Treating Pituitary Tumors

Medicines are the most common first treatment for these prolactin-secreting tumors. Surgery might be another option for some tumors if they can be removed completely.

Sometimes these tumors can just be watched, without treating them right away. If the tumor isn’t very large and isn’t causing bothersome symptoms, blood prolactin levels can be checked regularly. If they start to go up, an MRI can be done to see if the tumor is growing.

Medicine (dopamine agonist) as initial treatment

If treatment is needed, medicines known as dopamine agonists (cabergoline or bromocriptine) are used first. They usually lower prolactin levels and shrink prolactinomas enough so that surgery isn't needed.

These drugs usually lower prolactin levels within a few weeks, and they often shrink tumors within a few months, although sometimes this takes longer.

A person might take one of these medicines for the rest of their life. But if it continues to work for at least a year and MRI scans no longer show a tumor, lowering the dose and possibly stopping the medicine might be an option. You would still need regular checks of prolactin levels to see if the tumor comes back and whether medicine should be restarted.

If the tumor doesn’t respond well enough to the initial dose of the drug, going to a higher dose or switching to a different drug might be tried.

Effects on fertility and pregnancy: For women with prolactinomas who want to become pregnant, a dopamine agonist can be used both to treat the tumor and help restore regular menstrual cycles. However, these drugs haven’t been studied extensively during pregnancy, so they are usually stopped once a woman becomes pregnant. If the tumor grows large enough during the pregnancy to cause symptoms, the drug can be started again.

Other treatment options

Surgery to remove the tumor might be another option, either as the first treatment or if dopamine agonists aren’t helpful.

Radiation therapy might be used after surgery to try to lower the risk of the tumor coming back, especially for larger tumors (macroadenomas). It might also be an option if medicines and surgery do not work.

Pituitary tumors that make too much growth hormone (GH) can cause acromegaly in adults and gigantism in children. For more on these conditions, see Signs and Symptoms of Pituitary Tumors.

Surgery as initial treatment

Surgery is usually the first treatment for these adenomas. The goal is to remove the whole tumor, although this isn’t always possible, especially for larger tumors.

Sometimes, a somatostatin analog such as octreotide or lanreotide might be given for a few months before surgery. This might shrink the tumor and help with other symptoms, which might improve the chance of removing the tumor completely.

Blood levels of GH and insulin-like growth factor-1 (IGF-1) will be checked a few months after surgery, typically along with an MRI to look for signs of tumor. If any tumor remains, options might include:

• A second surgery, if it can be done
• Treatment with a somatostatin analog, such as octreotide or lanreotide, or a somatostatin receptor agonist, such as paltusotine
• Radiation therapy, most often when surgery and medicines don't work. This is because radiation is often very slow to work, and over time it can lead to low levels of other pituitary hormones.

Other treatment options

For people who can’t have surgery or who don’t want surgery, treatment with a somatostatin analog or a somatostatin receptor agonist is typically the first treatment.

If these drugs aren’t working, other types of drugs might be tried, such as pegvisomant (a GH antagonist), or cabergoline or bromocriptine (dopamine agonists). For more on the drugs used to treat these tumors, including how they’re given and possible side effects, see Medicines to Treat Pituitary Tumors.

These tumors cause the adrenal glands to make excess steroid hormones such as cortisol, which can lead to Cushing disease.

Surgery as the main treatment

Surgery is usually the main treatment for these tumors, if possible.

If the surgery doesn’t remove the tumor completely or if it grows back, further treatment options include a second surgery or radiation therapy. Radiation can often take many months to work, so medicines to help control cortisol levels might be given in the meantime.

Other treatment options

If surgery and radiation don't control cortisol levels, or if these treatments can't be used for some reason, other options might include medicines or removing the adrenal glands.

Medicines: Several types of medicines might be helpful for ACTH-secreting tumors, such as pasireotide (a somatostatin analog) or cabergoline (a dopamine agonist). Other medicines can help keep the adrenal glands from making cortisol or can help limit the effects of cortisol in the body. But some of these drugs can have serious side effects that make them hard to take for a long time. For more on these drugs, see Medicines to Treat Pituitary Tumors.

Removing the adrenal glands: If these treatments aren't helpful, or if a person can't take medicines because of their side effects, both adrenal glands can be removed in an operation called a bilateral adrenalectomy. This can usually be done with laparoscopic surgery that makes small cuts in the belly instead of 1 large one. The surgeon works through these small cuts with long, thin instruments, including one with a camera to look into the belly.

