Among few of its kind in the nation, the Pituitary and Neuroendocrine Program at Brigham and Women’s Hospital (BWH) provides expert, coordinated care for patients with pituitary tumors. Led by Medical Director Whitney Woodmansee, MD, and Surgical Director Edward R. Laws, MD, FACS, the Program incorporates subspecialists, including neuroendocrinologists, neurosurgeons, neurologists, neuroradiologists, neuro-ophthalmologists, neuropathologists, radiation oncologists, neuro-oncologists, psychiatrists, and others, to optimize outcomes for patients.
“Our collaborative approach is present in all aspects of the patient’s care, from evaluation through treatment and ongoing care,” said Dr. Woodmansee.
Patients are initially evaluated by both a neuroendocrinologist and a neurosurgeon in the Program during one visit, and additional specialists participate in each patient’s care as indicated. A full range of diagnostic testing is available to assess pituitary function, including advanced dynamic endocrine testing and inferior petrosal sinus sampling when indicated. These are used in conjunction with imaging and other techniques to aid in treatment planning.
Neuroendocrinologists in the Program use the latest therapies to treat hypersecreting pituitary adenomas and hormonal deficiencies. Therapies include dopamine agonists, somatostatin analogs, growth hormone receptor antagonists, and glucocorticoid receptor antagonists. Neuroendocrinologists in the Program also are participating in a number of clinical trials for acromegaly and growth hormone deficiency, including a Phase III trial, led at BWH by Site Principal Investigator Ursula Kaiser, MD, Chief of the BWH Division of Endocrinology, Diabetes, and Hypertension, that is assessing a long-acting growth hormone formulation delivered by weekly injection compared to the current standard daily injection in patients with growth hormone deficiency. Other upcoming trials will evaluate a new somatostatin analog therapy for acromegaly and a new treatment for Cushing’s disease.
One of the world's most experienced neuroendocrine surgeons, Dr. Laws has performed more than 5,700 transsphenoidal operations for pituitary disorders throughout his career. He has been a pioneer in the use of advanced technologies to resect pituitary tumors while preserving the gland. The newest approach combines powerful 3T (Tesla) MRI with the 3D endoscope for maximum clarity and surgical precision and is used with all types of pituitary tumors and cysts, including prolactinomas, that are not responsive to medical therapy. An early adopter of the 3D endoscope, Dr. Laws has performed more than 500 3D endoscopic transsphenoidal pituitary procedures with preservation of the pituitary gland in more than 96 percent of patients.
“The 3D endoscope provides excellent visualization and versatility, enabling us to tailor the procedure to the patient’s tumor,” said Dr. Laws. “Using this tool, we also are able to reduce operative time and minimize the risks of complications. Rates of bleeding, major vessel injury, and meningitis, for example, are extremely low with this technique,” said Dr. Laws.
For challenging cases, the procedure is performed in the Advanced Multimodality Image Guided Operating (AMIGO) suite at BWH, a state-of-the-art medical and surgical research environment that features advanced imaging equipment and interventional surgical systems. All AMIGO procedures are performed under a research protocol and IRB approval. Multidisciplinary teams of specialists use the equipment and the unique design of the suite to efficiently and precisely guide treatment — before, during and after surgery — without the patient or medical team ever leaving the operating room. AMIGO enables real-time imaging to be performed in the suite throughout a surgical procedure.
“We are able to obtain images throughout the procedure, which facilitates removal of the tumor without injuring the normal gland,” said Dr. Laws.
Researchers in the Program are actively involved in a wide range of investigator-led studies designed to advance care for pituitary patients. Dr. Woodmansee has a particular interest in research to optimize medical management of hypopituitarism. In collaboration with colleagues at Dana-Farber Cancer Institute and Boston Children’s Hospital, she has expanded treatment options for these patients and aids in transition from pediatric to adult care. She also has researched the incidence of second neoplasms in GH-treated childhood cancer survivors (Eur J Endocrinol. 2013 Mar 15;168(4):565-73.).
At the 2014 Endocrine Society Annual Meeting in Chicago, Dr. Woodmansee and her colleagues presented research that demonstrated an increased risk of diabetes mellitus in patients with pituitary tumors compared with the general population, after accounting for age, gender, and body mass index (BMI). Neuroendocrinologists and neurosurgeons in the Program also have developed a large clinical pituitary tumor patient database for future research.
Using pituitary tumor tissue in the BWH Tumor Bank, Dr. Kaiser is researching the role of epigenetic factors to better understand pituitary tumor pathogenesis, while BWH neurosurgeon Ian F. Dunn, MD, is analyzing chromosomes and genetic markers to understand the etiology of the disease, prevent recurrence, and uncover ways to manipulate tumor cells.