Last updated March 14, 2022

Management of Patients with Nonfunctioning Pituitary Adenomas


Radiosurgery and radiation therapy are recommended for treatment of residual or recurrent NFPAs to lower the risk of subsequent tumor progression.

(Level II)

When no residual tumor is present or only a small intrasellar tumor exists postoperatively, serial neuroimaging studies are recommended.

(Level II)

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.

(Level II)

Assessment of NFPA proliferative index and adrenocorticotrophic hormone staining to identify silent corticotroph adenomas are recommended for providing guidance on the risk of adenoma progression and the benefit of earlier adjuvant radiation.

(Level III)

Repeat resection is recommended for the treatment of symptomatic recurrent or residual NFPAs.

(Level III)

Radiosurgery or radiation therapy for NFPAs is recommended when residual/recurrent sellar or parasellar tumor exists and the risk of a repeat resection is high. (Level III)

Recommendation Grading



Management of Patients with Nonfunctioning Pituitary Adenomas

Authoring Organization

Publication Month/Year

November 1, 2016

Supplemental Implementation Tools

Patient Information

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adolescent, Adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users



Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D000236 - Adenoma, D049913 - ACTH-Secreting Pituitary Adenoma


radiosurgery, Stereotactic radiosurgery, Nonfunctioning pituitary adenoma, Residual , Radiation therapy , microsurgical resection, fractionated radiation therapy


Number of Source Documents
Literature Search Start Date
January 1, 1966
Literature Search End Date
October 31, 2014
Description of External Review Process
The completed systematic review was then distributed to the Joint Guidelines Committee (JGC) of the American Association of Neurological Surgeons (AANS) and CNS for consideration of endorsement by the CNS Executive Committee and the AANS Board of Directors. JGC reviewers were permitted to critique the content and methodology used to create this systematic review. Any concerns of the JGC were addressed by the Task Force, and the document was resubmitted to the JGC for endorsement.
Specialties Involved
Neurological Surgery, Neurology, Surgery General
Description of Systematic Review
CNS/AANS has an established methodology. The grading of recommendations is unique to their specialty.
List of Questions
What is the consensus within the scientific literature for the primary treatment strategy for patients with symptomatic nonfunctioning pituitary adenomas (NFPAs)? (2) What is the consensus within the scientific literature for the primary treatment strategy for patients with asymptomatic NFPAs?
Description of Search Strategy
Two electronic databases, PubMed and the Cochrane Central Register of Controlled Trials, were searched. Strategies for searching the electronic databases were constructed by the task force members and the medical librarian using previously published search strategies to identify relevant studies. Twenty-three studies met inclusion criteria for analysis.
Description of Study Selection
Each article was reviewed by at least 2 independent reviewers to determine whether they met the qualifications for full text review.
Description of Evidence Analysis Methods
Information was compiled by that subgroup and then distributed to the entire group for review until a final consensus by means of group discussion, voting, and approval was achieved. The Task Force implemented a modified structured voting technique to finalize and approve the recommendations and strength of recommendations presented in this review. If and when a disparity in opinions occurred, every effort was made to amend the guideline to adequately address each viewpoint until all members were in agreement. In the event that a unanimous decision could not be made, the question was posed to the Task Force as a whole, and the majority opinion was used. This method was agreed upon by all members of the Task Force.
Description of Evidence Grading
The strength of evidence of each article that underwent full text review was graded according to the criteria established by the AANS/CNS JGC. The class of evidence (i.e., Class I, II, or III) assigned to each article was determined after review of the sample size, study design, follow-up, and outcome measures (refer to Table 1 in the original guideline).
Description of Recommendation Grading
Level I: High degree of clinical certainty (Class I evidence or overwhelming Class II evidence) Level II: Clinical certainty (Class II evidence or a strong consensus of Class III evidence) Level III: Clinical uncertainty (inconclusive or conflicting evidence or opinion)
Description of Funding Source
All NFPA Guideline Task Force members were required to disclose all potential COIs prior to beginning work on the guideline, using the COI disclosure form of the AANS/CNS Joint Guidelines Committee. The CNS Guidelines Committee and Guideline Task Force Chair reviewed the disclosures and either approved or disapproved the nomination and participation on the task force. The CNS Guidelines Committee and Guideline Task Force Chair may approve nominations of Task Force Members with possible conflicts and restrict the writing, reviewing and/or voting privileges of that person to topics that are unrelated to the possible COIs.
Company/Author Disclosures
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Percentage of Authors Reporting COI