Pituitary adenoma: treatment, symptoms, prognosis
Pituitary adenoma is the most frequent benign tumor of this body, and among all neoplasms of the brain to its share according to different sources up to 20% of cases. Such a high percentage of the prevalence of disease explains the frequent asymptomatic when detection of the adenoma becomes a godsend.
Adenoma – a tumor is benign and slow growing, but its ability to synthesize hormones, to compress surrounding structures and cause serious neurological disorders makes the disease sometimes life-threatening patient. Even slight fluctuations in hormone levels can provoke a variety of metabolic disorders with pronounced symptoms.
The pituitary gland is a small gland located in the Sella of the sphenoid bone of the skull base. The frontal lobe called the anterior pituitary cells which produce different hormones: prolactin, somatotropin, follikulostimulirutee and luteinizing hormones that regulate the activity of the ovaries in women, as well as adrenocorticotropic hormone, under control of which are the adrenal glands. Increase production of a hormone occurs in the formation of adenoma – benign tumor of certain cells of the anterior pituitary.
By increasing the amount of hormone that produces the tumor, a decrease in other due to compression by a tumor the rest of the gland.
Depending on the secretory activity of the adenoma are hormone-producing and inactive. If the first group causes the entire spectrum of endocrine disorders characteristic of a hormone at higher concentrations, the second group (inactive adenomas) for a long time asymptomatic, and their manifestation is possible only with a significant size of the adenoma. They consist of symptoms of compression of brain structures and hypopituitarism, which is a consequence of the reduction in the other divisions of the pituitary gland under the pressure of the tumor and a decrease in the production of their hormones.
Among hormone-producing adenomas, almost half of new cases of prolactinoma, somatotropic adenomas is up to 25% of tumors, while other tumors are quite rare.
Suffer from pituitary adenoma most often people aged 30-50 years. The disease is equally susceptible to both men and women. In all cases of clinically significant adenomas the patient requires the assistance of an endocrinologist, and upon detection of asymptomatic occurring neoplasias need dynamic observation.
Varieties of pituitary adenomas
Especially the location and functioning of the tumor lie in the basis of allocation of various varieties.
Depending on the secretory activity are:
The tumor size is divided into:
- Microadenomas up to 10 mm.
- Macroadenoma (10 mm).
- Giant adenomas whose diameter reaches 40-50 mm or more.
Great importance is given to the peculiarities of the location of the tumor relative to the Turkish saddle:
If the tumor secretes hormones, but the correct diagnosis for whatever reason is not installed, the next step of the disease will be impaired and neurological disorders, and the direction of growth of the adenoma will determine not only the nature of the symptoms, but the choice of treatment.
The causes of pituitary adenoma
Causes of pituitary adenomas continues to be researched, and precipitating factors include:
- The decrease in the function of peripheral glands, resulting in enhanced working of the pituitary gland, development of hyperplasia and adenoma is formed;
- Traumatic brain injury;
- Infectious-inflammatory processes of the brain (encephalitis, meningitis, tuberculosis);
- The impact of adverse factors during pregnancy;
- Long-term use of oral contraceptives.
Relationship pituitary adenomas and hereditary predisposition has not been proven, however, the tumor is often diagnosed in persons with other inherited forms of endocrine pathology.
Manifestations and diagnosis of pituitary adenomas
Symptoms of pituitary adenoma are diverse and are associated with the nature of testosterone-secreting tumors, as well as with compression of surrounding structures and nerves.
In the clinic of neoplasms of the anterior pituitary secrete ophthalmic neurological, endocrine-metabolic syndrome and complex radiographic signs of neoplasia.
Ophthalmic neurological syndrome caused by the increase of the tumor, which compresses the surrounding tissues and structures, so that there are:
Headache often dull, localized in the frontal or temporal regions, analgesics rarely brings relief. A sharp increase in pain may be due to hemorrhage into tissue neoplasia or accelerated growth.
Visual disturbances are typical for large tumors that compress the optic nerves and optic chiasm. When the formation of 1-2 cm are possible atrophy of the optic nerve including blindness.
Endocrine-metabolic syndrome is associated with increased or, conversely, a decrease in hormone produced pituitary function and since the body has a stimulating effect on other peripheral gland, the symptoms are usually associated with an increase in their activity.
Prolactinoma is the most common type of pituitary adenoma, which in women is characterized by:
- Menstrual cycle until amenorrhea (absence of menstruation);
- Galactorrhea (spontaneous outflow of milk from the breast);
- The increase of body weight;
- The growth of hair in male pattern;
- Decreased libido and sexual activity.
