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Nonfunctioning pituitary adenoma

What's new

The Pituitary Society (PS) has published a consensus guideline on the evaluation and management of pituitary incidentalomas. In the absence of new or worsening signs or symptoms, surveillance imaging is recommended every 2-3 years for microadenomas, annually for macroadenomas located ≥5 mm from the optic chiasm, and every 6-12 months for macroadenomas located <5 mm from the optic chiasm, assuming surgical resection is not performed. Repeat MRI is recommended every 1-2 years for slowly enlarging macroadenomas and for stable macroadenomas located <5 mm from the optic chiasm, with shorter intervals for enlarging or invasive lesions. For stable macroadenomas located ≥5 mm from the optic chiasm, MRI should be repeated every 2-3 years. Follow-up of pituitary hormones is recommended in all patients with microadenomas or macroadenomas at 1-2 years, or earlier if new clinical symptoms arise. .

Background

Overview

Definition
A NFPA is a benign neoplasm of neuroendocrine origin that lacks clinical evidence of hormonal hypersecretion.
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Pathophysiology
The factors that induce neoplastic transformation of pituitary cells include various abnormalities in cell cycle regulation and genetic mutations (p16, PTTG1, PRKRA1, and AIP.
2
Epidemiology
The prevalence and incidence of non-functioning pituitary adenoma are 7.0-41.3 per 100,000 population and 0.65-2.34 per 100,000 person-years, respectively.
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Disease course
The clinical manifestations of NFPAs are related to local mass effect (headache, visual field abnormalities, pituitary apoplexy, hypopituitarism, and hyperprolactinemia).
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Prognosis and risk of recurrence
A complete surgical resection of symptomatic NFPAs is achieved in 40-50% of patients undergoing surgery.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of nonfunctioning pituitary adenoma are prepared by our editorial team based on guidelines from the Pituitary Society (PS 2025), the European Society of Endocrinology (ESE 2021), the American College of Radiology (ACR 2019), the Congress of Neurological Surgeons (CNS 2016), the French Endocrine Society (FES 2015), and the Endocrine Society (ES ...
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Diagnostic investigations

Pituitary imaging: as per PS 2025 guidelines, obtaini a MRI with pituitary-dedicated sequences in most patients after incidental detection of a pituitary or sellar lesion on other brain imaging, such as CT, brain MRI, or 18F-FDG PET-CT.
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  • Endocrine evaluation

  • Ophthalmologic evaluation

Diagnostic procedures

Histopathology: as per CNS 2016 guidelines, calculate the NFPA proliferative index and perform staining for adrenocorticotrophic hormone to identify silent corticotroph adenomas and provide guidance on the risk of adenoma progression as well as the benefit of earlier adjuvant radiation.
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Medical management

Watchful waiting: as per FES 2015 guidelines, do not obtain imaging or hormonal surveillance in patients with nonfunctioning microadenoma of ≤ 5 mm diameter. Provide reassurance to the patient.
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Perioperative care

Preoperative hormone replacement: as per CNS 2016 guidelines, initiate hormone replacement therapy preoperatively in all patients with adrenal insufficiency or significant hypothyroidism.
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  • Perioperative corticosteroids

  • Postoperative laboratory assessment

Surgical interventions

Surgical resection, indications: as per PS 2025 guidelines, perform surgery for incidentally detected hypersecreting pituitary adenomas.
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  • Surgical resection (technical considerations)

Specific circumstances

Pregnant patients, evaluation: as per ESE 2021 guidelines, obtain neuro-ophthalmologic evaluation in pregnant patients with adenomas impinging visual pathways or in case of suspected tumor progression or pituitary apoplexy.
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  • Pregnant patients (management)

  • Pregnant patients (monitoring)

  • Pregnant patients (delivery and breastfeeding)

  • Patients with cystic sellar lesions

Patient education

Preoperative counseling: as per CNS 2016 guidelines, counsel older patients and patients with longer duration (> 4 months) of vision loss regarding the reduced chance of postoperative vision improvement.
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Follow-up and surveillance

Imaging surveillance: as per PS 2025 guidelines, individualize the timing of the first imaging procedure after diagnosis. Obtain imaging at intervals of 2-3 years for microadenomas, 1 year for macroadenomas that are ≥ 5 mm away from the optic chiasm, and 6-12 months for macroadenomas that are < 5 mm from the optic chiasm, in the absence of new or worsening signs or symptoms and assuming surgical resection is not undertaken.
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  • Endocrine surveillance

  • Ophthalmologic surveillance

  • Postoperative surveillance (imaging)

  • Postoperative surveillance (endocrine)

  • Postoperative surveillance (ophthalmic)

  • Management of residual or recurrent adenoma (repeat surgery)

  • Management of residual or recurrent adenoma (radiosurgery and radiotherapy)