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Pituitary Incidentaloma:An Endocrine Society Clinical Practice Guideline
T h e E n d o c r i n e S o c i e t y ’ s
CliniCal Guidelines
Authors: Pamelau.Freda,albertM.Beckers,laurenceKatznelson,Marke.Molitch,VictorM.Montori,Kalmond.Post,andMaryleeVance
Co-Sponsoring Associations: europeansocietyofendocrinology.
Affiliations: ColumbiaCollegeofPhysicians&surgeons(P.u.F.)newYork,newYork;CHudeliège,universityofliègedomaineuniversitairedusart-Tilman(a.M.B.)liège,Belgium;stanforduniversity(l.K.)stanford,California; northwestern university Feinberg school of Medicine (M.e.M.) Chicago, illinois; Mayo ClinicRochester (V.M.M.), Rochester, Minnesota; Mount sinai Medical Center (K.d.P.) new York, new York; anduniversityofVirginiaHealthscienceCenter(M.l.V.)Charlottesville,Virginia
Disclaimer: Clinical Practice Guidelines are developed to be of assistance to endocrinologists and otherhealthcareprofessionalsbyprovidingguidanceandrecommendationsforparticularareasofpractice.TheGuide-linesshouldnotbeconsideredinclusiveofallproperapproachesormethods,orexclusiveofothers.TheGuidelinescannotguaranteeanyspecificoutcome,nordotheyestablishastandardofcare.TheGuidelinesarenotintendedto dictate the treatment of a particular patient. Treatment decisions must be made based on the independentjudgmentofhealthcareprovidersandeachpatient’sindividualcircumstances.
The endocrine society makes no warranty, express or implied, regarding the Guidelines and specificallyexcludesanywarrantiesofmerchantabilityandfitness foraparticularuseorpurpose.Thesocietyshallnotbeliable for direct, indirect, special, incidental, or consequential damages related to the use of the informationcontainedherein.
FirstpublishedinJournal of Clinical Endocrinology & Metabolism,96(4):894–904,2011.
©Theendocrinesociety,2011
Pituitary Incidentaloma:An Endocrine Society Clinical Practice Guideline
T h e E n d o c r i n e S o c i e t y ’ s
CliniCal Guidelines
Table of Contents
abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
summaryofRecommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Methodofdevelopmentofevidence-BasedClinicalPracticeGuidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
definition,etiology,andepidemiologyofPituitaryincidentalomas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
initialevaluationofaPatientwithaPituitaryincidentaloma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Follow-upTestingofthePituitaryincidentaloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
indicationsforsurgicalTherapyofthePituitaryincidentaloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
OrderForm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Reprintinformation,Questions&Correspondences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . insideBackCover
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Abstract
Objective:Theaimwastoformulatepracticeguide-lines for endocrine evaluation and treatment ofpituitaryincidentalomas.
Participants: The Task Force consisted of a chair,selectedbythetheClinicalGuidelinessubcommitteeof The endocrine society, five additional experts, amethodologist,andamedicalwriter.TheTaskForcereceivednocorporatefundingorrenumeration.
Evidence: This evidence-based guideline was devel-opedusingtheGradingofRecommendations,assess-ment,development,andevaluation(GRade)systemtodescribeboththestrengthofrecommendationsandthequalityofevidence.
Consensus Process: Consensuswasguidedbysystem-atic reviews of evidence and discussions through aseriesofconferencecallsande-mailsandonein-personmeeting.
Conclusions: We recommend that patients with apituitary incidentaloma undergo a complete historyand physical examination, laboratory evaluationsscreening forhormonehypersecretionand forhypo-pituitarism,andavisualfieldexaminationifthelesionabutstheopticnervesorchiasm.Werecommendthatpatients with incidentalomas not meeting criteriaforsurgicalremovalbefollowedwithclinicalassess-ments, neuroimaging (magnetic resonance imagingat6monthsformacroincidentalomas,1yrforamicro-incidentaloma, and thereafter progressively lessfrequentlyifunchangedinsize),visualfieldexamina-tions for incidentalomas that abut or compress theopticnerve andchiasm(6months andyearly), andendocrine testing for macroincidentalomas (6 andyearly) after the initial evaluations.We recommendthat patients with a pituitary incidentaloma bereferredforsurgeryiftheyhaveavisualfielddeficit;signs of compression by the tumor leading to othervisual abnormalities, such as ophthalmoplegia, orneurologicalcompromisedue tocompressionby thelesion;a lesionabutting theopticnervesorchiasm;pituitary apoplexy with visual disturbance; or if theincidentalomaisahypersecretingtumorotherthanaprolactinoma.
J Clin Endocrinol Metab 96(4):894–904, 2011
Abbreviations: CT, Computed tomography; GHD, GH deficiency; MRI, magnetic resonance imaging; VF, visual field.
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SummAry Of rECOmmEndATIOnS
1.0. Initial evaluation of a patient with a pituitary incidentaloma
1.1. Werecommendthatpatientspresentingwithapituitary incidentaloma undergo a complete historyand physical examination that includes evaluationsforevidenceofhypopituitarismandahormonehyper-secretionsyndrome.Patientswithevidenceofeitherof theseconditions shouldundergoanappropriatelydirectedbiochemicalevaluation:
1.1.1. We recommend that all patients witha pituitary incidentaloma, including those withoutsymptoms, undergo clinical and laboratory evalua-tionsforhormonehypersecretion(1| ).
1.1.2. We recommend that patients with apituitary incidentaloma with or without symptomsalso undergo clinical and laboratory evaluations forhypopituitarism(1| ).
1.1.3. We recommend that all patientspresenting with a pituitary incidentaloma abuttingthe optic nerves or chiasm on magnetic resonanceimaging (MRi) undergo a formal visual field (VF)examination(1| ).
1.1.4. Werecommend that all patientshavea MRi scan, if possible, to evaluate the pituitaryincidentaloma [if the incidentaloma was initiallyonlydiagnosedbycomputedtomography(CT)scan]to better delineate the nature and extent of theincidentaloma(1| ).
2.0. follow-up testing of the pituitary incidentaloma
2.1. Patientswithincidentalomaswhodonotmeetcriteria for surgical removal of the tumor shouldreceive nonsurgical follow-up (2| ) withclinicalassessmentsandthefollowingtests:
2.1.1. MRiscanofthepituitary6monthsafterthe initial scan if the incidentaloma is amacroinci-dentaloma and 1 yr after the initial scan if it is amicro-incidentaloma(1| ).inpatientswhoseincidentaloma does not change in size, we suggestrepeating the MRi every year for macroinciden-talomasandevery1–2yrinmicroincidentalomasforthefollowing3yr,andgraduallylessfrequentlythere-after(2| ).