When prolaktinome men, as a rule, expressed in ophthalmic neurological symptom, to which are added impotence, galactorrhea, breast enlargement. As these symptoms develop rather slowly and is dominated by changes in sexual function, a tumor of the pituitary gland in men, can be suspected not always, so it is often detected at a fairly large scale, while women have a clear clinical picture indicating a possible loss of anterior pituitary already at the stage of microadenomas.
Kortikotropinom produces a significant amount of adrenocorticotropic hormone which has a stimulating effect on the adrenal cortex, so the clinic has a bright signs of hyperadrenocorticism and consists of:
Complex disorders in corticotropinomas called the disease of Itsenko-Kushinga. Kortikotropinom more than other types of adenomas prone to malignancy and metastasis.
Somatotropic pituitary adenoma secretes a hormone that causes gigantism if the tumor in childhood and acromegaly in adults.
Gigantism is accompanied by the intensive growth of the whole body, such patients have an extremely tall, long limbs, and internal organs possible functional disorders related to the rapid uncontrolled growth of the body.
Acromegaly is manifested in the increase in the size of individual body parts – hands and feet, facial structures, the growth of the patient remains unchanged. Somatotropinoma often accompanies obesity, diabetes, thyroid disease.
Tireotropina relates to rare types of tumors of the anterior pituitary. It produces a hormone that increases the activity of the thyroid gland, resulting in thyrotoxicosis: weight loss, tremor, sweating and heat intolerance, emotional lability, tearfulness, tachycardia, etc.
Gonadotropinom synthesize hormones that have a stimulating effect on the sex glands, but the clinic such changes most often are not expressed and may consist of reduction of sexual function, infertility, impotence. In the forefront among the signs of swelling out ophthalmic neurological symptoms.
For large adenomas tumor tissue squeezes not only neural structures, but the remaining parenchyma of the gland, which disrupted the synthesis of hormones. Reduced hormone production of the anterior pituitary is called hypopituitarism, and it is manifested by weakness, fatigue, impaired sense of smell, reduced sexual function and infertility, symptoms of hypothyroidism, etc.
To suspect a tumor, the physician needs to conduct some research, even if the clinical picture is pronounced and quite characteristic. In addition to determining the level of hormones of the pituitary gland, must be made x-ray examination of the Sella, where it is possible to detect the characteristic signs of swelling: the circuit design of the bottom of the Turkish saddle, destruction of the underlying bone tissue (osteoporosis). More detailed information is provided by CT and MRI, but if the tumor is very small, undetectable even using the most modern and accurate methods.
When ophthalmic neurological disorder, the patient with symptoms can come on reception to the ophthalmologist who will perform the appropriate inspection, measuring visual acuity, fundus examination. Severe neurological symptoms causes the patient to consult a neurologist, who, after inspection and conversation with the patient may suspect a lesion of the pituitary gland. All patients, regardless of the predominant clinical expression of the disease should be seen by an endocrinologist.
The effects of pituitary adenoma depend on the size of the tumors at the time of its discovery. As a rule, with timely treatment, patients return to normal life at the end of the rehabilitation period, but if the tumor is large, requiring surgical removal, the consequences can be damage to the nervous tissue of the brain, the cerebral circulation, leakage of CSF through the nasal passage, infectious complications. Visual disorders can recover with microadenomas that do not cause significant compression of the optic nerve and atrophy.
If there is loss of vision, and endocrine-metabolic disorders are not removed after the surgery or by the use of hormonal therapy, the patient becomes unhealthy and assigned a disability.
Treatment of pituitary adenoma
Treatment of pituitary adenoma depends on the nature of the tumor, size, clinical symptoms and sensitivity to a particular type of impact. Its effectiveness depends on the stage of the disease and the severity of endocrine disorders.
- Drug therapy;
- Substitution treatment;
- Surgical removal of tumors;
- Radiation therapy.
Medication is usually administered with small size of tumors and after a thorough examination of the patient. If the tumor is devoid of the appropriate receptors, then conservative treatment will not give result and the only option would be surgical or radiation removal of the tumor.
Drug therapy is justified only when the small size of the neoplasia and the absence of signs of visual disorders. If the tumor is large, it is performed before surgery to improve the patient’s condition before surgery or after it as a replacement therapy.
The most effective is treatment with prolactin-producing hormone prolactin in large amounts. Purpose of drugs from the group of dofaminomimetikov (parlodel, cabergoline) has a good therapeutic effect and even allows you to do without surgery. Cabergoline is a drug of new generation, he is able not only to reduce the Hyper-production of prolactin and tumor size, but also to restore sexual function and the semen in men with minimal side effects. Conservative treatment is possible in the absence of progressive visual impairment, but if it is a young woman who is planning pregnancy, the medication will not be an obstacle.
