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Suffer nausea, diarrhea and flu symptoms. Feeling weak. Blood work showed low sodium. CT scan showed macropituitary adenoma. What to do?

May 2014
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Practicing since : 2002
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It all came to a head the end of April with flu like symptoms which continued to get worse with nausea and diarrhea until I was so weak I couldn't stand. Admitted to hosp., blood work showed very low sodium level 110, followed by chest xray and CT scan (I have a pacemaker, so therefore no MRI) which showed a 2.9cm. macropituitary adenoma. A CT scan had been done 71/2 yrs. earlier for other reasons which when looking back showed that the tumor was there at a size of 1.9 cm.
Last week I saw the endocrinologist again, after all the repeat blood work had been done. The original blood work for my cortisol levels while in hospital had showed that they were fine, which had surprised the Dr., but the repeat blood work showed a lower level of the cortisol hormone, which means that my pituitary gland is not producing the way it should. Therefore she gave me a prescription for hydrocortisone (cortef) which is a steroid and I am to take 10mg. in the am. and 5mg. at suppertime. After a day and a half of taking the medication there was a significant increase in my energy level. However none of these drugs are without their side effects and although the increased energy feels great, it is not naturally being produced, it’s the medication that is doing it. For this reason I was of the opinion that if/when I had surgery, my pituitary would possibly be able to resort back to functioning on it’s own and was lead to believe that surgery was probably the best option. (at least in my mind, it was). Long term effects of the cortisone can have other implications, such as diabetes, kidney problems etc.

Phase two: Yesterday, I saw the Neurosurgeon. He discussed the options and asked how I felt about surgery. I said I was anxious to have it done and over with. He proceeded to discuss all the risk factors involved in surgery, which are many, but some of them quite rare. In my mind, the logic was, that the sooner I get the tumor out of there, the better I would be on all accounts, i.e., risk of having a repeat episode of sodium level dropping, risk of further damage to the pituitary gland and subsequent problems with continuing to take the steroids, risk to the optic nerve if the tumor continues to grow larger, so I was fully prepared to go forward. However, in conclusion when I asked the Dr. what he would advise if one of his loved ones were faced with the same thing, he brought up the fact that I’m not as young as I used to be ( I am a 68yr.old female) and possibly there might not be any further problems with the tumor being there, also my chances of discontinuing the hydrocortisone, even after surgery are probably not so great, so perhaps it would be better to monitor it for the next year or so and see what happens. That comment sort of ‘burst my bubble of logic’, so even though I signed papers agreeing to go forward with the procedure, I’m beginning to second guess my decision and don’t have the peace about it that I had going into the appt.
Any comments or suggestions gratefully received.
Posted Fri, 19 Jul 2013 in Brain Tumor
Answered by Dr. Vivek Chail 4 hours later
Thanks for writing in.

I have gone through your medical history with diligence. In short you are having a pituitary macroadenoma since 7 years and which was 1.9 cms initially, has now grown into 2.9 cms. You had hyponatremia (low sodium) and were put on steroids but dont have any problems with your vision right now. After consultation with your neurosurgeon, an operative treatment has been decided upon. However, you need to reconsider the risk benefit part following surgical treatment.

Your question is very important and reasonable.

There are three methods in the treatment of pituitary macroadenomas, medical, surgical and radiation therapy (using gamma knife).

1. Medical therapy: You are taking this for quite sometime and are familiar with the advantages and disadvantages of taking steroids for a long time.

2.Gamma knife therapy: Radiosurgery using a gamma knife allows targeting maximal radiation to the tumor while minimizing radiation to the surrounding tissues. This is done using highly accurate computer-assisted stereotactic technique followed by few radiation treatment sessions to the tumor. Incidence of hypopituitarism (decreased functioning of pituitary) is less.

3. Surgery: In this the endonasal transphenoidal endoscopic surgery is the approach of choice. The doctor operates on the tumor through the nose. It is highly successful. Surgery is done after pre operative hormone level workup and correction.

Sometimes, more than one method of treatment can be used in a patient to get better end-results and reduce recurrence.

The main idea behind treating pituitary macroadenoma lies in correcting any excess or deficient hormones in the body as a result of the tumor.

There are conditions like transient diabetes insipidus and hyponatremia that can occur in the immediate post operative period but your doctor will correct that before sending you home.

After discharge you may need monitoring for the development of hypopituitarism after surgical treatment. This happens years after gamma knife surgery.

As an outpatient you may be assessed for any hormone deficiencies and particular medications can be prescribed. Please be informed that the post operative complications including diabetes insipidus, hypothyroidism, and hypogonadism, may occur. At your age however, they can be well managed and will not have any severe effect on your quality of life.

Finally all I would say is that the tumor has been growing very slowly in your case and all you need to be aware of is any visual loss because of the tumor. Other than that you are already aware of the consequences of steroid treatment.

I wish the above information will help you in taking an appropriate decision on whether to go for the surgery.
Wishing you good health.

Dr Vivek

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