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Another reason is some of these tumors can simply just get massive. They are so massive that they grow and when they grow, they primarily grow up rather than down into the sphenoid sinus. We’d love them if they all grew into this sphenoid sinus cavity, but because that bottom part’s covered with bone, the easiest place for these pituitary tumors to grow is up and then sideway, and then lastly down. But when they grow up, they can get very, very large and then all of a sudden distort the optic chiasm. They can then even sometimes grow around the optic chasm and truly massive ones can even go beyond that. When they do get that large, while we often will still do a transsphenoidal approach, it becomes pretty apparent to surgeons experience with this that, um, there are some of these tumors that you’re not going to get enough tumor out from below and then coming from above becomes the correct course of action. And so, that’s definitely one set of reasons that we would come from above and do a transcranial approach.
The main goal of the surgery remains though, decompressing what we call the optic apparatus. That typically remains the main goal when you are moving these large tumors. And once the optic nerves are decompressed, we still definitely want to try and remove the rest of the tumor. But the primary goal of surgery remains decompressing the optic apparatus and protecting vision.
So while surgery is probably still considered the mainstay of treatment of pituitary Adenomas that need some sort of intervention, there is another category of treatment that has entered into the treatment of pituitary tumors, and that would be radiation. And specifically stereotactic radiation, which is the more precise delivery of radiation to a specified volume of tissue. And the reason that’s become important for pituitary tumors is because sometimes you’ll have hormonally active tumors. So you have these small tumors that are hormonally active and wreaking havoc through the body, and you’ve had a patient who maybe has had prior surgery or another scenario where they’ve had surgery and the tumor, now you almost can’t see. And so, you’re, stuck with, hey, the mass effect of the tumor is gone, but it’s still hormonally active and radiation entered the picture to solve problems like that.
Radiation can be delivered and so it’s really a blast of radiation that’s given to the target. And the target usually ends up being the pituitary gland. So radiation is fairly indiscriminate of that. Like the surgeon, which can distinguish between what’s tumor and what’s not, radiation has no power to do that. But it’s one advantage is that it can kill at the cellular level and so you’ve got a patient say with Cushing’s disease and it’s tiny tumor producing large amounts of ACTH which is producing ultimately large amounts of cortisol in the body and that if left untreated can be fatal and certainly reduces lifespan. So radiation can enter the picture and kill those cells that are producing that hormone perhaps when surgery has failed to accomplish its goal. And then radiation can enter the picture and maybe in the absence of surgery altogether in somebody who may be just medically unfit to undergo surgery, but they’ve got a tumor that is threatening to compress the optic chiasm, radiation can work. Some of the advantages of radiation, are it can be applied in patients who are not perhaps medically fit for surgery. And other times it’s actually a good choice for some hormonally active tumors that still persists despite surgery.
Pituitary masses are one of the peculiar masses of the brain because there are some of them, in fact, a substantial fraction of them that can be treated with medication alone. And actually cured in many instances with medication alone, and so as scary as the prospect of a pituitary tumor sounds, about a third of them are actually a condition that we call, or a tumor that we call, a prolactinoma. And that word is chosen because that tumor, about a third of pituitary tumors are secreting this hormone called prolactin. And if we remember back, prolactin is the hormone that is secreted that allows milk production, post pregnancy, and it is a hormone that we can control and it’s a hormone that we can actually suppress with the use of some medication.
So let’s summarize very, very quickly. Prolactin, milk production, and a lot of pituitary tumors do that. Growth Hormone, you get gigantism or acromegaly depending on the stage of life if that pituitary tumor is to creating that. You’ve got Cushing’s disease, too much steroid production, and that’s another uncommon pituitary tumor, but a common condition in the neurosurgical world. And then, thyroid hormone, which you don’t see many pituitary tumors produce too much of, but a lot of cases where they’re producing too few of. You’ve got, then the dysfunction of the sexual hormones. And then the water hormone irregulation which dysfunctional if they get an operation, but otherwise, not too many tumors that produce that as a problem. And then, finally oxytocin, which we don’t make much of a fuss of.