2.1.2. VFtesting inpatientswithapituitaryincidentalomathatenlargestoabutorcompresstheopticnervesorchiasmonafollow-upimagingstudy(1| ).WesuggestthatcliniciansdonotneedtotestVFinpatientswhose incidentalomasarenotclosetothechiasmandwhohavenonewsymptomsandarebeingfollowedcloselybyMRi(2| ).
2.1.3. Clinical and biochemical evaluationsforhypopituitarism6monthsaftertheinitialtestingand yearly thereafter in patients with a pituitarymacro-incidentaloma,althoughtypicallyhypopituita-rismdevelopswiththefindingofanincreaseinsizeofthe incidentaloma (1| ). We suggest thatcliniciansdonotneedtotest forhypopituitarisminpatients with pituitary microincidentalomas whoseclinicalpicture,history,andMRidonotchangeovertime(2| ).
2.2. Patients who develop any signs or symptomspotentiallyrelatedtotheincidentalomaorwhoshowan increase in size of the incidentaloma on MRishouldundergomorefrequentordetailedevaluationsasindicatedclinically(1| ).
3.0. Indications for surgical therapy of the pituitary incidentaloma
3.1. We recommend that patients with a pituitaryincidentalomabereferredforsurgeryiftheyhavethefollowing(1| ):
• aVFdeficitduetothelesion.
• Othervisualabnormalities,suchasophthal-moplegiaorneurologicalcompromiseduetocompressionbythelesion.
• lesionabuttingorcompressingtheopticnervesorchiasmonMRi.
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• Pituitaryapoplexywithvisualdisturbance.
• Hypersecretingtumorsotherthanprolacti-nomasasrecommendedbyotherguidelinesofTheendocrinesocietyandThePituitarysociety.
3.2. Wesuggestthatsurgerybeconsideredforpatientswith a pituitary incidentaloma if they have thefollowing(2| ):
• Clinicallysignificantgrowthofthepituitaryincidentaloma.
• lossofendocrinologicalfunction.
• alesionclosetotheopticchiasmandaplantobecomepregnant.
• unremittingheadache.
mEThOd Of dEvElOPmEnT Of EvIdEnCE-BASEd ClInICAl PrACTICE GuIdElInES
TheClinicalGuidelinessubcommitteeofTheendo-crinesocietydeemedthesubjectofpituitaryinciden-talomasapriorityareainneedofpracticeguidelinesand appointed a Task Force to formulate evidence-based recommendations. Consensus was guided bysystematic reviews of evidence and discussionsthrougha seriesofconferencecalls ande-mailsandonein-personmeeting.aninitialdraftguidelinewaspreparedbytheTaskForce,withthehelpofamedicalwriter,andreviewedandcommentedonbymembersofTheendocrinesocietyandtheeuropeansocietyof endocrinology. a second draft was reviewed andapprovedbyTheendocrinesocietyCouncil.ateachstage of review, the Task Force received writtencomments and incorporated substantive changes.The evidence was developed using the Grading ofRecommendations, assessment, development, andevaluation(GRade)systemtodescribethestrengthof recommendations and the quality of evidence,whichwasloworverylow.TheGRadegroupisaninternational group with expertise in developmentand implementation of evidence-based guidelines
(1).adetaileddescriptionofthegradingschemehasbeen published elsewhere (2). The Task Force usedthe best available research evidence identified andonecommissionedsystematicreviewtodevelopsomeoftherecommendations(3).TheTaskForcealsousedconsistent language and graphical descriptions ofboth the strength of a recommendation and thequality of evidence. in terms of the strength of therecommendation, strong recommendations use thephrase“werecommend”andthenumber1,andweakrecommendationsusethephrase“wesuggest”andthenumber 2. Cross-filled circles indicate the quality ofthe evidence, such that denotes very lowquality evidence; , low quality; ,moderatequality;and ,highquality.Thefinalcategory may include circumstances in which thereisaconsistentobservationofuniformlypoorseriousoutcomes that will not reverse spontaneously, butwhen treated, often through surgical means, maydramaticallyimproveorbecured.TheTaskForcehasconfidence that persons who receive care accordingto the strong recommendations will derive, onaverage,moregood thanharm.Weak recommenda-tionsrequiremorecarefulconsiderationoftheperson’scircumstances, values, and preferences to determinethebestcourseofaction.linkedtoeachrecommen-dationisadescriptionoftheevidenceandthevaluesthatpanelistsconsideredinmakingtherecommenda-tion;insomeinstances,thereareremarks,asectioninwhichpanelistsoffertechnicalsuggestionsfortestingconditions,dosing,andmonitoring.Thesetechnicalcommentsreflectthebestavailableevidenceappliedtoatypicalpersonbeingtreated.Oftenthisevidencecomes from the unsystematic observations of thepanelistsandtheirvaluesandpreferences;therefore,theseremarksshouldbeconsideredsuggestions.
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10%(6,7,9). inanother seriesof139mass lesionswithoutovertsymptoms,73hadacysticappearanceonimagingstudy(5).CysticlesionsaremostlikelytobeRathke’scleftcysts,whichoftenpresentinciden-tally, or craniopharyngiomas (11, 12). Of thenon-cystic-appearing incidentalomas, nearly all arelikely to be pituitary adenomas, and most clinicallynonfunctioning pituitary adenomas are of gonado-trope origin as determined by immunocytochemicalstudies(13–15).However,thedifferentialdiagnosisofsellar incidentalomas is broad and should includeotherpossibilities(10).
