Friday, April 15, 2011

Treatment Guidelines for Pituitary Incidentalomas Issued

Emma Hitt, PhD

April 12, 2011 — The Endocrine Society has issued clinical guidelines for the endocrine assessment and treatment of pituitary incidentaloma that indicates surgical therapy under some conditions.

Pamela U. Freda, MD, with the Columbia College of Physicians & Surgeons in New York, NY, led the panelists who developed the guidelines, which were reported in the April 2011 issue of the Journal of Clinical Endocrinology & Metabolism.

The 7-member panel sought to develop practice guidelines for the endocrine evaluation and treatment of pituitary incidentalomas through the evaluation of systematic reviews of evidence. They also participated in conference calls and email discussions to develop the guidelines.

The panel recommends that patients with a pituitary incidentaloma undergo a complete history and physical examination, laboratory evaluations screening for hormone hypersecretion and hypopituitarism, and a visual field examination if the lesion abuts the optic nerves or optic chiasm.

They also recommend that patients with incidentalomas who do not meet criteria for surgical removal be monitored with clinical assessments and neuroimaging, which should include a magnetic resonance imaging (MRI) scan at 6 months for macroincidentalomas, 1 year for a microincidentaloma, and thereafter progressively less frequently if the incidentaloma is unchanged in size.

Patients should also undergo visual field examinations if they have incidentalomas that abut or compress the optic nerve and optic chiasm (6 months and yearly), as well as endocrine testing in the case of macroincidentalomas (6 months and yearly) after initial evaluation.

According to the study authors, the evidence for or against a recommendation for surgery because of growth of a pituitary incidentaloma is limited. The panel suggests that surgery is indicated if patients have a visual field deficit resulting from the lesion; other visual abnormalities, such as ophthalmoplegia or neurologic compromise from compression by the lesion; a lesion abutting or compressing the optic nerves or optic chiasm on MRI; pituitary apoplexy with visual disturbance; or hypersecreting tumors other than prolactinomas as recommended by other Endocrine and Pituitary Society guidelines.

In addition, surgery should be considered in patients with a pituitary incidentaloma if there is clinically significant growth of the pituitary incidentaloma, if there is loss of endocrinologic function, if a patient is planning pregnancy with a lesion close to the optic chiasm, or if a patient has unremitting headache.

The study authors add that the "success of surgery for hormone secreting tumors is highly dependent on the expertise, skill, and case volume of a pituitary surgeon supported by an experienced team."

Medical therapy for pituitary incidentalomas has not been systematically studied, the authors note. "In patients with incidentalomas and hyperprolactinemia that may be due to tumoral compression of the hypothalamic-pituitary stalk, symptomatic hyperprolactinemia may be treated with a dopamine agonist," they write. However, they add that incidentalomas other than a prolactinoma are unlikely to shrink, and lesions should still be monitored regardless of changes in prolactin levels.

The study authors have disclosed various financial relationships with Novartis, Ipsen, Pfizer, Novo Nordisk, Tercica/Ipsen, and/or KER Unit (Mayo Clinic).

J Clin Endocrinol Metab. 2011;96:894-904. Abstract