Chapters Transcript Video The Pituitary Playbook — Functional Tumors, Vision Risk & Endoscopic Solutions Baptist Health 32K subscribers Subscribe Like Today we're diving into one of the body's most powerful yet often overlooked regulators of human function, the pituitary gland, sometimes called the master gland. When disorders of the pituitary go undetected, they can disrupt the entire body's function, leading to complex and sometimes life-altering conditions. Welcome to Baptist Health. Doc, a podcast built for innovation and collaboration by physicians for physicians. Hello, I'm Doctor Michael McDermott, the chief medical executive in Irma and Calman Bass, Endowed chair in clinical neuroscience at Baptist Health Miami Neuroscience Institute. Joining us today is Doctor Evan Bander, director of endoscopic skull-based surgery and co-director of the pituitary program and a neurosurgeon at Baptist Health Miami Neuroscience Institute. Evan. Thank you for having me. Um, could you please tell us to start, um, about your training and specifically endoscopic surgery for pituitary tumors? Yeah, of course. So, you know, I grew up in New York and most of my training was done in New York City. I trained at Weill Cornell, New York Presbyterian for neurosurgery residency. And while I was there, I was trained by one of the leading endoscopic neurosurgeons, Dr. Theodore Schwartz, who really pioneered the use of endoscopic endonasal surgery for pituitary tumors. So, as a neurosurgery resident, I decided to do a subspecialty focus in pituitary tumors and paracellar tumors and really all of minimally invasive neurosurgery with Doctor Schwartz at Cornell. In addition to that, I actually did an additional fellowship in neurosurgical oncology at MD Anderson Cancer Center in Houston, Texas, where I also learned additional advanced endoscopic techniques with really pioneers in the field of uh treating other tumors around the pituitary gland, including chodomas and skull-based tumors. Great. What about uh pituitary disorders interested you as a neurosurgeon to focus your practice, uh, in this area? Well, really, my interest came from being an interest in really all brain tumors and being able to sort of treat and support patients through these really difficult diagnoses. You know, as a neurosurgeon, it's our job and our ability to take the opportunity to support these patients and their families after getting this very difficult diagnosis and get the patient to a more functional or at least help them maintain. Their quality of life after such a diagnosis. And when it came to pituitary tumors, really these are the second most common tumor we see uh in the benign brain tumor field, uh right after meningiomas, which you know plenty about, uh, and Pituitary adenomas can have really uh really important impact on patients' function. You know, a pituitary tumor can affect a patient's vision, which obviously can severely impact their ability to function normally, as well as functional pituitary adenomas can really have a strong impact on a wide range of systemic functions throughout our body. Metabolism, growth, etc. So pituitary tumors really require subspecialty focus. These patients, uh, in neurosurgery, we have a certain skill set, but pituitary tumors really require a specific set of skills to treat these endoscopically, which is different than our typical open procedures. Now, uh, for our medical colleagues who are watching, can you discuss the most common syndromes, uh, for functional pituitary tumors and what are they commonly called? So, functional pituitary tumors can come in a few different forms. One of the most common and actually the most common is prolactinomas, so tumors of the pituitary gland that secrete excess prolactin. And prolactin can have multiple effects on the body, including causing what we call galacteria or excessive production of uh milk from the breasts. There can also be effects on sexual function, um, sexual dysfunction, uh, as well as osteoporosis, um, in, in women in particularly you can have irregular menses, uh, and that's how many of these patients can present. That's the most common, um, functional pituitary tumor, but one of the more, um, Widespread effects of the pituitary gland is really from cortisol, and so one functional adenoma is a ACTH secreting adenoma, which causes Cushing's disease, which can have, you know, significant effect on the body, including effects on metabolism, weight gain, patients can have osteoporosis. weakening of their bones, frequent fracturing of their bones. They can have significant effects on diabetes, high blood pressure, really affects multiple organs throughout our body, which can be extremely be difficult for patients and also be difficult to diagnose because of the widespread effects. And so that really takes a specialized uh diagnostician to help diagnose these patients. Uh, other than ACTH secreting tumors or Cushing's disease, the other more common functional adenoma is acromegaly or gigantism in kids, which is a uh uh sorry, pituitary tumor that is secreting um growth hormone, and so that can cause excessive growth