Pituitary Incidentaloma: An Endocrine Society Clinical Practice Guideline Incidentaloma Guide 2011

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S P E C I A L

F E A T U R E

C l i n i c a l

P r a c t i c e

G u i d e l i n e

Pituitary Incidentaloma: An Endocrine Society Clinical
Practice Guideline
Pamela U. Freda, Albert M. Beckers, Laurence Katznelson, Mark E. Molitch,
Victor M. Montori, Kalmon D. Post, and Mary Lee Vance
Columbia College of Physicians & Surgeons (P.U.F.), New York, New York 10032; Centre Hospitalier
Universitaire de Liège (A.M.B.), University of Liège Domaine Universitaire du Sart-Tilman, 4020 Liège,
Belgium; Stanford University (L.K.) Stanford, California 94305; Northwestern University Feinberg School
of Medicine (M.E.M.) Chicago, Illinois 60611; Mayo Clinic Rochester (V.M.M.), Rochester, Minnesota
55905; Mount Sinai Medical Center (K.D.P.) New York, New York 10029; and University of Virginia
Health Science Center (M.L.V.) Charlottesville, Virginia 22903

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. (J Clin Endocrinol Metab 96: 894 –904, 2011)

Summary of Recommendations
1.0 Initial evaluation of a patient with a pituitary
incidentaloma
1.1 We recommend that patients presenting with a pituitary incidentaloma undergo a complete history and
physical examination that includes evaluations for evidence of hypopituitarism and a hormone hypersecretion
syndrome. Patients with evidence of either of these con-

ISSN Print 0021-972X ISSN Online 1945-7197
Printed in U.S.A.
Copyright © 2011 by The Endocrine Society
doi: 10.1210/jc.2010-1048 Received May 6, 2010. Accepted December 7, 2010.
For editorial see page 939

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ditions should undergo an appropriately directed biochemical evaluation:
1.1.1 We recommend that all patients with a pituitary
incidentaloma, including those without symptoms, undergo clinical and laboratory evaluations for hormone hypersecretion (1ⱍQQQE).
1.1.2 We recommend that patients with a pituitary incidentaloma with or without symptoms also undergo clinical
and laboratory evaluations for hypopituitarism (1ⱍQQQE).
1.1.3 We recommend that all patients presenting with
a pituitary incidentaloma abutting the optic nerves or chiasm on magnetic resonance imaging (MRI) undergo a formal visual field (VF) examination (1ⱍQQQQ).
Abbreviations: CT, Computed tomography; GHD, GH deficiency; MRI, magnetic resonance
imaging; VF, visual field.

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1.1.4 We recommend that all patients have a MRI scan,
if possible, to evaluate the pituitary incidentaloma [if the
incidentaloma was initially only diagnosed by computed
tomography (CT) scan] to better delineate the nature and
extent of the incidentaloma (1ⱍQQQQ).

• Lesion abutting or compressing the optic nerves or
chiasm on MRI.
• Pituitary apoplexy with visual disturbance.
• Hypersecreting tumors other than prolactinomas as
recommended by other guidelines of The Endocrine
Society and The Pituitary Society.

2.0 Follow-up testing of the pituitary
incidentaloma
2.1 Patients with incidentalomas who do not meet criteria for surgical removal of the tumor should receive nonsurgical follow-up (2ⱍQQEE) with clinical assessments
and the following tests:
2.1.1 MRI scan of the pituitary 6 months after the initial scan if the incidentaloma is a macroincidentaloma and
1 yr after the initial scan if it is a microincidentaloma
(1ⱍQQEE). In patients whose incidentaloma does not
change in size, we suggest repeating the MRI every year for
macroincidentalomas and every 1–2 yr in microincidentalomas for the following 3 yr, and gradually less frequently thereafter (2ⱍQQEE).
2.1.2 VF testing in patients with a pituitary incidentaloma
that enlarges to abut or compress the optic nerves or chiasm
on a follow-up imaging study (1ⱍQQQQ). We suggest that
clinicians do not need to test VF in patients whose incidentalomas are not close to the chiasm and who have no new
symptoms and are being followed closely by MRI
(2ⱍQEEE).
2.1.3 Clinical and biochemical evaluations for hypopituitarism 6 months after the initial testing and yearly
thereafter in patients with a pituitary macroincidentaloma, although typically hypopituitarism develops with
the finding of an increase in size of the incidentaloma
(1ⱍQQEE). We suggest that clinicians do not need to test
for hypopituitarism in patients with pituitary microincidentalomas whose clinical picture, history, and MRI do
not change over time (2ⱍQQEE).
2.2 Patients who develop any signs or symptoms potentially related to the incidentaloma or who show an increase in size of the incidentaloma on MRI should undergo
more frequent or detailed evaluations as indicated clinically (1ⱍQQEE).

3.2 We suggest that surgery be considered for patients
with a pituitary incidentaloma if they have the following
(2ⱍQQEE):

3.0 Indications for surgical therapy of the pituitary
incidentaloma
3.1 We recommend that patients with a pituitary incidentaloma be referred for surgery if they have the following (1ⱍQQQQ):
• A VF deficit due to the lesion.
• Other visual abnormalities, such as ophthalmoplegia
or neurological compromise due to compression by
the lesion.

