Somatuline is used because these medications act directly on the tumor and may prevent tumor growth. In patients with a large tumor, surgery is recommended as the first treatment to remove as much as possible with medical treatment afterward if there is continued excessive growth hormone production.
Pegvisomant Somavert : Does not cause tumor shrinkage. This medication does not act directly on the tumor — it acts to block the action of growth hormone on the liver and reduces IGF-1 production and does not cause reduction in tumor size. Please note: the costs of the drugs are as of March, The manufacturer, Novartis, also has a home administration program in which a nurse comes to the home to administer the injection this does not apply to Medicare patients.
Somatuline: May be administered as a deep subcutaneous below the skin by a partner or by the patient, once a month. Pegvisomant Somavert self-injection, under the skin, once a day: Please note: this medication is dispensed through the Pfizer Bridge Program, the prices quoted are the actual wholesale cost provided by Pfizer.
Since octreotide, Sandostatin LAR, Somatuline and pegvisomant Somavert are so expensive, is there any financial help available? Yes, possibly. Sandostatin LAR: Novartis has an assistance program for patients who qualify. Pegvisomant Somavert : The Pfizer Bridge program works with PSI, and independent company, to provide assistance for patients who qualify for financial reasons.
I have had surgery, why do I still have a problem and have to undergo radiation treatment and take medication? Some patients are not cured with surgery. The reason for this is most commonly because of the size of the tumor: the larger the tumor, the less likely it can be removed completely. Additionally, the tumor may have spread to nearby structures such as bone, the cavernous sinus location of carotid artery and the nerves controlling eye movements and the membrane surrounding the gland dura mater.
In this situation, the neurosurgeon removes all that can be safely removed, but if the tumor has invaded surrounding structures such as bone or the cavernous sinus or the membrane covering the pituitary, excessive growth hormone production may persist. Surgery is usually the first step to remove as much of the tumor as possible, since the medical treatments do not always shrink the tumor and, if present, relieve the pressure on the optic nerve or improve vision problems. Yes and no.
There are medications that can reduce cortisol production by the adrenal glands, but medication doesnot have any effect on the pituitary overproduction of the hormone ACTH the pituitary hormone that stimulates the adrenal glands to make too much cortisol.
Thus, medication is used to control adrenal gland cortisol overproduction, but does not treat the source of the problem — the pituitary gland. Ketoconazole is a medication that reduces adrenal gland cortisol production.
If a drug to lower cortisol is prescribed, careful monitoring is necessary to determine if the dose is effective measure 24 hour urine cortisol level , to make sure it does not reduce cortisol to below normal measure morning blood cortisol level and to make sure there is no ill effect on the liver.
Another medication that reduces cortisol production by the adrenal glands is mitotane Lysodren. There are some experiments in mice that suggest that the diabetes medication, rosiglitazone, may reduce the size of implanted ACTH producing tumors and reduce cortisol production. This is a potentially exciting area of research, but it is currently a research project. This drug is only available at centers that are participating in clinical trials. Ketoconazole: the most common side effect is nausea and abnormalities in liver function.
Before this medication is taken, a blood test should be measured to make sure there are no liver abnormalities. It is a good idea to have regular liver tests when taking ketoconazole. If fatigue or jaundice occurs, liver tests must be measured and if the liver tests are abnormal, the medication stopped immediately. If liver tests become abnormal, they usually return to normal after the ketoconazole is stopped.
Other side effects include vomiting, abdominal pain and itching. This is the best outcome after pituitary surgery. It may take several months for the normal ACTH producing cells to regain function to stimulate the adrenal glands to produce a normal amount of cortisol hormone necessary for life. In the mean time, steroid replacement is necessary to protect against adrenal insufficiency.
At a later date, the need for continued steroid replacement is determined by blood tests off of the steroid medication. This is a common question and a very common problem. It is quite common for patients to still feel weak and have achy muscles and joint pains several months after successful surgery.
Patients may also notice dry skin and itching — this is part of recovery. Frequent use of skin moisturizers is recommended. More positively, the problems with depression, concentration and memory seem to improve fairly soon after successful treatment according to questionnaires completed by our patients who had successful pituitary surgery.
Usually most patients have improvement in mood and depression within 3 to 6 months after successful treatment. The important word here is: patience. In other patients, the amount of medication to treat these conditions may be reduced. Generally, no. There are no specific medical treatments for this type of tumor.
