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Medical Intel

Jul 17, 2018

Pituitary tumors are more common than many people realize, with up to 17 percent of people at risk for developing one in their lifetimes. Dr. Susmeeta T. Sharma, Director of Pituitary Endocrinology, discusses how our team of experts recognizes and treats pituitary tumors.


Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.


Host: Thank you for joining us today. We’re talking with Dr. Susmeeta T. Sharma, Director of Pituitary Endocrinology at MedStar Washington Hospital Center. Welcome, Dr. Sharma.


Dr. Sharma: Thank you for having me.


Host: Today we’re discussing pituitary tumors, which are much more common than many patients and physicians realize. Dr. Sharma, what types of pituitary tumors do you treat?


Dr. Sharma: So, one of the most common functional pituitary tumors would be a prolactin-secreting pituitary tumor. So, prolactin is a hormone that the normal pituitary gland makes that’s involved in the development of breast mammary glands and milk production in females, and so when a tumor is making prolactin, that excess prolactin in females can lead to irregular menstrual cycles, can lead to breast milk production, feeling of breast engorgement, breast pain. This irregular menstrual cycle and excess prolactin levels can also lead to difficulty or inability to have children, and that’s many times how it comes to attention to a physician. In men, it can cause decreased libido and some signs and symptoms of low testosterone, so low energy levels, decreased libido, erectile dysfunction, inability to have children, um, decreased hair growth, some of the symptoms that you see related to low testosterone levels. Given that we don’t have the menstrual cycle marker in men, many times the prolactin-secreting tumors in men tend to be larger in size, and so many of them can have headaches and vision changes related to just the size of the pituitary tumor, and so that’s how they may manifest to a physician.


Host: How do you determine if the patient’s symptoms are caused by a pituitary tumor or another condition?


Dr. Sharma: Right, so some of the symptoms a patient may present with, for example, low energy levels, decreased libido, can be related to various different hormonal disorders, or it may not be related to a hormonal disorder at all, and so the first time, if the patient is presenting with these symptoms, we need to assess the levels of these hormones to see if there is a hormonal disorder there. So, one would measure testosterone, prolactin levels in a woman, FSH, estrogen levels, get a detailed history and exam, and all of that can help detect whether or not there could be a hormonal dysfunction, which can then lead us to assess for a pituitary tumor. So, they may come to us already with a diagnosis of a pituitary tumor where we are trying to see if it’s making some hormone, or they may come to us with these symptoms where we are trying to see if there could be hormonal dysfunction, which can then lead us to a diagnosis of a pituitary tumor.


Host: After a patient is diagnosed with a pituitary tumor, what is their next step for getting treatment?


Dr. Sharma: So, yeah, once we have...there might be 2 or 3 steps involved in the diagnosis of a hormonal dysfunction. We may do some initial screening tests, followed by some confirmatory testing, but, yes, once the diagnosis has been made that a person has a functional or a nonfunctional pituitary tumor, then we would go on to treatment. The treatment can vary from just simple observation and monitoring, which would be the case in a nonfunctional small tumor that’s not causing any mass effect, to medical treatment, which would be a case in a prolactin-secreting tumor, which we can treat effectively with medication group called dopamine agonist therapy, which are now well-tolerated medications, uh, to surgeries. So, most functional tumors, other than the prolactin-secreting tumor, will require surgery, and any nonfunctioning tumor that’s causing mass effect would require surgery. Many of the pituitary tumors after surgery may require further adjunct therapy, uh, so if there is residual hormonal excess or residual tumor, um, they may require radiation therapy for that or adjunct medications for further hormonal control.   


Host: How common are prolactin-secreting pituitary tumors?


Dr. Sharma: So, pituitary tumors in general, I think, they are underrecognized. If you look at the studies done for diagnosing pituitary tumors, the data that comes available comes from either radiological studies, so MRIs that are done in the general population, or autopsy studies, so done after the death of a person, and so, uh, the data coming from there shows that among the population, about anywhere from 10 to 20% of the individuals, depending on the study you look at, can have a pituitary tumor, and in some it may be causing hormonal excess or hormonal dysfunction; in others it may be not. Among those pituitary tumors, about 40 to 50% are actually gonna be a prolactin-secreting pituitary tumor, so I always say, when I’m talking to a group of people, that if we are about 100 people sitting in that room, about 10 to 15 of us could have a pituitary tumor, and out of that about 5 to 6 could have a prolactin-secreting tumor, and that’s how common it can be.


