Carl Maronich (Host): Welcome to Community Connect, presented by Tampa General Hospital. I'm Carl Maronich, your host. And we have two providers with us today who are going to be talking about pituitary issues. One is Dr. Siviero Agazzi, Professor and Vice Chairman, Director of Cranial Neurosurgery at University of South Florida's Department of Neurosurgery. Welcome, doctor.

Dr. Siviero Agazzi: Thank you. Good to be here.

Host: Also joining us today is Dr. Marla Sevilla, who is an endocrinologist and Co-Director of the Pituitary Program and Associate Professor of Medicine. Welcome, doctor.

Dr. Marla Sevilla: It is a pleasure to be here.

Host: Well, we're delighted to have both of you to talk about this very complex issue, really, the pituitary gland. Small but mighty, I will say. And maybe we should start the conversation by defining, you know, what is the pituitary gland?

Dr. Marla Sevilla: Sure. The pituitary gland is a small gland at the base of our brain. We call the pituitary gland the master gland, because it controls many of our body's hormones. And sometimes an adenoma can form there. Most of the time, they are benign, but they can still cause problems depending on their size and the hormones that they affect.

Host: I see. How are they detected when there are issues with the pituitary gland?

Dr. Marla Sevilla: There's some situations that may lead us to suspect a pituitary adenoma such as initial hormone symptoms, for example, fatigue, unexplained weight gain or loss, infertility issues in females, irregular periods or milk discharge, even if not pregnant. In males, low sex drive or erectile dysfunction among others. And these symptoms may suggest hormonal imbalance, which often leads us to check the pituitary function.

In other patients, the first symptoms of a pituitary adenoma are vision changes, especially loss of peripheral vision, which is the side vision. And this happens when the tumor grows large enough to press on the part of the brain where the optic nerve cross. And because of these vision symptoms, many people first go to an ophthalmologist thinking that they need glasses or are developing another eye condition. But when the ophthalmologist notices a specific pattern of vision loss or suspect there is a pressure on the optic nerve, they often order a brain or a pituitary MRI and refer the patient to a neurosurgeon. And sometimes lab tests are done for other reasons, revealing high or low levels of hormones

Dr. Siviero Agazzi: And then, believe it or not, the majority of cases, those adenomas are found just by accident. For example, you know, somebody has a car accident or maybe just hits their head against a cabinet, they have a headache, any kind of symptoms, and their doctor prescribes an MRI of the brain or a CAT scan of the brain, and those tumors are found. And we call those incidental adenoma. So, this is really the majority of these cases that are referred to us for evaluation.

Now, there is one situation where actually those adenomas present as an emergency. Very rarely, but sometimes they can bleed. So if these adenomas they bleed, that has a specific name, it's called a pituitary apoplexy. Patients can present with very severe headache and sometimes also visual loss. Now, these are the patient that come to the emergency room complaining of bad headaches and vision loss. And we find this tumor and then we go ahead and treat them as an emergency. But this is pretty much how we found those.

Host: Similar to stroke symptoms, it sounds like.

Dr. Siviero Agazzi: Absolutely. It can be the same as stroke symptoms, and they actually get evaluated as a stroke, like with a CAT scan of the head or MRI of the head, and then that's how they're found.

Host: Yeah. And what are the next steps if someone suspects they have a pituitary adenoma?

Dr. Marla Sevilla: If we are suspecting an adenoma, we need to do blood tests to look at hormone levels, MRI of the brain to focus on the pituitary gland, visual field testing to determine if vision is affected. And then, a referral to an endocrinologist or a neurosurgeon depending on the findings.

Host: It may seem like a silly question, but that's my job to ask these questions. Do all pituitary tumors need to be treated? And what would those treatments be like if they're seeking treatment?

