Pituitary incidentaloma: an endocrine society clinical practice guideline

Pamela U Freda, Albert M Beckers, Laurence Katznelson, Mark E Molitch, Victor M Montori, Kalmon D Post, Mary Lee Vance, Endocrine Society, Pamela U Freda, Albert M Beckers, Laurence Katznelson, Mark E Molitch, Victor M Montori, Kalmon D Post, Mary Lee Vance, Endocrine Society

Abstract

Objective: The aim was to formulate practice guidelines for endocrine evaluation and treatment of pituitary incidentalomas.

Consensus process: Consensus was guided by systematic reviews of evidence and discussions through a series of conference calls and e-mails and one in-person meeting.

Conclusions: We recommend that patients with a pituitary incidentaloma undergo a complete history and physical examination, laboratory evaluations screening for hormone hypersecretion and for hypopituitarism, and a visual field examination if the lesion abuts the optic nerves or chiasm. We recommend that patients with incidentalomas not meeting criteria for surgical removal be followed with clinical assessments, neuroimaging (magnetic resonance imaging at 6 months for macroincidentalomas, 1 yr for a microincidentaloma, and thereafter progressively less frequently if unchanged in size), visual field examinations for incidentalomas that abut or compress the optic nerve and chiasm (6 months and yearly), and endocrine testing for macroincidentalomas (6 months and yearly) after the initial evaluations. We recommend that patients with a pituitary incidentaloma be referred for surgery if they have a visual field deficit; signs of compression by the tumor leading to other visual abnormalities, such as ophthalmoplegia, or neurological compromise due to compression by the lesion; a lesion abutting the optic nerves or chiasm; pituitary apoplexy with visual disturbance; or if the incidentaloma is a hypersecreting tumor other than a prolactinoma.

Figures

Fig. 1.
Fig. 1.
Flow diagram for the evaluation and treatment of pituitary incidentalomas. a, Baseline evaluation in all patients should include a history and physical exam evaluating for signs and symptoms of hyperfunction and hypopituitarism and a laboratory evaluation for hypersecretion. b, This group may also include large microlesions (see Section 2.1 Evidence). c, The recommendation for surgery includes the presence of abnormalities of VF or vision and signs of tumor compression (Section 3.1); surgery is also suggested for other findings (seeSection 3.2). d, VF testing is recommended for patients with lesions abutting or compressing the optic nerves or chiasm at the initial evaluation and during follow-up. e, Evaluation for hypopituitarism is recommended for the baseline evaluation and during follow-up evaluations. This is most strongly recommended for macrolesions and larger microlesions (see Section 1.3). f, Repeat MRI in 1 yr, yearly for 3 yr, and then less frequently thereafter if no change in lesion size. g, Repeat the MRI in 6 months, yearly for 3 yr, and then less frequently if no change in lesion size. [Modified from Molitch ME: J Clin Endocrinol Metab 80:3–6, 1995 (49).]