• Clinically significant growth of the pituitary
incidentaloma.
• Loss of endocrinological function.
• A lesion close to the optic chiasm and a plan to become pregnant.
• Unremitting headache.

Method of Development of EvidenceBased Clinical Practice Guidelines
The Clinical Guidelines Subcommittee of The Endocrine
Society deemed the subject of pituitary incidentalomas a
priority area in need of practice guidelines and appointed
a Task Force to formulate evidence-based recommendations. Consensus was guided by systematic reviews of evidence and discussions through a series of conference calls
and e-mails and one in-person meeting. An initial draft
guideline was prepared by the Task Force, with the help of
a medical writer, and reviewed and commented on by
members of The Endocrine Society and the European Society of Endocrinology. A second draft was reviewed and
approved by The Endocrine Society Council. At each stage
of review, the Task Force received written comments and
incorporated substantive changes. The evidence was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to
describe the strength of recommendations and the quality
of evidence, which was low or very low. The GRADE
group is an international group with expertise in development and implementation of evidence-based guidelines
(1). A detailed description of the grading scheme has been
published elsewhere (2). The Task Force used the best
available research evidence identified and one commissioned systematic review to develop some of the recommendations (3). The Task Force also used consistent language and graphical descriptions of both the strength of a
recommendation and the quality of evidence. In terms of
the strength of the recommendation, strong recommendations use the phrase “we recommend” and the number
1, and weak recommendations use the phrase “we suggest” and the number 2. Cross-filled circles indicate the
quality of the evidence, such that QEEE denotes very low

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quality evidence; QQEE, low quality; QQQE, moderate
quality; and QQQQ, high quality. The final category may
include circumstances in which there is a consistent observation of uniformly poor serious outcomes that will not
reverse spontaneously, but when treated, often through
surgical means, may dramatically improve or be cured.
The Task Force has confidence that persons who receive
care according to the strong recommendations will derive,
on average, more good than harm. Weak recommendations require more careful consideration of the person’s
circumstances, values, and preferences to determine the
best course of action. Linked to each recommendation is
a description of the evidence and the values that panelists
considered in making the recommendation; in some instances, there are remarks, a section in which panelists
offer technical suggestions for testing conditions, dosing,
and monitoring. These technical comments reflect the
best available evidence applied to a typical person being
treated. Often this evidence comes from the unsystematic observations of the panelists and their values and
preferences; therefore, these remarks should be considered suggestions.
Definition, etiology, and epidemiology of pituitary
incidentalomas
Definition of pituitary incidentaloma
A pituitary incidentaloma is a previously unsuspected
pituitary lesion that is discovered on an imaging study
performed for an unrelated reason. By definition, the imaging study is not done for a symptom specifically related
to the lesion, such as visual loss, or a clinical manifestation
of hypopituitarism or hormone excess, but rather for the
evaluation of symptoms such as headache, or other head
or neck neurological or central nervous system complaints
or head trauma (4 –9). Studies reviewed for these guidelines vary, however, in their definition of a “pituitary incidentaloma.” For example, some studies exclude cystic
lesions and include only those that fulfill radiographic
criteria for a pituitary adenoma (4, 5), whereas others
include all lesions (6 –9). The guidelines presented here
are relevant to all pituitary incidentalomas, those that
have the appearance typical of a pituitary adenoma as
well as cystic lesions. By convention, microincidentalomas are less than 1 cm and macroincidentalomas are
at least 1 cm in size.
Etiology of pituitary incidentalomas
Because incidentalomas infrequently come to surgery,
the true pathological diagnoses of most are unknown. In
a series of sellar masses that required surgery, 91% were
pituitary adenomas and about 9% were nonpituitary in
origin, of which most were craniopharyngiomas and

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Rathke’s cleft cysts (10). It is unknown whether the
etiologies of incidentalomas are similar to this surgical
cohort, but in one series of 29 incidentalomas that did
come to surgery, 23 were found to be pituitary adenomas, four were Rathke’s cleft cysts, and two were craniopharyngiomas (6, 7, 9). Immunohistochemical analysis of 20 of these adenomas was reported as negative in
50%, plurihormonal in 20%, gonadotroph positive in
15%, and GH positive in 10% (6, 7, 9). In another series
of 139 mass lesions without overt symptoms, 73 had a
cystic appearance on imaging study (5). Cystic lesions
are most likely to be Rathke’s cleft cysts, which often
present incidentally, or craniopharyngiomas (11, 12).
Of the non-cystic-appearing incidentalomas, nearly all
are likely to be pituitary adenomas, and most clinically
nonfunctioning pituitary adenomas are of gonadotrope
origin as determined by immunocytochemical studies
(13–15). However, the differential diagnosis of sellar
incidentalomas is broad and should include other possibilities (10).
Epidemiology of pituitary incidentalomas
The prevalence of pituitary incidentalomas has been
estimated from data on pituitary adenomas found at autopsy and from imaging in patients who underwent a CT
or MRI of the head for reasons other than pituitary disease. Because most pituitary incidentalomas are adenomas, autopsy data on adenomas may provide information
relevant to incidentaloma detected during life. In combined autopsy data, the average frequency of a pituitary
adenoma was 10.6% (16). The tumors were distributed
equally across genders and the adult age range, and nearly
all of these incidentalomas were microadenomas (16). In
adults who underwent cranial imaging studies for reasons
other than pituitary disease, microincidentalomas were
seen on CT in 4 –20% (17–19) or on MRI in 10 –38% (20)
of patients. Macroincidentalomas were found in 0.2% of
patients who underwent CT scans for central nervous system symptoms (21) and by MRI in 0.16% of a population
study cohort (22). In pooled data from 10 series of pituitary incidentalomas, 160 of 353 (45%) were macroincidentalomas (4 –9, 23–26), a larger percentage than has
been found on autopsy studies and the other screening
studies. This suggests that these patients may in fact have
had some symptom that was not readily apparent or reported but that led to the imaging study or that microincidentalomas were not referred to these centers for
evaluation.
Data are not available on pituitary incidentalomas in
the pediatric population; these guidelines are limited to
adults.