In the case of somatotropic tumors are used are somatostatin analogues, thyrotoxicosis appoint thyreostatics, a disease Itsenko-Kushinga, triggered by pituitary adenoma, effective derivatives of aminoglutetimid. It is worth noting that in the latter two cases, drug therapy may not be permanent, and serves only as a preparatory step to subsequent operations.
Side effects of the drugs can be:
The ineffectiveness or failure of conservative therapy, the doctors resort to surgical treatment of pituitary adenomas. The difficulty of their removal is connected with the peculiarities of the proximity to brain structures and constraints operational access to the tumor. The question of surgical treatment and the choice of a particular variant performs neurosurgeon after a detailed evaluation of the patient’s condition and the characteristics of the tumor.
Modern medicine offers minimally invasive and non-invasive methods of treatment of pituitary adenomas, which allows in many cases to avoid a very traumatic and dangerous in terms of complications of craniotomy. So, apply to endoscopic surgery, radiosurgery and remote removal of the tumor with cyber knife.
Endoscopic removal of pituitary adenoma is transnasally access when the surgeon inserts the probe and the instruments through the nasal passage and the main sinus (transsphenoidal adenomectomy), and for adenomektomii tracked on the monitor. The operation is minimally invasive, requires no incisions and, moreover, opening the cranial cavity. The effectiveness of endoscopic treatment reaches 90% for small tumors and decreases with increasing tumor size. Of course, large tumors cannot be removed this way, so it is used usually in adenomas less than 3 cm in diameter.
The result of endoscopic adenomectomy should be:
- Removal of the tumor;
- Normalization of hormonal background;
- Elimination of visual impairment.
Complications occur rarely, among them bleeding, disturbance of liquor circulation, damage tissues of the brain and infection with subsequent meningitis. Of the likely effects of the operation, the doctor always warns in advance of the patient, but the minimum probability is not a reason to refuse treatment, without which the disease has a very serious prognosis.
The postoperative period after transnasal removal of the adenoma often occurs favorably, and on the 1-3 day after surgery, the patient can be discharged from the hospital under observation of the endocrinologist on a residence. To correct the possible endocrine disorders in the postoperative period may be hormone replacement therapy.
Traditional treatment with transcranial approach was used less and less, giving way to minimally invasive operations. Removal of the adenoma through a craniotomy is very traumatic and has a high risk of postoperative complications. However, it is indispensable, if the tumor is large and significant part of it is over the Turkish saddle, and asymmetric for large tumors.
In recent years increasingly used the so-called radiosurgery (CyberKnife, gamma knife) that is more radiation treatment than surgical operation. The undoubted advantage it is considered an absolute non-invasiveness and ability to affect deep-seated education even of small size.
When conducting radiosurgical treatment on the tumor tissue focuses the radiation of small intensity, the accuracy of the exposure is up to 0.5 mm, so the risk of damaging surrounding tissues is minimized. The tumor is removed under constant supervision by CT or MRI. Since the method is associated, albeit small, but still radiation, it is used usually in case of recurrence of the tumor and also to remove small remnants of tumor tissue after surgical treatment. A case of primary radiosurgery can serve as the refusal of patient from operation or inability due to severe condition and contraindications.
Goals of radiosurgical treatment be reduction of tumor size and normalization of endocrinological indicators. Advantages of this method are:
The effect of radiotherapy does not occur immediately, because the tumor is not removed mechanically with our usual way, and for cell death neoplasms in the irradiated area may take several weeks. In addition, the method has limited application for large tumors, but then in combination with surgery.
The combination of methods of treatment depends on the type of adenoma:
- At prolactinomas is first assigned to medical therapy, the ineffectiveness of which resort to surgical removal. For large tumors surgery Supplement radiation therapy.
- When somatotropic adenomas prefer microsurgical removal or radiation therapy, if the tumor is large, grows surrounding structures of the brain tissue of the orbit, they are supplemented by gamma-irradiation and drug treatment.
- For the treatment of corticotropin usually choose external beam radiation as the primary method. In severe disease receive chemotherapy and even the removal of the adrenal gland to reduce the effects of hypercortisolism, and the next stage irradiate the diseased pituitary gland.
- When thyrotropinoma and gonadotropinom treatment starting with hormone replacement therapy, supplementing it if necessary, surgery or radiation.
Treatment of any type of pituitary adenoma, the more effective the sooner the patient gets to the doctor, so when the first signs of the disease, alarming symptoms endocrinological or visual disorders you need to seek help from a specialist. The first thing is to consult a endocrinologist who will survey and determine the further treatment plan, which if necessary includes neurosurgeons and radiation therapists.
Prognosis after removal of pituitary adenomas is often favorable postoperative period after minimally invasive surgery is mild, and possible endocrine abnormalities can be corrected by the appointment of hormonal drugs. Than smaller the tumor is discovered, the easier the patient will tolerate treatment and the less chance of any complications.