Epidemiology of pituitary incidentalomas
Theprevalenceofpituitaryincidentalomashasbeenestimated fromdataonpituitaryadenomas foundatautopsyandfromimaginginpatientswhounderwenta CT or MRi of the head for reasons other thanpituitary disease. Because most pituitary inciden-talomasareadenomas,autopsydataonadenomasmayprovide information relevant to incidentalomadetected during life. in combined autopsy data, theaveragefrequencyofapituitaryadenomawas10.6%(16). The tumors were distributed equally acrossgenders and the adult age range, and nearly all ofthese incidentalomas were microadenomas (16). inadults who underwent cranial imaging studies forreasons other than pituitary disease, microinciden-talomas were seen on CT in 4–20% (17–19) or onMRi in 10–38% (20) of patients. Macroinciden-talomaswere found in0.2%of patientswho under-wentCTscansforcentralnervoussystemsymptoms(21) and by MRi in 0.16% of a population studycohort(22).inpooleddatafrom10seriesofpituitaryincidentalomas, 160 of 353 (45%) were macroinci-dentalomas (4 –9, 23–26), a larger percentage thanhas been found on autopsy studies and the otherscreening studies. This suggests that these patientsmay in fact have had some symptom that was notreadily apparent or reported but that led to theimagingstudyorthatmicroincidentalomaswerenotreferredtothesecentersforevaluation.
dataarenotavailableonpituitaryincidentalomasinthepediatricpopulation;theseguidelinesarelimitedtoadults.
dEfInITIOn, ETIOlOGy, And EPIdEmIOlOGy Of PITuITAry InCIdEnTAlOmAS
definition of pituitary incidentaloma
apituitaryincidentalomaisapreviouslyunsuspectedpituitarylesionthatisdiscoveredonanimagingstudyperformedforanunrelatedreason.Bydefinition,theimagingstudyisnotdoneforasymptomspecificallyrelatedtothelesion,suchasvisualloss,oraclinicalmanifestationofhypopituitarismorhormoneexcess,but rather for the evaluation of symptoms such asheadache, or other head or neck neurological orcentral nervous system complaints or head trauma(4–9). studies reviewed for these guidelines vary,however, in their definition of a “pituitary inciden-taloma.” For example, some studies exclude cysticlesionsandincludeonlythosethatfulfillradiographiccriteriaforapituitaryadenoma(4,5),whereasothersinclude all lesions (6–9). The guidelines presentedherearerelevanttoallpituitaryincidentalomas,thosethat have the appearance typical of a pituitaryadenoma as well as cystic lesions. By convention,microincidentalomasarelessthan1cmandmacroin-cidentalomasareatleast1cminsize.
Etiology of pituitary incidentalomas
Becauseincidentalomasinfrequentlycometosurgery,thetruepathologicaldiagnosesofmostareunknown.inaseriesofsellarmassesthatrequiredsurgery,91%werepituitaryadenomasandabout9%werenonpitu-itary in origin, of which most were craniopharyngi-omas and Rathke’s cleft cysts (10). it is unknownwhether the etiologiesof incidentalomas are similartothissurgicalcohort,butinoneseriesof29inciden-talomasthatdidcometosurgery,23werefoundtobepituitaryadenomas,fourwereRathke’scleftcysts,andtwowerecraniopharyngiomas(6,7,9).immunohisto-chemical analysis of 20 of these adenomas wasreportedasnegativein50%,plurihormonalin20%,gonadotroph positive in 15%, and GH positive in
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Theevaluationforhypersecretionshouldincludeanassessmentforprolactin,GH,andaCTHhypersecre-tion.evidenceisstrongestfortheneedtomeasureaserumprolactin level inallpatientspresentingwithan incidentaloma. ideally, for patients with largemacroincidentalomas,thelaboratoryshouldmeasureprolactinlevelsindilutedserumtoensurethatlevelsarenotfalselyloweredbyahookeffectintheassay.Hyperprolactinemiawas foundinfiveof42patientswith microincidentalomas at initial evaluation (4),butinotherstudiesnoneof22developedaprolactinelevation on prospective follow-up (8, 9). in otherstudies, prolactinomas were detected in seven of 46patients with incidentalomas (micro and macrocombined) (7). in macroincidentalomas, prolactinlevelswereelevatedintwoof16(9).inalargeautopsystudy,39.5%oftheadenomasdetected(mostmicro-adenomas)werefoundtostainpositiveforprolactin(30).Thesedatamightsuggestthatprolactinomasareverycommonamongpituitaryincidentalomas,whichis contrary to the literature. autopsy data shouldcautiously be considered representative of inciden-talomaspresentinginlifebecausetheautopsystudieslack clinical data, and prolactin staining may nothave been associated with clinically relevant circu-latinghyperprolactinemia.Patientswithhyperprolac-tinemia could receive a trial of dopamine agonisttherapysolongasitisrecognizedthatmild/moderateelevations may be due to stalk compression from alesionother thanaprolactinoma. in thesepatients,tumor shrinkage isunlikely,andgrowthof the inci-dentaloma is still possible, so continued follow-upwith repeat imaging is warranted. The treatment ofhyperprolactinemiahasbeenrecentlyreviewed(31).
although silent somatotroph-secreting tumors arerare,evaluationforthepossibilityisrecommended.ina prospective study, one of 11 macroincidentalomaswerefoundtohaveanelevatediGF-iconsistentwithsubclinicalGHexcess(8),andinanotherstudy,twoof 13 incidentalomas that were surgically removedwerepositiveonimmunohistochemistryforGH(7).One series of 3048 autopsies reported 334 pituitaryadenomas, of which 1.8% stained positive for GH(30).BecausetheinitialtreatmentforaGH-secretingtumor is surgery and GH secreting microadenomascanbecuredsurgicallyinalmostallcases,screening
1.0. InITIAl EvAluATIOn Of A PATIEnT wITh A PITuITAry InCIdEnTAlOmA
Recommendations
1.1. Werecommendthatpatientspresentingwithapituitary incidentaloma undergo a complete historyand physical examination that includes evaluationsforevidenceofhypopituitarismandahormonehyper-secretionsyndrome.Patientswithevidenceofeitherof theseconditions shouldundergoanappropriatelydirectedbiochemicalevaluation.
1.1.1. We recommend that all patients witha pituitary incidentaloma, including those withoutsymptoms, undergo clinical and laboratory evalua-tionsforhormonehypersecretion(1| ).
1.1.–1.1.1. Evidence
The goals of the endocrine evaluation of pituitaryincidentalomas are to identify hormone hypersecre-tionandhypopituitarism.The recommendations forevaluationofpituitaryfunctionconsideredthelikeli-hoodofanabnormalityinagivenpatient.However,valid estimates of the pretest probability of anabnormaltestofpituitaryfunctioncouldnotbedefin-itivelydeterminedbecauseliteratureonthistopic issparse. Therefore, recommendations for the evalua-tionreliedheavilyonclinicalexperience.
dataontheprevalenceofhormonehypersecretioninpatients with an incidentaloma are available fromsmall observational studies (most retrospective) andestimatedfromautopsydata.screeningforhypersecre-tionisimportanttoperformbecausetheprevalenceofclinically evident pituitary adenomas has recentlybeenappreciatedtobeashighas1/1000inaBelgianpopulation(27),and0.776/1000(ofwhich0.542/1000were hormone secreting) in a region of the unitedKingdom(28),oraslowas0.04/1000inFinland(29).The incidence of incidentally discovered pituitaryadenomas was recently reported as 0.016/1000 in aretrospectivereviewfromFinland(29).