Host: What surgical options are available for individuals with prolactin-secreting pituitary gland tumors?


Dr. Sharma: So, for a prolactin-secreting tumor I would say about 80 to 90% of the time we are able to manage that medically. The time that we need a surgery for a prolactin-secreting tumor would be A) if it has gone undiagnosed for a long period of time and it has become really large, and then it bleeds into itself, so as the tumor grows the blood supply sometimes is not able to keep up with itself and it may bleed suddenly into the tumor, which is what we call pituitary apoplexy and, if that happens, that’s a surgical emergency. The patient can develop sudden-onset hormonal deficiency, sudden-onset vision changes, sudden severe headaches, and so that is definitely a time when they would need pituitary surgery. Other times a prolactin-secreting tumor may need surgery is if the patient is not able to tolerate the medications, so most of the time these medications are well tolerated, but occasionally the patient may develop gastrointestinal side effects, dizziness, or...and is just not able to tolerate the medication. In those cases, one may need surgery. Uh, another scenario would be although the majority of these tumors do respond to this group of medication called dopamine agonists, there are a small percentage which are resistant to the medication, so resistant prolactinomas. If a tumor is growing or the prolactin levels are increasing while being on an optimal dose of the medication, then that would be another case where we would need surgical intervention.


Host: Are there any life-threatening complications associated with prolactin-secreting tumors?


Dr. Sharma: Uh, so, it…from the prolactin itself, the high prolactin levels may not be life threatening, but from the pituitary tumor, as the tumor grows, you can have hormonal deficiencies, so the hormonal deficiency that can be life threatening is a cortisol deficiency, so again, in the scenario where it’s very large, and over time the patient develops, from mass effect of the tumor, loss of pituitary cell function that makes ACTH, which then leads to cortisol production, they can have cortisol deficiency, and cortisol is a life-sustaining hormone. The same way, you can have TSH or thyroid-stimulating hormone deficiency, which then leads to thyroid hormone deficiency. And, again, those are both two life-sustaining hormones, and if that goes undetected, one can have serious consequences.


Host: Is the physiological response to starting therapy gradual, or is it a big shift for patients?


Dr. Sharma: These tumors are very...if they’re going to respond, they’re very responsive to the medications where the prolactin levels start to decreasing within days, and so even in patients where you actually have the tumor compressing on the eye nerve and causing vision changes, you can...and the medication will start making a difference right away, and as long as they are compliant with the medication and we are titrating up the dose to get the prolactin levels normal, uh, the tumor size will also respond in most cases.


Host: What about some of the more rare tumor types you treat?


Dr. Sharma: Other functional tumors that are more rare, it can be a growth hormone-secreting tumor, so that’s called acromegaly or gigantism, so if the growth hormone-secreting tumor occurs in a child who is still growing and their growth plates have not fused, uh, they can become really tall and that’s why the disorder is then called gigantism. On the other hand, if the growth hormone excess happens as an adult, you have a condition called acromegaly, and so these patients have a change in facial features. The facial features become really coarse. They will have change in...increase in ring size, increase in shoe size, they develop these enlarged hands and feet. They can also develop high blood pressure and have an effect on their heart, so the heart gets enlarged, uh, which can then make them prone to developing arrhythmias or irregular heart rhythms. Um, they can have increased chances of polyps in the colon and the intestine, and so although not clearly established, they can be at an increased risk of colon cancer. They can develop sleep apnea, they can develop carpal tunnel syndrome and then they can also develop pre-diabetes and diabetes, so many comorbidities can be associated with a growth hormone-secreting disorder. So, when that presents, the treatment for that functional pituitary tumor is surgery. One does want to make sure that they don’t have other hormonal deficiencies or hormonal excess. Sometimes, these tumors can be co-secretors, so they can secrete more than one pituitary hormone, but after that initial hormonal evaluation the treatment is gonna be surgery. Many times, because these growth hormone-secreting tumors are large, because the presentation can be subtle and the transformation in the clinical features can be gradual, they do often get detected in a larger size, so as a macroadenoma, and so many times they require adjunct treatment after surgery in the form of medical therapies or radiation therapy. So, we actually had a patient, a young male, who presented to his dental surgeon for jaw surgery, and so basically his main complaint was that he’s lost his smile. And so, he ultimately ended up having a growth hormone-secreting disorder, and exposure to these high growth hormone levels had led to protrusion of his jaw such that when he smiled, only his lower teeth were visible and his upper teeth were no longer visible, so that’s why he said he lost his smile. But, an astute dental surgeon at MedStar Washington Hospital Center, while looking at his dental x-rays, saw that the bone where the pituitary gland sits, that sella, that looked enlarged, and so he referred the patient to us for evaluation, and for sure he had a pituitary tumor about a centimeter and a half that was making growth hormone. He’s now status post-surgery for the pituitary tumor and his growth hormone levels are much lower now, but he’s requiring adjunct treatment with a medication that is a once a month injection.


