Pituitary Incidentaloma and Nonincidentaloma: A Comparison of Pretreatment and Postoperative Characteristics

Background: With the advent of more advanced imaging modalities and its widespread use, pituitary incidentalomas (PI) are increasingly being detected at a higher rate than before when patients are worked up for nonpituitary–related conditions. Criteria for surgical and nonsurgical management of this clinical entity are now more clearly delineated than previously. This study analyzes our institution’s robust experience in the operative management of PIs over a 14-year period, making it the largest cohort of surgical PIs in the literature.

Methods: Retrospective chart review of pituitary adenoma patients who underwent a transsphenoidal hypophysectomy from 2005 to 2019 performed at a single tertiary care facility. Patients were subdivided into those whose tumors were detected incidentally (PI) versus those who presented with a disease-specific complaint such as vision changes or hormone-related symptoms (non-PI). Primary outcome measures included reason for PI detection, indication for surgery, and length of time from detection to surgery. Secondary outcome measures included comorbidities, tumor size, length of stay (LOS), complications, readmission, and resurgery.

Results: Pituitary incidentaloma detection: 684 patients were included in the study, of which 159 (23%) patients had PI. The most common modality for detection was CT (43%, n = 69) followed by MRI (17%, n = 27). Headache and/or migraine (14%, n = 23) was the most common reason for the initial imaging workup that detected PI. Increase in size during follow-up (27%, n = 43) was the most common indication for surgery. Median time of detection to date of surgery was 5.3 months.

Demographics: Gender, age, BMI, smoking, preoperative comorbidities—hypertension, congestive heart failure, atrial fibrillation, thromboembolism, and COPD were comparable between both groups (p > 0.05).

Tumor and Treatment Characteristics: Smaller tumor size (p < 0.0001) and lower tumor volume (p < 0.0001) were seen in PI. The PI group was more likely to have optic nerve involvement (p < 0.001), more likely to be secretory type (p = 0.04), and acromegaly comprised 67% of PI. PIs were more likely to undergo complete resection (p < 0.001), therefore less likely to require reoperation (p = 0.005). Cavernous sinus involvement, invasiveness, apoplexy at presentation, and rate of intraoperative CSF leak were comparable.

Postoperative Outcomes: Synechiae (p = 0.001) as a postoperative complication was significantly less in the PI group, while rates of sinusitis, septal perforation, thromboembolism, epistaxis, sellar hemorrhage, and crusting were comparable. LOS (p = 0.025) was lower for PI, while 30-day readmission rate was comparable.

Conclusion: This study serves as the largest single institution analysis of surgically managed PIs currently in the literature. Based on our data, workup of headaches/migraines is the most common reason for detection of PI, and an increase in tumor size is the most common indication for surgery. On average, patients had surgery approximately 5 months after diagnosis with shorter LOS. PIs have a similar rate of complications as compared with non-PIs. As our cohort continues to expand, we will be able to draw more meaningful conclusions regarding our experience with pituitary incidentalomas.