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screening for certain hormone hypersecretionsyndromes was considered important, even if thepatientwas asymptomaticor if the abnormalitywasunlikely in the patient population. screening forhyperprolactinemiawasconsideredessentialbecauseofthepotentialforsuccessfultreatmentwithanoraldopamine agonist. screening for GH excess with aserum iGF-i level was recommended because earlydetection of a GH-secreting tumor, which wouldlikely be asymptomatic, could reduce long-termmorbidityandincreasethelikelihoodofsurgicalcure.someconsiderscreeningalsoforglucocorticoidexcessin all patients, but others may limit screening topatientsforwhomthereisaclinicalsuspicion,duetothehighfalsepositiverateandlowrateoftrue-posi-tivetestingintheformergroupofpatients.
1.1.–1.1.1. Remarks
Theprosandconsofdetailedvs.limitedscreeningforhypersecretion syndromes (other than for prolacti-noma)weredebated,andtheTaskForcewassplitonthispoint.Thequalityofevidencefororagainstoneparticulartestingstrategywasweak.
Recommendation
1.1.2. Werecommendthatpatientswithapituitaryincidentaloma with or without symptoms alsoundergoclinicalandlaboratoryevaluationsforhypo-pituitarism(1| ).
1.1.2. Evidence
evidencetosupportscreeningforhypopituitarisminpatientswithanincidentalomaalsocomesfromsmallobservationalstudies.incombineddatainmicro-andmacroincidentalomas,hypopituitarismwaspresentinsevenof66(5)and19of46patients(7).deficitsofgonadotropins (not associated with hyperprolac-tinemia)weredetectedinupto30%ofpatients(4,7,8), of the aCTH/cortisol axis in up to 18% (7, 8),thyroidaxisinupto28%(7,8),andGHaxisinupto8%(4).
different approaches can be taken to the initialevaluation of the patient for hypopituitarism. someTaskForcemembersrecommendaminimalscreening
foraGH-secretingtumorbymeasurementofaniGF-ileveliswarranted.ifthisiselevated,furtherevalua-tionforGHexcessissuggested.
screeningforglucocorticoidexcessduetoapossiblecorticotrophtumormayalsobeconsideredwhenthisissuspectedclinically.intheseriesof3048autopsies,13.8%of334pituitaryadenomasstainedpositiveforaCTH (30). no systematic screening of inciden-talomasforsubclinicalglucocorticoidexcesshasbeenreported(8,9).However,patientswithadrenalinci-dentalomasmayhaveCushing’ssyndrome-associatedmorbidities such as diabetes mellitus, hypertension,obesity,andosteoporosis(32),soinapatientwithapituitaryincidentalomasubclinicalCushing’sdiseasecouldalsobeassociatedwiththesemorbidities(16).inpatientswithaclinicalsuspicionforglucocorticoidexcess, laboratory screening is therefore suggested.detection of subclinical hypercortisolism should befollowedbyevaluationforpossibleCushing’sdisease.The screening and evaluation of Cushing’s diseasehas been reviewed in the “diagnosis of Cushing’ssyndrome: an endocrine society Clinical PracticeGuideline”(33).
The Task Force does not recommend the routinemeasurement of plasma aCTH levels in patientswith incidentalomas. However, some of the TaskForce members often measure aCTH because asmall percentage of incidentalomas may be silentcorticotroph tumors (34), and occasionally plasmaaCTHlevelsareelevatedinpatientsharboringthesetumorsdespite the lackof clinicalmanifestationsofcortisolexcess(34).
inpatientswhosepersonalorfamilyhistorysuggeststhe possibility of a multiple endocrine neoplasiasyndrome, additional screening and follow-up asappropriate to the suspected syndrome should beundertaken.
1.1.–1.1.1. Values and preferences
The recommendations for screening for hypersecre-tionneededtobalancethepotentialbenefitsofearlydetectionwiththerelativelylowlikelihoodoffindingcertainabnormalitiesinagivenpatientandthecostsandburdenofpotentiallyunnecessarytesting.
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ofhypopituitarismandotheranatomiccharacteristicsof the incidentaloma need to be considered. Theevidencewasdowngradedbecauseonlyobservationaldata from relatively small studies are available, andsomedecisionshadtobemadebasedontheclinicalexperiences of the Task Force members rather thanrigorousstudies.
1.1.2. Remarks
Our recommendations include routine screening forGH deficiency (GHd) with an iGF-i level in allpatients,buttheTaskForcerecognizedthatthisaloneisinsufficientevidencefororagainstGHdinadults.in patients with a clinical suspicion of GHd, inparticulariftheiGF-iislow,furthertestingshouldbeundertakenasrecommendedinthe“evaluationandTreatmentofadultGrowthHormonedeficiency:anendocrinesocietyClinicalPracticeGuideline”(36).Theauthorsofthisguidelinealsorecognizedthattheapproach taken to the testing for and treatment ofGHd varies among endocrinologists and that somewould only consider performing the testing if theclinicalsettingsuggestedthepotentialforabenefitofGHtherapy.
Recommendation
1.1.3. We recommend that all patients presentingwithapituitaryincidentalomaabuttingorcompressingtheopticnervesorchiasmonMRiundergoaformalVFexamination(1| ).
1.1.3. Evidence
BaselineVF testing is recommended for all patientswith an incidentaloma abutting the optic nerves orchiasm,evenwithoutvisualsymptoms(Fig.1).inoneprospective study of 11 macroincidentalomas, onepatienthadVFabnormalities,andtwohadcompres-sion of the optic chiasm (8). in other studies, 15%(32) and 5% (4) of patients had unrecognized VFabnormalitiesatpresentation.
