Saturday, June 7, 2008

Pituitary Gland & Surgery FAQs

Where is the pituitary gland located?
The pituitary is a small, pea-sized gland located at the base of the brain that functions as "the Master Gland."

Why is the pituitary gland so important?
From its lofty position above the rest of the body it sends signals to the thyroid gland, adrenal glands, ovaries and testes, directing them to produce thyroid hormone, cortisol, estrogen, testosterone, and many more. These hormones have dramatic effects on metabolism, blood pressure, sexuality, reproduction, and other vital body functions. In addition, the pituitary gland produces growth hormone for normal development of height and prolactin for milk production.

The pituitary is the control center for the endocrine system, which controls all of the hormones produced in the body.

Is pituitary surgery the only cure for Cushing's?
YES. Researchers are currently doing clinical trials with medications, but the use of that medicine to cure Cushing's could be years and years away.

When and where will you have surgery?
I plan to have pituitary surgery in the Spring of 2009. March or April.

Lucky for me, a very skilled neurosurgeon works right here in Houston at MD Anderson Cancer Center. My husband and I consulted with him in November 2007, and he has agreed to take me on as a patient and do my surgery. People come from all over the US and Canada to have him do surgery.

Did you have a second opinion?
Yes, of course. I spoke to a San Antonio neurosurgeon as well. He is willing to do surgery, too. Due to the proximity of my friends and family, as well as the skill of the Houston surgeon, I have decided to have surgery here at home.

What's your tumor like?
This is from an email from my neurosurgeon:

"It is true that the two MRI brain scans have somewhat different readings, and they really do look different. The earlier 1.5 scan from Seattle does suggest that, as you mentioned, a 5 mm tumor is present on the right. It also suggests a separate focus on the left, but this is more subtle and you can argue over whether it is really there or not, as this spot abuts the wall of the cavernous sinus and thus is difficult to pinpoint with certainty. However, that may explain why the later scan, at higher magnet strength of 3T, showed a left lesion or tumor better. It also suggests that there is something on the right, but more subtly. Thus, both scans really do suggest both lesions but one is better at showing the left, and the other is better at showing the right. Why this is so, I cannot give a good explanation for. We might take that to suggest that there is actually a tumor of the type occasionally seen, in which a "wrap-around" effect is seen as the tumor embraces the gland from both sides with a connecting portion in the middle--thus giving the appearance of 2 tumors when really only one is there. This kind of thing can only be determined at the time of pituitary surgery. The right way to do such an operation is to go first to the point on the scan that looks suspicious for tumor, but then look at all the rest of the gland too, so as not to miss something subtle hiding somewhere else in its substance. Two separate tumors are possible, but that is pretty rare and I think most such cases actually are one tumor with a bilobed shape that looks like two on scans, but really isn't."

So, how's that for specific?

What does the pituitary look like with a tumor in it?

What is involved in pituitary surgery ?

Neurosurgeons access the pituitary gland through the nose or under the lip.
The team at Thomas Jefferson University Hospital in Philadelphia, PA use endoscopic endonasal transsphenoidal surgery. If you would like to watch the video, click here, then select Web Broadcast on the right tool bar. I did watch this video after I got my first batch of high cortisol results. I cried for the first 20 minutes out of fear. Soon, I became so intrigued by the medical advances that make such a surgery possible that I forgot about myself and focused instead on the intricacies of the surgery and skill of the surgeons.

From their Pituitary team at Thomas Jefferson University Hospital:

At Jefferson’s Center for Minimally Invasive Cranial Base Surgery and Endoscopic Neurosurgery, surgeons are now applying an advanced, “pure” endoscopic endonasal transsphenoidal surgery, which is a new approach for the removal of pituitary tumors.

This leading-edge, minimally invasive procedure uses the nose and nasal sinuses to gain access to the cranial base and brain, providing surgeons improved exposure to pituitary, sino-nasal, skull base and other intracranial tumors. Benefits of this innovative procedure include enhanced exposure leading to improved resection rates, lower incidence of neurological impairment and reduced hospital stay. In addition, the shortened recovery time often allows certain patients requiring adjuvant therapy, such as radiation and chemotherapy, to begin these treatments sooner. As a result, we are able to achieve a better patient outcome and satisfaction.

