Daniela Esposito, Daniel S Olsson, Oskar Ragnarsson, Michael Buchfelder, Thomas Skoglund, Gudmundur Johannsson
Non-functioning pituitary adenomas: indications for pituitary surgery and post-surgical management.
Pituitary. 2019 Aug;22(4):422-434. doi: 10.1007/s11102-019-00960-0.
Abstract/Text
PURPOSE: Non-functioning pituitary adenomas (NFPAs) are associated with impaired well-being, increased comorbidities, and reduced long-term survival. Data on optimal management of NFPAs around surgical treatment are scarce, and postoperative treatment and follow-up strategies have not been evaluated in prospective trials. Here, we review the preoperative, perioperative, and early postoperative management of patients with NFPAs.
METHODS: We searched Medline and the Cochrane Library for articles published in English with the following items "Pituitary neoplasms AND Surgery" and "Surgery AND Hypopituitarism". Studies containing detailed analyses of the management of NFPAs in adult patients, including pituitary surgery, endocrine care, imaging, ophthalmologic assessment and long-term outcome were reviewed.
RESULTS: Treatment options for NFPAs include active surveillance, surgical resection, and radiotherapy. Pituitary surgery is currently recommended as first-line treatment in patients with visual impairment due to adenomas compressing the optic nerves or chiasma. Radiotherapy is reserved for large tumor remnants or tumor recurrence following one or more surgical attempts. There is no consensus of optimal pre-, peri-, and postoperative management such as timing, frequency, and duration of endocrine, radiologic, and ophthalmologic assessments as well as management of smaller tumor remnants or tumor recurrence.
CONCLUSIONS: In clinical practice, there is a great variation in the treatment and follow-up of patients with NFPAs. We have, based on available data, suggested an optimal management strategy for patients with NFPAs in relation to pituitary surgery. Prospective trials oriented at drawing up strategies for the management of NFPAs are needed.
Brian T Ragel, William T Couldwell
Pituitary carcinoma: a review of the literature.
Neurosurg Focus. 2004 Apr 15;16(4):E7. Epub 2004 Apr 15.
Abstract/Text
Pituitary carcinomas, defined as distant metastases of a pituitary neoplasm, are rare; fewer than 140 reports exist in the English literature. The initial presenting pituitary tumor is usually a secreting, invasive macroadenoma, with adrenocorticotropic hormone (ACTH)--and prolactin (PRL)--secreting tumors being the most common. The latency period between the diagnosis of a pituitary tumor and the diagnosis of a pituitary carcinoma is 9.5 years for ACTH-producing lesions and 4.7 years for PRL-secreting tumors. Survival after documentation of metastatic disease is poor; 66% of patients die within 1 year. Treatment options include additional surgery, radiotherapy, and chemotherapy, all of which are associated with poor results. Future studies will focus on identifying those invasive pituitary tumors most likely to metastasize and treating them aggressively before they progress to pituitary carcinomas.
A Teramoto, K Hirakawa, N Sanno, Y Osamura
Incidental pituitary lesions in 1,000 unselected autopsy specimens.
Radiology. 1994 Oct;193(1):161-4. doi: 10.1148/radiology.193.1.8090885.
Abstract/Text
PURPOSE: To elucidate the frequency of false-positive results in imaging diagnoses of a functioning pituitary microadenoma, the authors studied various kinds of incidental lesions greater than 2 mm in diameter from a larger series of pituitary glands.
MATERIALS AND METHODS: One thousand pituitary glands were studied in a nonselected autopsy series. Most causes of death were acute diseases or accidents. Each gland was fixed in 10% formalin and was then cut horizontally into three or four pieces, which were prepared for usual light microscopy.
RESULTS: Of 178 glands found to have incidental lesions, 61 (34%) lesions were larger than 2 mm. Included were adenomas and hyperplasias (n = 20), Rathke cysts (n = 37), infarctions (n = 2), and hemorrhages (n = 2). Seventeen (74%) of 23 laterally localized lesions were adenomas, and 33 (87%) of 38 medially situated lesions were Rathke cleft cysts. These lesions were found in 5.8%-8.3% of subjects in every generation aged 30 years or older.
CONCLUSION: Incidental lesions should be considered a cause of false-positive findings (6.1%) when an imaging diagnosis is made of a functioning pituitary microadenoma.
厚生労働科学研究費補助金難治性疾患克服研究事業 間脳下垂体機能障害に関する調査研究班 :平成13年度 総括・分担研究報告書 .2002;57.
