Current Perspectives on Recurrent Pituitary Adenoma

The Role and Timing of Surgery vs Adjuvant Treatment

Caroline Hayhurst; Peter N. Taylor; Andrew J. Lansdown; Nachi Palaniappan; Dafydd Aled Rees; John Stephen Davies

Disclosures

Clin Endocrinol. 2020;92(2):89-97. 

In This Article

Abstract and Introduction

Abstract

The clinical course of pituitary adenoma can be highly variable. Aggressive pituitary tumours may require multimodal therapy with multiple operations. Even standard pituitary adenomas exhibit relatively high long-term recurrence rates and delayed intervention is often required. The indications for revision surgery in the endoscopic era are expanding for both functioning and nonfunctioning tumours, including access to the cavernous sinus and intracranial compartments. Although revision surgery can be challenging, it has been demonstrated to be both safe and effective. The question of the use of early radiotherapy in pituitary adenoma remains controversial. Our increasing understanding of pituitary tumour biology facilitates individualized treatment and surveillance protocols, with early intervention in high-risk adenoma subtypes. In this review, we discuss the treatment options for recurring pituitary tumours and focus on the role of revision surgery.

Introduction

Pituitary adenomas are benign, slow-growing neoplasms in the majority of cases, with an incidence of clinically relevant tumours of 4–7 per 100 000 annually.[1,2] Surgery is usually the first-line treatment for larger nonfunctioning adenomas, where there is compression of the optic apparatus and the majority of functioning tumours, with the exception of prolactinoma. However, even in the setting of complete surgical resection, there is a high long-term recurrence rate of approximately 7%-12% at 10 years.[3,4] Often a complete resection at first surgery may not be achievable due to anatomical limitations and in these cases progression or recurrence is often inevitable, reported in 53% of those with extrasellar residual tissue at 5 years and over 80% at 10 years.[4]

Additionally, there is a subset of histologically aggressive adenomas which display early and multiple recurrences despite multimodal therapy. The prevalence of aggressive pituitary adenoma is not known and furthermore, the exact definition of these tumours in the literature has been variable.

There is currently little international consensus on the management of either recurrent pituitary adenoma or aggressive pituitary adenoma, particularly on the timing of revision surgery vs early or late radiotherapy and the use of chemotherapy, such as temozolomide. Data on the efficacy and safety of revision endoscopic pituitary surgery are emerging but questions remain on the potential impact of radiotherapy in the modern era on long-term outcomes, both endocrinological and surgical.

This review aims to highlight the advantages and limitations of revision endoscopic pituitary surgery, identify 'at risk' patients who may require multiple interventions or multimodal therapy and review current guidelines on management, in order to provide an evidence base to guide clinical practice in the multidisciplinary setting.

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