Recurrence of Nonfunctioning Pituitary Macroadenoma
A 74-year-old patient had a nonfunctioning pituitary macroadenoma surgically removed via the transsphenoidal approach approximately 20 years ago. A recent MRI has shown recurrence with mild mass effect upon the optic chasm, but visual field exam is thus far normal. Other than gradual unexplained weight loss, the patient has no other symptoms. What options would you recommend for this patient?

Nonfunctioning pituitary macroadenomas require medical and/or surgical treatment when they result in pituitary hypofunction or visual symptoms. This 74-year-old patient has no visual symptoms. Therefore, unless periodic magnetic resonance imaging (MRI) has been performed, close follow-up by MRI is recommended, as is medical examination to determine the cause of the patient's gradual weight loss. Medical examination should include gastrointestinal and rectal inspection and endocrinologic assessment of pituitary hormones. Although no information was provided regarding replacement therapy such as thyroid hormone or adrenocorticosteroids, these should be supplemented if their values are less than standard.

The natural history of nonfunctioning pituitary adenomas remains unclear. According to a recent report analyzing growth patterns and rates in residual nonfunctioning pituitary adenomas, tumor volume doubling time in elderly patients is much longer (2566 days) than has previously been reported. When the tumor of the patient grows to cause a deterioration of visual fields, transsphenoidal removal should be considered. If the patient has any serious problems with general endotracheal anesthesia, stereotactic radiosurgery or conventional local irradiation would be indicated.

If this patient wants to undergo surgical removal this time, transsphenoidal surgery may be considered if he has no cardiopulmonary contraindications. In this case, general medical care for the older adult would be indicated during the perioperative period.