Host: In adults, are the physical changes gradual or sudden?


Dr. Sharma: Yeah, no, these...most of these changes in an adult will be very subtle and so, many times they get overlooked, especially if you are seeing the person every day, the changes in facial features can be very subtle. Many times, the change in ring size or shoe size, um, a patient or a person may attribute it to gaining weight or fluid retention, things like that, or just aging process and it may not get detected. I have had people whose shoe size has changed from an 8 to an 11 before it gets diagnosed so no, it doesn’t happen overnight. It’s a gradual process. Many times, um, we ask people to bring out their driver’s license or other prior photographs to actually compare how they have changed. Many times, it takes for a visit to a relative who has not seen you for a year, and they comment that you look different and sometimes that can lead to an evaluation, but many times it can be because they have developed high blood pressure or a heart issue or a diabetes that then leads to being seen by a physician and that leads to further evaluation, so the presentation can be at various different points.


Host: So, for these patients, is medication management a more likely treatment option than surgery?


Dr. Sharma: For most functional tumors, it will be surgery as first-line treatment. The only medical treatable pituitary tumor is prolactinoma, but many times medical therapy is needed as an adjunct, even after surgery has been done, and so you need to look at various different treatment modalities, with the goal being to optimize hormone levels and make sure that the tumor is either completely gone or, um, the residual tumor is...remains stable over time, and so it would be a mix of different treatment modalities.


Host: Why is MedStar Washington Hospital Center the place to go for pituitary tumor care?


Dr. Sharma: So, I think whenever we think of a pituitary tumors, it’s important to remember that not one physician can treat all pituitary tumors. The pituitary tumors involve hormonal dysfunction, which needs an endocrinologist, who is...has expertise in the evaluation of pituitary disorders. You need an experienced neurosurgeon as most functional tumors and many nonfunctional tumors require surgical treatment. You need a neuro-ophthalmologist who is experienced in recognizing the visual field defects that can go with pituitary tumor disorders. You need improved MRI techniques and a good neuroradiologist to detect these pituitary tumors. And you need state of the art radiation therapy, stereotactic radiosurgery modalities, as another treatment option to be available. And then you need a team that is keeping in mind and discussing the treatment plan with each other and coming up with a treatment plan that’s best optimized for the patient instead of just giving a one-sided recommendation. So, the reason I think a pituitary center is really important, rather than just going to a physician, is because we are looking at the patient as a whole and coming up with a multidisciplinary team approach for these pituitary tumors.


Host: Is there anything patients can do to prevent pituitary tumors?


Dr. Sharma: So, yeah, we don’t completely...there are certain hereditary disorders where you...that are associated with pituitary tumors, and if...those are very rare, um, most commonly multiple endocrine neoplasia, and if that runs in the family, then that could be something that you need screening for, but otherwise it’s not completely understood what causes pituitary tumors. That’s another area of research. We are developing more and more mutations, but those are not specific for a pituitary tumor and not everybody with that mutation is going to have pituitary tumors, so we are still at a learning stage for that and nothing in particular that one can do to decrease their risk of pituitary tumors because primarily we don’t completely understand why they develop. One of the most common questions that patients ask me is that they had a very stressful period where they were leading a very stressful life, and that by increasing their cortisol levels, did that cause Cushing’s or any other form of pituitary tumors, and no, we do not think that, at least as of now we don’t have any current evidence to suggest that. Uh, so the main thing that one can do is to be in tune with your own body, to recognize any new symptoms that one may be developing and make sure you’re following up with your physician as many times they may detect if there is any evidence of any pituitary disorder and then, if needed, refer to an endocrinologist or a pituitary specialist.


Host: Are certain patient populations more at risk than others?


Dr. Sharma: Oh, so yes, uh, age-wise there is. But also, there are certain pituitary tumors which tend to occur in a younger age group or in more in females versus males. For example, Cushing’s disease, which is a tumor, where the tumor makes ACTH, which then causes cortisol excess - that tends to be more common in young females compared to males, so there are certain gender predilections in some of the pituitary tumors, but not always.


Host: Thanks for joining us today Dr. Sharma.


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