Nonfunctioning Pituitary Macro Incidentalomas Benefit from Early Surgery before Becoming Symptomatic

Objective: Pituitary incidentalomas (Pis) are increasingly diagnosed. While the therapeutic management is well defined for symptomatic non-functioning PIs (NFPIs), a controversy still exists for asymptomatic macro-NFPIs between surgery and a “wait and see” approach. In this study, postoperative outcome comparison was performed between symptomatic and asymptomatic macro-NFPIs and results were interpreted after reviewing the current literature on NFPIs.

Methods: A cohort of 76 cases with newly diagnosed symptomatic or asymptomatic macro-NFPIs surgically treated during a 10 year’s period was retrospectively analyzed. Age, tumor size (using Knosp’s grading system and tumor height) and surgical outcome were compared between the asymptomatic and the symptomatic group, focusing on the quality of resection, morbidity, hormonal and visual (acuity and fields) status. Multivariate logistic regression analysis was performed to underline possible independent associations of predefined factors.

Results: 48 out of 76 (63%) macro-NFPIs cases were found to be symptomatic after pre-operative evaluation. Symptomatic cases were older than asymptomatic one (p < 0.001). Mean tumor height and volume were significantly higher in symptomatic cases (p < 0.05). In the symptomatic group (n = 48), 21 (41%) cases presented with visual impairment exclusively, 13 (27%) cases with hormone deficiencies exclusively and 14 (29%) cases with both visual and hormonal impairment. Gross total removal (GTR) rate was significantly higher in asymptomatic cases (82% versus 58%; p = 0.03). In multivariate analysis, GTR was strongly associated with Knosp's classification (OR=6.9, 95%CI 1.5-32.3; p = 0.01). Postoperative hormonal impairment/worsening was significantly associated with the existence of preoperative symptoms, being 10 times less frequent in the asymptomatic than in the symptomatic group (OR 0.1, 95%CI 0.04-0.5,; p = 0.03). In the symptomatic group, postoperative visual and hormonal impairment rate (either persisting after surgery or worsened by surgery) were 35% and 76.5%, respectively. No case in the asymptomatic group developed visual function deterioration after surgery and postoperative hormonal impairment was present in only 14%of cases.

Conclusions: Extent of tumor resection, hormonal and visual outcome are better in cases undergoing surgery for asymptomatic than in those with symptomatic macro-NFPIs. It is appropriate to offer surgery to patients with asymptomatic macro-NFPIs.