of the hands and feet. Uh, patients may notice that they're increasing shoe size or increasing hand size, glove size. Um, they may notice different facial features increase, uh, including widening of the nose and frontal bossing, um, so these features can sometimes present, uh, with acromegaly. Is it true that these two functional tumors, um, ACTH producing and growth hormone secreting tumors can shorten a patient's life and if undiagnosed and treated properly? Yes, absolutely. You know, particularly Cushing's disease and acromegaly of the functional uh adenomas, they can definitely severely affect a patient's overall lifespan. What about non-functional tumors? How do they present? So non-functional pituitary tumors can actually go unnoticed for a very long period of time. Many patients present incidentally uh in an emergency room after a car accident, getting a CT scan, they get noticed to have a non-functional adenoma. Um, some patients present with headaches or sort of vague symptoms, but really the most common uh finding that we see from large functional and non-functional adenomas is vision loss. So patients can present with, uh, severe vision loss, particularly by temporal hemianopsia or loss of vision in the periphery, um, from compression of the optic chiasm from these tumors. Do all non-functional tumors that are not symptomatic require surgical treatment? So nonfunctional adenomas, it really takes a lot of work up and thought in terms of how to treat these. Observation is very reasonable for non-functional adenomas that are not compressing the optic chiasm, for tumors that are growing or for tumors that have compression of the optic chiasm on imaging or evidence of visual loss, even subclinical vision loss, that could be an indication for surgery. So a non-functional adenoma that's touching the underside of the chiasm. With normal Humphrey visual fields and occullocoherence tomography testing and acuity, does that require surgical treatment? So really that depends on a patient, uh, and their age, how they, you know, how, what their field of work is, you know, what their expectations of, uh, you know, their long term outcomes will be. So it's a discussion with a patient, you know, I don't tell anyone you need surgery unless, you know, it's something that they're willing to undergo and understand the risks and the benefits of it. But certainly in a younger patient who has a, a tumor that's touching the optic chiasm, to prevent vision loss or to prevent, um, worsening of their vision surgery can be indicated even if they have no evidence of vision loss yet. So let's say you're gonna, you've decided with the patient that surgery is necessary. What kind of preoperative workup do you routinely do before surgery? You know that's sort of the beauty of a pituitary center is that the workup is really a very important part of the decision making process for a pituitary tumor. So that workup generally includes blood testing. Uh, so we test all of the hormones that the pituitary normally produces, and we do that in conjunction with our endocrinologists as part of our pituitary center. We look at all of the, um, all of these hormones and assess, is this a functional adenoma or a non-functional adenoma. That's really the first step in determining treatment, uh, treatment paradigms for these tumors. And once we can determine whether this is a functional or non-functional tumor, then we can start looking at the anatomy, uh, looking at our MRI scans, or CT scans, assessing whether there's, uh, this tumor is touching the optic chiasm, whether there's room, uh, between the opticism and the tumor itself, and that sort of anatomical decision making can play into whether this is a functional or non-functional adenoma. We talked about prolactinomas, so a very large prolactinoma can be touching the optic chiasm. But if we have endocrinologic evidence that this is secreting prolactin, even if they have visual deficits, it may be reasonable to start with medication. Um, prolactinomas are one of the few pituitary tumors that are actually quite responsive to medication. So those kinds of conversations are really important in a pituitary center in a multidisciplinary manner. Um, during surgery, what kind of, uh, specialty equipment and colleagues do you use to carry out these operations? So, you know, for pituitary tumor surgery, endoscopic endonasal surgery has really come to the forefront of treatment. In the past, we used to neurosurgeons often would do craniotomies for treating these tumors or do transfinoidal surgery through a microscope, but really an endoscope is a long telescope that brings the illumination and the camera to the depth of the field inside the nose. And so that really allows for a wider field of view within the nose and within the sphenoid sinus. And so using these telescopes or endoscopes, we get a much better view of the bony anatomy, we can see the carotid arteries which surround the pituitary gland on either side. We can visualize the cavernous sinus and in some cases enter the cavernous sinuses if necessary. And We do the surgery with our ENT