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1.0 Initial evaluation of a patient with a pituitary
incidentaloma
Recommendations
1.1 We recommend that patients presenting with a pituitary incidentaloma undergo a complete history and
physical examination that includes evaluations for evidence of hypopituitarism and a hormone hypersecretion
syndrome. Patients with evidence of either of these conditions should undergo an appropriately directed biochemical evaluation.
1.1.1 We recommend that all patients with a pituitary
incidentaloma, including those without symptoms, undergo clinical and laboratory evaluations for hormone hypersecretion (1ⱍQQQE).
1.1–1.1.1 Evidence
The goals of the endocrine evaluation of pituitary incidentalomas are to identify hormone hypersecretion and
hypopituitarism. The recommendations for evaluation of
pituitary function considered the likelihood of an abnormality in a given patient. However, valid estimates of the
pretest probability of an abnormal test of pituitary function could not be definitively determined because literature on this topic is sparse. Therefore, recommendations
for the evaluation relied heavily on clinical experience.
Data on the prevalence of hormone hypersecretion in
patients with an incidentaloma are available from small
observational studies (most retrospective) and estimated
from autopsy data. Screening for hypersecretion is important to perform because the prevalence of clinically evident
pituitary adenomas has recently been appreciated to be as
high as 1/1000 in a Belgian population (27), and 0.776/
1000 (of which 0.542/1000 were hormone secreting) in a
region of the United Kingdom (28), or as low as 0.04/1000
in Finland (29). The incidence of incidentally discovered
pituitary adenomas was recently reported as 0.016/1000
in a retrospective review from Finland (29).
The evaluation for hypersecretion should include an
assessment for prolactin, GH, and ACTH hypersecretion.
Evidence is strongest for the need to measure a serum prolactin level in all patients presenting with an incidentaloma. Ideally, for patients with large macroincidentalomas, the laboratory should measure prolactin levels in
diluted serum to ensure that levels are not falsely lowered
by a hook effect in the assay. Hyperprolactinemia was
found in five of 42 patients with microincidentalomas at
initial evaluation (4), but in other studies none of 22 developed a prolactin elevation on prospective follow-up (8,
9). In other studies, prolactinomas were detected in seven
of 46 patients with incidentalomas (micro and macro combined) (7). In macroincidentalomas, prolactin levels were
elevated in two of 16 (9). In a large autopsy study, 39.5%

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of the adenomas detected (most microadenomas) were
found to stain positive for prolactin (30). These data might
suggest that prolactinomas are very common among pituitary incidentalomas, which is contrary to the literature.
Autopsy data should cautiously be considered representative of incidentalomas presenting in life because the autopsy studies lack clinical data, and prolactin staining may
not have been associated with clinically relevant circulating hyperprolactinemia. Patients with hyperprolactinemia
could receive a trial of dopamine agonist therapy so long
as it is recognized that mild/moderate elevations may be
due to stalk compression from a lesion other than a prolactinoma. In these patients, tumor shrinkage is unlikely,
and growth of the incidentaloma is still possible, so continued follow-up with repeat imaging is warranted. The
treatment of hyperprolactinemia has been recently reviewed (31).
Although silent somatotroph-secreting tumors are rare,
evaluation for the possibility is recommended. In a prospective study, one of 11 macroincidentalomas were
found to have an elevated IGF-I consistent with subclinical
GH excess (8), and in another study, two of 13 incidentalomas that were surgically removed were positive on
immunohistochemistry for GH (7). One series of 3048
autopsies reported 334 pituitary adenomas, of which
1.8% stained positive for GH (30). Because the initial
treatment for a GH-secreting tumor is surgery and GHsecreting microadenomas can be cured surgically in almost
all cases, screening for a GH-secreting tumor by measurement of an IGF-I level is warranted. If this is elevated,
further evaluation for GH excess is suggested.
Screening for glucocorticoid excess due to a possible
corticotroph tumor may also be considered when this is
suspected clinically. In the series of 3048 autopsies, 13.8%
of 334 pituitary adenomas stained positive for ACTH
(30). No systematic screening of incidentalomas for subclinical glucocorticoid excess has been reported (8, 9).
However, patients with adrenal incidentalomas may have
Cushing’s syndrome-associated morbidities such as diabetes mellitus, hypertension, obesity, and osteoporosis
(32), so in a patient with a pituitary incidentaloma subclinical Cushing’s disease could also be associated with
these morbidities (16). In patients with a clinical suspicion
for glucocorticoid excess, laboratory screening is therefore suggested. Detection of subclinical hypercortisolism
should be followed by evaluation for possible Cushing’s
disease. The screening and evaluation of Cushing’s disease has been reviewed in the “Diagnosis of Cushing’s
Syndrome: an Endocrine Society Clinical Practice
Guideline” (33).
The Task Force does not recommend the routine measurement of plasma ACTH levels in patients with inciden-