Dr. Siviero Agazzi: No, no, no. Not at all. And that is very important because, once again, we find them often by accident. So, pituitary adenoma, they don't all need to be treated. And what really makes a difference, well, believe it or not, size matters. So, we recognize two types of adenomas. The big ones, they're called macroadenomas; and the small ones, they're called microadenomas. So, the big ones, the microadenoma, they often need to be treated. Why? Because as these adenomas grow, they grow up towards the brain and they compress the optic nerves and cause vision loss. So first, it's like the tunnel vision, and eventually people can get blind.

So when we find a big adenoma, it compresses the optic nerves. The indication is always to treat it. Now, for the smaller adenomas it's different. Some smaller adenomas don't cause any problem, and we can just watch them and see if they grow. Now, some small adenomas, they secrete hormones. And believe it or not, even tiny adenomas that secrete a very small amount of excess hormones can cause a lot of problems. The most well known are called Cushing's disease or acromegaly. And then, we have to treat them even if they're small, simply because those diseases are very serious.

Host: Yeah. Then, what would those treatment options be?

Dr. Siviero Agazzi: So, it depends what they are. So once we decide to treat an adenoma, we have three options. One is giving medications, one is surgery, and the other one is a sophisticated type of radiation that we called radiosurgery. Now, once again, size matters. Big adenomas that compress the optic nerves, they almost invariably need to go to surgery.

Now, believe it or not, it's great because we have a very minimal invasive way of removing these tumors. We actually can put small cameras, those are called endoscopes that go into your nostril, and we can make all the way up to the base of the skull, which is where the pituitary gland is located. And there, we can remove those tumors from the nose using endoscope without even seeing the brain or disturbing the brain.

Now, for small adenomas, it's different. If they secrete hormones, once again, they often require surgery. Why? Because if we can remove those cells that produce these hormones, that's the best way to treat the Cushing or treat the acromegaly.

Now, if the surgery doesn't work or cannot get the patient cured, then we step to something called radiotherapy or radiosurgery. Radiosurgery is often used as an adjunct to surgery, so after the surgery and can treat these tumors to prevent them from either growing back or to further kill those cells that secrete the hormones in order to cure those Cushings or acromegaly patient. And then, obviously, there is also some tumors that can be treated with medication. And I'm going to let Dr. Sevilla talk about those.

Dr. Marla Sevilla: Yes, absolutely. Not all the adenomas require surgery. And in fact, one of the most common types of pituitary adenomas, prolactinomas, usually they respond very well to medical therapy. And there are two primary medications that we use to treat prolactinomas. And they work by lowering prolactin levels and shrinking the tumor. And around 90% of the prolactinomas, they respond very well to medical therapy.

But then, when it comes with the conditions like acromegaly and Cushing disease, the first treatment option, if possible, is surgery, as Dr. Agazzi mentioned. However, surgery doesn't always resolve the problem completely or sometimes a patient may not be a good candidate for surgery. In some situations, we have medications available to help control hormone levels and manage symptoms. Although these medicines, they don't cure the condition, they can make a significant difference in helping people feel better, improve quality of life, and normalize their hormone levels.

Dr. Siviero Agazzi: Yeah. I tell my patients, you know, if they come with a pituitary adenoma and it is a prolactinoma, I tell them, "You won the lottery." Because really, if it is the only one that we can really very, very effectively treat without surgery, without radiation, just with a very, very effective medication. So, that's what I tell them.

Host: So, maybe we could talk a little bit about why Tampa General decided to have a dedicated pituitary center.

Dr. Marla Sevilla: Pituitary conditions are complex. And for this reason, it's very important to have a team of different experts who work together. The benefits of being treated in our pituitary center include having a specialized team with vast expertise in managing pituitary disorders, eliminating the need for patients to see different doctors in different places. And we also provide long-term monitoring and support for all of our patients within the Tampa Bay region and beyond.

Host: That's great. Well, medicine really should be a collaborative effort. And I think patients benefit from that. And maybe we could talk a little about the advanced technologies that Tampa General and the University of South Florida have for the treatment of pituitary adenomas.