Pituitary masses produce an entire new different wrinkle into this because a pituitary mass can be awfully small, so small that it’s not really pushing on anything. The pituitary really isn’t implicated and it doesn’t really, cause seizures can’t do that. Pituitary tumors have to get really massive before they produce water on the brain. But the new wrinkle that they have is that even this teeny little mass can start secreting hormones and those hormones can wreak havoc all through the body and produce all these changes in different parts of the body and so pituitary masses can present with symptoms in a patient and a whole different way, and namely hormonal dysfunction. And so pituitary masses can certainly produce symptoms by what they push into if they get big enough. But they’ve got this different way of producing symptoms by the dysfunction that they produce on hormones, either by too much hormone secretion or too little hormone secretion.
If we had to break it down into the big classes of hormones that it produces. So one big hormone that it produces, or what one organ that it controls is the thyroid gland. So the thyroid gland is heat and cold intolerance. It’s what, to some extent, gives us the energy to get through the day. People without thyroid hormone get very, very lethargic, hard to arouse and wake up, and ultimately a very, very low thyroid level can even lead to death. Pituitary tumors that produce thyroid hormone are very, very rare. In fact, it’s usually the opposite problem where you’ve got a pituitary tumor and it doesn’t allow the normal pituitary to won’t function right and people get a slightly low thyroid state.
It’s very common for people in their eighties or nineties to have this tiny spot on their pituitary. What a spot probably though deserves is the following, is a first a check of the hormones because sometimes these small spots or dots are hormonally active and you would want to know that and catch that early rather than late. And so seeing an endocrinologist or a neurologist or a neurosurgeon or even that patient’s internist would be a wise idea because they would probably want to run a battery of blood tests to make sure that this spot isn’t producing some dysfunction of the hormone system. But let’s say for the sake of argument that it’s not, because usually it isn’t. Then the appropriate next step for a small, and what does small mean? A few millimeters in size, abnormality. Well, how do we typically manage it? Well we do what we call surveillance imaging? And what that means is we basically check it again in a few months, make sure it’s not growing. And if it’s not, sometimes we’ll say, hey, look, it hasn’t grown in a three month period. Let’s check it every year or sometimes every other year to kind of keep an eye on it. And sometimes, you know, after an appropriate period of time and both patient and doctor get bored at looking at the same spot, a decision is made not to look any further and there is nothing inappropriate about that.
Transcranial approach does usually meet a bit longer recovery for the patient but the surgeon definitely gets excellent visualization of all of the structures above the pituitary gland itself. Paradoxically it’s very, it’s sometimes difficult to see the bottom most part of the pituitary gland when you’re coming from above. And that’s definitely, you’re much more easily accessed from below. But from above, it’s typically an incision that starts near the ear and then curls forward behind the hairline towards the midline. And so it’s a bit longer incision and then we do have to remove a portion of skull. And then after that we opened the lining of the brain, but we do not go actually through any brain tissue. The brain is moved aside and we have ways of doing that safely. And then we typically bring in a operating room microscope. We actually visualize the tumor, we visualize the critical nerves and blood vessels and the nerves that are usually in the surgeon’s field or the optic nerves. So those nerves that are transmitting the signal from the eyes back to the brain. So very, very important structures. And then the tumor is removed often piecemeal, and the surgeon hopes it’s again, soft, which they often are, and we’ll come out with the use of a sucker and other specialized instruments that we have for neurosurgery to remove these tumors.
Pituitary tumors can be, all kinds of tumors of course, but in general, most pituitary tumors, when we talk about pituitary tumors, the most common type is something called the pituitary adenoma, which the overwhelming majority are benign. But chemotherapy just as the word means, anything that you’re using chemicals to treat. So technically a lot of the medications we use would be called chemotherapy, but, but most people, when they hear the word chemotherapy, they’re thinking of cancer treatment and chemotherapy. And so pituitary Adenomas are overwhelmingly benign. Now, the interesting thing about pituitary Adenomas is there’s no way for the pathologist to know whether it’s benign or not, and it’s clinical behavior determines whether it’s benign or malignant, but virtually all and what do I mean by that? 99 plus percent of pituitary Adenomas are benign tumors, and it’s an exceptional tumor that actually metastasizes. So chemotherapy and pituitary adenoma in general, in clinical practice, we are combining the use of those two treatments.