Removing the adrenals, which sit on top of the kidneys, stops all cortisol production. High cortisol levels will no longer be a problem, but a person will need to take pills to replace the adrenal steroid hormones for the rest of their life.

If the adrenal glands are going to be removed, the pituitary gland might first be treated with radiation. This is because removing the adrenals can cause the pituitary tumor to get larger and even start growing into the structures near the pituitary. This is known as Nelson syndrome.

If the adenoma gets large enough, it can damage the remaining normal parts of the pituitary and cause problems from hormone deficiency. It can also lead to high levels of ACTH, which can darken the skin. Whether radiation is given or not, close monitoring for Nelson syndrome is very important.

These rare tumors make too much thyroid-stimulating hormone (TSH), which causes the thyroid to make excess thyroid hormones.

The main treatment for these tumors is typically surgery. This usually works well for smaller tumors, although larger tumors are often harder to remove completely. It’s important to restore thyroid hormone levels to normal before surgery. This is usually done by giving a somatostatin analog such as octreotide for several months before the surgery. This might also help shrink the tumor and help make the surgery easier.

If surgery doesn’t remove the tumor completely, or if it can’t be done for some reason, treatment options might include:

• Medicines such as a somatostatin analog, like octreotide or lanreotide, or a dopamine agonist, like cabergoline or bromocriptine
• Radiation therapy

Each of these treatments can have pros and cons. For example, if medicines are effective, they’ll need to be taken for the rest of a person’s life.

Radiation often takes many months to work, so medicines like those above often need to be given in the meantime. Radiation might also cause side effects such as damage to the normal parts of the pituitary, while medicines can have their own side effects.

Regardless of which type of treatment is used, it’s important to watch for signs of the tumor coming back after treatment. This can be done with blood tests of thyroid hormone levels as well as MRIs.

The hormones made by these tumors – follicle-stimulating hormone (FSH) and luteinizing hormone (LH) – often don’t cause symptoms, so these tumors usually aren't found until they grow large enough to cause symptoms by pressing on nearby structures.

Because of this, nearly all of these tumors are essentially non-functional adenomas and are treated as such.

Many non-functioning pituitary tumors grow large enough to cause local symptoms such as vision problems or headaches before they are found. These macroadenomas might also cause symptoms by pressing on the normal parts of the pituitary, which can lead to lower levels of pituitary hormones.

Surgery

These tumors are most often treated with surgery if it can be done. The goal of surgery is to remove as much of the tumor as possible. This can usually help relieve any symptoms the tumor is causing and can lower the chances the tumor will come back and cause problems in the future. Some macroadenomas can be removed completely, but this might not be possible for other tumors.

Radiation therapy

If the tumor can’t be removed completely, if it comes back after surgery, or if a person can’t have surgery for some reason, radiation therapy might be done.

Radiation often takes many months to work, so it’s not usually the first treatment tried, especially in people who are having symptoms. Medicines might be tried in the meantime to help relieve any symptoms the tumor is causing, although they aren’t always helpful for non-functioning tumors.

Follow-up after initial treatment

MRI scans typically are done for many years after treatment. Eye exams and blood tests of hormone levels might be done, too. If the tumor comes back, more surgery or radiation might be used.

Medicines

Medicines are not usually helpful in treating non-functioning tumors, but some of the same drugs used when treating functioning pituitary tumors might be tried if surgery and radiation therapy aren't good options. Some doctors have reported success using the chemotherapy drug temozolomide for fast-growing tumors.

Pituitary incidentalomas are tumors that are seen on scans of the head done for other reasons. Many of these are smaller tumors (microadenomas), but some of them are larger (macroadenomas). These tumors usually don't cause obvious symptoms because they're not big enough to press on nearby structures and they don't make excess hormones.

For larger incidentalomas, tests and exams are often done to see if the tumor is making any excess hormones, or if it is causing subtle symptoms that a person might not be aware of. If either of these is true, then treatment is often recommended. Otherwise, the tumor might be watched closely over time with MRIs to see if it is growing.

Smaller incidentalomas usually do not change over time, and doctors often recommend just watching them with regular MRI scans to see if the tumor starts growing. Hormone levels might be checked, too, although not all doctors agree on which ones should be checked or how often. If the tumor starts growing or causing symptoms, it can then be treated. It's important to find the right balance so that people with incidentalomas aren't getting tests or treatments that they don't need.