Naoko Sanno, Ken'ichi Oyama, Shigeyuki Tahara, Akira Teramoto, Yuzuru Kato
A survey of pituitary incidentaloma in Japan.
Eur J Endocrinol. 2003 Aug;149(2):123-7.
Abstract/Text
OBJECTIVE: The development of computed tomography (CT) and magnetic resonance imaging (MRI) has resulted in the discovery of unsuspected endocrinologically silent pituitary masses (pituitary incidentalomas). The aim of this study was to perform a national survey on pituitary incidentalomas in order to establish an appropriate approach to them.
DESIGN AND METHODS: Five hundred and six patients with pituitary incidentalomas were obtained by questionnaire from March 1999 to May 2000 under the auspices of the Ministry of Health, Labor and Welfare in Japan. Two hundred and fifty-eight patients underwent surgery (surgical group), while 248 patients were followed up conservatively for a mean period of 26.9 Months (range 6-173 Months) (non-surgical group). Clinical and biochemical assessment, CT or MRI of the pituitary, and visual field testing by Goldman perimetry were assessed at baseline and 6 Months and Yearly thereafter.
RESULTS: Thirty-three patients with pituitary incidentalomas (13.3%) developed tumor enlargement during the mean follow-up period of 45.5 Months. Of 115 estimated non-functioning adenomas, 23 tumors (20.0%) increased during a mean follow-up period of 50.7 Months (range 10-173 Months), while 5 of 94 (5.3%) estimated Rathke's cysts increased in size during follow-up. Pituitary apoplexy occurred in one of 248 patients (0.4%).
CONCLUSIONS: Pituitary incidentalomas usually follow a benign course. We recommend transsphenoidal adenectomy for a solid mass attached to the optic chiasma estimated to be a pituitary adenoma by MRI. Other patients should be followed up by MRI every 6 Months for the first 2 Years, and then Yearly.
Pamela U Freda, Albert M Beckers, Laurence Katznelson, Mark E Molitch, Victor M Montori, Kalmon D Post, Mary Lee Vance, Endocrine Society
Pituitary incidentaloma: an endocrine society clinical practice guideline.
J Clin Endocrinol Metab. 2011 Apr;96(4):894-904. doi: 10.1210/jc.2010-1048.
Abstract/Text
OBJECTIVE: The aim was to formulate practice guidelines for endocrine evaluation and treatment of pituitary incidentalomas.
CONSENSUS PROCESS: Consensus was guided by systematic reviews of evidence and discussions through a series of conference calls and e-mails and one in-person meeting.
CONCLUSIONS: We recommend that patients with a pituitary incidentaloma undergo a complete history and physical examination, laboratory evaluations screening for hormone hypersecretion and for hypopituitarism, and a visual field examination if the lesion abuts the optic nerves or chiasm. We recommend that patients with incidentalomas not meeting criteria for surgical removal be followed with clinical assessments, neuroimaging (magnetic resonance imaging at 6 months for macroincidentalomas, 1 yr for a microincidentaloma, and thereafter progressively less frequently if unchanged in size), visual field examinations for incidentalomas that abut or compress the optic nerve and chiasm (6 months and yearly), and endocrine testing for macroincidentalomas (6 months and yearly) after the initial evaluations. We recommend that patients with a pituitary incidentaloma be referred for surgery if they have a visual field deficit; signs of compression by the tumor leading to other visual abnormalities, such as ophthalmoplegia, or neurological compromise due to compression by the lesion; a lesion abutting the optic nerves or chiasm; pituitary apoplexy with visual disturbance; or if the incidentaloma is a hypersecreting tumor other than a prolactinoma.
厚生労働科学研究費補助金 難治性疾患政策研究事業「間脳下垂体機能障害に関する調査研究」班：間脳下垂体機能障害と先天性腎性尿崩症および関連疾患の診療ガイドライン2023年版（令和5年度改訂）．59～61、156頁.
厚生労働科学研究費補助金 難治性疾患政策研究事業「間脳下垂体機能障害に関する調査研究」班：間脳下垂体機能障害と先天性腎性尿崩症および関連疾患の診療ガイドライン2023年版（令和5年度改訂）62～63、164頁.