Hormonal manipulation as a therapy for other hormone producing conditions of the pituitary are much more difficult. There are treatments for acromegaly, which is another type of tumor which secretes excessive amounts of growth hormone. And there are some medication avenues to treat that condition, but none of them are as good as the treatments we see for prolactin secreting tumors. The last hormonal secreting tumor that we see clinically is the excess production of ACTH which produces incredibly high levels of cortisol, which can wreak havoc through the body. And for that medical treatment exists, but it’s probably the poorest of the three and the three meaning prolactinomas then growth hormone, secreting tumors. And then finally, uh, we are least successful with medication treatment of ACTH secreting tumors.
You could get cysts there. So there’s Rathke cleft cyst, or there’s other pituitary cysts, and those are actually fairly common, but you can easily distinguish them from tumors on an MRI scan typically. Finally you’ve got stranger tumors like craniopharyngioma yet another tumor. But with modern MRI imaging, you can usually distinguish them from the most common type of pituitary mass, which is a benign pituitary tumor. And to a large extent, we’ll probably want to focus our attention on that because the other ones are, you know, rare, have more specialized care behind them, and by and large, when people are looking for what to do with, you know, their mass, they’re usually talking about a benign pituitary tumor or a benign pituitary Adenomas.
The recovery after this, once the surgery is complete and often the surgery can be completed in 90 minutes, two hours, one hour, again, depending on the size of the tumor, the consistency of the tumor and the experience of the surgeon. But once either the endoscope is withdrawn or the surgery is a otherwise complete, the patient is usually brought to the recovery room and often it’s a same day, stay overnight, stay, it wouldn’t it be any longer, unusual in the world of pituitary surgery, particularly if the case went well and there were no complications during surgery. Most patients typically imagine that their nose will be dramatically swollen and it really will alter their physical appearance. But the reality is that except for the patient and maybe their very close family members, most people would not even know that that person had pituitary surgery, if they met somebody, say in a mall, even two days after surgery, it would be an almost unbeknownst to any observer that they had. And what would be typically considered, you know, a neurosurgical procedure, and most people, when they think of neurosurgery, they’re thinking of, you know, hospitals several days, a scars on the head. So this is an operation that’s definitely in many respects different than that.
After say several years of looking at the same spot there may be enough confidence on the part of both patient and a physician that checking this further is not going to be meaningful. A perfect case in point would be, let me get a case illustration might be somebody who’s in their late eighties, medically, somewhat frail already. A pituitary spot gets discovered. Hormones get checked, they’re completely normal and another one year, two years, five years passes and the spot hasn’t changed in size. Now the patient is now in the early nineties. And I think then it’s perfectly reasonable for both patient and physician to come to some sort of conclusion that maybe it’s not going to be that worthwhile checking this again because it costs time, energy, money and at the end of the day does it really change the decision making that would be involved even if that spot where to grow a tiny bit more, you sort of plot out that hey look, it’s going to be 30 years before that spot at that growth rate is going to create some sort of mass effect problem. And patients already in their late eighties and some patients might say, Hey, doc, let’s forego it. And the doc may say, yeah, I think that’s reasonable.
So the pituitary is what regulates our growth. So when all of a sudden when puberty hits, it’s got to kick in and produce this hormone called growth hormone. And there are pituitary tumors that produce too much of this. And if somebody has a pituitary tumor and is unfortunate enough to have it produce growth hormone during adolescence, before the growth plates have fused, then all of a sudden you get a condition called gigantism. And that’s where you see in the Guinness Book of World Records these people are, you know, eight feet, nine feet tall. They had a pituitary tumor producing growth hormone. But if that tumor gets, starts producing growth hormone after puberty and the growth plates have fused and you get a condition that, Andre the giant is a perfect example where you get these very coarse facial features and we can even talk later about all the other things that it might do to the body aside from the coarseness of facial features. But that’s probably the most recognizable thing people get are these massive hands and a face that looks block-like and loses its fine, fine features.
