First German Guideline on Diagnostics and Therapy of Clinically Non-Functioning Pituitary Tumors

Abstract

Although non-functioning pituitary tumors are frequent, diagnostic and therapeutic concepts are not well standardized. We here present the first German multidisciplinary guideline on this topic. The single most important message is to manage the patients by a multidisciplinary team (consisting at least of an endocrinologist, a neurosurgeon, and a (neuro-) radiologist). The initial diagnostic work-up comprises a detailed characterization of both biochemical (focusing on hormonal excess or deficiency states) and morphological aspects (with magnetic resonance imaging of the sellar region). An ophthalmological examination is only needed in presence of symptoms or large tumors affecting the visual system. Asymptomatic, hormonally inactive tumors allow for a 'wait and scan' strategy. In contrast, surgical treatment by an experienced pituitary surgeon is standard of care in case of (impending) visual impairment. Therapeutic options for incompletely resected or recurrent tumors include re-operation, radiotherapy, and observation; the individual treatment plan should be developed multidisciplinary. Irrespective of the therapeutic approach applied, patients require long-term follow-up. Patient with larger pituitary tumors or former surgery/radiotherapy should be regularly counseled regarding potential symptoms of hormonal deficiency states.

UK practice on incidentally detected non-functioning pituitary microadenomas: analysis of two national surveys during a 12-year interval

“…In agreement with international guidelines and expert recommendations, nearly all clinicians in both surveys would request prolactin measurement in the diagnostic work-up of an incidentally found pituitary microadenoma [22][23][24][25][26]. This is justified by the high prevalence of prolactinomas presenting to clinical services, the majority being microadenomas [2,27].…”

“…Screening is further justified based on cost-analysis, with a single prolactin measurement reported to be most cost-effective investigation in the evaluation of a pituitary microincidentaloma [29]. IGF-1 measurement was selected by nearly all respondents in the 2021 survey and is currently recognised as the initial screening test for acromegaly [22][23][24]30]. Acromegaly is attributed to a microadenoma in 14-32% of cases [2,31,32].…”

“…Acromegaly is attributed to a microadenoma in 14-32% of cases [2,31,32]. Smaller tumours are more likely to lead to successful surgical results [33] and screening is, therefore, recommended by relevant guidelines [22][23][24]30]. It is of interest that clinicians participating in the 2009 survey would less often check IGF-1 and more frequently random GH measurement, reflecting the evolution in the diagnostic approach [30].…”

“…A survey amongst UK and US endocrinologists exploring their approach in the evaluation of incidental pituitary adenomas was conducted in 1997 [21] and demonstrated large variation in clinical practice. Since then, the publication of guidelines on the diagnostic and management approach for such tumours has, therefore, been welcome, though caution may be needed for some recommendations that rely solely on expert opinion [22][23][24].…”

Ultra-High-Field 7 T Magnetic Resonance Imaging Including Dynamic and Static Contrast-Enhanced T1-Weighted Imaging Improves Detection of Secreting Pituitary Microadenomas

“…Currently, high-field 3 T MRI (if available) is the preferred field strength for PG imaging in the clinical routine; by combining high spatial resolution and the advantage of dynamic contrast-enhanced (DCE) sequences, 3 T MRI enables the reliable detection of pituitary pathologies in general. [1][2][3] However, in some cases, 3 T MRI is not able to delineate intrasellar microadenomas-the most common pituitary lesions 4 -despite up-to-date MRI technology and various sequences.…”