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Neurology (Expert Forum)
Nonfunctional Pituitary Microadenoma: When to Operate?
Answered by
Cleveland - OH
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Nonfunctional Pituitary Microadenoma: When to Operate?
by Millypo, Nov 15, 2007 08:41AM
Hi, I have a nonfunctional pituitary microadenoma and was wondering when surgery is indicated. I have been to MGH for a brief appointment and they suggested that they do surgery when the tumor grows over 1 cm. This is due to the fact that in their experience, the tumors continue to grow once over 1 cm. At the time of my appointment last year, my adenoma measured 8mm x 5mm x 7mm. They thought it would probably never grow. However, a recent MRI showed that it has slight enlargement at 8mm x 9mm x 7mm. I have adrenal insufficiency secondary to ACTH insufficiency but no other hormones are deficient yet. The tumor is located along the right cavernous sinus but doesn't invade the cavernous sinus yet. I have a few questions about this.
1. When does the Cleveland Clinic operate on nonfunction pituitary microadenomas?
2. Do you ever see ACTH as being the only affected stimulating hormone or the first deficient stimulating hormone?
Also, I have some T2 hyperintensities in the deep white matter of the brain consistent with microvascular changes. I'm only 39 and have some kind of autoimmune process with anticardiolipin antibodies. Could this be the cause? Should I be evaluated for something else? The pattern of the T2 hyperintensities is not consistent with MS. Could it be caused by Lyme? Will they progress?
Thank you.
1. When does the Cleveland Clinic operate on nonfunction pituitary microadenomas?
2. Do you ever see ACTH as being the only affected stimulating hormone or the first deficient stimulating hormone?
Also, I have some T2 hyperintensities in the deep white matter of the brain consistent with microvascular changes. I'm only 39 and have some kind of autoimmune process with anticardiolipin antibodies. Could this be the cause? Should I be evaluated for something else? The pattern of the T2 hyperintensities is not consistent with MS. Could it be caused by Lyme? Will they progress?
Thank you.
Doctor's Answer
by Joyce K Lee, MD, Nov 15, 2007 02:24PM
, Nov 15, 2007 02:24PMTo: Millypo
Thank you for submitting your question.
I will answer your concerns to the best of my abilities, but please be informed that I am unable to offer a diagnosis based on your history and list of symptoms.
This is solely for educational purposes and should in no way be a substitute for a formal evaluation by a certified physician.
Please also understand that historically, pituitary macroadenomas are handled by our neurosurgery colleagues and I am a neurologist.
I have curbsided my neurosurgery colleagues however to assist in answering your question.
To begin, please allow me to offer an educational segment concerning pituitary adenomas.
Pituitary adenomas are usually slow-growing and invariably benign. They are arbitrarily designated as microadenomas (10 mm in diameter). Functional tumors are more common at younger ages, whereas nonfunctional tumors are seen mostly at older ages. Most nonfunctional pituitary adenomas on morphologic examination reveal secretory granules suggestive of hormonal synthesis, but they fail to secrete functional hormones.
Here is a table I obtained from a Cleveland Clinic website than illustrates the prevalence of different adenoma types
(reference: http://clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/pituitary/pituitary.html.)
Adenoma Type Prevalence (%)
GH cell adenoma 15
PRL cell adenoma 30
GH and PRL cell adenoma 7
ACTH cell adenoma 10
Gonadotroph cell adenoma 10
Nonfunctioning adenoma 25
TSH cell adenoma 1
Unclassified adenoma 2
Abbreviations:
ACTH=Adrenocorticotropic hormone; GH=Growth hormone; PRL=Prolactin; TSH=Thyroid-stimulating hormone
To answer your question, the classic sequential loss of pituitary hormones secondary to a mass effect is in the following order: growth hormone (GH), gonadotropins (LH, FSH), adrenocorticotropic hormone (ACTH) and thyroid-stimulating hormone (TSH).1 The underlying etiology for typical earlier loss of GH and gonadotropins is not known. Isolated deficiencies of various anterior pituitary hormones can also occur.
The goals for treatment of a pituitary tumor include reduction or complete removal of tumor, elimination of mass effect if present, normalization of hormone hypersecretion, and restoration of normal pituitary function. Some patients, especially those with large tumors, may require several therapeutic modalities including medical, surgical, and radiation therapy. The most important factor in pituitary surgery is availability of a good neurosurgeon. The referring physician has the responsibility of referring the patient to an experienced neurosurgeon, who may be available only in a neuroendocrine (pituitary) center. Radiation therapy is used primarily as an adjunctive therapy when surgical or medical therapy is not successful.
To be quite honest with you, I am not aware of a an exact number cut-off that our surgeons use to determine whether to operate or not.
I believe that most of their decision is based on the patient's personalized profile and on the size, location and nature of the tumor itself.