Dr. Siviero Agazzi: I think that's a very important part, because unless you won the lottery and you have pituitary adenoma and then you can be treated with medication, in many other instances, you need surgery. And for surgery, because it's a minimal invasive treatment, they are very technologically heavy. And so, at TGH, we do have, you know, 4K high-definition endoscopy. We have 3D, three-dimension, high-definition endoscopy that allows us to remove this tumor again through your nostril without really having any incision on your head, any incision on your face, anywhere.

We also have something called an intraoperative MRI that allows us, if we need to, to get an MRI of your pituitary gland in the middle of the surgery while you're asleep to confirm that we did what we wanted to do, that the entire tumor has been removed. We also have something called an advanced navigation system. It's a bit like a GPS that we use in the operating room that always tells us exactly where we are or where the important structures of the brain are. And we also have fluorescent angiography that allows us to enhance our visualization of the tumors, of the blood vessels around the tumors, and that makes this surgery very safe.

Finally, if we need the radiation, Tampa General Hospital and USF have the latest version of this machine called the CyberKnife S7, which is a highly sophisticated machine that delivers radiosurgery in a very precise way, and also leverages the benefits of AI to improve accuracy and safety.

Host: Very comprehensive program with a lot of important technology as you pointed out. And maybe we could talk now a little bit about the recovery process after a pituitary tumor surgery.

Dr. Siviero Agazzi: Yeah, absolutely. So usually, patients go to the intensive care unit for about 24, sometimes 48 hours. And then, the third day, they go home after the surgery. When the patients are home, they're fully independent and they can do all their daily activities such as eating, walking, showering, et cetera. We just ask them not to strain, to move furniture or to wash the baseboard or something like this, heavy lifting for about six weeks. That allows everything to heal in their nose. Now, people that have a desk job, they can go back to work maybe two weeks later. And people that have a more labor-intensive work, they have probably to stay home for about four to six weeks, again, to avoid any straining or heavy lifting.

And finally, our hospital is the first one in the region who offers a service called Hospital at Home. Now, this is a big topic. We're not going to be able to give all the details. But pretty much, it allows patients to receive the same level of care that they would in the hospital, but just remaining in their own home. And that's something we can offer to our patients that live locally around Tampa General Hospital.

Host: Yeah, that's great. And more information on that can be found on the website. And maybe we could talk a little also about the team that makes up the pituitary program. As we said earlier, medicine is really a collaborative effort. And it sounds like very much so in this program. So, perhaps we could talk about all the specialists that are involved.

Dr. Marla Sevilla: Sure. We have an endocrinologist specializing in pituitary disorders as well as neurosurgeons and ENT surgeons that they specialize in skull base and pituitary surgery. We have radiation-oncologists, neuro-oncologists that they have vast expertise on the management of patient with pituitary disorders. And then, we have dedicated neurocritical care physicians and nurses, neurohospitalists, and we have a nurse navigator who support patients throughout their journey.

Dr. Siviero Agazzi: Yes, I would say that, you know, the team is really the most important aspect of our pituitary center. All the sophisticated machinery, technology, everything would be useless without the expertise and the collaboration of all our team members. And really, the value of the team work is well-recognized across the nation. And our hospital was designated as a Skull Base Team of Distinction by the North American Skull Base Society in recognition of this multidisciplinary team that takes care of skull base diseases and of pituitary tumors.

Host: Wow. Such a great program. Congratulations to both of you for being able to bring this to the community. Dr. Agazzi, Dr. Sevilla, a lot of great information. Thank you very much. And for more information, you can visit the tampageneralhospital.org website. If you've enjoyed this episode, be sure to like and subscribe and follow Community Connect, presented by Tampa General Hospital on your favorite podcast platform. I'm Carl Maronich. And this has been Community Connect, presented by Tampa General Hospital. Thanks for listening.