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Factsheet 3 The most common type of Pituitary tumour is non-functioning (i.e., it does not cause excessive hormone production). Tumours of this type most commonly become apparent when the patient has visual symptoms or headaches due to pressure on the optic nerve and it is often the optician who refers the patient to the GP with abnormal visual fields (in which case the GP would want to refer to an ophthalmologist who, in turn, is likely to refer to an Endocrinologist). The tumour may also damage the adjacent, normal Pituitary gland (causing hypopituitarism - factsheet 7) or occasionally compress the pituitary stalk, causing Hyperprolactinaemia (factsheet 6). Please see ‘Who and When to Refer’ (factsheet 15). PRESENTING SYMPTOMS INVESTIGATIONS
An MRI scan will be carried out to determine the size and site of the tumour. Visual field tests are used to determine the degree of functional impairment of the visual pathway. Blood tests will be needed to assess pituitary function. TREATMENT POSSIBILITIES
IN THE ABSENCE OF PRESSURE SIGNS/SYMPTOMS
Patients may not need treatment, but will be monitored closely using MRI scans and visual field checks at intervals of 6 or 12 months. Alternatively surgery or rarely Radiotherapy may be advised. IN THE PRESENCE OF PRESSURE SIGNS/SYMPTOMS
Patients will usually need Transsphenoidal surgery (factsheet 10), which may be followed by radiotherapy to prevent recurrence (factsheet 11). If pituitary hormones are deficient, pituitary hormone replacement therapy will be given (factsheet 12). PATIENT MANAGEMENT
POST-OPERATIVE
Most patients will have improved, or at least stabilised, visual fields. Removal of the nasal packing is often the only part of the procedure that patients find uncomfortable. Some patients may find that their frequency of headaches changes. Other complications, such as Cerebral Spinal Fluid leaks can occur, although rarely, and need to be treated by a further small operative procedure (factsheet 10). LONG-TERM
Regular visual field assessments may be needed. MRI scans are usually repeated within the first post-operative months and follow-up scans are initially carried out at increasing intervals from 6 months to 5 years. RADIOTHERAPY
Pituitary radiotherapy (factsheet 11) may be used after surgery to reduce the risk of regrowth of the tumour. Since radiotherapy can cause hypopituitarism at variable times after treatment, patients should be tested for pituitary function on a regular basis, probably at 6 months, 1 year, 2 years and then bi- or triennially. WATCHPOINTS
Urgent - refer to hospital Non-urgent (but still very important) If the patient is on Hydrocortisone, ensure that replacement therapy is increased when seriously ill or under major physical or psychological stress (factsheet 5) Treat headaches and migraine Ask about erectile function General wellbeing - consider whether the patient is Growth hormone deficient e.g., if energy lacking, otherwise for replacement therapy Menstrual cycle loss - consider whether the patient needs hormone replacement therapy
QUESTIONS PATIENTS MAY ASK Why do I bump into objects?
The pituitary normally sits under the optic apparatus. When the pituitary enlarges, visual problems caused by compression of the visual pathway are often the first symptom. Visual acuity (vision that can be corrected by wearing spectacles) may not be changed, but visual fields are reduced, firstly in the upper outer quadrant, then the whole temporal field (the field of vision on both left and right sides of the head as opposed to central vision). Will my sight return after treatment?
The chances of at least partial recovery are good if the tumour is treated promptly. Treatment is effective in stopping any further visual loss in almost all cases. Why have my periods stopped?
The tumour may prevent the normal pituitary from being able to secrete the hormones that control menstruation and fertility. Have I inherited this, will my children get it?
In all but very exceptional circumstances there is no hereditary link.
RESOURCES FOR PATIENTS
available from The Pituitary Foundation HelpLine or our website www.pituitary.org.uk or our Endocrine Nurse HelpLine Patient Information Booklets Other information and resource links available at http://www.pituitary.org.uk/ FOR GPs MORE SPECIALIST RESOURCES Management of Pituitary Tumors: The Clinician’s Practical Guide (2003)
(Second Edition), Editors and authors Michael P. Powell, Stafford L. Lightman andEdward R. Laws. Humana Press, Totowa, New Jersey Pituitary Tumours. Recommendations for service provision and guidelines for management of patients. Consensus statement of a working party (1997) RN Clayton & JAH Wass (Eds)
London: Royal College of Physicians The Diagnosis and Treatment of Pituitary Insufficiency (1997) Lamberts SWJ (Ed) Bristol, UK: BioScientifica Endocrinology (1997) Levy A & Lightman SL New York: Oxford University Press The Epidemiology, Pathogenesis and Management of Pituitary Tumours (1998) Webb SM (Ed) Bristol, UK: BioScientifica
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