Practice guidelines for the endocrine evaluation and treatment of pituitary incidentalomas are presented, including indications for surgery.

Pituitary incidentaloma: an endocrine society clinical practice guideline.

Objective To provide an overview of the evidence on prevalence and outcomes of incidental imaging findings. Design Umbrella review of systematic reviews. Data sources Searches of MEDLINE, EMBASE up to August 2017; screening of references in included papers. Eligibility criteria Criteria included systematic reviews and meta-analyses of observational studies that gave a prevalence of incidental abnormalities (“incidentalomas”). An incidental imaging finding was defined as an imaging abnormality in a healthy, asymptomatic patient or an imaging abnormality in a symptomatic patient, where the abnormality was not apparently related to the patient’s symptoms. Primary studies that measured the prevalence of incidentalomas in patients with a history of malignancy were also considered in sensitivity analyses. Results 20 systematic reviews (240 primary studies) were identified from 7098 references from the database search. Fifteen systematic reviews provided data to quantify the prevalence of incidentalomas, whereas 18 provided data to quantify the outcomes of incidentalomas (13 provided both). The prevalence of incidentalomas varied substantially between imaging tests; it was less than 5% for chest computed tomography for incidental pulmonary embolism in patients with and without cancer and whole body positron emission tomography (PET) or PET/computed tomography (for patients with and without cancer). Conversely, incidentalomas occurred in more than a third of images in cardiac magnetic resonance imaging (MRI), chest computed tomography (for incidentalomas of thorax, abdomen, spine, or heart), and computed tomography colonoscopy (for extra-colonic incidentalomas). Intermediate rates occurred with MRI of the spine (22%) and brain (22%). The rate of malignancy in incidentalomas varied substantially between organs; the prevalence of malignancy was less than 5% in incidentalomas of the brain, parotid, and adrenal gland. Extra-colonic, prostatic, and colonic incidentalomas were malignant between 10% and 20% of the time, whereas renal, thyroid, and ovarian incidentalomas were malignant around a quarter of the time. Breast incidentalomas had the highest percentage of malignancy (42%, 95% confidence interval 31% to 54%). Many assessments had high between-study heterogeneity (15 of 20 meta-analyses with I2 >50%). Conclusions There is large variability across different imaging techniques both in the prevalence of incidentalomas and in the prevalence of malignancy for specific organs. This umbrella review will aid clinicians and patients weigh up the pros and cons of requesting imaging scans and will help with management decisions after an incidentaloma diagnosis. Our results can underpin the creation of guidelines to assist these decisions. Systematic review registration PROSPERO: CRD42017075679.

https://www.bmj.com/content/bmj/361/bmj.k2387.full.pdf

Prevalence and outcomes of incidental imaging findings: umbrella review

Non-functioning pituitary adenomas (NFPAs) are benign pituitary neoplasms that do not cause a hormonal hypersecretory syndrome. An improved understanding of their epidemiology, clinical presentation and diagnosis is needed. A literature review was performed using Pubmed to identify research reports and clinical case series on NFPAs. They account for 14–54% of pituitary adenomas and have a prevalence of 7–41.3/100,000 population. Their standardized incidence rate is 0.65–2.34/100,000 and the peak occurence is from the fourth to the eighth decade. The clinical spectrum of NFPAs varies from being completely asymptomatic to causing significant hypothalamic/pituitary dysfunction and visual field compromise due to their large size. Most patients present with symptoms of mass effect, such as headaches, visual field defects, ophthalmoplegias, and hypopituitarism but also hyperprolactinaemia due to pituitary stalk deviation and less frequently pituitary apoplexy. Non-functioning pituitary incidentalomas are found on brain imaging performed for an unrelated reason. Diagnostic approach includes magnetic resonance imaging of the sellar region, laboratory evaluations, screening for hormone hypersecretion and for hypopituitarism, and a visual field examination if the lesion abuts the optic nerves or chiasm. This article reviews the epidemiology, clinical behaviour and diagnostic approach of non-functioning pituitary adenomas.

Epidemiology, clinical presentation and diagnosis of non-functioning pituitary adenomas

Object Pituitary adenomas are fairly common intracranial neoplasms, and nonfunctioning ones constitute a large subgroup of these adenomas Complete resection is often difficult and may pose undue risk to neurological and endocrine function Stereotactic radiosurgery has come to play an important role in the management of patients with nonfunctioning pituitary adenomas This study examines the outcomes after radiosurgery in a large, multicenter patient population Methods Under the auspices of the North American Gamma Knife Consortium, 9 Gamma Knife surgery (GKS) centers retrospectively combined their outcome data obtained in 512 patients with nonfunctional pituitary adenomas Prior resection was performed in 479 patients (936%) and prior fractionated external-beam radiotherapy was performed in 34 patients (66%) The median age at the time of radiosurgery was 53 years Fifty-eight percent of patients had some degree of hypopituitarism prior to radiosurgery Patients received a median dose of 16 Gy to the tumor margin The median follow-up was 36 months (range 1–223 months) Results Overall tumor control was achieved in 934% of patients at last follow-up; actuarial tumor control was 98%, 95%, 91%, and 85% at 3, 5, 8, and 10 years postradiosurgery, respectively Smaller adenoma volume (OR 108 [95% CI 102–113], p = 0006) and absence of suprasellar extension (OR 210 [95% CI 096–461], p = 0064) were associated with progression-free tumor survival New or worsened hypopituitarism after radiosurgery was noted in 21% of patients, with thyroid and cortisol deficiencies reported as the most common postradiosurgery endocrinopa thies History of prior radiation therapy and greater tumor margin doses were predictive of new or worsening endocrinopathy after GKS New or progressive cranial nerve deficits were noted in 9% of patients; 66% had worsening or new onset optic nerve dysfunction In multivariate analysis, decreasing age, increasing volume, history of prior radiation therapy, and history of prior pituitary axis deficiency were predictive of new or worsening cranial nerve dysfunction No patient died as a result of tumor progression Favorable outcomes of tumor control and neurological preservation were reflected in a 4-point radiosurgical pituitary score Conclusions Gamma Knife surgery is an effective and well-tolerated management strategy for the vast majority of patients with recurrent or residual nonfunctional pituitary adenomas Delayed hypopituitarism is the most common complication after radiosurgery Neurological and cranial nerve function were preserved in more than 90% of patients after radiosurgery The radiosurgical pituitary score may predict outcomes for future patients who undergo GKS for a nonfunctioning adenoma