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talomas. However, some of the Task Force members often
measure ACTH because a small percentage of incidentalomas may be silent corticotroph tumors (34), and
occasionally plasma ACTH levels are elevated in patients harboring these tumors despite the lack of clinical
manifestations of cortisol excess (34).
In patients whose personal or family history suggests
the possibility of a multiple endocrine neoplasia syndrome, additional screening and follow-up as appropriate
to the suspected syndrome should be undertaken.
1.1–1.1.1 Values and preferences
The recommendations for screening for hypersecretion
needed to balance the potential benefits of early detection
with the relatively low likelihood of finding certain abnormalities in a given patient and the costs and burden of
potentially unnecessary testing.
Screening for certain hormone hypersecretion syndromes was considered important, even if the patient was
asymptomatic or if the abnormality was unlikely in the
patient population. Screening for hyperprolactinemia was
considered essential because of the potential for successful
treatment with an oral dopamine agonist. Screening for
GH excess with a serum IGF-I level was recommended
because early detection of a GH-secreting tumor, which
would likely be asymptomatic, could reduce long-term
morbidity and increase the likelihood of surgical cure.
Some consider screening also for glucocorticoid excess in
all patients, but others may limit screening to patients for
whom there is a clinical suspicion, due to the high falsepositive rate and low rate of true-positive testing in the
former group of patients.
1.1–1.1.1 Remarks
The pros and cons of detailed vs. limited screening for
hypersecretion syndromes (other than for prolactinoma)
were debated, and the Task Force was split on this point.
The quality of evidence for or against one particular testing strategy was weak.
Recommendation
1.1.2 We recommend that patients with a pituitary incidentaloma with or without symptoms also undergo
clinical and laboratory evaluations for hypopituitarism
(1ⱍQQQE).
1.1.2 Evidence
Evidence to support screening for hypopituitarism in
patients with an incidentaloma also comes from small observational studies. In combined data in micro- and macroincidentalomas, hypopituitarism was present in seven of
66 (5) and 19 of 46 patients (7). Deficits of gonadotropins

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(not associated with hyperprolactinemia) were detected in
up to 30% of patients (4, 7, 8), of the ACTH/cortisol axis
in up to 18% (7, 8), thyroid axis in up to 28% (7, 8), and
GH axis in up to 8% (4).
Different approaches can be taken to the initial evaluation of the patient for hypopituitarism. Some Task Force
members recommend a minimal screening with the measurement of free T4, morning cortisol, and testosterone
levels, whereas others recommend that the initial evaluation should also include the measurement of TSH, LH, and
FSH and IGF-I. A broad initial approach to this testing is
favored by some to avoid the repeated blood sampling that
would be needed to confirm a central origin of target organ
deficiencies should they be detected. Low gonadotropin
levels in postmenopausal women provide evidence of hypopituitarism and in men exclude primary hypogonadism
when testosterone levels are low. Similarly, normal or low
TSH levels help distinguish a pituitary etiology of hypothyroidism when the free T4 is low. Gonadal function can
be assessed in premenopausal women by history and examination. If baseline testing suggests hypopituitarism,
further stimulation tests of the pituitary-adrenal or GHIGF-I axis should be performed.
1.1.2 Values and preferences
The size of the incidentaloma may also be relevant to
the risk of hypopituitarism, so the Task Force debated
whether the size should factor into the decision to screen
or not to screen for hypopituitarism. The Task Force more
strongly favored routine testing for hypopituitarism in
macroincidentalomas and larger microincidentalomas,
for example 6 –9 mm, and not necessarily in smaller microincidentalomas because asymptomatic pituitary hormone deficits can be detected and larger lesions seem more
likely to be associated with hypopituitarism. Although
there are no specific data on the prevalence of hypopituitarism in larger vs. smaller microincidentalomas, in the
Task Force’s experience some larger microincidentalomas
may behave more like macroincidentalomas, which leads
some endocrinologists to routinely evaluate larger microincidentalomas for hypopituitarism. Routine screening
for hypopituitarism among smaller microincidentalomas
may not be necessary because the rate of hypopituitarism
among them appears to be very low, although the number
of patients reported is very small (4, 8, 9). However, recent
data do show that hypopituitarism can occur in microadenomas (35). The Task Force recognized that there is a
continuum of size of pituitary incidentalomas, so a 1-cm
size cutoff may be arbitrary in evaluating the risk of hypopituitarism and other anatomic characteristics of the
incidentaloma need to be considered. The evidence was
downgraded because only observational data from rela-