References

    1. Atkins D , Best D , Briss PA , Eccles M , Falck-Ytter Y , Flottorp S , Guyatt GH , Harbour RT , Haugh MC , Henry D , Hill S , Jaeschke R , Leng G , Liberati A , Magrini N , Mason J , Middleton P , Mrukowicz J , O'Connell D , Oxman AD , Phillips B , Schünemann HJ , Edejer TT , Varonen H , Vist GE , Williams JW , Zaza S. 2004. Grading quality of evidence and strength of recommendations. BMJ 328:1490.
    1. Swiglo BA , Murad MH , Schünemann HJ , Kunz R , Vigersky RA , Guyatt GH , Montori VM. 2008. A case for clarity, consistency, and helpfulness: state-of-the-art clinical practice guidelines in endocrinology using the grading of recommendations, assessment, development, and evaluation system. J Clin Endocrinol Metab 93:666–673
    1. Fernandez-Balsells M MM , Barwise A , Gallegos-Orozco J , Paul A , Lane M , Carpio I , Perestelo-Perez LI , Ponce de Leon Lovaton P , Erwin P , Carey J , Montori VM. 2010. The natural history of pituitary incidentalomas: a systematic review and meta-analysis. J Clin Endocrinol Metab (In press)
    1. Feldkamp J , Santen R , Harms E , Aulich A , Mödder U , Scherbaum WA. 1999. Incidentally discovered pituitary lesions: high frequency of macroadenomas and hormone-secreting adenomas—results of a prospective study. Clin Endocrinol (Oxf) 51:109–113
    1. Arita K , Tominaga A , Sugiyama K , Eguchi K , Iida K , Sumida M , Migita K , Kurisu K. 2006. Natural course of incidentally found nonfunctioning pituitary adenoma, with special reference to pituitary apoplexy during follow-up examination. J Neurosurg 104:884–891
    1. Sanno N , Oyama K , Tahara S , Teramoto A , Kato Y. 2003. A survey of pituitary incidentaloma in Japan. Eur J Endocrinol 149:123–127
    1. Fainstein Day P , Guitelman M , Artese R , Fiszledjer L , Chervin A , Vitale NM , Stalldecker G , De Miguel V , Cornaló D , Alfieri A , Susana M , Gil M. 2004. Retrospective multicentric study of pituitary incidentalomas. Pituitary 7:145–148
    1. Reincke M , Allolio B , Saeger W , Menzel J , Winkelmann W. 1990. The ‘incidentaloma’ of the pituitary gland. Is neurosurgery required? JAMA 263:2772–2776
    1. Donovan LE , Corenblum B. 1995. The natural history of the pituitary incidentaloma. Arch Intern Med 155:181–183
    1. Freda PU , Post KD. 1999. Differential diagnosis of sellar masses. Endocrinol Metab Clin North Am 28:81–117, vi
    1. Zada G , Lin N , Ojerholm E , Ramkissoon S , Laws ER. Craniopharyngioma and other cystic epithelial lesions of the sellar region: a review of clinical, imaging, and histopathological relationships. Neurosurg Focus 28:E4
    1. Kanter AS , Sansur CA , Jane JA , Laws ER. 2006. Rathke's cleft cysts. Front Horm Res 34:127–157
    1. Black PM , Hsu DW , Klibanski A , Kliman B , Jameson JL , Ridgway EC , Hedley-Whyte ET , Zervas NT. 1987. Hormone production in clinically nonfunctioning pituitary adenomas. J Neurosurg 66:244–250
    1. Esiri MM , Adams CB , Burke C , Underdown R. 1983. Pituitary adenomas: immunohistology and ultrastructural analysis of 118 tumors. Acta Neuropathol 62:1–14
    1. Al-Shraim M , Asa SL. 2006. The 2004 World Health Organization classification of pituitary tumors: what is new? Acta Neuropathol 111:1–7
    1. Molitch ME. 2008. Nonfunctioning pituitary tumors and pituitary incidentalomas. Endocrinol Metab Clin North Am 37:151–171, xi
    1. Wolpert SM , Molitch ME , Goldman JA , Wood JB. 1984. Size, shape, and appearance of the normal female pituitary gland. AJR Am J Roentgenol 143:377–381
    1. Chambers EF , Turski PA , LaMasters D , Newton TH. 1982. Regions of low density in the contrast-enhanced pituitary gland: normal and pathologic processes. Radiology 144:109–113
    1. Peyster RG , Adler LP , Viscarello RR , Hoover ED , Skarzynski J. 1986. CT of the normal pituitary gland. Neuroradiology 28:161–165
    1. Hall WA , Luciano MG , Doppman JL , Patronas NJ , Oldfield EH. 1994. Pituitary magnetic resonance imaging in normal human volunteers: occult adenomas in the general population. Ann Intern Med 120:817–820
    1. Nammour GM , Ybarra J , Naheedy MH , Romeo JH , Aron DC. 1997. Incidental pituitary macroadenoma: a population-based study. Am J Med Sci 314:287–291
    1. Yue NC , Longstreth WT , Elster AD , Jungreis CA , O'Leary DH , Poirier VC. 1997. Clinically serious abnormalities found incidentally at MR imaging of the brain: data from the Cardiovascular Health Study. Radiology 202:41–46
    1. Igarashi T , Saeki N , Yamaura A. 1999. Long-term magnetic resonance imaging follow-up of asymptomatic sellar tumors—their natural history and surgical indications. Neurol Med Chir (Tokyo) 39:592–598; discussion 598–599
    1. Karavitaki N , Collison K , Halliday J , Byrne JV , Price P , Cudlip S , Wass JA. 2007. What is the natural history of nonoperated nonfunctioning pituitary adenomas? Clin Endocrinol (Oxf) 67:938–943
    1. Dekkers OM , Hammer S , de Keizer RJ , Roelfsema F , Schutte PJ , Smit JW , Romijn JA , Pereira AM. 2007. The natural course of non-functioning pituitary macroadenomas. Eur J Endocrinol 156:217–224