Recommendation
1.1.4. Werecommend that all patientshave aMRiscan,ifpossible,toevaluatethepituitaryincidentaloma
with the measurement of free T4, morning cortisol,and testosterone levels, whereas others recommendthat the initial evaluation should also include themeasurement of TsH, lH, and FsH and iGF-i. abroad initial approach to this testing is favored bysometoavoidtherepeatedbloodsamplingthatwouldbeneededtoconfirmacentraloriginoftargetorgandeficiencies should they be detected. low gonado-tropin levels in postmenopausal women provideevidence of hypopituitarism and in men excludeprimary hypogonadism when testosterone levels arelow.similarly,normalorlowTsHlevelshelpdistin-guishapituitaryetiologyofhypothyroidismwhenthefree T4 is low. Gonadal function can be assessed inpremenopausalwomenbyhistoryandexamination.ifbaseline testing suggests hypopituitarism, furtherstimulationtestsofthepituitary-adrenalorGHiGF-iaxisshouldbeperformed.
1.1.2. Values and preferences
Thesizeoftheincidentalomamayalsoberelevanttotheriskofhypopituitarism,sotheTaskForcedebatedwhether the size should factor into the decision toscreen or not to screen for hypopituitarism. TheTaskForcemore strongly favored routine testing forhypopituitarism in macroincidentalomas and largermicroincidentalomas, forexample6–9mm,andnotnecessarily in smaller microincidentalomas becauseasymptomatic pituitary hormone deficits can bedetected and larger lesions seem more likely to beassociatedwithhypopituitarism.although therearenospecificdataontheprevalenceofhypopituitarisminlargervs.smallermicroincidentalomas,intheTaskForce’s experience some larger microincidentalomasmay behave more like macroincidentalomas, whichleads some endocrinologists to routinely evaluatelarger microincidentalomas for hypopituitarism.Routinescreeningforhypopituitarismamongsmallermicroincidentalomas may not be necessary becausetherateofhypopituitarismamongthemappearstobeverylow,althoughthenumberofpatientsreportedisvery small (4, 8, 9). However, recent data do showthat hypopituitarism can occur in microadenomas(35). The Task Force recognized that there is acontinuum of size of pituitary incidentalomas, so a1-cmsizecutoffmaybearbitraryinevaluatingtherisk
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rismdevelopswiththefindingofanincrease insizeof the incidentaloma (1| ). We suggest thatcliniciansdonotneedtotest forhypopituitarisminpatients with pituitary microincidentalomas whoseclinicalpicture,history,andMRidonotchangeovertime(2| ).
2.1. Evidence
Theoptionsfortreatmentofpatientswithasymptom-atic, clinically nonfunctioning pituitary inciden-talomas are conservative follow-up without surgery(Fig.1)orimmediatesurgerydespitethelackofindi-cations for this. Conservative follow-up was recom-mended with the recognition that the properalgorithm for this and its appropriateness and safetyhave not been tested prospectively. Few data areavailable for or against a nonsurgical approach tomanagement of asymptomatic pituitary inciden-talomas. Therefore, evidence in support of theseguidelines also relied on the clinical experiences oftheTaskForcemembers.
The proper algorithm for endocrine testing duringthis follow-up has not been tested as prospectivelyconductedendocrinetestingofpatientswithpituitaryincidentalomas who were followed without surgeryhasonlybeenreportedin49patients(8,9).Follow-up endocrine testing is recommended for patientswithmacroincidentalomasbecausetheyareatriskofdeveloping hypopituitarism. Of the macroinciden-talomas followedprospectively,worseninghypopitu-itarismdevelopedinoneofseven(8)andthreeof28(25)patients,allofwhomhadenlargementof theirtumors.Hypopituitarismalsodevelopedinfourof37(5) and one of 248 (6) patients who developedapoplexy on follow-up. Follow-up endocrine testingwasrecommendeddespitethepaucityofdatabecauseofthepotentialhighrisktothepatientofuntreatedhypopituitarism.inameta-analysisofincidentalomastudies,newendocrinedysfunctiondevelopedoverallin 2.4% of patients per year (3). it is unclear howoftennewhypopituitarismdevelopsintheabsenceoftumorgrowth.Rapidgrowthmayincreasetheriskofnew hypopituitarism. Routine follow-up endocrinetestingisnotrequiredformicroincidentalomaswhoseclinical picture does not change because the risk of
(iftheincidentalomawasinitiallyonlydiagnosedbyCTscan)tobetterdelineatethenatureandextentoftheincidentaloma(1| ).
1.1.4. Remarks
For theMRi, a specificpituitaryprotocol shouldbedonethat includesfinecuts thoroughthe sellawithandwithouttheadministrationofthecontrastagentgadolinium. Guidelines for the evaluation of renalfunctionbeforeadministrationofgadoliniumshouldbefollowed.
2.0. fOllOw-uP TESTInG Of ThE PITuITAry InCIdEnTAlOmA
Recommendations
2.1. Patientswithincidentalomaswhodonotmeetcriteria for surgical removal of the tumor shouldreceive nonsurgical follow-up (2| ), withclinicalassessmentsandthefollowingtests:
2.1.1. MRi scan of the pituitary 6 monthsaftertheinitialscaniftheincidentalomaisamacro-incidentalomaand1yraftertheinitialscanifitisamicro-incidentaloma(1| ).inpatientswhoseincidentaloma does not change in size, we suggestrepeating the MRi every year for macroinciden-talomasandevery1–2yrinmicroincidentalomasforthefollowing3yrandgraduallylessfrequentlythere-after(2| ).
2.1.2. VFtesting inpatientswithapituitaryincidentalomathatenlargestoabutorcompresstheopticnervesorchiasmonafollow-upimagingstudy(1| ).WesuggestthatcliniciansdonotneedtotestVFinpatientswhose incidentalomasarenotclosetothechiasmandwhohavenonewsymptomsandarebeingfollowedcloselybyMRi(2| ).
2.1.3. Clinical and biochemical evaluationsforhypopituitarism6monthsaftertheinitialtestingand yearly thereafter in patients with a pituitarymacro-incidentaloma,althoughtypicallyhypopituita-
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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).]
Evaluation & Treatment of Pituitary Incidentalomas
Evaluation of Pituitary Functiona
hyperfunctioning Clinically nonfunctioning
Prolactinoma micro- Incidentaloma
Other macro- Incidentalomab
dopamine Agonist
Surgery/medical Therapy
vf testingd hypopituitarism
Evaluatione
Surgery
repeat mrI f repeat mrIg
Pituitary functione,vf d
Tumor Growth, vf Abnormality
Surgery
abnormal c
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so long as the lesion continues not to threaten thepatient’s health. some Task Force members wouldcontinue imaging every 5 yr. uncertainty as to theoptimalintervalanddurationoflong-termfollow-upimaging can be shared with the patient, and theschemefollowedcanbeindividualizedtobalancethephysician’sassessmentoftheriskthatthelesionposestothepatient’shealthwiththeburdentothepatientofsurveillancetesting.