colleagues, you know, we do this because the ENTs are experienced in opening up the sphenoid sinus and the nose and giving us access to the regions of the skull base that we need to access, and also because it improves the quality of life of these patients postoperatively. Following up with the ENT doctors can be an important part of the post-operative care of these pituitary patients. Now, uh, Baptist Main Hospital on North Kendall Drive has an intraoperative MR. An intraoperative CT scan. Do you use any of these after your procedure? It's a great question. You know, there's been a lot of studies looking at intraoperative MRI for evaluating pituitary tumors and, and uh extended resection, and many, many of these studies do show that you can get a better extent of resection using intraoperative MRI. If you see residual tumor, you can go back to the surgery and complete any additional resection. So we do use our intraoperative MRI for almost all of our pituitary patients here. Miami Neuroscience Institute. Now, you've mentioned, uh, I've been in neurosurgery since 1988, so I've lived through the microscopic, um, you know, trans-nasal sublabial times. Now, um, now we're using the endoscope exclusively. Um, the cavernous sinus was usually considered no man's land. In the past, but not so much anymore. And is there anything that you use on preoperative imaging to determine whether or not there's cavernous sinus invasion and does that alter what you do intraoperatively? Absolutely. So, you know, our MRI's are very helpful for preoperative imaging in terms of evaluating for cavernous sinus invasion. And whether to open the cavernous sinus uh is a question that is also determined by patient factors, whether they have a non-functional adenoma versus a functional adenoma, whether this is their first surgery or redo surgery. Um, so not everybody who has cavernous sinus invasion requires opening the cavernous sinus on the first surgery, but it's something that we're now capable of doing because we have this experience and because we have endoscopes that can help us visualize the carotid artery which sits within the cavernous sinus, uh. Better than the microscope used to be able to, we can see everything and allow for more microscopic dissection as we're used to in sort of open cranial neurosurgery. We can now use more two-handed dissection and opening of the cavernous sinus in a more safe manner with low rates of injury to the carotid arteries. Yeah, one thing I want to bring up for our viewers is uh intraoperative carotid artery injury, right, which is obviously potentially life threatening, could be morbid. Uh, but with the endoscopic techniques, we've developed methods at least to temporize to get hemostasis and then follow that up with uh angiography and determine whether the patient needs other treatment. Do you want to tell our viewers what the standard methods are for dealing with intraoperative carotid artery injury? You know, in most cases, we hope to never have that experience, uh, to have an intraoperative carotid injury. Uh, it is reported rarely in the literature and in many cases you have to be very careful working around the carotid artery to, to avoid this, and that's why specialized training and endoscopic and nasal surgery is recommended for anyone who's going to do such an opening. That being said, when you do have these, Uh, rare events, obtaining hemostasis, visualizing, you know, because you can visualize exactly where you may have had that injury, you can see, you know, did you vulse a small vessel, you can apply pressure like any in any hemostasis, uh, you know, in any attempted hemostasis, you apply pressure directly to the region and then you obtain hemostasis to get them, the patient to an end endovascular procedure. Yeah, can you talk about the use of um Uh, the patient's own muscle tissue as a patch temporarily as advocated by the Australian group. I mean, there are a lot of different ways that you can obtain hemostasis and, and using a muscle patch, using things like tissse or other hemostatic agents, um, flow seal, you know, these are all options, you know, in most cases you're really just trying to obtain the basic hemostasis so that you can protect a patient from losing excessive amounts of blood. Yeah. I've had one intraoperative experience with a carotid rupture was unpleasant. It wasn't my case, but I was called to help. Um, and as you said, once we got the bleeding controlled with direct pressure, we were able to take the patient angiography, then it went endovascular repair. Ultimately, the patient did fine and then a delay. Basis went back for the definitive surgery, uh, you know, kudos to them for the courage to go back after an event like that. But yeah, you really don't wanna have that intraoperative experience as a neurosurgeon or logist. Um, so once the surgery is done, how long do the patients stay in the hospital and are there any, any other specialists you get to see the patients before they go home? So, you know, most patients stay in the hospital around 2 to 3 days at minimum after a surgery like this, mostly because after