Another hormone is ACTH and you don’t have to remember the letters there, but that’s what controls our steroid function. And there are pituitary tumors that secrete too much of this. And then people get a condition called Cushing’s disease, named after one of the famous neurosurgeons, probably the grandfather of neurosurgery. Another hormone that it produces is prolactin. And Prolactin is a hormone produced after pregnancy in a woman which allows milk production. And this is actually a very common, pituitary tumor where too much prolactin and gets made. And there’s men who start lactating. And if you don’t think that’s a strange thing, it is to the point that some men are afraid to even bring it to the attention of their physicians. On the other hand, some men are of course, so frightened by it that that’s the first thing they run to is Oh, Geez, I’ve got breast development and lactation going on. So that’s another hormone.
Another set of symptoms are too much hormone production. So the hormones that pituitary tumors typically overproduce are prolactin, which will produce milk production in male or females, or too much steroid production, which can do a whole bunch of things to the body in a bad way, or too much growth hormone, which produces a condition called acromegaly. And that’s fundamentally the two ways that pituitary tumors can present. Hormone dysfunction or disturbance by growth and that would be typically visual disturbance or double vision.
So pituitary masses, the way they can produce symptoms in a person, you can basically break it down into a couple of categories and then you can certainly look at it in a very complicated way or I’m going to hopefully present a simpler way. And so one way mass is in the brain or masses anywhere in the body can produce symptoms is they just grow so big that they start pushing on their neighbor and their neighbor stops working the way it’s supposed to or whatever structure is next to them, stops working the way it’s supposed to do. The pituitary sort of sits in almost the geometric center of somebody’s head pretty close actually. So it’s between the two orbits and in the midline, it’s not a paired organ. So in other words, there’s not a left and a right pituitary like there is with so many of the other organs. So there it is, it can grow in a variety of directions. And if we just sort of look and see what sits in every direction, that’ll give us an idea of what symptoms it can produce if it just grows and stops or doesn’t allow whatever structure pushes onto to work right.
There’s a big category of tumors which are hormonally inactive, which means you’ve got a large mass of the pituitary, you check a hormonal profile and it comes back showing, hey, there is no hormone excess production. And for those, that category, which is the largest category of pituitary tumors, there is no medical treatment options. You are either stuck, wait and watch if the mass is small enough, or you have to do surgery.
Yet another set of hormones controls our sexual function. And so pituitary tumors are rarely producing this stuff, but if a tumor grows and pushes on this, then men can get low testosterone, and that can sometimes be impaired libido and impaired directions. The other hormones revolve around water balance. And that’s rarely a problem with pituitary tumors unless they’ve been operated on, in which case, that can get dysfunctional. Yet another hormone is oxytocin, which in clinical practice, we almost never make any fuss out of it, but for completion sake, I’ll throw that in there as well.
So let’s talk a little bit about pituitary adenomas and surgical approaches and specifically now we’ll shift gears a little bit and talk a little bit about transcranial approaches to pituitary masses. The first question is, you know, why would you come from above when you’ve got a nice corridor, the transsphenoidal approach that lets you get to the pituitary from below and usually gets you there faster. Patient recovers faster. Surgeon typically likes that operation better. Patient typically likes that operation better. But there are times when you have to access the pituitary gland and any tumor associated with it from above or a transcranial approach. And the reasons for that are sometimes you’ll come from below or transsphenoidal approach, and the tumor, and this is uncommon by the way, but the tumor is simply so firm that it doesn’t deliver itself down to the surgeon and, sometimes that would obligate a transcranial approach. Admittedly, that’s quite uncommon.
Pituitary tumors, we’ll chat a little bit about, first of all, who actually should get treatment for a pituitary tumor because not everybody who harbors a pituitary tumor or pituitary mass needs any treatment at all. So in the case of pituitary tumors, if we just remember back to where they’re located, sort of near the geometric center of somebody’s head, the base of the skull, in a little hollow called the Sella Turcica. When pituitary tumors or pituitary masses grow, one of the first things that they’re going to see is a structure called the optic chiasm, which is where the two optic nerves meet. And if that gets compressed, then people can suffer visual decline. And so one fairly compelling reason to treat pituitary tumors is when the tumor size gets so large that it pushes on this structure, produces dysfunction of this structure called the optic chiasm, and people’s vision is threatened. And that’s a very, very compelling reason to do something about pituitary masses.