In the patients that I have seen undergo surgery however have had a transphenoidal approach and did markedly well post-operatively.
It is important however to mention that hypopituitarism can be seen after tumor removal and require hormonal supplementation.
All in all, if for some reason you would like another formal opinion with one of the Cleveland Clinic neurosurgeons, I highly recommend Dr. Robert Weil. He specializes in pituitary tumors and is a wonderful surgeon.
As for your additional question, I would not become too perplexed over these T2 HI seen on your MRI -- we see these a lot.
These are non-specific changes, often grouped as "small vessel disease" or "microvascular changes" by the radiologists.
The autoimmune process you mentioned does predispose you to vessel occlusive disease (i.e. strokes and cardiac disease) so you should definitely have this managed appropriately by a vascular medicine specialist, but I cannot attribute these MRI changes entirely to this disease process.
Most importantly, stay on top of your routine medical care -- take aspririn to prevent stroke and heart attacks, stop smoking if you are a current smoker, watch what you eat, check your cholesterol, stay fit, etc.
Hope this help,
Best of luck,
JKL, MD
I will answer your concerns to the best of my abilities, but please be informed that I am unable to offer a diagnosis based on your history and list of symptoms.
This is solely for educational purposes and should in no way be a substitute for a formal evaluation by a certified physician.
Please also understand that historically, pituitary macroadenomas are handled by our neurosurgery colleagues and I am a neurologist.
I have curbsided my neurosurgery colleagues however to assist in answering your question.
To begin, please allow me to offer an educational segment concerning pituitary adenomas.
Pituitary adenomas are usually slow-growing and invariably benign. They are arbitrarily designated as microadenomas (10 mm in diameter). Functional tumors are more common at younger ages, whereas nonfunctional tumors are seen mostly at older ages. Most nonfunctional pituitary adenomas on morphologic examination reveal secretory granules suggestive of hormonal synthesis, but they fail to secrete functional hormones.
Here is a table I obtained from a Cleveland Clinic website than illustrates the prevalence of different adenoma types
(reference: http://clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/pituitary/pituitary.html.)
Adenoma Type Prevalence (%)
GH cell adenoma 15
PRL cell adenoma 30
GH and PRL cell adenoma 7
ACTH cell adenoma 10
Gonadotroph cell adenoma 10
Nonfunctioning adenoma 25
TSH cell adenoma 1
Unclassified adenoma 2
Abbreviations:
ACTH=Adrenocorticotropic hormone; GH=Growth hormone; PRL=Prolactin; TSH=Thyroid-stimulating hormone
To answer your question, the classic sequential loss of pituitary hormones secondary to a mass effect is in the following order: growth hormone (GH), gonadotropins (LH, FSH), adrenocorticotropic hormone (ACTH) and thyroid-stimulating hormone (TSH).1 The underlying etiology for typical earlier loss of GH and gonadotropins is not known. Isolated deficiencies of various anterior pituitary hormones can also occur.
The goals for treatment of a pituitary tumor include reduction or complete removal of tumor, elimination of mass effect if present, normalization of hormone hypersecretion, and restoration of normal pituitary function. Some patients, especially those with large tumors, may require several therapeutic modalities including medical, surgical, and radiation therapy. The most important factor in pituitary surgery is availability of a good neurosurgeon. The referring physician has the responsibility of referring the patient to an experienced neurosurgeon, who may be available only in a neuroendocrine (pituitary) center. Radiation therapy is used primarily as an adjunctive therapy when surgical or medical therapy is not successful.
To be quite honest with you, I am not aware of a an exact number cut-off that our surgeons use to determine whether to operate or not.
I believe that most of their decision is based on the patient's personalized profile and on the size, location and nature of the tumor itself.
In the patients that I have seen undergo surgery however have had a transphenoidal approach and did markedly well post-operatively.
It is important however to mention that hypopituitarism can be seen after tumor removal and require hormonal supplementation.
All in all, if for some reason you would like another formal opinion with one of the Cleveland Clinic neurosurgeons, I highly recommend Dr. Robert Weil. He specializes in pituitary tumors and is a wonderful surgeon.
As for your additional question, I would not become too perplexed over these T2 HI seen on your MRI -- we see these a lot.
These are non-specific changes, often grouped as "small vessel disease" or "microvascular changes" by the radiologists.
The autoimmune process you mentioned does predispose you to vessel occlusive disease (i.e. strokes and cardiac disease) so you should definitely have this managed appropriately by a vascular medicine specialist, but I cannot attribute these MRI changes entirely to this disease process.
Most importantly, stay on top of your routine medical care -- take aspririn to prevent stroke and heart attacks, stop smoking if you are a current smoker, watch what you eat, check your cholesterol, stay fit, etc.
Hope this help,
Best of luck,
JKL, MD