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tic nerves or chiasm on MRI undergo a
formal VF examination (1ⱍQQQQ).
1.1.3 Evidence
Baseline VF testing is recommended for all patients with an incidentaloma abutting the optic nerves
or chiasm, even without visual symptoms (Fig. 1). In one prospective study
of 11 macroincidentalomas, one patient had VF abnormalities, and two
had compression of the optic chiasm
(8). In other studies, 15% (32) and
5% (4) of patients had unrecognized
VF abnormalities at presentation.

FIG. 1. Flow diagram for the evaluation and treatment of pituitary incidentalomas. a, Baseline
evaluation in all patients should include a history and physical exam evaluating for signs and
symptoms of hyperfunction and hypopituitarism and a laboratory evaluation for hypersecretion. b,
This group may also include large microlesions (see Section 2.1 Evidence). c, The recommendation
for surgery includes the presence of abnormalities of VF or vision and signs of tumor compression
(Section 3.1); surgery is also suggested for other findings (see Section 3.2). d, VF testing is
recommended for patients with lesions abutting or compressing the optic nerves or chiasm at the
initial evaluation and during follow-up. e, Evaluation for hypopituitarism is recommended for the
baseline evaluation and during follow-up evaluations. This is most strongly recommended for
macrolesions and larger microlesions (see Section 1.3). f, Repeat MRI in 1 yr, yearly for 3 yr, and
then less frequently thereafter if no change in lesion size. g, Repeat the MRI in 6 months, yearly
for 3 yr, and then less frequently if no change in lesion size. [Modified from Molitch ME: J Clin
Endocrinol Metab 80:3– 6, 1995 (49).]

tively small studies are available, and some decisions had
to be made based on the clinical experiences of the Task
Force members rather than rigorous studies.
1.1.2 Remarks
Our recommendations include routine screening for
GH deficiency (GHD) with an IGF-I level in all patients,
but the Task Force recognized that this alone is insufficient
evidence for or against GHD in adults. In patients with a
clinical suspicion of GHD, in particular if the IGF-I is low,
further testing should be undertaken as recommended in
the “Evaluation and Treatment of Adult Growth Hormone Deficiency: an Endocrine Society Clinical Practice
Guideline” (36). The authors of this guideline also recognized that the approach taken to the testing for and treatment of GHD varies among endocrinologists and that
some would only consider performing the testing if the
clinical setting suggested the potential for a benefit of GH
therapy.
Recommendation
1.1.3 We recommend that all patients presenting with
a pituitary incidentaloma abutting or compressing the op-

Recommendation
1.1.4 We recommend that all patients have a MRI scan, if possible, to
evaluate the pituitary incidentaloma (if
the incidentaloma was initially only diagnosed by CT scan) to better delineate
the nature and extent of the incidentaloma (1ⱍQQQQ).

1.1.4 Remarks
For the MRI, a specific pituitary protocol should be done that includes fine
cuts thorough the sella with and without the administration of the contrast
agent gadolinium. Guidelines for the evaluation of renal
function before administration of gadolinium should be
followed.
2.0 Follow-up testing of the pituitary
incidentaloma
Recommendations
2.1 Patients with incidentalomas who do not meet criteria for surgical removal of the tumor should receive nonsurgical follow-up (2ⱍQQEE), with clinical assessments
and the following tests:
2.1.1 MRI scan of the pituitary 6 months after the initial scan if the incidentaloma is a macroincidentaloma and
1 yr after the initial scan if it is a microincidentaloma
(1ⱍQQEE). In patients whose incidentaloma does not
change in size, we suggest repeating the MRI every year for
macroincidentalomas and every 1–2 yr in microincidentalomas for the following 3 yr and gradually less frequently thereafter (2ⱍQQEE).
2.1.2 VF testing in patients with a pituitary incidentaloma that enlarges to abut or compress the optic nerves or
chiasm on a follow-up imaging study (1ⱍQQQQ). We sug-