2.1. Values and preferences
The decision to proceed with conservative nonsur-gical management of pituitary incidentalomas notmeetingcriteriaforsurgery(seeSection 3.0)putsarela-tively high value on avoiding surgical interventionanditsassociatedmorbidityandcost,andarelativelylow value in avoiding apoplexy. The evidence thatmost incidentalomas do not progress over time tocausevisualorotherdisturbancessupportsthisvaluejudgment.Ontheotherhand,apoplexydevelopedinsevenof248patientswithincidentalomas(4–6,8,9,26). large-scale prospective studies of conservativenonsurgicalmanagementofpituitaryincidentalomasareneededtofurtherinformthisjudgment.
2.1. Remarks
TheTaskForcerecognizedthatacontinuumofsizeofincidentalomas exists, and some large microinciden-talomas(6–9mm)maybehavemorelikemacroinci-dentalomas. Therefore, some Task Force memberswouldalsoperformfollow-upMRisandhypopituita-rismevaluationsinlargermicroincidentalomasastheywouldformacroincidentalomas.somealsoconsideredthat follow-up evaluations for hypopituitarism wereneededonlyforpatientswithenlargingincidentalomasbecausenewhypopituitarismwouldbeveryunlikelytodevelopwithouttumorgrowth.However,nodataareavailable to support one particular size threshold fortheincreaseinsizethatshouldtriggerthisevaluation.TheTaskForcewassplitonthesepoints.
Recommendation
2.2. Patients who develop any signs or symptomspotentiallyrelatedtotheincidentalomaorwhoshowan increase in size of the incidentaloma on MRi
developingnewhypopituitarismisextremelylow.inpreviousstudies,noneofthepituitarymicroinciden-talomas followed prospectively was reported to beassociatedwithchangesinpituitaryfunction(4–9).
The proposed algorithms for the MRi follow-up ofpituitary incidentalomas took into account thoseadopted in prior studies. However, those algorithmsvaried considerably from study to study (4–9), andnonewasvalidated.asaresult,theimagingfollow-up proposed in this guideline incorporated theexperiences of the Task Force’s members. Follow-upMRi scans were recommended for macroinciden-talomas because it has been demonstrated thatalthoughgenerallytheselesionsgrowslowly,somedoenlargeandbecomesymptomatic.indatacombinedfrom a number of studies, macroincidentalomasenlarged in85of353 (24%)patients (4–9,23–26).VFabnormalitiesdevelopedin28(8%)patientsovertime, which demonstrated that the enlargementadversely affected the patient’s health. Pituitaryapoplexydevelopedinsevenof353(2%)patients,ofwhom most developed permanent hypopituitarismandonehadpermanentvisionimpairment(5).inameta-analysisofthesestudies,8.2%ofincidentalomasenlargedperyearwithafollow-upof472person-years(3).lessfrequentsurveillanceofmicroincidentalomaswasrecommendedbecausetheirrateofenlargementwaslow,beingreportedin17of160patients(10.6%)followedfrom2.3to7yr(5–9,23–25).inthemeta-analysis, 1.7% of microincidentalomas enlarged peryear(3).importantly,noneofthepatientswiththesemicroincidentalomas developed new VF abnormali-tiesthatwouldhavenecessitatedsurgery.
Overall,theTaskForceconsideredthatrepeatscan-ningwithinthefirstyearwaswarrantedforallpatientsbecause, although most incidentalomas grow slowly,somedoenlarge,andthetrueproliferativenatureoftheincidentalomaisunknown(Fig.1).ifnogrowthisdetected,thentheintervalbetweenMRiscanscanbeincreased. evidence does not support one particularalgorithmforthefrequencyoffollow-upimaging,butwe recommend repeating the MRi every year inmacroincidentalomas,every1–2yrinmicroinciden-talomasforthenext3yr,andtheneveryotheryearforthenext6yrandgraduallylessfrequentlyindefinitely
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orforthosewithincertainproximityofthechiasmbutwherenoVFabnormalitiesarepresenthavenotbeenquantified, in the Task Force’s experience significantriskoffuturevisiondisturbanceinthesepatientsexiststo warrant surgery. The age of the patient is also animportant consideration. surgery may be favored inyounger vs. older patients given the higher lifetimeprobabilityoftumorenlargementintheformerandthegreaterrisksofsurgicalinterventioninthelattergroupofpatients.somemayelecttofollowelderlypatientswith significant risks to surgery conservatively andcloselyforanydeteriorationinvision.Thedecisiontorecommend surgery should also consider whetherfuture fertility is of concern to the patient. difficultcasescouldalsobediscussedatapituitarymultidisci-plinaryteammeetingwhenthisisavailable.
surgery is indicated in patients with apoplexy andvisual disturbance. in a retrospective review of 30subjects with pituitary apoplexy, the 20 who werefollowedconservativelyhadasimilarlong-termriskofhypopituitarism as those treated surgically (37).Therefore,patientswithapoplexyandwithoutvisualcompromise may be followed conservatively withserialimagingandhormonalassessments.
3.1. Values and Preferences
Ourrecommendationsforsurgeryforincidentalomasputahighvalueonalleviatingorpreventingvisualorneurological compromise. although the benefits ofsurgery inpreventing futurevisualabnormalitiesarenotknown,arelativelyhighervaluewasputonthepreventionofVFabnormalitiesthanonavoidingthemorbidity (e.g. diabetes insipidus, hypopituitarism)and the cost of surgery. new hypopituitarism as aresult of transsphenoidal surgery is rare in the TaskForce’sexperience,buttheriskshouldbeconsideredintheclinicalcontextoftheparticularpatient.
3.1. Remarks
Therecommendationsforsurgicaltherapyofapitu-itary incidentaloma were based on the Task Force’sexpectationsforoutcomeandimprovementsinvisionand endocrine function. These expectations werebasedonknownliteratureandTaskForcemembers’clinical experience with surgery performed by a
shouldundergomorefrequentordetailedevaluationsasindicatedclinically(1| ).
3.0. IndICATIOnS fOr SurGICAl ThErAPy Of ThE PITuITAry InCIdEnTAlOmA
Recommendation
3.1. We recommend that patients with a pituitaryincidentalomabereferredforsurgeryiftheyhavethefollowing(1| ):
• aVFdeficitduetothelesion.
• Othervisualabnormalities,suchasophthal-moplegiaorneurologicalcompromiseduetocompressionbythelesion.
