The Case of the Big Man With a Little Lesion

Albert Lowenfels, MD

Disclosures

June 27, 2011

How Would This Condition Be Managed Today?

Remarkable advances have been made in the management of pituitary tumors. In the latter half of the 18th century, when Byrne became ill, about the only neurosurgical procedure performed was elevation of depressed cranial fractures -- a condition often seen in miners.

Autopsy studies reveal that pituitary adenomas can occur in up to 20% of the adult population, but they are rare in childhood -- which, as judging by Byrne's rapid early growth, is when 'his tumor must have first developed. These tumors are now best diagnosed with magnetic resonance imaging (MRI) with contrast enhancement and thin sections, which can detect small tumors. About one half of pituitary tumors are prolactinomas; these often successfully treated with dopamine agonists, such as bromocriptine, and surgery is usually reserved for those tumors that do not respond to drug therapy.[8,9]

Byrne's obvious gigantism indicated that his tumor secreted growth hormone. In this condition, surgery is the treatment of choice, although drug therapy before operation may help shrink the tumor. These tumors can be large and prone to recur.

What is the best surgical approach to these deep-seated tumors? Cushing, in the early years of the 20th century, favored a transcranial approach; this achieved satisfactory results with an overall mortality rate less than 5%. The current surgical method has shifted to an endoscopic transsphenoidal approach, which allows direct access to the gland and offers good visualization without requiring major craniotomy.[10,11] Robotic surgery is also currently under investigation.[12]

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