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gest that clinicians do not need to test VF in patients whose
incidentalomas are not close to the chiasm and who have
no new symptoms and are being followed closely by MRI
(2ⱍQEEE).
2.1.3 Clinical and biochemical evaluations for hypopituitarism 6 months after the initial testing and yearly
thereafter in patients with a pituitary macroincidentaloma, although typically hypopituitarism develops with
the finding of an increase in size of the incidentaloma
(1ⱍQQEE). We suggest that clinicians do not need to test
for hypopituitarism in patients with pituitary microincidentalomas whose clinical picture, history, and MRI do
not change over time (2ⱍQQEE).
2.1 Evidence
The options for treatment of patients with asymptomatic,
clinically nonfunctioning pituitary incidentalomas are conservative follow-up without surgery (Fig. 1) or immediate
surgery despite the lack of indications for this. Conservative
follow-up was recommended with the recognition that the
proper algorithm for this and its appropriateness and safety
have not been tested prospectively. Few data are available for
or against a nonsurgical approach to management of asymptomatic pituitary incidentalomas. Therefore, evidence in
support of these guidelines also relied on the clinical experiences of the Task Force members.
The proper algorithm for endocrine testing during this
follow-up has not been tested as prospectively conducted
endocrine testing of patients with pituitary incidentalomas who were followed without surgery has only been
reported in 49 patients (8, 9). Follow-up endocrine testing
is recommended for patients with macroincidentalomas
because they are at risk of developing hypopituitarism. Of
the macroincidentalomas followed prospectively, worsening hypopituitarism developed in one of seven (8) and
three of 28 (25) patients, all of whom had enlargement of
their tumors. Hypopituitarism also developed in four of
37 (5) and one of 248 (6) patients who developed apoplexy
on follow-up. Follow-up endocrine testing was recommended despite the paucity of data because of the potential
high risk to the patient of untreated hypopituitarism. In a
meta-analysis of incidentaloma studies, new endocrine
dysfunction developed overall in 2.4% of patients per year
(3). It is unclear how often new hypopituitarism develops
in the absence of tumor growth. Rapid growth may increase the risk of new hypopituitarism. Routine follow-up
endocrine testing is not required for microincidentalomas
whose clinical picture does not change because the risk of
developing new hypopituitarism is extremely low. In previous studies, none of the pituitary microincidentalomas
followed prospectively was reported to be associated with
changes in pituitary function (4 –9).

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The proposed algorithms for the MRI follow-up of pituitary incidentalomas took into account those adopted in
prior studies. However, those algorithms varied considerably from study to study (4 –9), and none was validated.
As a result, the imaging follow-up proposed in this guideline incorporated the experiences of the Task Force’s
members. Follow-up MRI scans were recommended for
macroincidentalomas because it has been demonstrated
that although generally these lesions grow slowly, some do
enlarge and become symptomatic. In data combined from
a number of studies, macroincidentalomas enlarged in 85
of 353 (24%) patients (4 –9, 23–26). VF abnormalities
developed in 28 (8%) patients over time, which demonstrated that the enlargement adversely affected the patient’s health. Pituitary apoplexy developed in seven of
353 (2%) patients, of whom most developed permanent
hypopituitarism and one had permanent vision impairment (5). In a meta-analysis of these studies, 8.2% of incidentalomas enlarged per year with a follow-up of 472
person-years (3). Less frequent surveillance of microincidentalomas was recommended because their rate of enlargement was low, being reported in 17 of 160 patients
(10.6%) followed from 2.3 to 7 yr (5–9, 23–25). In the
meta-analysis, 1.7% of microincidentalomas enlarged per
year (3). Importantly, none of the patients with these microincidentalomas developed new VF abnormalities that
would have necessitated surgery.
Overall, the Task Force considered that repeat scanning
within the first year was warranted for all patients because,
although most incidentalomas grow slowly, some do enlarge, and the true proliferative nature of the incidentaloma
is unknown (Fig. 1). If no growth is detected, then the interval
between MRI scans can be increased. Evidence does not support one particular algorithm for the frequency of follow-up
imaging, but we recommend repeating the MRI every year in
macroincidentalomas, every 1–2 yr in microincidentalomas
for the next 3 yr, and then every other year for the next 6 yr
and gradually less frequently indefinitely so long as the lesion
continues not to threaten the patient’s health. Some Task
Force members would continue imaging every 5 yr. Uncertainty as to the optimal interval and duration of long-term
follow-up imaging can be shared with the patient, and the
scheme followed can be individualized to balance the physician’s assessment of the risk that the lesion poses to the
patient’s health with the burden to the patient of surveillance
testing.
2.1 Values and preferences
The decision to proceed with conservative nonsurgical
management of pituitary incidentalomas not meeting criteria for surgery (see Section 3.0) puts a relatively high
value on avoiding surgical intervention and its associated

J Clin Endocrinol Metab, April 2011, 96(4):894 –904

morbidity and cost, and a relatively low value in avoiding
apoplexy. The evidence that most incidentalomas do not
progress over time to cause visual or other disturbances
supports this value judgment. On the other hand, apoplexy developed in seven of 248 patients with incidentalomas (4 – 6, 8, 9, 26). Large-scale prospective studies of
conservative nonsurgical management of pituitary incidentalomas are needed to further inform this judgment.
2.1 Remarks
The Task Force recognized that a continuum of size of
incidentalomas exists, and some large microincidentalomas (6 –9 mm) may behave more like macroincidentalomas. Therefore, some Task Force members would also
perform follow-up MRIs and hypopituitarism evaluations
in larger microincidentalomas as they would for macroincidentalomas. Some also considered that follow-up evaluations for hypopituitarism were needed only for patients
with enlarging incidentalomas because new hypopituitarism would be very unlikely to develop without tumor
growth. However, no data are available to support one
particular size threshold for the increase in size that should
trigger this evaluation. The Task Force was split on these
points.
Recommendation
2.2 Patients who develop any signs or symptoms potentially related to the incidentaloma or who show an increase in size of the incidentaloma on MRI should undergo
more frequent or detailed evaluations as indicated clinically (1ⱍQQEE).
3.0 Indications for surgical therapy of the pituitary
incidentaloma
Recommendation
3.1 We recommend that patients with a pituitary incidentaloma be referred for surgery if they have the following (1ⱍQQQQ):
• A VF deficit due to the lesion.
• Other visual abnormalities, such as ophthalmoplegia
or neurological compromise due to compression by
the lesion.
• Lesion abutting or compressing the optic nerves or
chiasm on MRI.
• Pituitary apoplexy with visual disturbance.
• Hypersecreting tumors other than prolactinomas as
recommended by other guidelines of The Endocrine
Society and The Pituitary Society (31, 33).
3.1 Evidence
The decision to recommend surgery as initial therapy for
a patient with a pituitary incidentaloma needs to be individ-