• lesionabuttingorcompressingtheopticnervesorchiasmonMRi.
• Pituitaryapoplexywithvisualdisturbance.
• Hypersecretingtumorsotherthanprolacti-nomasasrecommendedbyotherguidelinesofTheendocrinesocietyandThePituitarysociety(31,33).
3.1. Evidence
Thedecisiontorecommendsurgeryasinitialtherapyforapatientwithapituitaryincidentalomaneedstobeindividualized (Fig. 1). Few data are available thatspecifically examine the outcome of surgery for inci-dentalomas.someoftheevidenceconsideredindevel-opingtherecommendedcriteria forsurgerywas fromtranssphenoidal surgical series of symptomatic andoftenlargepituitarylesions.FromthesedataandbasedontheclinicalexperiencesoftheTaskForcemembers,itisclearthatsubstantialevidencesupportstheneedforsurgeryforpituitaryincidentalomascausingvisualorneurologicalcompromise.Thepresenceofvisualorneurologicalabnormalitiesduetocompressionoftheoptic nerves or chiasm by the incidentaloma is thestrongestindicationforsurgery.althoughtherisksofnotperformingsurgeryontumorsthatabutthechiasm
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threatenvisioninthenearfuture)shouldbeconsid-ered for surgery before the incidentaloma progressesto abut the chiasm or produce visual deficits. aconsideration of the clinical characteristics of thepatientincludingtheirageandotherrisksforsurgeryneedstobeincorporatedintothedecisiontoproceedtosurgery.
The evidence for or against a recommendation forsurgerybecauseofthepresenceofhypopituitarismisalso limited.although some surgical seriesof symp-tomatic incidentalomas show that hypopituitarismcanimprovewithsurgery(40,41),thesedatamaynotbe applicable to the incidentaloma, and as a resulthypopituitarismwasconsideredonlyarelativeindica-tionforsurgery.adequatereplacementtherapyshouldbeinstitutedwhetherornotsurgeryisrecommended.somepatientsplanningpregnancymaybenefitfromsurgery if their tumor is close to the optic chiasmbecause there is a small risk that lactotroph hyper-plasiainthenormalglandmayleadtotumorcompres-sionoftheopticnerveorchiasm,andcloserfollow-upinsuchpatientsshouldbeundertaken.Headachemayormaynotimprovewithtranssphenoidalremovalofthetumor,soitcanonlybesuggestedasanindicationforsurgery,andthequalityofevidenceislow.
Medical therapy of the pituitary incidentaloma
in patients with incidentalomas and hyperprolac-tinemia thatmaybedue to tumoral compressionofthehypothalamic-pituitarystalk,symptomatichyper-prolactinemia may be treated with a dopamineagonist.However,incidentalomasotherthanaprolac-tinoma will rarely shrink, and dopamine agonistscannot be relied upon for this purpose. Therefore,continued monitoring of lesion size is necessary,regardlessofchangesinprolactinlevels.
Medical therapy of pituitary incidentalomas hasnotbeensystematicallystudied.someparallelstotheeffectsofmedicaltherapyonpathologicallyconfirmednonfunctioning pituitary tumors are possible, butthis connection needs to be made cautiously. Thereported efficacy of dopamine agonist therapy ofnonfunctioning pituitary adenomas varies widely.With cabergoline or bromocriptine treatment forpatients with residual tumor after surgery, some
surgeon experienced in transsphenoidal pituitarysurgery.Thesuccessofsurgeryforhormone-secretingtumorsishighlydependentontheexpertise,skill,andcase volume of a pituitary surgeon supported by anexperienced team (38, 39). This is likely to also betrueforpituitarysurgeryofothertypesoflesions.Theavailability of such a pituitary surgeon needs to beconsideredwhenfollowingtheseguidelines.
Recommendation
3.2. Wesuggestthatsurgerybeconsideredforpatientswith a pituitary incidentaloma if they have thefollowing(2| ):
• Clinicallysignificantgrowthofthepituitaryincidentaloma.
• lossofendocrinologicalfunction.
• alesionclosetotheopticchiasmandaplantobecomepregnant.
• unremittingheadache.
3.2. Evidence
The evidence for or against a recommendation forsurgerybecauseofgrowthofapituitaryincidentalomais limited. surgery was suggested for incidentalomasthat demonstrate clinically significant growth onfollow-upimagingstudies,whichisgrowththatcouldposeahealthrisktothepatientsuchastotheirvision.such growing incidentalomas typically continue togrow,andsurgeryismosteffectiveforsmallerlesions.a specific size cutoff for the incidentaloma was notconsidered a requirement for surgery because somelarge incidentalomas are predominantly intra- andinfrasellar.althoughtherearenoestablishedchangesinsizeorgrowthratethatwouldautomaticallytriggerthe need for surgery, the pattern of growth of theincidentaloma was considered more important. Forexample, a 1-mm enlargement within the sella of a5-mm intrasellarmicroadenomawouldnotbe clini-callysignificant,buta1-mmenlargementtowardthechiasminalesiononly3mmfromthechiasmwouldbe significant. Therefore, incidentalomas exhibitingsignificant growth (which includes growth that israpid,occurringovera1-to2-yrperiod,and/orthatis toward the optic chiasm and if continued could
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degree of tumor shrinkage was detected in 8–45%(42–44), and the amount of shrinkage varied from10–62%(43, 44) or 3–14 mm(42). somatostatinanalogshavealsobeentried.Withnomorethan1yrof octreotide therapy, shrinkage was reported inapproximately5–25%,increasein12%,andstabiliza-tionin83%oftumors(45–48).insufficientdataareavailabletosuggesttheroutineuseofmedicaltherapyofpituitaryincidentalomas.
