Pituitary incidentaloma: an endocrine society clinical practice guideline

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.

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 (see Section 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).]