Maria Fleseriu, Richard Auchus, Irina Bancos, Anat Ben-Shlomo, Jerome Bertherat, Nienke R Biermasz, Cesar L Boguszewski, Marcello D Bronstein, Michael Buchfelder, John D Carmichael, Felipe F Casanueva, Frederic Castinetti, Philippe Chanson, James Findling, Mônica Gadelha, Eliza B Geer, Andrea Giustina, Ashley Grossman, Mark Gurnell, Ken Ho, Adriana G Ioachimescu, Ursula B Kaiser, Niki Karavitaki, Laurence Katznelson, Daniel F Kelly, André Lacroix, Ann McCormack, Shlomo Melmed, Mark Molitch, Pietro Mortini, John Newell-Price, Lynnette Nieman, Alberto M Pereira, Stephan Petersenn, Rosario Pivonello, Hershel Raff, Martin Reincke, Roberto Salvatori, Carla Scaroni, Ilan Shimon, Constantine A Stratakis, Brooke Swearingen, Antoine Tabarin, Yutaka Takahashi, Marily Theodoropoulou, Stylianos Tsagarakis, Elena Valassi, Elena V Varlamov, Greisa Vila, John Wass, Susan M Webb, Maria C Zatelli, Beverly M K Biller
Consensus on diagnosis and management of Cushing's disease: a guideline update.
Lancet Diabetes Endocrinol. 2021 Dec;9(12):847-875. doi: 10.1016/S2213-8587(21)00235-7. Epub 2021 Oct 20.
Abstract/Text
Cushing's disease requires accurate diagnosis, careful treatment selection, and long-term management to optimise patient outcomes. The Pituitary Society convened a consensus workshop comprising more than 50 academic researchers and clinical experts to discuss the application of recent evidence to clinical practice. In advance of the virtual meeting, data from 2015 to present about screening and diagnosis; surgery, medical, and radiation therapy; and disease-related and treatment-related complications of Cushing's disease summarised in recorded lectures were reviewed by all participants. During the meeting, concise summaries of the recorded lectures were presented, followed by small group breakout discussions. Consensus opinions from each group were collated into a draft document, which was reviewed and approved by all participants. Recommendations regarding use of laboratory tests, imaging, and treatment options are presented, along with algorithms for diagnosis of Cushing's syndrome and management of Cushing's disease. Topics considered most important to address in future research are also identified.
Copyright © 2021 Elsevier Ltd. All rights reserved.
厚生労働科学研究費補助金 難治性疾患政策研究事業「間脳下垂体機能障害に関する調査研究」班：間脳下垂体機能障害と先天性腎性尿崩症および関連疾患の診療ガイドライン2023年版（令和5年度改訂）.
E Knosp, E Steiner, K Kitz, C Matula
Pituitary adenomas with invasion of the cavernous sinus space: a magnetic resonance imaging classification compared with surgical findings.
Neurosurgery. 1993 Oct;33(4):610-7; discussion 617-8.
Abstract/Text
We present 25 pituitary adenomas that were confirmed surgically to have invaded the cavernous sinus space. The surgical results are compared with the preoperative magnetic resonance imaging findings. For comparable radiological criteria, we classified parasellar growth into five grades. This proposed classification is based on coronal sections of unenhanced and gadolinium diethylene-triamine-pentaacetic acid enhanced magnetic resonance imaging scans, with the readily detectable internal carotid artery serving as the radiological landmark. The anatomical, radiological, and surgical conditions of each grade are considered. Grades 0, 1, 2, and 3 are distinguished from each other by a medial tangent, the intercarotid line--through the cross-sectional centers--and a lateral tangent on the intra- and supracavernous internal carotid arteries. Grade 0 represents the normal condition, and Grade 4 corresponds to the total encasement of the intracavernous carotid artery. According to this classification, surgically proven invasion of the cavernous sinus space was present in all Grade 4 and Grade 3 cases and in all but one of the Grade 2 cases; no invasion was present in Grade 0 and Grade 1 cases. Therefore, the critical area where invasion of the cavernous sinus space becomes very likely and can be proven surgically is located between the intercarotid line and the lateral tangent, which is represented by our Grade 2. We also measured tumor growth rates, using the monoclonal antibody KI-67, which shows a statistically higher proliferation rate (P < 0.001) in adenomas with surgically observed invasion into the cavernous sinus space, as compared with noninvasive adenomas.
Felipe F Casanueva, Mark E Molitch, Janet A Schlechte, Roger Abs, Vivien Bonert, Marcello D Bronstein, Thierry Brue, Paolo Cappabianca, Annamaria Colao, Rudolf Fahlbusch, Hugo Fideleff, Moshe Hadani, Paul Kelly, David Kleinberg, Edward Laws, Josef Marek, Maurice Scanlon, Luis G Sobrinho, John A H Wass, Andrea Giustina
Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas.
