RAM Pituitary Center of Ramkhamhaeng Hospital

 

RAM Pituitary Center at Ramkhamhaeng Hospital

 

RAM Synergy Care: “Unparalleled pituitary tumor treatment is here”

 

 

     The RAM Pituitary Center at Ramkhamhaeng Hospital is fully equipped and prepared to provide comprehensive care to patients with pituitary tumors. Our collaboration between neurosurgeons and ear, nose, and throat doctors is where surgical expertise meets innovative medical technology, ensuring that brain tumor surgery is performed with the utmost safety and precision. Our goal is to help patients return to their normal lives as quickly as possible.

 

The establishment of the RAM Pituitary Center at Ramkhamhaeng Hospital

     Ramkhamhaeng Hospital's Brain Surgery Department, under the leadership of Professor Emeritus Dr. Sira Bunyaratvej, a renowned neurosurgery professor, has been providing treatment for patients with pituitary gland tumors in collaboration with the Department of Ear, Nose, and Throat for an extended period when this collaboration reached a significant turning point in 2005, when Dr. Phuripan Aramwattanapong, an ear, nose, and throat specialist, introduced the use of endoscopes in surgeries as an alternative to a traditional surgical method via incisions through the nasal septum.\

     In 2015, Dr. Noppasin Takerngdej, a neurosurgeon, joined the surgical team at Ramkhamhaeng Hospital and continued to advance the technique of endoscopic surgery for pituitary gland tumors. This led to the team's ongoing development of surgical techniques as well as continuous technological support from the hospital. As a result, the treatment of patients using this technique has received excellent feedback.

     After extensive collaboration, the surgical teams from both departments made a unanimous decision to establish the RAM Pituitary Center, a specialized endoscopic surgery center for pituitary tumors. This joint effort emphasizes the exceptional cooperation between the two departments in delivering high-quality medical care and ensuring maximum patient safety. By combining the expertise of doctors from both departments with state-of-the-art surgical equipment, the RAM Pituitary Center provides patients with excellent treatment and care.

 

Pituitary adenoma

• Pituitary adenoma accounts for 10% of all brain tumors
• Few pituitary adenomas are malignant. 90% are benign and slow-growing
• A pituitary adenoma that is larger than 1 cm. is called a “pituitary macroadenoma”
• Pituitary adenoma that is smaller than 1 cm., it is called “pituitary microadenoma”
• Pituitary adenoma that is incidentally detected in MRI (Magnetic Resonance Imaging) and is small in size when the patient has no symptom is called “incidentaloma”
• Pituitary adenoma that produces excess prolactin hormone is called “prolactinoma”
• Pituitary adenoma with internal hemorrhage is called “pituitary apoplexy”
• Three common symptoms of pituitary adenoma are :
  • (1) Blurry vision
  • (2) Hormonal abnormalities
  • (3) Sudden, severe headaches
• Based on hormone production, pituitary adenoma can be classified into two types: functioning (excessive hormone production) and non-functioning (no hormone production)
• Diagnosis requires an MRI Pituitary (with angiography)
• Diagnosis also requires hormone level checks and visual field and retinal nerve exams.
• Treatment varies depending on the symptoms
• Surgery is the primary treatment option for this condition

 

Pituitary gland

• The word “pituitary” derives from Latin and means  "mucus" because it was once believed to produce mucus that flowed down into the nose.
• Resembling a red bean in shape, the gland is situated in the deepest part of the nasal cavity, between the two eyes, and at the center of the head.
• The pituitary gland is surrounded by retinal nerves, large arteries that feed the brain, and cranial nerves 3, 4, 5, and 6.
•  It is responsible for producing numerous hormones that maintain the body's balance, including adrenocorticotropic hormone (ACTH), growth hormone, thyroid hormone, and sex hormones.

 

The treatment approaches for pituitary tumors can be classified into two groups.

• In cases where surgery is not required, pituitary tumors can be treated through monitoring methods, visual examinations, and MRI examinations.
• This group includes tumors that require treatment through surgery, radiation, or specific types of drugs.

 

Surgical Techniques at RAM Pituitary Center

     The RAM Pituitary Center adopts the  Endoscopic Endonasal approach for its ability to provide surgeons with a wider view of the operation and cover larger important areas, allowing for more accurate and safer surgery (as illustrated).

 

 

 

 

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This method also results in patients having no external wounds and experiencing minimal pain post-surgery, leading to a shorter hospital stay and faster recovery time.

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Additionally, the center uses NeuroNavigator, which creates a virtual model of the patient, to help guide the position and direction during surgery, much like a navigation map for surgeons. This enhances patient safety during surgical procedures.

 

 

 

The Key to Success: RAM Synergy Care & Multi-Specialty Care Medical Team

     The successful treatment of Pituitary adenoma relies on more than just the surgeon's expertise. It takes a collaborative effort of a team of staff from eight different departments working together to ensure patients' safe recovery.

