The options for treatment of patients with asymptomatic, clinically
nonfunctioning pituitary incidentalomas are conservative follow-up without
surgery (
Fig. 1) or immediate surgery
despite the lack of indications for this. Conservative follow-up was
recommended with the recognition that the proper algorithm for this and its
appropriateness and safety have not been tested prospectively. Few data are
available for or against a nonsurgical approach to management of
asymptomatic pituitary incidentalomas. Therefore, evidence in support of
these guidelines also relied on the clinical experiences of the Task Force
members.
The proper algorithm for endocrine testing during this follow-up has not been
tested as prospectively conducted endocrine testing of patients with
pituitary incidentalomas who were followed without surgery has only been
reported in 49 patients (8 (
link), 9 (
link)). Follow-up endocrine testing is
recommended for patients with macroincidentalomas because they are at risk
of developing hypopituitarism. Of the macroincidentalomas followed
prospectively, worsening hypopituitarism developed in one of seven (8 (
link)) and three of 28 (25 (
link)) patients, all of whom had
enlargement of their tumors. Hypopituitarism also developed in four of 37
(5 (
link)) and one of 248 (6 (
link)) patients who developed apoplexy on
follow-up. Follow-up endocrine testing was recommended despite the paucity
of data because of the potential high risk to the patient of untreated
hypopituitarism. In a meta-analysis of incidentaloma studies, new endocrine
dysfunction developed overall in 2.4% of patients per year (3 ). It is unclear how often new
hypopituitarism develops in the absence of tumor growth. Rapid growth may
increase the risk of new hypopituitarism. Routine follow-up endocrine
testing is not required for microincidentalomas whose clinical picture does
not change because the risk of developing new hypopituitarism is extremely
low. In previous studies, none of the pituitary microincidentalomas followed
prospectively was reported to be associated with changes in pituitary
function (4 (
link)– (
link)9 (
link)).
The proposed algorithms for the MRI follow-up of pituitary incidentalomas
took into account those adopted in prior studies. However, those algorithms
varied considerably from study to study (4 (
link)– (
link)9 (
link)), and none was validated. As a result,
the imaging follow-up proposed in this guideline incorporated the
experiences of the Task Force's members. Follow-up MRI scans were
recommended for macroincidentalomas because it has been demonstrated that
although generally these lesions grow slowly, some do enlarge and become
symptomatic. In data combined from a number of studies, macroincidentalomas
enlarged in 85 of 353 (24%) patients (4 (
link)– (
link)9 (
link), 23 (
link)– (
link)26 (
link)). VF abnormalities developed in 28
(8%) patients over time, which demonstrated that the enlargement adversely
affected the patient's health. Pituitary apoplexy developed in seven of 353
(2%) patients, of whom most developed permanent hypopituitarism and one had
permanent vision impairment (5 (
link)). In a
meta-analysis of these studies, 8.2% of incidentalomas enlarged per year
with a follow-up of 472 person-years (3 ). Less frequent surveillance of microincidentalomas was
recommended because their rate of enlargement was low, being reported in 17
of 160 patients (10.6%) followed from 2.3 to 7 yr (5 (
link)– (
link)9 (
link), 23 (
link)– (
link)25 (
link)). In the meta-analysis, 1.7% of microincidentalomas
enlarged per year (3 ). Importantly,
none of the patients with these microincidentalomas developed new VF
abnormalities that would have necessitated surgery.
Overall, the Task Force considered that repeat scanning within the first year
was warranted for all patients because, although most incidentalomas grow
slowly, some do enlarge, and the true proliferative nature of the
incidentaloma is unknown (
Fig. 1). If
no growth is detected, then the interval between MRI scans can be increased.
Evidence does not support one particular algorithm for the frequency of
follow-up imaging, but we recommend repeating the MRI every year in
macroincidentalomas, every 1–2 yr in microincidentalomas for the next 3 yr,
and then every other year for the next 6 yr and gradually less frequently
indefinitely so long as the lesion continues not to threaten the patient's
health. Some Task Force members would continue imaging every 5 yr.
Uncertainty as to the optimal interval and duration of long-term follow-up
imaging can be shared with the patient, and the scheme followed can be
individualized to balance the physician's assessment of the risk that the
lesion poses to the patient's health with the burden to the patient of
surveillance testing.
Freda P.U., Beckers A.M., Katznelson L., Molitch M.E., Montori V.M., Post K.D, & Vance M.L. (2011). Pituitary Incidentaloma: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology and Metabolism, 96(4), 894-904.