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Guidelines issued for evaluation, management of pituitary incidentalomas
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The evaluation and treatment of pituitary incidentalomas, a previously unsuspected pituitary lesion discovered on an unrelated imaging study, is the subject of new, evidence-based recommendations developed by The Endocrine Society.
“The pituitary incidentaloma is a common finding in clinical practice, and there are always questions on the best way to approach these lesions,” Laurence Katznelson, MD, medical director of the Pituitary Center at the Stanford Medical Center and guideline co-author, told Endocrine Today.
Katznelson said these are the first clinical guidelines on pituitary incidentalomas that have involved combining a systematic review of the literature with the clinical experience of a group of pituitary specialists to synthesize a concrete and reasonable approach to managing these patients.
Approaching assessment
It is recommended that patients with pituitary incidentalomas undergo a complete medical history, as well as physical, laboratory and clinical evaluations for evidence of hormone hypersecretion and hypopituitarism regardless of whether symptoms are present. Patients with incidentalomas abutting the optic nerves or chiasm should also undergo a formal visual field examination. The task force recommended that incidentalomas initially diagnosed via CT scan undergo MRI scan for further evaluation. For those patients who do not initially require surgery, physicians are recommended to perform a MRI scan 6 months after discovery of macroincidentalomas and 1 year after discovery of a microincidentaloma.
Follow-up scans should continue yearly for macroincidentalomas and every 1 to 2 years for microincidentalomas for a 3-year period. If the size of the incidentaloma does not change, follow-up scans may then become less frequent. However, if the incidentaloma increases in size to abut the optic nerves or chiasm, visual field testing is recommended during follow-up.
Physicians are encouraged to perform a clinical and biochemical evaluation for hypopituitarism 6 months after the initial evaluation and every year thereafter.
Treatment recommendations
Although not appropriate for all patients, the task force recommends surgery in certain situations. For instance, patients with visual field deficits, ophthalmoplegia or neurological compromise resulting from the incidentaloma should be referred for surgery. Similarly, surgery is recommended for those with lesions abutting or compressing the optic nerves or chiasm, pituitary apoplexy with visual disturbance and hypersecreting tumors besides prolactinomas.
Surgery may also be considered for patients with clinically significant growth of the incidentaloma, loss of endocrinologic function, unremitting headache or those who plan to become pregnant and have a lesion close to the optic chiasm. The quality of evidence supporting this suggestion, however, is low, according to the task force.
“Fortunately, incidentalomas are almost always benign and usually do not need surgery,” Pamela U. Freda, MD, of the Columbia College of Physicians and Surgeons in New York and chair of The Endocrine Society task force, said in a press release.
Because data on the medical management of pituitary incidentalomas are lacking, the task force made no recommendations regarding its routine use.
To learn more about these recommendations and others, the guidelines are published in the Journal of Clinical Endocrinology & Metabolism.
“Through these guidelines, we have reviewed all available literature and have suggested a management approach based on clinical evidence and experience,” Katznelson said. – by Melissa Foster
For more information:
Disclosure: Dr. Katznelson reports financial, business or organizational interests in Ipsen, Novartis and Novo Nordisk. Dr. Freda reports financial, business or organizational interests in Ipsen, Novartis and Pfizer.
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The Endocrine Society has developed clinical practice guidelines of how to approach the patient with a pituitary incidentaloma. The committee certainly has the credentials to make these recommendations; they have been leaders in the field of pituitary diseases for the last quarter century.
This review is excellent for addressing the right questions, such as which of these incidental masses should have surgery and which can be watched. The question always comes up when a patient is identified with a pituitary mass of just how much endocrine testing should be done both for hormonal excess and the possibility of the mass causing pituitary hypo function. Some of the suggestions are a bit vague of exactly which tests to perform, especially from the standpoint of a clinician not primarily working in the pituitary field.
Overall, this is a scholarly work and well referenced. It should be considered by clinicians who are faced with the dilemma of a mass found on an MRI done for other reasons. The clinician should remember that not all these masses are benign tumors and a ‘pituitary incidentaloma’ is a mass lesion with a wide differential until thoroughly investigated. The clinician should also keep in mind that mild hyperprolactinemia, mild growth hormone or cortisol excess can present in very non-specific ways and should always be considered in this context.
– David M. Cook, MD
Professor of Medicine
Oregon Health & Science University
Portland, OR
Disclosure: Dr. Cook reports receiving grant money from Eli Lilly, Endo Pharmaceuticals. He is also a speaker for Pfizer, Genentech and Novo Nordisk.
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