One of the findings with pituitary tumors that get big enough or visual dysfunction. And it’s not blurry vision, so it’s like somebody goes to an eye chart and says, “Hey, you know, I can’t read 20/20.” In fact it is 2020. But it’s more akin to maybe people, think of tunnel vision, but what, what really is, is they can’t see the peripheral part of their vision on either eye, and so that’s the kind of visual deficit they get, not, oh, you know, I need glasses to fix this type of visual disturbance. Of course, if you let it keep growing and it’s completely untreated, even blindness can result because eventually, all of the signals that are trying to get to the brain from the eyes get lost. So that’s one set of symptoms, if it grows up.
Another category of symptoms are where as a pituitary tumor grows, the pituitary gland no longer produces the hormones that it’s supposed to. So the hormone that’s typically involved versus the thyroid hormone. And so people get low thyroid or low testosterone, and that’s certainly led to people being diagnosed with pituitary tumors.
Another is if it grows to the side, and that’s harder for it to do, of course, cause there’s a bony tissue there. But pituitary tumors can do that. And the structures on the side are the nerves that go and move the eye. And pituitary tumors can produce double vision in that way where the nerves of the eye don’t work quite right. If they go down they sort of fall into this big air cavity called the sphenoid Sinus, and they’d really have to get massive before they produce any symptoms that way because there’s a lot of space for them to grow that direction. But in order for them to grow that direction, they really have to thin out bone. So it’s hard for them to do that, but the big ones do. So that’s one set of symptoms, on just sheer growth and pushing on neighboring structures.
The administration of this medication or this category of medication are called Dopamine agonists. But if you give somebody who has a tumor that is secreting high, high amounts of this hormone called prolactin, by giving them this category of medication, not only will you suppress the secretion of prolactin, but in doing so, the tumor will actually begin to die off slowly. And so after a period of one or two years of this therapy, a lot of patients actually experience not just dramatic shrinkage of the tumor, but a cure. The illustration with MRI imaging is rather dramatic. So you sometimes got patients who come in with truly massive tumors of the skull base, destroyed parts of the skull base, compression of the optic chiasm. And one of the very, very first things a neurosurgeon or an endocrinologist will check in that circumstances a prolactin level because if that comes back markedly high, and what do we mean by markedly high? Anything over 100, 200 we’re very, very confident is a prolactinoma. And usually tumors that size will produce prolactin level in the thousands. And by giving of this category of medication, we really can see that tumors shrink and actually in many cases be cured.
The easiest way for it to grow is up because up there no bone that direction. The pituitary sits in this little cup almost. It’s got a fancy word that’s associated with it called the Sella Turcica, which means Turkish saddle. But suffice it to say that it sort of sits in a cup of bone. And so the easiest way for it to grow is up. And if you were sitting in the pituitary and you look straight up, what you’d see is the two optic nerves on top of you forming an x. They come together and form a structure called the chiasm. But the bottom line is the both optic nerves, which are sending signals from your eye and ultimately to your brain, sit on top of the pituitary. So as this tumor grows, that’s the first structure it’s gonna touch and then distort.
Pituitary tumors, we’ll chat a little bit about. First of all, who actually should get treatment for a pituitary tumor because not everybody who harbors a pituitary tumor or pituitary mass needs any treatment at all. So in the case of pituitary tumors, if we just remember back to where they’re located, sort of near the geometric center of somebody’s head, the base of the skull, in a little hollow called the Sella Turcica. When pituitary tumors or pituitary masses grow, one of the first things that they’re going to see is a structure called the optic chiasm, which is where the two optic nerves meet. And if that gets compressed, then people can suffer visual decline. And so one fairly compelling reason to treat pituitary tumors is when the tumor size gets so large that it pushes on this structure, produces dysfunction of this structure called the optic chiasm, and people’s vision is threatened. And that’s a very, very compelling reason to do something about pituitary masses.
