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Melanie Cole, MS (Host):   UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.

This is UAB Medcast. I'm Melanie Cole. Today we’re discussing multidisciplinary evaluation and treatment of pituitary tumors. Joining me in this panel are Dr. Brooks Vaughan—he’s an endocrinologist and a professor at UAB Medicine—and Dr. Kristen Riley, she’s a professor of neurosurgery at UAB Medicine. Doctors I'm so glad to have you join us today. Dr. Vaughan I’d like to start with you. Please give us a little background on pituitary tumors, the incidence and prevalence and the different types that you see.

Brooks Vaughan, MD (Guest):   So pituitary tumors are quite common. Estimates are that between 15 and 20% of normal people if they were placed in a good MRI scanner would be found to have a small pituitary adenoma. These are benign tumors that in most people don’t cause any significant problems. However, a percentage of them get large enough that they may cause trouble with vision changes. That can be one way that patients come to attention to physicians. The other way they sometimes come to attention is that these tumors can make hormones that cause clinical syndromes that lead patients to be evaluated by us.

Host:   Dr. Riley as we’re talking about the clinical presentation. When patients come to you or are referred to you, what’s indicated in the workup? How does it involve an endocrine evaluation, imaging, ophthalmology evaluation. What studies do you perform? Tell us about that.

Kristen Riley, MD (Guest):   Dr. Vaughan and I see patients together in a multidisciplinary clinic, which is quite useful because these patients do require a variety of investigations. When we can work together we can do that most efficiently. Generally patients come to us, most often they have already had imaging such as an MRI scan, but sometimes we need to obtain a focused MRI scan to specifically look at the area of the pituitary as some standard sequences on brain MRIs don’t adequately visualize the pituitary. In addition to imaging, the endocrine workup is quite important. That involves a battery of lab investigations as well as clinical evaluation. That’s why it’s fantastic to have Dr. Vaughan in the clinic together with me so that we have a full evaluation of the patient. Not just by their lab work but also from clinical features that sometimes lead us to do some more detailed testing that might not be familiar to a general practitioner.

Depending on the size of the tumor ophthalmology evaluation is often quite critical. That’s generally for tumors that are larger than one centimeter and extend upward towards the optic nerve. Certainly we can see larger tumors that actually extend inferiorly away from the optic nerve. So strictly the size of a tumor by itself doesn’t tell us whether ophthalmology evaluation is needed. It’s really the size and location and direction of tumor growth that dictate whether an ophthalmology evaluation is needed. Within the specifics of an ophthalmology evaluation it’s quite important to have formal visual field testing that really gives us the best idea of a potential impact of tumor on patients vision. So the combination of radiology imaging typically with an MRI scan focused at the pituitary endocrine evaluation which is clinical and a laboratory of investigations as well as ophthalmology in indicated patients. Those really are the cornerstones of our initial evaluations with patients of pituitary tumors.  

Host:  Well thank you for that comprehensive answer Dr. Riley. Dr. Vaughan, as we’re talking about some of the latest treatment options for pituitary tumors, I’d also like you to mention as you were discussing radiologic imaging for diagnostic capabilities while you're speaking about treatment options. How have some of the advances in that radiologic imaging also augmented your therapeutic capabilities for these tumors? Please speak about some treatment options—non-surgical and surgical for us.  

Dr. Vaughan:   In terms of radiologic imaging, one thing that’s been very useful for us is having more advanced MRI capability. Occasionally a patient will come, and we are looking for a tumor and prior MRIs have not been conclusive. We’ve got very powerful MRIs here at UAB and occasionally can find a tumor that’s been difficult to localize before. The other thing that’s changing rapidly in terms of pituitary disease is that we have new medications for several of our more difficult to treat pituitary diseases. So specifically we have medications that can treat prolactin secreting tumors. Those medications have been around for a while. So that’s something we’ve been able to do for years.

We’re getting more advanced treatments for hormone secreting tumors that cause diseases such as Cushing’s disease, which is excess production of cortisol, and acromegaly, which is excess production of growth hormone. In the past we’ve had little to offer those patients, but now we have several medications that can treat Cushing’s disease. We have very effective medications that can treat acromegaly. In the past acromegaly was almost universally treated with surgery. Acromegaly is the state of excess growth hormone production. These days because the medications are so effective often we take a more balanced approach to these patients and are able to offer them surgery potentially. Often they're able to consider medical therapy without surgery with very good outcomes. For Cushing’s disease we literally had nothing for many years, but now we've got several medications that work although not quite as effectively as our medications for problems with growth hormone.

