Non functioning pituitary adenoma

Start appropriate therapy immediately if hypopituitarism is confirmed.

Arrange dynamic pituitary function testing with insulin or glucagon stress testing.

It is usually possible to differentiate between a NFPA and prolactinoma clinically. However, in certain difficult cases, consider instituting a trial of medical therapy with close monitoring of visual fields, serum prolactin and MRI appearance. 

Visual fields and MRI appearances should respond rapidly and dramatically in the case of a macroprolacinoma, with a smooth decline in serum prolactin.

Visual fields and MRI appearance will not change but there may be a massive immediate fall in prolactin with a NFPA since the prolactin emanates from normal not tumourous cells in this case.

If clinical doubt remains, and vision is threatened, early surgery should be considered.

If clinical features are unusual for example with a suprasellar or peripituitary mass on MRI scan, or with diabetes insipidus, consider other causes. Ensure that serum angiotensin converting enzyme, ESR, auto-antibody screen, alpha feto protein, human choriotropic hormone and chest radiograph have all been assessed before discussing at a multidisciplinary meeting to determine further management.

Review MRI scan, visual field testing and other results before deciding on conservative management or surgery. Consider urgent surgical referral in all cases with visual field involvement.

Repeat MRI at three to six months post-operatively according to multidisciplinary discussion.

Consider further surgery or radiotherapy if a significant disease remnant is visible on post operative MRI scan.

Clinical review with repeat assessment of pituitary function (basal +/- dynamic if necessary), visual fields and optimisation of pituitary replacement therapy is necessary at three, six and 12 months post-operatively.

MRI scans tend to be repeated at three to six months post op, then at one year, then at three years and then at three-yearly intervals if surgical clearance is satisfactory.

Always repeat MRI scan sooner if there is a clinical indication, for example a new headache, visual field or acuity loss.

Patients who have responded well to surgery and radiotherapy may not need such regular scanning.

Repeat basal pituitary function in all patients annually, with alternative year dynamic testing to seek GH and ACTH deficiency in patients who have undergone radiotherapy.

Ensure thyroxine levels are between the middle and upper end of the reference range.

Ensure patient is not clinically or biochemically over-replaced with glucocorticoid, and ensure that sex hormone and GH replacement therapy have been considered.

Monitor and treat cardiovascular risk factors aggressively.

Monitor and treat new cerebrovascular disease or new tumours.

Consider repeat surgery, radiosurgery or radiotherapy if regrowth or recurrent tumour detected after initial surgery and radiotherapy.