Preliminary guidelines for pituitary incidentalomas previewed

The Endocrine Society 92nd Annual Meeting

SAN DIEGO — Guidelines for the evaluation and treatment of pituitary incidentalomas are currently in the final stages of publication by The Endocrine Society and were previewed today during a special session.

Once published, the guidelines will provide a comprehensive set of recommendations for health care professionals for defining pituitary incidentalomas, initial evaluation, recommended screening, tumor classification, nonsurgical follow-up and surgical therapy.

“We faced limitations in guideline development because the true nature of pituitary incidentalomas usually remains unknown, due to the fact that most do not come to surgery,” Pamela Freda, MD, co-author of the guidelines and associate professor of medicine at Columbia University, N.Y., said.

“There are little prospective data on untreated incidentalomas and, as a result, objective data to base the guidelines on were limited,” she said. “The task force positions relied heavily on their clinical experiences.”

According to the session, a few recommendations from the yet-to-be-published guidelines include:

Laboratory screening for hormone hypersecretion during initial screening in all patients with pituitary incidentalomas, with or without symptoms.
Laboratory screening for hypopituitarism for patients with pituitary macroincidentalomas, with or without symptoms, due to benefits of early detection.
The initial screen should include prolactin. If prolactinoma is diagnosed, oral dopamine agonists can be used.
Patients who do not meet criteria for surgery should receive nonsurgical follow-up. Most incidentalomas will not progress over time to cause visual or other disturbances, and surgery is associated with morbidity and high cost, which need to be considered if the incidentaloma is asymptomatic.
An MRI scan of the pituitary and macroincidentalomas should be performed 6 months after the initial scan and after 1 year for microincidentalomas. If there is no change in size, this process should be repeated every year for macroincidentalomas and every 1 to 2 years for microincidentalomas, and gradually less frequently thereafter.
Patients with incidentalomas should be referred to surgery if they have a visual field deficit; signs of compression by the lesion leading to other visual abnormalities or neurological compromise; if the lesion is abating abutting the optic nerve; or if the endocrine evaluation is consistent with apresence of a hypersecreting tumor other than a prolactinoma.

The guidelines are expected to be published by The Endocrine Society in the near future. – by Matthew Brannon

This is a very well put together and thoughtful set of guidelines for a very difficult and controversial area. The guidelines are balanced, and are not self-serving or over-invasive. It is a cautious set of guidelines, which leaves a lot of room for individualized therapy. Because of the unpredictability of the natural progression, it is virtually impossible to be entirely prescriptive and one needs to look at the situation, the size of the tumor, undertake baseline function tests and go from there.

– Ken Ho, MD

Senior Principal Research Fellow and Head of the Pituitary Research Unit,
Neuroscience Research Program, Garvan Institute of Medical Research, Sydney, Australia

For more information:

Freda P. CP1: Pituitary incidentalomas: Endocrine Society Clinical Practice Guidelines. Presented at: The Endocrine Society 92nd Annual Meeting and Expo; June 19-22, 2010; San Diego.