Surgical resection for pituitary incidentalomas

The patient mentioned in a previous post came to see me for follow up as an outpatient. To review, he initially presented as an inpatient with hyponatremia due to central adrenal insufficiency. An MRI revealed a 2.2-cm pituitary macroadenoma. His serum sodium normalized on oral hydrocortisone replacement therapy. Laboratory evaluation confirmed panhypopituitarism. We spent most of our visit discussing hormone replacement therapy.

The next question to consider: Is surgical resection indicated? The patient was hesitant to proceed with surgery unless it was absolutely necessary. I understood and shared his reluctance.

The Endocrine Society recently released guidelines for the management of pituitary incidentalomas. These guidelines suggested surgical resection of pituitary incidentalomas in the following situations:

A visual field deficit due to the lesion.
Other visual abnormalities, such as ophthalmoplegia or neurological compromise due to compression by the lesion.
A lesion abutting or compressing the optic nerves or chiasm on MRI.
Pituitary apoplexy with visual disturbance.
Hypersecreting tumors other than prolactinomas

Additional circumstances where surgery may also be considered include:

Clinically significant growth of the pituitary incidentaloma.
Loss of endocrinological function.
A lesion close to the optic chiasm and a plan to become pregnant.
Unremitting headache.

At the present time, this patient does not meet any of the definite indications for surgery. Although this patient has a large pituitary macroadenoma, there is no impingement of the optic nerves or chiasm on the MRI. Formal visual field testing was normal, as we expected it would be. There is also no evidence of acromegaly, hyperprolactinemia or Cushing’s disease. It would be unlikely for the panhypopituitarism to resolve with surgery.

Given that he is in his mid-70s with cardiac disease and other comorbidities, both he and I agreed that it would be better not to proceed with surgery right now, but instead follow by close observation. The patient understands, however, that if there is growth of this macroadenoma or other changes, we would need to reconsider our decision.