The best treatment is pituitary surgery to remove the tumor. Bromocriptine has been used in a few patients who could not have surgery. A small minority of patients have had some improvement in vision because of slight reduction in tumor size and relief of pressure on the optic chiasm eye nerves above the pituitary gland.
However, this medicine does not cause dramatic tumor shrinkage — the best treatment is to remove as much of the tumor as possible with surgery. If surgery has to be delayed for a short time, dexamethasone may be given to reduce swelling and hopefully relieve the pressure on the optic chiasm this is not effective in everyone. However, dexamethasone is not an effective treatment long term treatment for this tumor, it is used as a temporary measure to try to reduce pressure on the optic eye nerve in a patient who has lost vision and who cannot have surgery immediately.
The most important and most effective treatment is to remove the tumor surgically. Not if there loss of vision. Unless there is a reason surgery cannot be performed, a trial of bromocriptine is reasonable, but the probability of shrinkage of the tumor is extremely low; the best treatment is prompt removal of as much of the tumor as possible.
Additional treatment such as pituitary radiation may be necessary to treat remaining tumor and to prevent re-growth. However, since these tumors are slow growing, radiation treatment is not routinely recommended as long as there is no tumor growth over time. It is important to have an MRI scan at least once a year to detect any tumor regrowth. Since there is no blood test to indicate excessive hormone production, the MRI scan is the only way to determine if there is regrowth of the tumor.
Technically, no. A craniopharyngioma arises from abnormal development of the pituitary gland during fetal in the womb development. It may be located within the pituitary gland or above the pituitary gland. This is a tumor that one is born with and may enlarge at any time, even in people over 60 years of age. It is not a cancer. A craniopharyngioma may be discovered in childhood or at any age in adulthood.
This type of tumor does not produce hormones but frequently interferes with normal pituitary gland function and may cause diabetes insipidus a disorder of water balance with frequent urination and excessive thirst; this is not sugar diabetes. No, there are no medicines to treat this type of tumor. Most patients require hormone replacement s because of damage to the normal pituitary gland by the tumor.
Surgery is the first choice because radiation treatment does not cause an immediate decrease in tumor size. A craniopharyngioma may be large and invade brain tissue and because of this, removal of as much as possible is necessary.
Some patients also require radiation treatment if there is remaining tumor after surgery; radiation treatment is used to prevent growth of any remaining tumor. Hypopituitarism means that one or more of the pituitary hormones is not being produced normally and hormone replacement is necessary. Other causes of loss of normal pituitary function, destruction of the normal gland, include bleeding into a tumor which destroys the normal gland called pituitary apoplexy , surgery and radiation therapy.
Regardless of the cause, hormone replacement s is required. Some patients have only 1 hormone deficiency, others have 2 or 3, and others have complete loss of pituitary function. ACTH deficiency: this hormone stimulates the adrenal glands to produce cortisol. Cortisol is necessary for life. Lack of adequate cortisol causes fatigue, weight loss, nausea, vomiting, low blood pressure and may result in shock and death unless this is treated.
TSH deficiency: this hormone stimulates the thyroid gland to produce thyroid hormone. Low thyroid hormone causes fatigue loss of energy , weight gain, constipation, feeling cold and memory problems. Thyroid hormone regulates body metabolism and is necessary for life.
LH and FSH deficiency: these hormones control the reproductive system and sexual function. Deficiency of these hormones causes loss of menstrual periods and infertility in women and causes loss of sexual function, a low blood testosterone level and infertility in men. Loss of growth hormone in children causes lack of normal growth growth retardation, short stature. In adults, symptoms of decreased energy and vitality are common.
Changes in body composition can also occur — more fat is accumulated especially in the abdomen and a decrease in muscle mass occurs. There is also a loss of bone density and an increased risk of bone fractures. Anitdiuretic horomone ADH also called vasopressin deficiency: this hormone is produced by the posterior or back part of the pituitary and is responsible for water and sodium salt balance.
Deficiency of this hormone causes excessive and frequent urination and excessive thirst. If the patient does not drink an adequate amount of water, the blood sodium can increase abnormally and causes dehydration. Many patients can drink enough water to maintain a normal blood sodium level, but this is extremely inconvenient for the patient — having to drink large amounts of water day and night and urinating every hour or so to make up for the large urine losses from the kidneys.
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