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Management of Nonfunctional Pituitary Adenomas

NOMINATED TOPIC | May 31, 2022

1. What is the decision or change (e.g. clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

We want to assess the most current and clinically relevant evidence for the management of patients with nonfunctional pituitary adenomas (NFPAs). Authors published guidelines in 2016 including evidence published from January 1, 1966, to October 1, 2014. Fortunately, new research has been published on this topic, and these guidelines are meant to be updated as new evidence emerges. The authors will develop a new guideline based on a new systematic review based on more recently published literature on this topic.

2. Why are you struggling with this issue?

There are multiple areas of research that have emerged since the 2014 literature cutoff used on the previous guidelines, including initial management, surgical techniques, and postoperative morbidity reduction strategies. In terms of initial management, NFPAs are very common with nearly 1 in 6 people having one on healthy volunteer MRI or autopsy studies, making it very important to define optimal management strategies using evidence-based methods. NFPAs are being increasingly diagnosed during life due to increasing use of brain MRIs, leaving uncertainty as to when to operate on versus observe incidental findings, and creating conflicting behavior with some practitioners operating on tumors that might be unlikely to grow during the patient’s lifetime and other practitioners observing tumors due to false perceptions about the risks of surgery. Thankfully, there have been new studies on this topic since 2014 that could lend clarity if integrated into guidelines. In terms of surgical techniques, at the time of the 2014 study endoscopy was just beginning to be applied to NFPA surgery, but since then numerous randomized trials have compared endoscopic techniques to microscopic techniques, and endoscopic techniques have advanced to include medical cavernous sinus wall resection to improve extent of resection and reduce recurrence. In terms of morbidity reduction strategies, since 2014 randomized studies have looked at postoperative sinonasal quality of life, the role for prophylactic antibiotics to reduce infection, the role for prophylactic fluid restriction to reduce SIADH, strategies to prevent readmissions, and identifying patients who could safely undergo a reduce length of inpatient stay.

This systematic review would help inform a clinical practice guideline to synthesize new evidence on this topic to help inform decision-making for providers and better patient outcomes for the large number of patients diagnosed with an NFPA every day.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

We would like to explore the following seven questions related to this topic, which have been modified slightly from the 7 questions asked as part of the 2016 guidelines, reflecting changes in the field that have occurred in the past 6 years:

  1. Initial assessment of patients with suspected NFPA
    • What is the optimal imaging modality to initially assess NFPAs?
    • Which pituitary hormones must be checked and treated before operating on NFAP patients?
    • What is the optimal technology to assess visual function in NFPA patients?
  2. Primary management of NFPAs
    • What is the natural history of observed NFPAs?
    • When should NFPAs be observed versus operated on?
  3. Surgical techniques and technologies (endoscopic transsphenoidal, microscopic transsphenoidal, craniotomy)
    • How does NFPA extent of resection compare between endoscopic vs. microscopic transsphenoidal?
    • How does postoperative sinonasal quality of life compare after endoscopic vs. microscopic transsphenoidal NFPA surgery?
    • What is the role for medial cavernous sinus wall resection during NFPA surgery?
  4. Intraoperative adjuncts for NFPA surgery
    • What is the role of prophylactic antibiotics during NFPA surgery?
    • Should all NFPA patients receive stress dose steroids during surgery?
    • What is the for lumbar CSF diversion during and after NFPA surgery?
    • What is the role for intraoperative MRI during NFPA surgery?
    • Fluorescent dyes
  5. Immediate postoperative care
    • Fluid restriction to reduce SIADH
    • Strategies to reduce length of stay
    • Strategies to reduce 30 day readmission
    • Should patients be discharged on maintenance steroids after NFPA surgery?
  6. Management of residual or recurrent NFPA
    • What is the role for radiation therapy or radiosurgery for residual or recurrent NFPA?
    • What is the role for repeat surgery for residual or recurrent NFPA?
    • What is the role for observation for residual or recurrent NFPA?
  7. Post-treatment follow-up evaluation (endocrine, visual, surveillance imaging)
    • What is the optimal timing of the first postoperative MRI after NFPA surgery?
    • How long after NFPA surgery should patients be followed with surveillance imaging?
    • How soon after NFPA surgery should patients undergo visual evaluation?
    • How soon after NFPA surgery should patients undergo endocrine evaluation?

4. When do you need the evidence report?

Fri, 06/30/2023

5. What will you do with the evidence report?

The purpose of this topic nomination is to evaluate all available evidence, from which, the Congress of Neurological Surgeons (CNS) will develop a guideline to aid clinicians and guide clinical practice by determining the best options for the management of nonfunctional pituitary adenomas (NFPAs).

The CNS maintains in-house infrastructure to lead, promote, and support the creation and methodological processes to produce evidence-based guidelines, which are critical tools to confront a rapidly changing health care environment. Using the CNS’s high quality, rigorous methodological process, a multidisciplinary task force containing several members of the task force that wrote the CNS’s 2016 NFPA guidelines, will develop recommendations based on the available evidence provided by the Evidence Based Practice Center. Throughout development, the task force will use evidence-based methodologies and strictly adhere to a priori defined criteria as defined by the Institute of Medicine’s (IOM) standards for conducting systematic reviews and clinical evidence-based guidelines.

The need to update the 2016 guidelines was determined by a group of multidisciplinary specialists designated by the CNS in an effort to have as broad a representation of opinions and expertise as possible. It is CNS’s goal to follow the IOM recommendations to be inclusive and inter-disciplinary when constructing our guidelines and subsequent recommendations. A conscientious effort will also be made to be sure that any conflict of interest is fully disclosed and avoided. Participants who have published extensively in certain areas will be asked to recuse themselves from voting and will be assigned to evaluate evidence in other topics. Every effort will be made to ensure that the guideline is accurate, reliable, and non-biased.

The CNS guidelines attempt to provide essential information for clinicians, globally, helping to improve patient care and outcomes. In addition to developing high quality guidelines, CNS is also committed to dissemination of guidelines in multiple, open access formats, such as publication in peer-reviewed journals, publication on the CNS webpage, webinars, conference seminars and courses, as well as other promotional efforts.

Optional Information About You

What is your role or perspective? Physician

If you are you making a suggestion on behalf of an organization, please state the name of the organization? Congress of Neurological Surgeons

May we contact you if we have questions about your nomination? Yes

Page last reviewed May 2022
Page originally created May 2022

Internet Citation: Management of Nonfunctional Pituitary Adenomas. Content last reviewed May 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/get-involved/nominated-topics/nonfunctional-pituitary-adenomas

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