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Pituitary Disorders
Advances in Surgery for Pituitary Tumors
Steven N Roper, MD
Edward Shedd Wells Professor of Neurosurgery, University of Florida
Abstract
Recent studies have provided important new information regarding the behavior and surgical management of pituitary tumors. One population study
from Belgium confirmed that incidentalomas are relatively common. Basic researchers found that stem cells continue to contribute cells to the
normal pituitary gland throughout adulthood in mice. A new imaging technique, 3D anisotropy contrast magnetic resonance imaging (MRI), may
improve our ability to predict surgical outcome for adenomas. A study from the University of California, San Francisco (UCSF) showed that radiation
therapy improved the long-term outcome of adenomas after subtotal resection, but not after total resection. Other studies provided additional
information on management of post-operative steroid replacement and cerebrospinal fluid (CSF) fistulae after pituitary surgery. New
recommendations for management of Cushing’s disease were provided by a panel of experts after a meeting in Budapest, Hungary, and surgical
results for Cushing’s disease from a large, single-center experience were published. Overall, these studies highlight the beneficial effects of surgery
for pituitary tumors, as well as addressing challenges that remain.
Keywords
Adenoma, incidentaloma, stem cells, radiation therapy, minimally invasive surgery, peri-operative management, cerebrospinal fluid fistula, diabetes
insipidus, Cushing’s disease, thyroid-stimulating hormone (TSH)
Disclosure: The author has no conflicts of interest to declare.
Acknowledgement: This article was previously published in US Neurology and is reprinted here with full permission. Citation: Roper SN, Advances in Surgery for Pituitary Tumors,
US Neurology, 2008;4(2):36–9.
Received: October 28, 2009 Accepted: June 22, 2009
Correspondence: Steven N Roper, MD, Department of Neurosurgery, University of Florida, 100 South Newell Drive, Room L2-100, Gainesville, FL 32610.
E: roper@neurosurgery.ufl.edu
Although benign in nature, pituitary tumors continue to offer many A recent population study from Belgium
5
found a prevalence of clinically
opportunities for improvement in therapy. Goals of treatment include relevant pituitary adenomas of 94 per 100,000. Of this group, 66% were
complete removal or ablation of tumor cells, maintenance of normal prolactinomas, 14.7% were not endocrine-active, 13.2% had acromegaly,
pituitary function, normalization of elevated hormone levels in 5.9% had Cushing’s disease, and 20.6% had hypopituitarism. These same
endocrine-active tumors, and minimizing adverse effects from therapy. authors provided a concise set of recommendations for management of
There have been many recent advances related to the surgical incidentalomas, including initial evaluation and periodic follow-up with
treatment of pituitary tumors and the purpose of this article is to review magnetic resonance imaging (MRI) and endocrine studies.
6
some of the more significant ones.
One recent paper reported new findings on the cellular biology of the
Behavior of Pituitary Tumors normal pituitary gland that may ultimately have implications for
One of the most notable features of pituitary adenomas is their ubiquity tumorigenesis of adenomas.
7
The investigators used a thoughtfully crafted
in population studies compared with the relatively small number of series of transgenic mice that coupled the gene for nestin (a marker of
tumors that actually present with clinical problems. Pituitary adenomas adult stem cells) to a reporter gene (green fluorescent protein). They
have been consistently reported in up to 25% of people in autopsy found that at birth the anterior pituitary gland is composed of cells that
studies dating back to 1936.
1
More recent studies have attempted to were created by embryonic stem cells. However, throughout post-natal
clarify the relative prevalence of ‘incidentalomas’ compared with life, adult stem cells contributed new pituitary cells of all major sub-types
clinically relevant tumors. A meta-analysis performed in 2004
2
found an to the gland. This means that the adult gland represents a mosaic of cells
incidence of 16.7% with autopsies reporting 14.4% and radiologic studies that have similar phenotypes (i.e. lactotrophs, somatotrophs, etc.) but
finding a rate of 22.5%. Prolactinomas represented 25–41% of have very different origins (i.e. embryonic or adult progenitor cells). They
incidentalomas in studies that included immunohistochemical staining.
3,4
also provided preliminary evidence that adult stem cells may be involved
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