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AcknowledgmentsThemembersoftheTaskForcethankTheendocrinesociety’sClinicalGuidelinessubcommittee,ClinicalaffairsCoreCommittee, andCouncil for their careful, critical reviewof earlierversionsof thismanuscript and theirhelpfulcommentsandsuggestions.Wealsothanktheleadershipoftheeuropeansocietyofendocrinologyfortheirreviewandcomments.inaddition,wethankthemanymembersofTheendocrinesocietywhoreviewedthedraftversionofthismanuscriptwhenitwaspostedonthesociety’swebsiteandwhosentagreatnumberofadditionalcommentsandsuggestions,mostofwhichwereincorporatedintothefinalversionofthemanuscript.Finally,wethankthestaffatthesocietyofficefortheirhelpfulsupportduringthedevelopmentofthisguideline.
financial disclosure of Task forcePamela U. Freda, M.D.*—FinancialorBusiness/Organizationalinterests:novartis,ipsen,andPfizer;significantFinancialinterestorleadershipPosition:nonedeclared.Albert M. Beckers, M.D., D.Sc., Ph.D.—FinancialorBusiness/Organizationalinterests:novartis,ipsen,andPfizer;significantFinancialinterestorleadershipPosition:nonedeclared.Laurence Katznelson, M.D.—FinancialorBusiness/Organizationalinterests:novartis,ipsen,andnovonordisk;significantFinancialinterestorleadershipPosition:nonedeclared.Mark E. Molitch, M.D.—FinancialorBusiness/Organizationalinterests:Tercica/ipsen,novartis;significantFinancialinterestorleadershipPosition:nonedeclared.Victor M. Montori, M.D.*—FinancialorBusiness/Organizationalinterests:KeRunit(MayoClinic);significantFinancial interestorleadershipPosition:nonedeclared.Kalmon D. Post, M.D.—FinancialorBusiness/Organizationalinterests:nonedeclared;significantFinancialinterestorleadershipPosi-tion:nonedeclared.Mary Lee Vance, M.D.—FinancialorBusiness/Organizationalinterests:novartis;significantFinancialinterestorleadershipPosition:nonedeclared.
*Evidence-based reviews for this guideline were prepared under contract with The Endocrine Society.
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Androgen Therapy in Women* $15.00 $20.00
Case Detection, Diagnosis & Treatment of Patients with Primary Aldosteronism $15.00 $20.00
Congenital Adrenal Hyperplasia Due to Steroid 21-hydroxylase Deficiency $15.00 $20.00
The Diagnosis of Cushing’s Syndrome $15.00 $20.00
Diagnosis & Treatment of Hyperprolactinemia $15.00 $20.00
Endocrine & Nutritional Management of the Post-bariatric Surgery Patient $15.00 $20.00
Evaluation & Management of Adult Hypoglycemic Disorders $15.00 $20.00
Evaluation & Treatment of Adult Growth Hormone Deficiency* $15.00 $20.00
Evaluation & Treatment of Hirsutism in Premenopausal Women $15.00 $20.00
Endocrine Treatment of Transsexual Persons $15.00 $20.00
Management of Thyroid Dysfunction during Pregnancy & Postpartum*
Executive Summary(MMTD07)—$10.00
Executive Summary (MMTD07)—$15.00
Guideline (MTSD07)—$10.00
Guideline (MTSD07)—$15.00
Pituitary Incidentaloma $15.00 $20.00
Prevention & Treatment of Pediatric Obesity $15.00 $20.00
Primary Prevention of Cardiovascular Disease & Type 2 Diabetes in Patients at Metabolic Risk $15.00 $20.00
Testosterone Therapy in Adult Men with Androgen Deficiency Syndromes (with CME) $25.00 $30.00
TOTAl All prices include sales tax $
*Special offer available on this guideline. See the Special Order Form located on the Society’s website for more details.
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Cl inical Guidel inesis a story worth telling
To purchase the available guidelines visit: www.endo-society.org/guidelines/Current-Clinical-Practice-Guidelines.cfm.
To view patient guides (companion pieces to the clinical guidelines), visit The Hormone Foundation’s Web site at www.hormone.org/public/patientguides.cfm.
Visit http://www.guidelinecentral.com to purchase pocket cards developed fromselect Endocrine Society guidelines.
Endocrine Society Clinical Guidelines ALSO AVAILABLE•Hyperprolactinemia
•Post-BariatricSurgeryPatient
•CongenitalAdrenalHyperplasia
•EndocrineTreatmentofTranssexualPersons
•AdultHypoglycemicDisorders
•PediatricObesity
•PrimaryPreventionofCardiovascularDiseaseandType2DiabetesinPatientsatMetabolicRisk
•CaseDetection,Diagnosis,andTreatmentofPatientswithPrimaryAldosteronism
•TheDiagnosisofCushing’sSyndrome
•HirsutisminPremenopausalWomen
•ManagementofThyroidDysfunctionduringPregnancy&Postpartum
•AndrogenTherapyinWomen
•TestosteroneTherapyinAdultMenwithAndrogenDeficiencySyndromes
•AdultGrowthHormoneDeficiency
Other Endocrine Society Guidelines COMING SOON
•ContinuousGlucoseMonitoring
•VitaminD
•Hypertriglyceridemia
•HyperglycemiainHospitalizedPatients
•OsteoporosisinMen
•Diabetes&Pregnancy
•Hyponatremia
•PCOS
•HypothalamicAmenorrhea
•Paget’sDiseaseoftheBone
•Medical,Nutritional,&PharmacologicManagementofObesity
Developed independently by a team of experts, evidence-based, and vetted through a rigorous, multi-step peer review process, the PituitaryIncidentalomaGuideline addresses:
• Initial evaluation of a patient with a pituitary incidentaloma
• Follow-up testing of the pituitary incidentaloma
• Indications for surgical therapy of the pituitary incidentaloma
© 2011 The Endocrine Society®
NEW
CG_PI10
Commercial reprint InformationForinformationonreprintrequestsof101andmoreandcommercialreprintscontact:
KarenBurkhardtWalchliTauberGroupinc
Phone: 443.512.8899,ext.111email: [email protected]
Single reprint InformationForinformationonreprintsof100andfewer,completetheguidelineorderformandreturnusingoneofthefollowingmethods:
Mail: Theendocrinesociety POBox17020 Baltimore,Md21297-1020
Fax: 301.941.0257email: [email protected]
Questions & CorrespondencesTheendocrinesocietyattn:Government&Public.affairsdepartment8401Connecticutavenue,suite900ChevyChase,Md20815
Phone: 301.941.0200email: [email protected]: www.endo-society.org
FormoreinformationonTheendocrinesociety’sClinicalPracticeGuidelines,visit:http://www.endo-society.org/guidelines/index.cfm
Toviewpatientguides(companionpiecestotheclinicalpracticeguidelines)visitTheHormoneFoundation’swebsiteat:http://www.hormone.org/Resources/patientguides.cfm.
Visithttp://www.guidelinecentral.comtopurchasepocketcardsdevelopedfromselectendocrinesocietyguidelines.
The Endocrine Society8401 Connecticut Avenue, Suite 900
Chevy Chase, md 20815
301.941.0200www.endo-society.org