pituitary surgery, we're monitoring patients' electrolytes. Uh, you know, patients can experience things like diabetes insippidus after resection of a pituitary tumor, uh, as well as delayed hyponatraemia. Uh, so these are things that we try to monitor for in the 1st 48 to 72 hours after surgery. Uh, monitoring the sodium balance and if we see signs of diabetes and syphilis treating it appropriately in the hospital. So most patients, it's about 2 to 3 days after surgery. That being said, some patients can have a longer stay with intraoperative CSF leak or cerebrospinal fluid leak. We do sometimes place lumbar drains, which we may keep in for 72 hours and then get the patient out of the hospital hopefully by day 4. Now, the uh postoperative follow up for these tumors likely is lifelong. And uh how do you do that follow-up and are there any uh options for patients who've already had surgery when their tumor recurs? So, you know, as you're mentioning, because these are benign tumors, they can slowly recur over a patient's lifetime, but in general, you know, patients have very good long term outcomes and good control after a gross total resection of a pituitary tumor. So in patients who do have a recurrence, you know, those are things that we look at, is surgery another option? If this is a tumor that is in an accessible area, uh, we do often do a second surgery for recurrence, and patients who are older or, you know, may be less amenable to a surgery for medical risk factors or medical comorbidities, radiation or stereotactic radiosurgery with our radiation oncology colleagues is also an option. Um, and medications in patients with, uh, functional pituitary adenomas is sometimes also an option that we always consider. Yeah. And what types of radiation therapy are commonly used for uh non-functional or functional pituitary adenomas at recurrence when repeat surgery is not an option? So stereotactic radiosurgery uh is a, is a very commonly and well reported um radiation, a form of radiation for treating pituitary adenomas. Sometimes in the upfront um uh diagnosis when patients aren't surgical candidates, but often in, in patients who have subtotal resections with further growth of residual. tumor or in patients who have a recurrence and are not a surgical candidate. So Gamma knife radiosurgery is something that has been reported in over thousands of patients with excellent outcomes and control rates up to 90% in some cases at 5 to 10 years. So it is definitely a good option. Uh, for patients even with functional pituitary tumors, we do sometimes treat these with stereotactic radiosurgery, um, and it's something that we discuss with every patient, you know, we talk about all of the options up front, and stereotactic radiosurgery has been shown to be effective in some cases of Cushing's disease and ACTH secreting adenomas and And acromegaly, although one of the downsides of that is that you can have delayed uh response times for uh endocrine function. So both the response and decreasing the the excess uh production of ACTH or uh growth hormone that can happen in a delayed fashion as opposed to surgery, which can be almost immediate. Uh, and secondly, patients after stereotactic radiosurgery can have higher rates of hypo hypopituitarism or pan-hypopituitarism, uh, after radiation. Yeah, thanks for pointing out the distinction between radiographic control versus endo control, right, the radiographic control um is more obvious early on and the endocrine control takes later. Um, so, um. Uh, any difference between the follow up, uh, between a functional adenoma and a non-functional adenoma? Well, so a non-functional adenoma in a patient who gets a gross total resection, uh, and doesn't have any postoperative hormone deficits may just need to follow with a neurosurgeon. Um, you know, we follow them over time because again this can have a slow. of recurrence, we do follow patients, you know, at first every 6 months and then in a year and then every year, and then eventually we spread out that follow-up, but that can often be done with just a neurosurgeon if there's no endocrinologic issues postoperatively. For patients with functional adenomas, that's often a lifelong diagnosis of following with both endocrinologists and neurosurgeons to evaluate their endocrine function postoperatively. Recurrence in Cushing's disease can occur despite resection of uh entire gross total resection of a tumor. Delayed recurrence can occur in Cushing's disease and often requires, you know, very technical endocrinologic workup to diagnose that. Great. Thank you, Doctor Bander. As we look ahead, the future of pituitary medicine is full of promise. Advancements in imaging, minimally invasive surgery, as we've just heard about, and personalized hormone therapies are opening the doors to earlier detection and more effective treatments than ever before. At Baptist Health, our commitment is not only to treat today's patients but also to pioneer innovations that will improve care for the generations to come. Thank you for joining us on this journey. 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