Management of Pituitary Adenomas

Initial Evaluation

The American College of Endocrinology recommends MRI with contrast as the imaging modality of choice for detailed anatomical delineation of the adenoma 3
Visual assessment, including visual acuity, visual fields, and fundoscopy, should be performed in all patients with pituitary macroadenoma 3
Genetic assessment should be offered to all patients to inform management and family surveillance, particularly important in children and young people (CYP) who have a higher likelihood of underlying genetic disease 2, 3

The Endocrine Society recommends first-line treatment with dopamine agonists (bromocriptine or cabergoline) for prolactinomas, even for macroadenomas with visual compromise 3
The American Association of Neurological Surgeons recommends transsphenoidal surgery as the first-line therapy for growth hormone-secreting adenomas, except for giant macroadenomas or when surgery is contraindicated 4
Surgery is the primary treatment for TSH-secreting adenomas, according to the European Society of Endocrinology 2

The American Association of Neurological Surgeons recommends transsphenoidal surgery as the technique of choice, even in patients with incompletely pneumatized sphenoid sinuses 6
Endoscopic rather than microscopic transsphenoidal surgery may be considered for potentially superior efficacy in preserving pituitary function 6
Strict fluid and electrolyte balance monitoring is essential peri-operatively and post-operatively, as recommended by the Society of Neurosurgeons 6, 3

The American College of Endocrinology recommends MRI surveillance at 3 and 6 months, and 1, 2, 3, and 5 years after surgery for non-functioning pituitary adenomas (NFPAs) 3, 4
Visual assessment should be performed within 3 months of first-line therapy, according to the European Society of Endocrinology 3
Regular hormone level assessments specific to the tumor type should be conducted during follow-up, as recommended by the Endocrine Society 3

Pituitary adenomas in children and young people (CYP) tend to have more occult presentation, aggressive behavior, and are more likely to have a genetic basis than in adults, according to the Pediatric Endocrine Society 2
CYP with pituitary adenomas should be treated by a pituitary-specific multidisciplinary team with experts from both pediatric and adult practice, as recommended by the American Academy of Pediatrics 1

Repeat resection is recommended for symptomatic recurrent or residual NFPAs, according to the American Association of Neurological Surgeons 5
Radiosurgery with single-session doses of ≥12 Gy or radiation therapy with fractionated doses of 45 to 54 Gy is recommended for greater local tumor control rate of ≥90% at 5 years after treatment, as recommended by the Society of Neurosurgeons 5