Not everybody who has a pituitary mass or pituitary abnormality needs treatment. In fact, there’s a whole category that we’ve now kind of termed, for lack of a better word, pituitary incidentalomas. Probably, I’m not sure it’s made itself into the official medical lexicon yet, but basically what it means is that you’ve got a pituitary mass that or pituitary abnormality that we ended up discovering because somebody came in for imaging for an entirely unrelated reasons. So they were dizzy, had a headache, stroke workup. Any one of a number of things. And during the course of the MRI image review, all of a sudden we see this small mass in the pituitary or abnormality in the pituitary. And the question is what do we do about it? And oftentimes, for that kind of circumstances, especially, and if the patient is in older category, we may choose to do nothing. So how do we know that we’re going to do nothing? One, here, age does play a big role in it. People have looked at some studies and sometimes even up to 10% of people that are in an elderly age group will have some sort of pituitary abnormality if you look really, really close.
Another compelling reason to do something is some pituitary tumors are tiny, so tiny, sometimes we don’t even see them very well on imaging. Yet, they produce enormous amounts of a hormone. And this excess production of hormone can sometimes wreak havoc throughout the body. And so sometimes we will have a compelling reason to treat a pituitary mass even when it’s not pushing on anything. And that’s a little different twist on many brain masses where usually we’re treating because they are pushing on a critical structure. Pituitary masses form one exception to that rule where even if the masses physically small, we will sometimes treat simply because the hormone that produces produces such a untoward effect on many, many systems of the body.
If a decision has been made that we’re going to proceed with surgical treatment of a pituitary adenoma, fundamentally there’s two corridors that you can access the pituitary from. One is essentially from below. So you’re coming either a incision on the inside the mouth above the teeth. That’s one corridor of access through the nose. But fundamentally they all get to a area of the pituitary, or an area that sits below the pituitary called the sphenoid Sinus, which is this air filled sort of cavity. And the pituitary sort of you can see hangs into this air sinus. So however you get to that air sinus, there’s variety of techniques. Some people make a decision in the nose, some people, like I said, make an incision and in the mouth, some people do it endoscopically, which means through a little scope or a little tube. However you get there, you’ll find yourself in this sphenoid sinus and you’ll find the pituitary gland, and therefore the pituitary tumor that’s housed there also sitting there and that’s one access corridor. Another access corridor is what a lot of people think of when they think of neurosurgery and that would be an incision on top of the head going through the skull and then gaining access to the pituitary from on top. So you’ve got a corridor from below and you’ve got a corridor from on top.
Surgical management of Pituitary adenomas. If it’s determined that a tumor should be removed surgically, a pituitary tumor and typically, we are talking about pituitary adenomas, the indications for surgery we sort of already discussed, but primarily would be one of two indications. Tumor is big and pushing on things. And typically that would be the optic apparatus. So some sort of visual threat may be involved here, or maybe the tumor is big, patient is young and we’re worried that the growth rate of the tumor would lead to future visual threat. So that’s one reason. Another reason would be a hormonally active tumor that can’t be treated with medication.
Let’s talk a little bit about the corridor from below, which is called a transsphenoidal approach. And again, transsphenoidal because you’re going through the sphenoid sinus to gain access to the pituitary tumor. That access corridor in many respects is the easiest on the patient. The incisions are usually smaller. The recovery period is usually faster. And to a large extent, these tumors are soft and in general, pituitary Adenomas are soft tumors. And so when you find yourself in the sphenoid sinus, surgeons looking into the sphenoid sinus, sees the pituitary mass sort of hanging down into the surgical field. There may be a thin layer of bone still covering it, but in large tumors, that bone is actually eroded away. And you’ll be faced with a thin layer of Mucosa and the lining of the brain, which is called the Dura.