jcem.endojournals.org

901

ualized (Fig. 1). Few data are available that specifically examine the outcome of surgery for incidentalomas. Some of
the evidence considered in developing the recommended criteria for surgery was from transsphenoidal surgical series of
symptomatic and often large pituitary lesions. From these
data and based on the clinical experiences of the Task Force
members, it is clear that substantial evidence supports the
need for surgery for pituitary incidentalomas causing visual
or neurological compromise. The presence of visual or neurological abnormalities due to compression of the optic
nerves or chiasm by the incidentaloma is the strongest indication for surgery. Although the risks of not performing surgery on tumors that abut the chiasm or for those within certain proximity of the chiasm but where no VF abnormalities
are present have not been quantified, in the Task Force’s
experience significant risk of future vision disturbance in
these patients exists to warrant surgery. The age of the patient
is also an important consideration. Surgery may be favored
in younger vs. older patients given the higher lifetime probability of tumor enlargement in the former and the greater
risks of surgical intervention in the latter group of patients.
Some may elect to follow elderly patients with significant
risks to surgery conservatively and closely for any deterioration in vision. The decision to recommend surgery should
also consider whether future fertility is of concern to the patient. Difficult cases could also be discussed at a pituitary
multidisciplinary team meeting when this is available.
Surgery is indicated in patients with apoplexy and
visual disturbance. In a retrospective review of 30 subjects with pituitary apoplexy, the 20 who were followed
conservatively had a similar long-term risk of hypopituitarism as those treated surgically (37). Therefore,
patients with apoplexy and without visual compromise
may be followed conservatively with serial imaging and
hormonal assessments.
3.1 Values and preferences
Our recommendations for surgery for incidentalomas put
a high value on alleviating or preventing visual or neurological compromise. Although the benefits of surgery in preventing future visual abnormalities are not known, a relatively higher value was put on the prevention of VF
abnormalities than on avoiding the morbidity (e.g. diabetes
insipidus, hypopituitarism) and the cost of surgery. New hypopituitarism as a result of transsphenoidal surgery is rare in
the Task Force’s experience, but the risk should be considered in the clinical context of the particular patient.
3.1 Remarks
The recommendations for surgical therapy of a pituitary incidentaloma were based on the Task Force’s expectations for outcome and improvements in vision and

902

Freda et al.

Guidelines on Pituitary Incidentaloma

endocrine function. These expectations were based on
known literature and Task Force members’ clinical experience with surgery performed by a surgeon experienced in
transsphenoidal pituitary surgery. The success of surgery
for hormone-secreting tumors is highly dependent on the
expertise, skill, and case volume of a pituitary surgeon
supported by an experienced team (38, 39). This is likely
to also be true for pituitary surgery of other types of lesions. The availability of such a pituitary surgeon needs to
be considered when following these guidelines.
Recommendation
3.2 We suggest that surgery be considered for patients
with a pituitary incidentaloma if they have the following
(2ⱍQQEE):
• Clinically significant growth of the pituitary
incidentaloma.
• Loss of endocrinological function.
• A lesion close to the optic chiasm and a plan to become pregnant.
• Unremitting headache.
3.2 Evidence
The evidence for or against a recommendation for surgery because of growth of a pituitary incidentaloma is
limited. Surgery was suggested for incidentalomas that
demonstrate clinically significant growth on follow-up
imaging studies, which is growth that could pose a health
risk to the patient such as to their vision. Such growing
incidentalomas typically continue to grow, and surgery is
most effective for smaller lesions. A specific size cutoff for
the incidentaloma was not considered a requirement for
surgery because some large incidentalomas are predominantly intra- and infrasellar. Although there are no established changes in size or growth rate that would automatically trigger the need for surgery, the pattern of growth of
the incidentaloma was considered more important. For
example, a 1-mm enlargement within the sella of a 5-mm
intrasellar microadenoma would not be clinically significant, but a 1-mm enlargement toward the chiasm in a
lesion only 3 mm from the chiasm would be significant.
Therefore, incidentalomas exhibiting significant growth
(which includes growth that is rapid, occurring over a 1to 2-yr period, and/or that is toward the optic chiasm and
if continued could threaten vision in the near future)
should be considered for surgery before the incidentaloma
progresses to abut the chiasm or produce visual deficits. A
consideration of the clinical characteristics of the patient
including their age and other risks for surgery needs to be
incorporated into the decision to proceed to surgery.
The evidence for or against a recommendation for surgery because of the presence of hypopituitarism is also

