Pituitaty Disorders - Comprehensive Management

Univ. of Arkansas for Medical Sciences, Little Rock. Comprehensive review and update of current knowledge of the pituitary gland and its disorders. Clinical guide for students, residents, and clinicians. Halftone illustrations. DNLM: Pituitary Neoplasms--diagnosis.

Harvey Cushing described the pituitary gland as "a tiny organ, which lies enveloped by an additional capsule and membrane like the nugget in the innermost of a series of Chinese boxes." The neurosurgeon has occupied center stage in the management of the enlarged pituitary for more than 100 years, but recently the endocrinologist has achieved considerable success with drug therapy and is moving in from the wings.

In 1986, Tindall and Barrow (from Atlanta) chose to write the well-known predecessor of this book almost entirely by themselves, in the belief that textbooks with just one or two authors avoid the repetition, contradiction, and lack of cohesiveness that surface in books by multiple authors. They also hoped to provide a broader and more comprehensive perspective on the subject than is possible in a multiauthored book. They wrote then for a relatively narrow audience, including neurosurgeons and endocrinologists in academic and clinical practice, with thoughts of neurologists, neuroradiologists, and neuropathologists, as well as those in training. More than 10 years later, Krisht and Tindall echo these aims, but the extended title indicates a change of focus: to provide a comprehensive reference as well as a clinical guide for medical students, internists, endocrinologists, gynecologists, pediatricians, and ophthalmologists, as well as neuroradiologists and neurosurgeons. Nevertheless, this multiauthored work still represents a predominantly neurosurgical view, and most of the authors are neurosurgeons. This is its strength, and its benefit, for readers who did not have the advantage of the neurosurgeons' intimate inspection of the inside of the Chinese box.

"Comprehensive management," the new theme indicated in the title, represents the inclusion of a number of succinct summaries from other neurologic disciplines such as neuroradiology and neuropathology, but more important, the endocrinologist's approach to the diagnosis and treatment of each of the different pituitary problems. There are useful summaries of current views on interventional neuropharmacologic management with drugs such as bromocriptine and octreotide, but relatively little on the long-term role of pituitary replacement therapy. It is unlikely that these chapters will be the final endocrinologic opinion, but they will broaden the neurosurgical viewpoint and are essential reading for the neurosurgical trainee. Throughout the book there are excellent reproductions of computed tomographic and magnetic resonance imaging scans. The previous book had line drawings of technical precision and artistic beauty but few of the images that are now almost as familiar on household television as in an endocrinologic center. The reference lists are complete but not excessive and have a helpful neurosurgical slant. From the technical neurosurgical viewpoint, a number of chapters are valuable, including those on anesthetic management in difficult pituitary surgery, the techniques of transsphenoidal surgery (Crawley and Tinsdale), the pterional approach (Krisht), the combined transsphenoidal-transcranial approach for rare giant dumbbell tumors, the skull-base approach to giant invasive tumors (Al-Mefty), and the concept of neuroendoscopic surgery as a logical extension of the nasal approach.

I review this book with the respect due to the neurosurgeon by a practicing endocrinologist. The titles of the chapters will immediately identify it as something different from the standard endocrinology textbook. Not only is operative management covered in detail for each type of pituitary adenoma, but there are also chapters on more obscure aspects such as pituitary apoplexy, the problem of long-term management of craniopharyngioma, and the special difficulties presented by pediatric pituitary tumors. In a new development, this book incorporates chapters that summarize the endocrinologic approach to each of the surgically defined conditions. These chapters are generally concise and clear, and the editors have achieved a useful amalgam of the sometimes different approaches of the surgeon and the endocrinologist to the same condition. The neurosurgeon will find these chapters easier to assimilate than the much more detailed presentations in some of the major endocrinology textbooks. The pituitary neurosurgeon will read this book because it is a work representing unrivaled surgical experience. The names in the author list -- Tindall, Rhoton, Laws, Oldfield, and Al-Mefty, among others -- will ensure that audience. But the endocrinologist should also read this relatively slim and very informative book, not to review knowledge of pituitary-function tests but rather to appreciate the surgical wisdom and experience it imparts and thereby improve what is ultimately a joint clinical opinion as to the best treatment option for a patient with a pituitary problem.

Reviewed by David R. Hadden, M.D.
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