Clin Endocrinol (Oxf). 2006 Aug;65(2):265-73. doi: 10.1111/j.1365-2265.2006.02562.x.
Abstract/Text
In June 2005, an ad hoc Expert Committee formed by the Pituitary Society convened during the 9th International Pituitary Congress in San Diego, California. Members of this committee consisted of invited international experts in the field, and included endocrinologists and neurosurgeons with recognized expertise in the management of prolactinomas. Discussions were held that included all interested participants to the Congress and resulted in formulation of these guidelines, which represent the current recommendations on the diagnosis and management of prolactinomas based upon comprehensive analysis and synthesis of all available data.
Maria Fleseriu, Beverly M K Biller, Pamela U Freda, Monica R Gadelha, Andrea Giustina, Laurence Katznelson, Mark E Molitch, Susan L Samson, Christian J Strasburger, A J van der Lely, Shlomo Melmed
A Pituitary Society update to acromegaly management guidelines.
Pituitary. 2021 Feb;24(1):1-13. doi: 10.1007/s11102-020-01091-7. Epub 2020 Oct 20.
Abstract/Text
Guidelines and consensus statements ensure that physicians managing acromegaly patients have access to current information on evidence-based treatments to optimize outcomes. Given significant novel recent advances in understanding acromegaly natural history and individualized therapies, the Pituitary Society invited acromegaly experts to critically review the current literature in the context of Endocrine Society guidelines and Acromegaly Consensus Group statements. This update focuses on how recent key advances affect treatment decision-making and outcomes, and also highlights the likely role of recently FDA-approved therapies as well as novel combination therapies within the treatment armamentarium.
日本脳ドック学会 脳ドックの新ガイドライン作成委員会 編：脳ドックのガイドライン2014．響文社，2014.
厚生労働科学研究費補助金 難治性疾患克服研究事業 間脳下垂体機能障害に関する調査研究班 平成21年度報告書.
A Teramoto, Y Yoshida, N Sanno, S Nemoto
Cavernous sinus sampling in patients with adrenocorticotrophic hormone-dependent Cushing's syndrome with emphasis on inter- and intracavernous adrenocorticotrophic hormone gradients.
J Neurosurg. 1998 Nov;89(5):762-8. doi: 10.3171/jns.1998.89.5.0762.
Abstract/Text
OBJECT: As an alternative method to inferior petrosal sinus sampling with administration of corticotropin-releasing hormone (CRH), the authors have developed a method of selective venous sampling directly from the cavernous sinus, which is performed using a superselective catheterization technique. The goal of this study is to assess this method.
METHODS: Catheterization to the cavernous sinus was performed in 44 patients with clinical and biochemical features of Cushing's syndrome. Forty of these patients in whom there was a definite clinical and/or histological diagnosis were evaluated. In 35 patients, a pituitary microadenoma was detected on magnetic resonance imaging and/or during surgery. Ectopic lesions were suspected in five patients, who later developed nonpituitary tumors. The central/peripheral (C/P) ratios of adrenocorticotrophic hormone (ACTH) without CRH administration ranged from 5.2 to 448.1 (mean+/-standard deviation, 66.7+/-91.2) in cavernous sinuses and from 1.1 to 52 (mean+/-standard deviation, 8.5+/-9.9) in the inferior petrosal sinuses. The petrosal sinus sampling contained false negative results in eight patients (23%) based on a cutoff point of 2. On the contrary, patients with ectopic lesions did not show any increase in ACTH levels in either sampling portion. The intercavernous gradients of ACTH, ranging from 1.2 to 506.4, indicated the correct lateralization of microadenoma in the lateral wing in all 30 patients. The interpetrosal gradients, ranging from 1 to 31.4, did not give a sufficient value (> or = 1.4) in four patients (13%) with a lateral lesion. In five cases of midline tumors, the intercavernous and interpetrosal gradients indicated false laterality in three and four cases, respectively. The intracavernous (posterior-anterior) gradients, ranging from 1.04 to 60.7 (mean 14.9), showed a higher concentration of ACTH in the posterior portion of the sinus in all patients.
CONCLUSIONS: These results suggest that 1) cavernous sinus sampling without CRH administration can demonstrate hypersecretion of ACTH from the pituitary gland with a high diagnostic accuracy; 2) intercavernous gradients will indicate the correct lateralization in laterally localized microadenomas; and 3) sampling should be performed from the posterior portion of the cavernous sinus.
