Treatment options vary considerable depending on the diagnosis and the results of the initial investigations.
Some lesions require nothing more than reassurance and surveillance by periodic MRI check-ups (often annually to begin with). Tumours or cysts may not continue to grow or may grow so slowly that nothing other than observation may be required at least initially. Often, the best thing for a surgeon to do is to know when not to operate.
In certain situations, treatment via medication may be needed either to support the pituitary by replacing any hormones that may be deficient or as definitive treatment for inflammatory conditions or some subtypes of pituitary adenoma (especially prolactin secreting tumours or so-called “prolactinomas”). Medications may be used in addition to surgery to maximise control of some other subtypes of secretory pituitary adenomas such as growth hormone secreting tumours.
Some tumours are very sensitive to radiotherapy, but unfortunately so too is the normal pituitary itself as well as the nearby optic nerves. Modern techniques including stereotactic targeting can reduce the long term risk of radiotherapy. However, in part because of these risks this type of treatment is usually best given in situations where a tumour has either not come under control with surgery (e.g. if it did not lend itself to be completely removed or it comes back again) or as an option if surgery alone has not completely normalised the overproduction of any hormone.
For many of the common types of tumour surgery may be needed with a view to remove the tumour to obtain a specimen for pathological diagnosis, eliminate or reduce the mass effect on surrounding structures, and where possibly cure or bring into remission the endocrinopathy caused by the excessive hormone production. Even when removed however tumours may come back and so regularly MRI and sometimes blood test surveillance is often required into the future. Pituitary conditions therefore are best thought of as chronic disease process that can be controlled over time rather than necessarily curable conditions that only require a one off treatment.
Due to the location of the pituitary fossa at the top and back of the sphenoid sinus of the nose in most cases a surgical approach via the nasal cavity is the most direct and least invasive way to remove the tumour. This is referred to as a transnasal transsphenoidal approach and is done by a team consisting of an ENT surgical specialist whose role is to gain access, and a neurosurgeon whose role is to remove the tumour. The procedure is done under a general anaesthetic with an anaesthetist skilled in neurosurgical anaesthesia, and often with endoscopic techniques, stereotactic navigation, and in Dr Brennan’s practice often with the use of the iMRI to help guide tumour resections. This team approach and use of technology increases the likelihood of tumour removal and reduces the risks involved.
On occasion it may sometimes be better to approach a tumour in the pituitary region from above the sella by coming in under and around the brain via a craniotomy or transcranial approach. Again stereotactic navigation and iMRI technology can be very valuable adjuncts in patient care when this approach is required. A careful assessment of all the patient and MRI features needs to be undertaken in order to determine the best operation in the individual case.
Postoperatively, patients can expect to be looked after in the high dependency unit initially where close checks are made on their general condition as well as specific pituitary issues such as urine output and blood chemistry. It is not uncommon for the pituitary gland to become “sleepy” early after surgery and so short term hormone replacement is often needed (e.g. cortisone supplements). The team approach continues here between the neurosurgeon, the intensive care specialist, and the endocrinologist.
Most patients can expect to be discharged home sometime in the first week after surgery depending on their course and how their pituitary gland behaves after surgery. The exact postoperative course depends very much on the issues in the individual case, and Dr Brennan will discuss this at greater length during the preoperative consultations.