How to Classify and Define Pituitary Tumors: Recent Advances and Current Controversies

Clinical characteristics and pathological features of growth hormone-secreting pituitary adenoma combined with hyperprolactinemia

PURPOSE

Large-scale reports on growth hormone-secreting pituitary adenomas (GHPA) with hyperprolactinemia (HPRL) remain limited. The relationship between clinical characteristics and pathological subtypes of GHPA patients, based on the 2022 classification of pituitary neuroendocrine tumors (PitNET), has rarely been elucidated. This study aims to enhance the understanding of clinicopathological features in GHPA and clarify differences between patients with and without HPRL.

METHODS

We retrospectively collected the clinical data of 810 patients diagnosed with GHPA. The clinical and pathological characteristics were compared between the HPRL and non-HPRL groups. Patients were categorized according to 2022 pathological classification and their differences were compared.

RESULTS

Compared to the non-HPRL group, the HPRL group exhibited more visual acuity/field impairment and galactorrhea and had higher GH levels. The tumor volume (TV) in the HPRL group was significantly larger, with more severe cavernous sinus invasion and optic chiasm compression, and a higher proportion of mammosomatotroph PitNETs. The most common pathological types of GHPA included sparsely granulated somatotroph PitNETs (46.19%), mammosomatotroph PitNETs (17.37%), and plurihormonal PitNETs (17.80%). Patients with immature PIT-1 lineage PitNETs had the lowest biochemical remission rate and highest tumor residual/recurrence rate.

CONCLUSION

The symptoms of galactorrhea and visual acuity/field impairment contribute to early diagnosis in GHPA patients with HPRL. Although TV is larger and invasiveness is greater, HPRL does not significantly affect the biochemical remission rate. Nearly half of GHPA cases are sparsely granulated somatotroph PitNETs, which are often associated with poor tumor outcomes, highlighting the critical role of pathological type in predicting clinical prognosis.

Social support and psychological distress of patients with pituitary adenomas: chain-mediated effects of self-efficacy and rumination

Introduction

Psychological distress in patients with pituitary adenomas affects their quality of life and is influenced by various aspects such as sociocultural factors, personal resources, and stressors. Therefore, the aim of this study was to investigate the chain-mediated role of self-efficacy and rumination in the relationship between social support and psychological distress.

Methods

The study was based on the Wilson-Cleary model of health-related quality of life and self-efficacy theory. We investigated 500 patients with surgically treated pituitary adenomas in three tertiary hospitals in Shaanxi Province, China. We used the "Social Support" and "General Self-Efficacy" scales, "Rumination Scale," and the "Psychological Distress in Patients with Pituitary Adenomas" questionnaire to conduct the survey, and the data were analyzed using structural equation modeling and bootstrap methods to examine the relationships between the variables.

Results

The results showed that there was a significant positive correlation between social support and self-efficacy, social support and self-efficacy negatively predicted rumination and psychological distress, respectively. Rumination significant positive correlation with psychological distress, and social support, indirectly affected psychological distress through the chain-mediated effect of self-efficacy and rumination. This represents a compound multiple mediating effect on psychological distress.

Discussion

Clinical practitioners should enhance social support for patients with pituitary adenomas, improve patients' self-efficacy, and mitigate rumination to reduce patients' psychological distress.

A Brief Overview of Molecular Biology in Pituitary Adenomas with a Focus on Aggressive Lesions

Arising from the anterior lobe of the hypophysis, pituitary neuroendocrine tumors (PitNETs), previously known as pituitary adenomas, constitute an intricate and heterogeneous entity. Although they are defined as benign pathology, these tumors can often invade neighboring structures and demonstrate aggressive behavior. The continuous advancement of molecular biology has begun to shed light on the genetic mutations behind the development and evolution of this pathology, providing a better understanding. Notwithstanding, the rising occurrence in recent decades can mainly be attributed to advanced diagnostic techniques; however, these tumors continue to increase in prevalence and incidence, creating a heavy burden on healthcare systems. Consequently, the need for further studies is dire, primarily due to a lack of tailored therapeutic approaches. Thus, this article aims to offer a brief overview of the molecular biology behind these complex tumors to contribute, even on a small scale, to more comprehensive care.

Spontaneous Cerebrospinal Fluid Rhinorrhea in Pre-operative Pituitary Adenoma: A Report of Two Cases

Pituitary macroadenomas are neuroendocrine tumors residing in the base of the skull. First-line therapies for prolactin-secreting adenomas (prolactinoma) include medical treatment with dopamine agonists and neurosurgical intervention. Cerebrospinal fluid (CSF) rhinorrhea is a well-known complication following skull base tumor treatment; however, spontaneous CSF rhinorrhea as the initial presenting feature of such tumors is rare. We present two cases of spontaneous CSF rhinorrhea in pre-operative invasive pituitary macroadenomas. Invasive pituitary macroadenomas have the potential to disrupt local skull base structures such as the sellar floor and cavernous sinus. Early warning signs can help aid in prompt diagnosis and successful treatment. Spontaneous CSF rhinorrhea as the initial presenting symptom is rare and may be pivotal in the early diagnosis of pituitary adenomas.

