Book Review

Diagnosis and Management of Pituitary Disorders

N Engl J Med 2009; 360:1684-1685April 16, 2009

Article

Diagnosis and Management of Pituitary Disorders
(Contemporary Endocrinology.) Edited by Brooke Swearingen and Beverly M.K. Biller. 475 pp., illustrated. Totowa, NJ, Humana Press, 2008. $139. ISBN: 978-1-58829-922-2

This excellent book is a comprehensive and succinct summary of the diagnosis and management of various types of pituitary disorders. The contributors, who are leaders in the field, have written very good reviews of specific topics. The book is well organized and includes discussions of pathogenesis, pathologic findings, diagnostic approaches (including endocrine, ophthalmologic, and imaging approaches), and management (including medical therapies, surgery, and pituitary radiation). Discussions of specific problems, such as pituitary disease and pregnancy, pituitary disease in children, pituitary apoplexy, infiltrative disease, and the always problematic pituitary lesions that are discovered incidentally, are also included.

A necessary limitation of a book on any medical topic is the delay between submission and publication. This delay makes it impossible for authors to include information on the most recent scientific studies — information that is particularly important for chapters that involve newly published outcomes of treatments. An example of this difficulty is found in chapter 17, “Radiation Therapy for Pituitary Adenomas.” Its authors provide an excellent summary of indications for treatment, methods of radiation delivery, outcomes, and complications, but the referenced studies are inclusive only up to 2007.

The three-part chapter on acromegaly is concise and informative. Its one shortcoming is the result of what has been a widespread problem in the United States for more than a year — the range of normal values according to age for the insulin-like growth factor I assays that are commercially available is too low. This inaccuracy can lead to misdiagnosis of acromegaly or relapse of treated acromegaly.

The chapter on the diagnostic evaluation of Cushing's disease addresses the most problematic area of pituitary disorders. The authors have been at the forefront of establishing that late-night levels of cortisol in saliva are an indicator of loss of the normal circadian rhythm of cortisol production. The presence of high levels of cortisol in saliva may be detectable before the 24-hour urinary-free cortisol concentration is abnormally elevated. A shortcoming of this discussion is that the authors fail to mention the variability or reliability in results from various commercial laboratories. Essentially, the diagnosis of Cushing's disease on the basis of the measurement of salivary and urinary-free cortisol levels remains problematic.

The discussions of the results of pituitary surgery are informative and well written by neurosurgeons who have experience in the field. What is not adequately discussed, however, is the need for a neurosurgeon who has adequate experience and expertise with this operation. The results of pituitary surgery are reported only by neurosurgeons who devote their practices to this procedure; outcomes from neurosurgeons who perform the operation infrequently are not reported.

Overall, this book is useful for the general medical community and for clinical endocrinologists. Its major strengths are the comprehensiveness of the chapters and the quality of the details and writing. This is a valuable addition to any medical library.

Mary Lee Vance, M.D.
University of Virginia Health System, Charlottesville, VA 22908