So the surgeon will make an opening in the mucosa, go through any small amount of bone that may be there, make an opening in the membrane that we called the Dura and come face to face with what’s typically a very, very soft tumor. And the tumor actually almost wants to get out of there. And so upon opening it in many, many tumors, the tumor will actually sort of almost gush out a little bit. And typically those tumors, they’re soft, they’re often milky white, sometimes a red tinge because of previous hemorrhage and soft enough that we don’t need to pull them out, but we’ve got these special blunt rings, they’re called ring curettes, and by putting those ring curettes into the area of the pituitary tumor, we can essentially almost scoop it out, like you’d scoop out soft ice cream. And, slowly with time the pulsation of the brain itself will push more and more tumor out into the surgical field. And eventually these ring curettes will recover less and less tumor and finally, no tumor. And that’s when the surgeon knows that, “hey, I’ve gotten out all the tumor I can from this corridor.” and typically stops. And either this is being done through operating room microscope. So a special microscope designed to look down corridors like this and offer good lighting and good magnification or through a scope, which is a technology that originally it was used for other parts of body brought to the neurosurgical field and found a great application in pituitary surgery where a scope is placed. But essentially, a lot of the mechanics of how the tumor is removed is the same, whether it’s through the operating room microscope or a endoscopic approach.
My name is Dr. Abhay Sanan. I’m a practicing neurosurgeon in Tucson, Arizona at the Center for Neurosciences. I essentially grew up here in Tucson, Arizona. I’m originally from India, but I moved to Tucson at the age of three and, did my elementary, middle school and high school in Tucson. From there, I went to Boston University School of Medicine where I did my undergraduate and medical school in a six-year accelerated program. From there, I went onto a neurosurgical residency at the University of Minnesota and I spent some time near the end as a chief resident at the Mayo Clinic in Rochester. From there, I took on a skull base and cerebrovascular fellowship at the University of Cincinnati. And after that I was lucky enough to come back to Tucson, my hometown, where I was fortunate enough to, become a neurosurgeon and partner within the Center for Neurosciences, which is a practice in Tucson, Arizona, entirely devoted to neurological sub-specialty care.
The pituitary is involved in, the main categories that it sort of regulates, regulates your thyroid. It regulates your steroid function. It regulates your sexual development. It regulates your growth during adolescence, puberty. It regulates your water balance and it regulates in women, lactation.
Pituitary. So let’s just step back for a moment and look at pituitary masses as a whole. So pituitary is just, it’s an anatomic organ that resides in this small confined space. And so pituitary masses can be, you got pituitary tumors, which can be benign or malignant, but by and large are almost always benign. The number of malignant pituitary tumors is, it’s a fraction of what is the big bucket of pituitary benign tumors. You can get infections there so you can get a pituitary abscess, but also fairly rare condition when compared to pituitary benign tumor.
The question really is about the physiology of the pituitary gland. Physiology is a word that physicians use that means the function of something. So what does it do? Not just where it is. So pituitary, its function is, it’s called the master gland. It’s ultimately controlled by something that sits on top of it, called the hypothalamus, which is really pulling the strings of the pituitary. And then the pituitary secretes these hormones that then go through the whole body. And the pituitary has several hormones and they’re sort of separated into two parts of the pituitary. And the pituitary has this front part, which we call the anterior pituitary. And this back part that we call the posterior pituitary.
Most pituitary tumors just happen because they want to happen. And it’s not because you know, somebody smoked too much or drank too much. There are a couple of rare genetic conditions that can lead to pituitary tumors, but those account for but a fraction of the pituitary tumors. So by and large, these are just benign tumors that happen, and in fact, remarkably common. So if you start looking at the pituitary of everybody that dies of whatever cause, so typically you’re looking at people that are over the age of 80, dying of whatever cause sometimes just old age and you start looking at their pituitary very, very closely, as much as you know, 10% or higher of people, will have some pituitary abnormality. And so very, very common. And so for those, you know, quite frankly, these tiny little pituitary abnormalities, we don’t do a whole lot about. Sometimes we just recognize that they’re there, we follow them along, make sure they don’t get, bigger, big enough to cause a problem. But the bottom line here is small pituitary abnormalities are actually very, very common. And so a small pituitary abnormality in an older person oftentime not something to stress about too much.
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