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Nonfunctioning pituitary adenoma

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.
3
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.
2
Disease course
The clinical manifestations of NFPAs are related to local mass effect (headache, visual field abnormalities, pituitary apoplexy, hypopituitarism, and hyperprolactinemia).
3
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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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 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 2011).
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Guidelines

1.Diagnostic investigations

Pituitary imaging: as per CNS 2016 guidelines, obtain high-resolution MRI for preoperative assessment in patients with NFPA.
B
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  • Endocrine evaluation

  • Ophthalmologic evaluation

2.Diagnostic procedures

Histopathology: 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.
B

3.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.
D
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4.Perioperative care

Preoperative hormone replacement: initiate hormone replacement therapy preoperatively in all patients with adrenal insufficiency or significant hypothyroidism.
B

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  • Perioperative corticosteroids

  • Postoperative laboratory assessment

5.Surgical interventions

Surgical resection, indications, CNS: perform surgical resection as first-line treatment in patients with symptomatic NFPA.
B

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  • Surgical resection (technical considerations)

6.Specific circumstances

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

  • Pregnant patients (monitoring)

  • Pregnant patients (delivery and breastfeeding)

7.Patient education

Preoperative counseling: counsel older patients and patients with longer duration (> 4 months) of vision loss regarding the reduced chance of postoperative vision improvement.
B

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  • Preconception counseling

8.Follow-up and surveillance

Postoperative imaging surveillance: as per ACR 2019 guidelines, obtain sellar MRI for surveillance after pituitary or sellar mass resection in adult patients.
B

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  • Postoperative endocrine surveillance

  • Postoperative ophthalmic surveillance

  • Management of residual or recurrent adenoma (repeat surgery)

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