 

 

A pituitary adenoma is a medical condition that can cause significant changes in the hormonal system, as the pituitary gland is responsible for producing and storing multiple hormones.

 

Each patient may experience different hormone imbalances depending on the location of the tumor. Therefore, before administering anesthesia, a clear understanding of each patient's unique condition is crucial, and before the surgery, preparation includes collaboration and consultation with the internal medicine team. The surgery for tumor removal is performed under general anesthesia, rendering the patient unconscious during the procedure. After the surgery, patients will wake up gently and without coughing. As the surgery involves endoscopy through the nose, it typically does not cause significant pain. An anesthesiologist will provide adequate and safe pain medications.

 

 

When a pituitary tumor is detected, an endocrinologist will conduct a medical history check with the patient, a physical examination, and an examination to measure the hormone levels to determine whether the tumor is producing excess hormones, such as acromegaly (growth hormone), thyroid, and, less commonly, Cushing's disease.

 

Most commonly found are cases where the tumor produces an excess of prolactin hormone, which can be treated with medication if the tumor is not very large, unlike other cases of excess hormones that require surgery.

 

 

However, in cases where there are hormonal deficiencies resulting from compression of the pituitary gland (such as adrenal insufficiency, hypothyroidism, sex hormone insufficiency, and posterior pituitary insufficiency leading to diabetes insipidus), an endocrinologist will administer adrenal hormones during surgery to prevent adrenal insufficiency, monitor fluids and electrolyte balance after surgery and assessing hormone levels 5-7 days after surgery, followed by every 3-6 months.

 

A pituitary tumor can compress the optic nerve, resulting in abnormal visual fields, and blurred vision, and can also compress the 3rd, 4th, and 6th cranial nerves, impacting the function of the eye muscles and leading to double vision.

 

Ophthalmologists play a crucial role in diagnosing this pituitary adenoma as some patients seek treatment for eye abnormalities like blurred vision, or double vision, and are then diagnosed with abnormal visual fields in both eyes. Ophthalmologists are also involved in the treatment process, monitoring the effectiveness of treatment to assess if the tumor's compression on the optic and cranial nerves has decreased, and evaluating if there is any tumor recurrence based on tests of the patient's visual acuity and field of vision.

 

 

Neurologists have an important role in diagnosing pituitary adenoma. They can be the first medical professionals to encounter patients with symptoms of pituitary adenoma such as headaches, muscle weakness, and lightheadedness. In severe cases where the tumor size is large, patients may have such symptoms as loss of visual field, abnormal vision, or acute headache with vomiting and blurred vision due to tumor hemorrhage. The doctors will conduct a thorough medical history check and physical examination to identify possible causes of the symptoms. Laboratory tests such as blood tests, hormone and electrolyte level analyses, and brain scans may also be performed. Neurologists will collaborate with doctors from other specialized departments to comprehensive care for patients with pituitary adenoma.

 

 

MRI can precisely detect abnormalities of the pituitary gland as well as pinpoint the location of the tumor.

 

The pituitary gland abnormalities can be precisely detected using MRI, which enables a detailed view of the gland. When combined with angiography, MRI can identify the location and nature of pituitary tumors as well as nearby brain and sinus organs. This information is crucial for developing a well-informed treatment plan, monitoring the tumor's response to treatment, and even for surgical intervention planning.

 

 

A cardiologist is crucial when it comes to preparing patients for brain surgery. While this type of surgery is considered moderate and not as major as heart surgery, advancements in technology have led to the adoption of endoscopic pituitary surgery instead of craniectomy. This approach can greatly reduce the risk of heart complications. The cardiologist's primary responsibility is to ensure a smooth surgery. This involves assessing the patient's medical history for any congenital or hidden diseases that may impact the surgery and developing a customized treatment plan accordingly. In some cases, medication may be necessary, while others may require precise timing for surgical intervention. To achieve the best possible outcome, patients should schedule a consultation with the surgeon's team.

 

 

Pathologists have a critical role in diagnosing diseases under a microscope, including the classification of pituitary adenoma (diagnosis), determining prognosis, and contributing to the development of a treatment plan. Their involvement ensures that patients receive the most effective treatment possible.

 

 

 

Pituitary gland tumors are classified into two types.

• those that affect normal hormonal function
• those that cause hormonal abnormalities. Type 2 tumors may require medication in addition to surgery or radiation to alleviate the symptoms of hormonal imbalances. Radiation therapy may be used as an adjunct treatment in patients with recurring tumors or abnormal hormone levels to prevent relapse and improve control of hormone levels. Typically, radiation therapy takes about 5-6 weeks (25-30 sessions). However, new radiation techniques such as stereotactic radiotherapy or stereotactic radiosurgery can reduce the number of sessions to just 1-5, making treatment more convenient. These techniques are particularly useful for small lesions that are far from the optic nerve or when using proton radiation to minimize the risk to the optic nerve. They may also be used in cases where surgery is not possible or when repeat irradiation is required.