**8.2 Evaluation**

All patients who their imaging studies showed pituitary adenoma, whether symptomatic or asymptomatic, should go thorough hormonal evaluation as recommended by The Clinical Guidelines Subcommittee of The Endocrine Society [70]. These include IGF-1 and GH, ACTH, prolactin, FSH/LH, and TSH. If ACTH and IGF-1 test are equivocal, stimulatory tests are recommended. Hypopituitarism is not uncommon and hormonal replacement therapy should be initiated in patients with hormonal deficiency. Panhypopituitarism can be seen in up to 30% of patients. Prolactin level could be elevated in 25–65% caused by pituitary stalk compression (stalk effect) [71]. Therefore, it is important to differentiate between hyperprolactinemia caused by a prolactinoma or NFPA. Prolactin level > 200 μg/L is unlikely to be caused by stalk effect.

The diagnostic approach and follow-up are different between symptomatic and asymptomatic NFPA. In symptomatic NFPA, and after doing the hormonal laboratory tests, all patients need to have ophthalmic evaluation for assessing optic apparatus

#### **Figure 9.**

*Simplified scheme of NFPA diagnosis and management.*

function. Also, it is important to have a detailed history and physical examination to assess the patient symptoms. In asymptomatic NFPA, patients need to have complete hormonal evaluation as mentioned previously to rule-out hyper-or-hypopituitarism. Asymptomatic microadenomas can be followed-up after 1 year of diagnosis by repeating the brain imaging only. In asymptomatic macroadenomas, follow-up is after 6 months with brain MRI and hormone levels, then every year if the follow-up images and laboratories did not show tumor progression or pituitary dysfunction (**Figure 9**).

#### **8.3 Management**

Treatment of patients with NFPA starts with hormonal replacement therapy in case of hypopituitarism. It is vital to recognize and treat cortisol deficiency efficiently. The same is true for secondary hypothyroidism as patients should receive thyroxine immediately after confirming its deficiency. Both cortisol and thyroxine should be initiated before surgery, and in non-emergency surgery, it is better to replace thyroxine and wait until hypothyroidism is adequately treated.

Surgical indications for NFPA are symptomatic optic nerve or chiasm compression, cranial nerves dysfunction, and pituitary apoplexy with visual impairment (**Figure 9**). However, surgery is also advised in asymptomatic growing adenomas that are close to or progressively abutting optic nerves and/or chiasm on follow-up imaging studies [70].

What about patients who have hypopituitarism or headache only?

Surgery in patients with hypopituitarism alone without visual symptoms is not recommended as only 30% of patients will have improvement over pituitary function. Also, headache is a common symptom in NFPA patients, but as headache has multiple causes, there is a high chance of headache persistence after adenoma resection. Therefore, only intractable headache that is affecting patient's daily activities should be an indication of surgery and the patient should be aware that headache relief cannot be guaranteed [71].

After surgery, patients should be evaluated for hypopituitarism 6 weeks after surgery. Also, pituitary MRI should be done 3 months after surgery to have it as a baseline for future follow-up. Gross-total resection of NFPA has a recurrence rate of 7–24%, and 47–64% of cases in partially resected ones [72].