Minimally Invasive Pituitary Surgery
Using an endoscope with a camera attached, surgeons enter a patient’s nose and sinuses, allowing them to approach the tumor without any external incisions. Guided by the endoscope and enhanced computer navigation, surgeons open small holes in the base of the skull and membrane covering the brain to remove the tumor. Better visualization and access to these lesions have enabled improved resection of the tumor without causing damage to the brain and lower risk of complications and follow up surgery. This results in surgery with a shorter hospital stay, a faster recovery and improved outcomes.

The video/procedure lasts 1 hour.

How long does it take to recovery from surgery?

Recovery from pituitary surgery is a long battle.

  • It varies from patient to patient.

  • Recovery is directly related to the length of time you've had Cushing's because of the damage that high cortisol does to the body's systems.

  • This process can take 12 to 18 months before the patient returns to ‘normal.’ This is only if further pituitary surgeries are not needed.

Once the tumor is removed from the pituitary, the body switches from producing too much cortisol to not producing enough. Cortisol supplements are taken to replace the off-kilter cortisol production. This must be taken not only on a daily and timed basis but also in certain situations: sickness and stress (good or bad). Cortisol supplements are taken after surgery to replicate the patient’s normal hormonal production. Each week, the patient reduces the amount of cortisol replacements. If the patient experiences terrible symptoms associated with adrenal insufficiency, then the patient must temporarily increase the amount of cortisol replacement hormones he/she takes and often go to the emergency room. This process varies from person to person, and it makes recovery very difficult for the patient.

Once you have surgery, are you cured?
Not necessarily, and isn’t that so unfortunate.

The pituitary is so small (less than 2 cms), and the tumors are so small, that the neurosurgeon does his best to remove all of the cells that are producing too much ACTH. In 60% of the cases, the surgeon succeeds. In 40% of the cases, he doesn’t. For some patients, several surgeries are needed to try to remove all the cells. A patient may choose to have a bilateral adrenalectomy, the removal of both adrenal glands. This surgery is performed after two pituitary surgeries fail to remove all of the tumor(s) present. The pituitary tumors secrete ACTH which stimulates the adrenals to produce cortisol. Since a surgeon does not want to remove all of the pituitary gland--as it controls many other vital hormones that the body needs--many opt for the final road to end Cushing's, which is to remove both adrenal glands aka bilateral adrenalectomy. These glands are responsible for the production of cortisol, and removing these glands is the only permanent way to end cortisol production once and for all. However, due to the important life-saving functions of cortisol, the patient must take cortisol medicine in pill form for the rest of his/her life.

However, it is not as simple as popping a pill every day. Let’s compare a Cushing’s patients post BLA with a Type I diabetic. Stress management for Cushing's patients is just as critically important as blood sugar management is for diabetics.

A diabetic must look at a plate of food, estimate the amount of carbohydrates contained therein, and take insulin for that amount of carbohydrates (which calculations are often aided by the nutritional facts on the packaging).

A Cushing's patient post BLA must take cortisol replacement medicine in response to the amount of 'sickness' or 'stress.' These events are unquantifiable and lack data on packaging. In addition, there is not a day goes by without stress or challenges of some sort. These episodes can prove challenging for a Cushing’s patient in determining how much medicine to take to offset these challenges. This makes it difficult for the Cushing’s patient to fully return to his/her lifestyle before Cushing’s.

What does a person need to watch for after pituitary surgery?

I have not had surgery yet, but I saw this summary online and thought it contained some things I have seen other Cushing's patients say after surgery.

To read Vanderbilt Medical Center Pituitary Clinic's discharge instructions for pituitary surgery patients, click here.

Where can I find out more about the pituitary gland? I'm intrigued!

One in five people have pituitary tumors.

The Pituitary Network Association has a great information about the pituitary. Check it out!


Click here to read New Approaches to Managing Tumors of the Pituitary Gland Offer Patients Hope.

Click here to read The Problem of the Aggressive Pituitary Tumor.

Pituitary Tumors: A Neurosurgeon’s Approach