BY ELIZABETH MECHCATIE
Surgical treatment of a pituitary incidentaloma is recommended when the lesion is causing a visual field deficit or other visual abnormalities, such as ophthalmoplegia “or neurological compromise,” according to evidence-based clinical practice guidelines published by the Endocrine Society.
Surgery is also recommended when the lesion is abutting or compressing the optic nerves or chiasm on MRI, when a patient is experiencing pituitary apoplexy with visual disturbance, or if a patient has a hypersecreting tumor other than a prolactinoma, according to the guidelines, which appear in the society’s journal (J. Clin. Endocrinol. Metab. 2011;96:894-904).
The guidelines pertain to adults, as there are no available data on these lesions in the pediatric population.
A pituitary incidentaloma is defined as “a previously unsuspected pituitary lesion that is discovered on an imaging study performed for an unrelated reason.” That does not include a symptom such as visual loss that is related to the lesion, “but rather [a study done] for the evaluation of symptoms such as headache, or other head or neck neurological or CNS complaints or head trauma.”
Such surprise findings are not uncommon, according to a statement from the society, which noted that small incidentalomas were discovered in as many as 20% of adults who had head imaging with MRI or CT scans for unrelated reasons.
“Fortunately, incidentalomas are almost always benign and usually do not need surgery,” Dr. Pamela Freda, an endocrinologist at Columbia University in New York who chaired the task force that wrote the guidelines, said in the statement. The guidelines make recommendations about evaluating and treating such patients, “indicating when surgical therapy may be necessary,” she added.
Surgery may be considered for patients with pituitary incidentalomas if there is clinically significant growth of the lesion, loss of endocrinologic function, or an “unremitting headache,” or if a patient is planning a pregnancy and has a lesion close to the optic chiasm.
The guidelines include recommendations on the initial evaluation of patients, follow-up testing of patients who do not meet criteria for surgical removal of the lesion, and medical therapy. For example, after an incidentaloma is identified, a patient should undergo a complete history and physical examination “that includes evaluations for evidence of hypopituitarism and a hormone secretion syndrome,” as well as biochemical evaluations, if there is evidence for either of these conditions, the guidelines state.
None of the seven authors of the guidelines declared a “significant financial interest” or a “leadership position” within the pharmaceutical industry. Dr. Freda’s disclosure states that she has “financial, business or organization interests” in Novartis, Ipsen, and Pfizer. Other authors also disclosed financial, business, or organization interests in those three companies, and/or in Novo Nordisk, Tercica/Ipsen, or no relevant financial interests.
The guidelines are cosponsored by the European Society of Endocrinology.
The society’s patient-education affiliate, the Hormone Foundation, is publishing a related patient guide that can be found at www.hormone.org/Resources/upload/Pituitary-Incidentaloma-Web.pdf.