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Physicians Update

 
Fall 2013

Endoscopic Approach Makes Surgery for Pituitary Tumors Easier

Marvin Bergsneider, MDBecause of their location near the brain and their influence on the endocrine-hormone functions of the body, treating and removing pituitary tumors can be complex. Today, however, advanced endoscopic technology and high-definition visualization are making things easier for surgeons and their patients.

Until recently, for example, it has been a significant technical challenge to completely remove large pituitary tumors utilizing what is called the pseudocapsular dissection technique. “Five years ago, we were rarely able to identify the pseudocapsule. Instead, our technique relied on blindly scooping out a tumor, largely by feel, from within this pseudocapsule because we had a limited view of the tumor using the surgical microscope,” says Marvin Bergsneider, MD, codirector of UCLA’s Pituitary Tumor Program. “Because the pseudocapsule frequently has some tumor cells embedded in it, leaving it behind increased the chances of an incomplete removal. The endoscopic approach has radically changed pituitary tumor surgery, allowing us to accurately define and maintain the very thin pseudocapsule during dissection to actually peel out the tumor, often in one piece, in a more anatomical manner.”

But with new minimally invasive endoscopic surgery, the encapsulated tumor can be removed entirely through the nose without an incision. “With the endoscope, we can literally look around corners and see things we were completely blinded to in the recent past,” Dr. Bergsneider says. “It’s a whole different surgery now.”

While pituitary tumors generally are benign, and many will never produce symptoms, there can be potentially life-threatening complications that arise when hormone-seeking tumor cells grow out of control. When that happens, severe hormonal abnormalities can result. Neurological dysfunction, rapid growth, infertility and problems related to an overproduction of hormones such as prolactin (absent periods, reduced libido and breast milk production), growth hormone (enlargement of body parts, high blood pressure and heart disease), cortisol (obesity, high blood sugar and high blood pressure, for example) are among the most debilitating symptoms. Because pituitary tumors often masquerade as other clinical conditions, multidisciplinary evaluation and treatment are needed to address potentially life-threatening complications that arise when hormone-secreting tumor cells grow out of control.

When surgery is called for, the endoscopic approach, which may be used to remove most pituitary tumors, reduces the chance that residual tumor cells will be left behind and may be associated with improved cure rates, according to Dr. Bergsneider. To date, more than 500 endoscopic pituitary-tumor surgeries have been performed at UCLA. For the rare case in which a pituitary tumor extends laterally into the brain cavity, UCLA surgeons are experts at the minimally invasive “key-hole” craniotomy (opening of the skull), utilizing a small incision hidden in the eyebrow to access and remove the tumor.

Pituitary tumor, pre-op and post opTop: Pituitary tumor, pre-op.
Bottom: Pituitary tumor, post-op.

Despite important surgical advances over the last decade, Dr. Bergsneider emphasizes that abnormalities associated with hormone-secreting pituitary tumor cells, rather than the actual tumors, are most problematic if left untreated. At UCLA, experts in the Pituitary Tumor and Neuroendocrine Program collaborate to provide comprehensive evaluation and management for all types of pituitary tumors and related disorders. Outpatient evaluations are available, often within 24-to-48 hours of initial contact, by a UCLA neurosurgeon, endocrinologist and other pituitary-tumor experts, during a single, coordinated visit.

“Many patients with pituitary tumors face serious disease morbidity or mortality caused by excess hormones secreted from the pituitary tumor cells or following treatment for the tumors, such as repeated surgery and/or radiation therapy, that can damage the pituitary gland,” says endocrionologist Anthony Heaney, MD, PhD, codirector of the UCLA Pituitary Tumor Program. “The beauty of our program is that we work together to accurately identify these problems, which are not always obvious, and then we collectively employ multiple strategies to fix them.”

For example, Cushing’s disease is a relatively rare but potentially life-threatening hormonal disorder caused by prolonged exposure of the body’s tissues to high levels of the hormone cortisol. The symptoms of Cushing’s disease are sometimes difficult to differentiate from other conditions and may require months of testing to reach a definitive diagnosis. Once diagnosed, however, surgery is performed to remove the tumor. Newly FDA-approved medications are also now available to manage this debilitating disease.

“We’re attempting to get at the heart of what drives hormone production in Cushing’s disease,” Dr. Heaney says. “Discovery of factors that impact adrenocorticotrophic hormone (ACTH) in Cushing’s has the potential to go from bench to bedside and may have applications in related disorders where altered cortisol dynamics may play a role, including certain forms of depression and metabolic syndrome.” Dr. Heaney and colleagues recently published findings related to a potential novel therapeutic target in Cushing’s disease in the Proceedings of the National Academy of Sciences.

UCLA also is participating in several multicenter clinical trials to evaluate the efficacy of new medications for treatment of various pituitary tumors, including acromegaly and Cushing’s disease.





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