http://www.neurosurgery.med.wayne.edu/pdfs/gamma_knife_radiosurgery_for_the_management_of_nonfunctioning_pituitary_adenomas_a_multicenter_study.pdf

Gamma Knife radiosurgery for the management of nonfunctioning pituitary adenomas: a multicenter study.

Abstract All endocrine glands are susceptible to neoplastic growth, yet the health consequences of these neoplasms differ between endocrine tissues. Pituitary neoplasms are highly prevalent and overwhelmingly benign, exhibiting a spectrum of diverse behaviors and impact on health. To understand the clinical biology of these common yet often innocuous neoplasms, we review pituitary physiology and adenoma epidemiology, pathophysiology, behavior, and clinical consequences. The anterior pituitary develops in response to a range of complex brain signals integrating with intrinsic ectodermal cell transcriptional events that together determine gland growth, cell type differentiation, and hormonal production, in turn maintaining optimal endocrine health. Pituitary adenomas occur in 10% of the population; however, the overwhelming majority remain harmless during life. Triggered by somatic or germline mutations, disease-causing adenomas manifest pathogenic mechanisms that disrupt intrapituitary signaling to promote benign cell proliferation associated with chromosomal instability. Cellular senescence acts as a mechanistic buffer protecting against malignant transformation, an extremely rare event. It is estimated that fewer than one-thousandth of all pituitary adenomas cause clinically significant disease. Adenomas variably and adversely affect morbidity and mortality depending on cell type, hormone secretory activity, and growth behavior. For most clinically apparent adenomas, multimodal therapy controlling hormone secretion and adenoma growth lead to improved quality of life and normalized mortality. The clinical biology of pituitary adenomas, and particularly their benign nature, stands in marked contrast to other tumors of the endocrine system, such as thyroid and neuroendocrine tumors.

Clinical Biology of the Pituitary Adenoma

Pituitary incidentalomas and non-functioning pituitary adenomas have fairly rare complications that may be more common when lesions are large (> 10 mm) and solid.

/pdf/natural-history-of-nonfunctioning-pituitary-adenomas-and-1ga7bw097q.pdf

Natural History of Nonfunctioning Pituitary Adenomas and Incidentalomas: A Systematic Review and Metaanalysis

It presents a case of a healthy woman of 28 years with a tumor in his leg attached to soft tissue, she doesn’t have epidemiological history of travel outside Lima, without pulmonary, hepatic or systemic disease and with negative serology for Equinococcus granulosus before, during and after the surgical excision. In a first opportunity, they removed tumor and they didn’t suspect of hydatidosis so they didn’t give a proper treatment, so 16 weeks after, she came back with a relapse, where with a specific diagnosis was performed the surgery and treatment with albendazole, followed up after six months, the patient didn’t have recurrence.

/pdf/hidatidosis-muscular-primaria-reporte-de-un-caso-330srp8ldw.pdf

Hidatidosis muscular primaria: reporte de un caso

Summary
Background Surgery is commonly used in the management of pituitary nonfunctioning adenomas (NFPA). The goal of this systematic review and meta-analysis is to evaluate the effect of surgery on mortality, surgical complications, pituitary function and vision.

Methods  We searched MEDLINE, EMBASE and Cochrane CENTRAL, queried experts and reviewed the reference list of included publications. Eligible studies were comparative and noncomparative longitudinal studies that enroled patients with NFPA who underwent surgery (alone or in combination with other therapies). Reviewers, working independently and in duplicate, determined study eligibility with adequate reproducibility and extracted descriptive, quality and outcome data. Risks, relative risks (RR) and 95% confidence intervals (CIs) were estimated from each study and pooled using random-effects meta-analysis.

Results  Most included studies were uncontrolled case series in which patients received a combination of surgery and radiotherapy. The overall quality of the evidence was very low. Median follow-up was 4·29 years. When surgery was not combined with radiotherapy, there was an increased risk of tumour recurrence (RR 1·97; 95% CI, 1·15–3·35). Complications were more likely with the transcranial than with the transsphenoidal approach (mortality RR 4·89; 95% CI, 3·15–6·47; new anterior pituitary deficits RR 4·90; 95% CI, 2·94–7·82; and persistent diabetes insipidus RR 2·50; 95% CI, 1·05–5·35). Overall, transsphenoidal surgery had fairly low perioperative mortality (≤1%) and low complication rate (≤5% for all patient-important outcomes), but only less than a third of the patients had improvement in pituitary function.

Conclusions  Observational evidence supports the association between a combined approach of transsphenoidal surgery with radiotherapy and improvements in visual field defects and reduction in tumour recurrence.

Outcomes of surgical treatment for nonfunctioning pituitary adenomas: a systematic review and meta-analysis

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Natural History of Nonfunctioning Pituitary Adenomas and Incidentalomas: A Systematic Review and Metaanalysis

Hidatidosis muscular primaria: reporte de un caso

Outcomes of surgical treatment for nonfunctioning pituitary adenomas: a systematic review and meta-analysis