J Clin Endocrinol Metab, April 2011, 96(4):894 –904

limited. Although some surgical series of symptomatic incidentalomas show that hypopituitarism can improve
with surgery (40, 41), these data may not be applicable to
the incidentaloma, and as a result hypopituitarism was
considered only a relative indication for surgery. Adequate
replacement therapy should be instituted whether or not
surgery is recommended. Some patients planning pregnancy may benefit from surgery if their tumor is close to
the optic chiasm because there is a small risk that lactotroph hyperplasia in the normal gland may lead to tumor
compression of the optic nerve or chiasm, and closer follow-up in such patients should be undertaken. Headache
may or may not improve with transsphenoidal removal of
the tumor, so it can only be suggested as an indication for
surgery, and the quality of evidence is low.
Medical therapy of the pituitary incidentaloma
In patients with incidentalomas and hyperprolactinemia that may be due to tumoral compression of the hypothalamic-pituitary stalk, symptomatic hyperprolactinemia may be treated with a dopamine agonist. However,
incidentalomas other than a prolactinoma will rarely
shrink, and dopamine agonists cannot be relied upon for
this purpose. Therefore, continued monitoring of lesion
size is necessary, regardless of changes in prolactin levels.
Medical therapy of pituitary incidentalomas has not
been systematically studied. Some parallels to the effects of
medical therapy on pathologically confirmed nonfunctioning pituitary tumors are possible, but this connection
needs to be made cautiously. The reported efficacy of dopamine agonist therapy of nonfunctioning pituitary adenomas varies widely. With cabergoline or bromocriptine
treatment for patients with residual tumor after surgery,
some degree of tumor shrinkage was detected in 8 – 45%
(42– 44), and the amount of shrinkage varied from 10 –
62% (43, 44) or 3–14 mm (42). Somatostatin analogs have
also been tried. With no more than 1 yr of octreotide therapy, shrinkage was reported in approximately 5–25%,
increase in 12%, and stabilization in 83% of tumors (45–
48). Insufficient data are available to suggest the routine
use of medical therapy of pituitary incidentalomas.

Acknowledgments
The members of the Task Force thank The Endocrine Society’s
Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and Council for their careful, critical review of earlier
versions of this manuscript and their helpful comments and suggestions. We also thank the leadership of the European Society
of Endocrinology for their review and comments. In addition, we
thank the many members of The Endocrine Society who reviewed the draft version of this manuscript when it was posted

J Clin Endocrinol Metab, April 2011, 96(4):894 –904

on the Society’s web site and who sent a great number of additional comments and suggestions, most of which were incorporated into the final version of the manuscript. Finally, we thank
the staff at the Society office for their helpful support during the
development of this guideline.
Address all correspondence and requests for reprints to: The
Endocrine Society, 8401 Connecticut Avenue, Suite 900, Chevy
Chase, MD 20815. E-mail: govt-prof@endo-society.org, Telephone: 301-941-0200. Address all commercial reprint requests
for orders 101 and more to: Walchli Tauber Group Inc., E-mail:
Karen.burkhardt@wt-group.com. Address all reprint requests
for orders for 100 or fewer to Society Services, Telephone: 301941-0210, E-mail: societyservices@endo-society.org, or Fax:
301-941-0257.
Cosponsoring Associations: European Society of Endocrinology.
Financial Disclosures of the Task Force: Pamela U. Freda,
M.D.*—Financial or Business/Organizational Interests: Novartis, Ipsen, and Pfizer; Significant Financial Interest or Leadership Position: none declared. Albert M. Beckers, M.D., D.Sc.,
Ph.D.—Financial or Business/Organizational Interests: Novartis, Ipsen, and Pfizer; Significant Financial Interest or Leadership Position: none declared. Laurence Katznelson, M.D.—
Financial or Business/Organizational Interests: Novartis, Ipsen,
and Novo Nordisk; Significant Financial Interest or Leadership
Position: none declared. Mark E. Molitch, M.D.—Financial or
Business/Organizational Interests: Tercica/Ipsen, Novartis; Significant Financial Interest or Leadership Position: none declared.
Victor M. Montori, M.D.*—Financial or Business/Organizational Interests: KER Unit (Mayo Clinic); Significant Financial
Interest or Leadership Position: none declared. Kalmon D. Post,
M.D. —Financial or Business/Organizational Interests: none declared; Significant Financial Interest or Leadership Position:
none declared. Mary Lee Vance, M.D.—Financial or Business/
Organizational Interests: Novartis; Significant Financial Interest
or Leadership Position: none declared.
*Evidence-based reviews for this guideline were prepared under contract with The Endocrine Society.

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Title                           : Pituitary Incidentaloma: An Endocrine Society Clinical Practice Guideline
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