Dr. Riley:   I’d like to add to what Dr. Vaughan just said. Again, highlighting the importance of being seen at a multidisciplinary clinic that sees a high volume of pituitary patients. It’s really critical for me as a surgeon to be able to, as Dr. Vaughan said, offer patients a balance of treatment options. Some of the medical treatment for Cushing’s disease, some of the advances in treatment for acromegaly, the medial treatment, certainly were not present when I was in training. It really is critical to have his knowledge and expertise there. So when we see a patient we can counsel them very comprehensively about their options. Certainly obviously as a surgeon I like to do operations. If I can cure somebody with an operation, we most definitely are happy to offer that. In some cases patients require a combination approach. Really it’s critical to be able to have those conversations between the endocrinologist and the neurosurgeon in the clinic with a patient simultaneously to provide the most comprehensive care to those patients.

Host:   Dr. Riley, as you’ve mentioned the multidisciplinary approach and how important that is for these patients, tell us how your outcomes have been and the prognosis of patients. For referring physicians, what would you like them to know about the specialists at UAB?

Dr. Riley:   In our clinic, as I said, Dr. Vaughan and I see patients together. We do all the lab work in the clinic. So it’s really an efficient system to get patients comprehensively evaluated. As far as outcomes, as you can imagine most patients are quite often terrified when they hear they have a tumor within the cranium. They panic they have a brain tumor. Fortunately these patients do quite, quite well. Many patients do not require any surgery or medication. Those that do, we have a very high success rate in treating those tumors successfully for patients who have visual decline related to the tumor. Most often they have vision improvement following surgery or other treatments. From a medical standpoint, we’re quite successful in controlling hormone issues related to the tumors. Surgery, when necessary, is done endoscopically. So it’s done without cuts on the face. It’s done through the nose. Typically it’s a two night stay in the hospital. Patients are out of bed walking around the day after surgery. Generally they tolerate the surgery very well. So our patients do well and are quite pleased with the service that we’re able to offer them.

Host:   Dr. Vaughan, as we wrap up what would you like other providers to know about the importance of referral when they do get a patient that exhibits some of the clinical manifestations you’ve discussed here today? What would you like them to know about this team and referral?

Dr. Vaughan:   We know that pituitary disease because it is so complex and requires multiple specialists including ophthalmologists, radiation oncologists, surgeons, and endocrinologists that it’s best treated in a center that has all of that available. There are, in fact, guidelines that suggests these tumors should only be treated in what we call centers of excellence that have all of those services available. Dr. Riley and I really feel that this can't be done without this type of approach. I cannot tell you how many times we have changed treatment decisions based on discussion we’ve had face to face either looking at scans or looking at labs together. Many of those decisions I never would have made on my own. Generally that is in the best interest of the patient to have that discussion at one time with all the specialists that are involved in their care.

Dr. Riley:   Just to add on that, Dr. Vaughan and I are in together one day a week on Tuesdays. For the most part with new referrals we see patients within one to two weeks. Certainly there are occasions where I might see the patient without Dr. Vaughan initially if it’s quite urgent and it’s not around a Tuesday, but we’re happy to help facilitate appointments and evaluations and certainly welcome those referrals. Just to wrap up as Dr. Vaughan said, it’s really critical to have patients evaluated at a center of excellence so they can have the most up to date treatment options presented to them. Having said that, we do collaborate with the outside endocrinologists and physicians for the coordination of patient’s care. We really enjoy working with our colleagues in the community and elsewhere in the state and certainly welcome those referrals from endocrinologists and neurosurgeons in the state as well.

Host:   Thank you so much, both of you. What an excellent segment. Such an interesting topic. Thank you for explaining that comprehensive multidisciplinary approach and why it’s so important for patients with pituitary tumors. A community physicians can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Medcast. For more information on resources available at UAB Medicine, please visit our website at uabmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB podcasts. I'm Melanie Cole.