    1. Nishizawa S , Ohta S , Yokoyama T , Uemura K. 1998. Therapeutic strategy for incidentally found pituitary tumors (“pituitary incidentalomas”). Neurosurgery 43:1344–1348; discussion 1348–1350
    1. Daly AF , Rixhon M , Adam C , Dempegioti A , Tichomirowa MA , Beckers A. 2006. High prevalence of pituitary adenomas: a cross-sectional study in the province of Liege, Belgium. J Clin Endocrinol Metab 91:4769–4775
    1. Fernandez A , Karavitaki N , Wass JA. Prevalence of pituitary adenomas: a community-based, cross-sectional study in Banbury (Oxfordshire, UK). Clin Endocrinol (Oxf) 72:377–382
    1. Raappana A , Koivukangas J , Ebeling T , Pirilä T. 2010. Incidence of pituitary adenomas in Northern Finland in 1992–2007. J Clin Endocrinol Metab 95:4268–4275
    1. Buurman H , Saeger W. 2006. Subclinical adenomas in postmortem pituitaries: classification and correlations to clinical data. Eur J Endocrinol 154:753–758
    1. Casanueva FF , Molitch ME , Schlechte JA , Abs R , Bonert V , Bronstein MD , Brue T , Cappabianca P , Colao A , Fahlbusch R , Fideleff H , Hadani M , Kelly P , Kleinberg D , Laws E , Marek J , Scanlon M , Sobrinho LG , Wass JA , Giustina A. 2006. Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas. Clin Endocrinol (Oxf) 65:265–273
    1. Angeli A , Terzolo M. 2002. Adrenal incidentaloma—a modern disease with old complications. J Clin Endocrinol Metab 87:4869–4871
    1. Nieman LK , Biller BM , Findling JW , Newell-Price J , Savage MO , Stewart PM , Montori VM. 2008. The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 93:1526–1540
    1. Karavitaki N , Ansorge O , Wass JA. 2007. Silent corticotroph adenomas. Arq Bras Endocrinol Metabol 51:1314–1318
    1. Yuen KC , Cook DM , Sahasranam P , Patel P , Ghods DE , Shahinian HK , Friedman TC. 2008. Prevalence of GH and other anterior pituitary hormone deficiencies in adults with nonsecreting pituitary microadenomas and normal serum IGF-1 levels. Clin Endocrinol (Oxf) 69:292–298
    1. Molitch ME , Clemmons DR , Malozowski S , Merriam GR , Shalet SM , Vance ML , Stephens PA. 2006. Evaluation and treatment of adult growth hormone deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 91:1621–1634
    1. Gruber A , Clayton J , Kumar S , Robertson I , Howlett TA , Mansell P. 2006. Pituitary apoplexy: retrospective review of 30 patients—is surgical intervention always necessary? Br J Neurosurg 20:379–385
    1. Barker FG , Klibanski A , Swearingen B. 2003. Transsphenoidal surgery for pituitary tumors in the United States, 1996–2000: mortality, morbidity, and the effects of hospital and surgeon volume. J Clin Endocrinol Metab 88:4709–4719
    1. Gittoes NJ , Sheppard MC , Johnson AP , Stewart PM. 1999. Outcome of surgery for acromegaly—the experience of a dedicated pituitary surgeon. QJM 92:741–745
    1. Arafah BM , Kailani SH , Nekl KE , Gold RS , Selman WR. 1994. Immediate recovery of pituitary function after transsphenoidal resection of pituitary macroadenomas. J Clin Endocrinol Metab 79:348–354
    1. Arafah BM. 1986. Reversible hypopituitarism in patients with large nonfunctioning pituitary adenomas. J Clin Endocrinol Metab 62:1173–1179
    1. Greenman Y , Tordjman K , Osher E , Veshchev I , Shenkerman G , Reider-Groswasser II , Segev Y , Ouaknine G , Stern N. 2005. Postoperative treatment of clinically nonfunctioning pituitary adenomas with dopamine agonists decreases tumour remnant growth. Clin Endocrinol (Oxf) 63:39–44
    1. Lohmann T , Trantakis C , Biesold M , Prothmann S , Guenzel S , Schober R , Paschke R. 2001. Minor tumour shrinkage in nonfunctioning pituitary adenomas by long-term treatment with the dopamine agonist cabergoline. Pituitary 4:173–178
    1. Pivonello R , Matrone C , Filippella M , Cavallo LM , Di Somma C , Cappabianca P , Colao A , Annunziato L , Lombardi G. 2004. Dopamine receptor expression and function in clinically nonfunctioning pituitary tumors: comparison with the effectiveness of cabergoline treatment. J Clin Endocrinol Metab 89:1674–1683
    1. Shomali ME , Katznelson L. 2002. Medical therapy of gonadotropin-producing and nonfunctioning pituitary adenomas. Pituitary 5:89–98
    1. Merola B , Colao A , Ferone D , Selleri A , Di Sarno A , Marzullo P , Biondi B , Spaziante R , Rossi E , Lombardi G. 1993. Effects of a chronic treatment with octreotide in patients with functionless pituitary adenomas. Horm Res 40:149–155
    1. de Bruin TW , Kwekkeboom DJ , Van't Verlaat JW , Reubi JC , Krenning EP , Lamberts SW , Croughs RJ. 1992. Clinically nonfunctioning pituitary adenoma and octreotide response to long term high dose treatment, and studies in vitro. J Clin Endocrinol Metab 75:1310–1317
    1. Colao A , Di Somma C , Pivonello R , Faggiano A , Lombardi G , Savastano S. 2008. Medical therapy for clinically non-functioning pituitary adenomas. Endocr Relat Cancer 15:905–915
    1. Molitch ME. 1995. Clinical review 65. Evaluation and treatment of the patient with a pituitary incidentaloma. J Clin Endocrinol Metab 80:3–6

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren