The Congress of Neurological Surgeons just released four guidelines focusing on components of functioning pituitary adenoma treatment: Role of Medical Perioperative Management for Patients with Functioning Pituitary Adenomas; Role of Radiosurgery for Patients with Functioning Pituitary Adenomas; Role of Surgery for Patients with Functioning Pituitary Adenomas; Role of Imaging for Patients with Functioning Pituitary Adenomas.

Because patients with functioning pituitary adenomas benefit greatly from multidisciplinary care, guidelines for varying components of care are ideal for patient outcomes. 

Below, we outline the major components of each of the four guidelines, as well as providing links to summarized and full-text versions of these CNS guidelines on functioning pituitary adenomas.

Role of Medical Perioperative Management for Patients with Functioning Pituitary Adenomas

Summary of Recommendations:

  • In adult patients with functioning pituitary adenomas who undergo trans-sphenoidal surgery, fluid restriction after surgery is a suggested effective approach to prevent delayed hyponatremia and reduce hospital readmission for hyponatremia. There is not enough evidence to support serum sodium check without fluid restriction as a preventative strategy to reduce hyponatremia.
  • Preoperative medical treatment with somatostatin analogs for patients with GH-secreting tumors is not routinely suggested, as there is insufficient evidence demonstrating a benefit to long-term biochemical remission, medical comorbidities, or surgical complications.
  • Postoperative serum cortisol monitoring within the immediate postoperative period (≤72 h) is suggested using a cutoff level of <2 ug/dL as a predictor of remission and an indicator for glucocorticoid replacement.
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Role of Radiosurgery for Patients with Functioning Pituitary Adenomas

Summary of Recommendations:

  • In adult patients with signs/symptoms, endocrine evaluation, and imaging supportive of functioning pituitary microadenomas secreting prolactin, medical management is suggested over surgery for the treatment at primary diagnosis in providing a better clinical outcome.
  • In adult patients with signs/symptoms, endocrine evaluation, and imaging supportive of functioning pituitary microadenomas secreting ACTH, there is insufficient evidence to favor surgery over medical management in providing a better clinical outcome.
  • In adult patients with signs/symptoms, endocrine evaluation, and imaging supportive of functioning pituitary microadenomas secreting growth hormone, surgery is suggested over medical management to provide a better clinical outcome and biochemical remission. There is insufficient evidence to support pretreatment with a somatostatin analog before surgery.
  • In adult patients with signs/symptoms, endocrine evaluation, and imaging supportive of functioning pituitary microadenomas secreting TSH, there is insufficient evidence to favor surgery over medical management in providing a better clinical outcome. (Insufficient)
  • In adult patients with signs/symptoms, endocrine evaluation, and imaging supportive of functioning pituitary requiring surgical resection, endoscopic techniques are not superior to microscopic techniques for extent of surgical resection (EOR), hormone remission, length of stay, or complication rates, in the treatment of functional pituitary adenomas. There is a suggestion, however, that the endoscopic technique may be superior to the microscopic technique, for a shorter operative time and for EOR and hormone remission rates for pituitary macroadenomas without cavernous sinus invasion.
  • There is insufficient evidence to make recommendations regarding adjuvant surgical techniques for transsphenoidal surgery for functioning pituitary adenomas compared with standard TSS techniques regarding outcome improvement.
  • In adult patients with recurrent Cushing disease, or recurrent acromegaly, there is insufficient evidence to recommend that a second operation provides improved radiographic or biochemical control compared with medical treatment or radiotherapy.
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Role of Surgery for Patients with Functioning Pituitary Adenomas

Summary of Recommendations:

  • In adult patients with signs/symptoms, endocrine evaluation, and imaging supportive of progressive/recurrent FPAs, it is suggested clinicians use SRS, hypofractionated SRS, FRT, and conventional radiation therapy to provide improved radiographic control with variable rates of hormonal reduction.
  • In adult patients with signs/symptoms, endocrine evaluation, and imaging indicative of FPA requiring radiosurgery treatment, clinicians may continue to administer endocrine suppressive medical treatment before SRS as this may not affect radiographic control.
  • There is insufficient evidence to make a recommendation about the effects of stopping the endocrine suppressive medications before radiosurgery on biochemical normalization.
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Role of Imaging for Patients with Functioning Pituitary Adenomas

Summary of Recommendations

  • In adult patients with endocrinological suspicion of functioning pituitary adenoma, assessment with MRI is suggested as it provides a more accurate confirmation of the pituitary tumor than endocrine assessment alone. In patients with endocrinologically suspected ectopic adrenocorticotrophic hormone (ACTH) syndrome, computed tomography of the abdomen/pelvis rather than pituitary MRI is suggested.
  • In adult patients with signs/symptoms and endocrine evaluation suggestive of ACTH-secreting functioning pituitary adenomas with magnetic resonance images negative for tumor, bilateral inferior petrosal sinus sampling is suggested as a diagnostic benefit.
  • In adult patients with signs/symptoms and endocrine evaluation suggestive of functioning pituitary microadenomas with negative MRIPET using radioactive metabolic tracers is suggested as a diagnostic benefit.
  • In adult patients with signs/symptoms and endocrine evaluation suggestive of functioning pituitary adenomas, MRI grading systems and/or newer sellar imaging is suggested to further predict postoperative biochemical control and/or complete tumor resection.
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