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Pituitary tumors require collaborative care for best treatment results

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September 27, 2017

A statement released by the Pituitary Society outlines criteria for developing pituitary tumor centers of excellence and asserts that the best care for patients comes from a collaboration of endocrinologists and experienced pituitary surgeons.

“Such a core team needs to be supported by a collaborative environment of specialists in other areas, such as neuroradiology, neuropathology, radiation oncology, neuro-ophthalmology, otorhinolaryngology, plus trained nursing,” the authors wrote.

Felipe F. Casanueva, MD, PhD, professor of medicine in the department of medicine, endocrine division at Santiago de Compostela University in Spain, and nine other experts served as a task force to develop the statement.

The authors wrote that goals of the collaborative team should include the following:

  • detecting the tumor early;
  • diagnosing the tumor;
  • determining the most suitable treatment, whether observation, surgical, medical or radiotherapy;
  • removing the pituitary mass and preserving normal pituitary tissue, if surgical treatment is needed;
  • using treatments that eliminate hormonal hypersecretion and/or its effects;
  • preventing tumor recurrence; and
  • recognizing and caring for delayed complications.

“The final goal is the elimination or at least reduction of the excess morbidity and mortality associated with the tumor and hypersecretion syndrome as well as treatment of accompanying pituitary hormone insufficiencies,” the authors wrote. “For many patients, this requires a program of care, including medical therapy, surgery and radiation therapy, in addition with long-term follow-up.”

Further, pituitary tumor centers of excellence should be patient-centered and focus on engagement activity, family impact, educational platforms and digital infrastructure to facilitate care across specialties.

“In the last few decades, a considerable body of evidence supports the concept that patients with pituitary tumors would receive the best care from units of excellence composed of expert neurosurgeons performing pituitary surgery by transsphenoidal and other approaches, plus experienced neuroendocrinologists devoted to these types of tumors,” the authors wrote. “These experts, working in liaison with supporting units, would form a center of excellence for pituitary tumors (PTCOE). Such a center would be the optimal organization for patients, the most cost-effective for health administrators, and a more suitable structure to allow for derivation and presentation of results, and advancement of pituitary science.” – by Amber Cox

Disclosures: Casanueva reports he is a consultant and receives lecture fees from Novo Nordisk, Orexigen and Pronokal and is a member of the board of directors of the Pituitary Society. Please see the study for all other authors’ relevant financial disclosures.

itj+ Perspective

Tamara Wexler
Perspective

There is a need for the further development of Pituitary Tumor Centers of Excellence (PTCOEs). The authors of this paper, representing The Pituitary Society, suggest guidelines to inform the evaluation of PTCOEs, highlighting necessary pillars: a multidisciplinary team, dedicated subspecialists with significant continuous experience in pituitary tumors, tracking outcomes. A form of these guidelines may be used to help develop additional, necessary, PTCOEs.

The paper details several key elements: dedicated pituitary neurosurgeons with significant consistent experience in performing pituitary tumor surgery; tracked and reported outcomes; institutional support (without which it would be difficult for any PTCOE to reach its full potential) and administrative independence; reliance on a core team of multidisciplinary sub-specialists.

Expanding on these guidelines, I suggest the following:  

  • Specialized nursing is mentioned as one supporting unit for a PTCOE. Of particular use to patient care is a support staff to conduct diagnostic testing and assist in obtaining any necessary replacement hormones, a point of difficulty for many patients.
  • Ideally, patients will have a single point of contact, with needed appointments systematically arranged with PTCOE physicians in different specialties.
  • Authors note the need for outcome reporting from neurosurgeons; the same requirements can be applied to subspecialist radiation oncologists, adding to the field's understanding of the utility of different modalities and approaches. Moreover, all radiation oncologists treating the hypothalamic-pituitary area should have referral pathways to neuroendocrinologists, given the increased rate of eventual pituitary deficiencies. 
  • The authors speak to the needed teamwork of subspecialists who are dedicated to this field and have significant experience. If needed, this can be accomplished by collaboration across individual medical centers. In addition to allowing establishment of a PTCOE in areas where a relatively small group of specialists focus on pituitary tumors and that otherwise may not meet criteria, cross-center collaboration will drive progress in patient care and medical discovery. This can be done even in communities with significant expertise, and can provide a geography-specific alternative to pituitary neurosurgery, neuropathology, and/or radiation oncology regional centers.
  • Center-wide (or cross-center) registries, including tumor banking and blood samples, will facilitate further research. 

Tamara Wexler, MD, PhD

Endocrine Today Editorial Board Member
Assistant professor
Department of Rehabilitation Medicine
NYU Langone Medical Center

Disclosure: Wexler reports no relevant financial disclosures.