Diagnosis and Management of Aggressive/Refractory Growth Hormone-Secreting Pituitary Neuroendocrine Tumors

The majority of acromegaly and gigantism are caused by growth hormone-secreting pituitary neuroendocrine tumors (PitNETs). Most cases can be cured or controlled by surgery, medical therapy, and/or radiotherapy. However, a few of these tumors are resistant to traditional therapy and always have a poor prognosis. The title aggressive/refractory is used to differentiate them from pituitary carcinomas. To date, there is no definitive conclusion on how to diagnose aggressive/refractory growth hormone-secreting PitNETs, which may have slowed the process of exploring new therapeutical strategies. We summarized the literature described diagnosis and treatment of the disease. Potential disease markers and prospective therapies were also included.

Collision of pituitary neuroendocrine tumor and anterior clinoid meningioma treated with a two-stage minimally invasive surgical strategy: illustrative case

BACKGROUND

The locations of pituitary neuroendocrine tumor (PitNET) and anterior clinoid meningioma (ACM) appear to be very close but essentially different, as the former is inside the sella turcica while the latter is in the intradural space. A collision tumor thus requires a specific treatment strategy but has been rarely reported.

OBSERVATIONS

A 77-year-old woman presented with progressive visual impairment due to significant compression of the optic apparatus by a collision of PitNET and ACM. With a minimally invasive two-stage therapeutic strategy, the ACM was first resected using an endoscopic mini-pterional approach, then the PitNET was removed with an endoscopic transnasal approach 8 weeks later, leading to significant improvement in visual function. The authors' literature search identified only 2 documented cases of a similar collision.

LESSONS

This case underscores the complexity of the decision-making process in the management of collision tumors and suggests the potential benefit of staged minimally invasive surgical interventions in preserving visual function. Further accumulation of cases is warranted for refining the treatment strategy. https://thejns.org/doi/10.3171/CASE24240.

Expression analysis of necroptosis related genes and lncRNAs in patients with pituitary neuroendocrine tumors

Necroptosis can either be the cause of tumorigenesis or it can impede its process. Recently, it has been proved that long non-coding RNAs (lncRNAs) have different crucial roles at cellular level, especially on cell death. Regarding the important role of necroptosis and lncRNAs in the pathogenesis of different cancers, especially pituitary adenomas (PAs), we assessed expression levels of two necroptosis related genes, namely TRADD and BIRC2, in addition to three related lncRNAs, namely FLVCR1-DT, MAGI2-AS3, and NEAT1 in PAs compared with adjacent normal tissues (ANTs). TRADD had no significant difference between two groups; however, BIRC2, FLVCR1-DT, MAGI2-AS3, and NEAT1 were upregulated in PAs compared to ANTs (Expression ratios [95% CI] = 2.3 [1.47-3.6], 2.13 [1.02-4.44], 3.01 [1.76-5.16] and 2.47 [1.37-4.45], respectively). When taking into account different types of PAs, significant upregulation of BIRC2, MAGI2-AS3 and NEAT1 was recorded in non-functioning PAs compared with corresponding ANTs (Expression ratios [95% CI] =1.9 [1.04-3.43], 2.69 [1.26-5.72] and 2.22 [0.98-5.01], respectively). Additionally, higher levels of BIRC2 were associated with higher flow of CSF (P value=0.048). Moreover, higher Knosp classified tumors had lower levels of BIRC2 (P value=0.001). Finally, lower levels of MAGI2-AS3 were associated with larger tumor size (P value=0.006). NEAT1 expression was correlated with FLVCR1-DT and TRADD. TRADD expression was correlated with FLVCR1-DT. Additional correlation was observed between expression of BIRC2 and MAGI2-AS3. In sum, this study provides evidence that dysregulated levels of studied genes could contribute to the pathogenesis of pituitary tumors.

Does New WHO 2022 Nomenclature of Pituitary Neuroendocrine Tumors Offer an Extra Edge to the Neurosurgeons for Its Management? A Narrative Review

The new World Health Organization nomenclature of pituitary tumors was introduced in the year 2022 after much deliberation. This nomenclature clearly demarcates the anterior lobe (adenohypophyseal), posterior lobe (neurohypophyseal), and hypothalamic tumors. There is also focus on other tumors arising in the sellar region. The nomenclature has also advocated the routine use of immunohistochemistry in describing the pituitary transcription factors that plays a fundamental role in distinguishing the cell lineage of these tumors. However, the nomenclature is complex in understanding due to inclusion of pathological correlates like transcription factors, hormones, biomarkers, and various controversies that have emerged regarding the renaming of pituitary adenomas (PA) as PiTNETs ("Pituitary Neuroendocrine tumors") because majority of the adenomas are benign and have rare metastatic behavior while classifying them as PiTNETs will create unnecessary misinterpretation of these as aggressive tumors that will lead to apprehension among the patients. The new classification gives deeper insight into the histological picture of the various pituitary tumors but other than contributing to the follow-up strategy and postsurgery management, this classification does not add anything new that could be advantageous for the neurosurgeons in clinical practice and decision making, especially in deciding the plan of action for surgery. Hence, there is need of a more comprehensive, integrated, neuroradiological-based classification with more emphasis on the invasiveness of these tumors that would assist the neurosurgeons in planning the treatment strategy and managing patients of pituitary tumors.

Personalized Management of Malignant and Non-Malignant Ectopic Mediastinal Thyroid: A Proposed 10-Item Algorithm Approach

We aimed to analyze the management of the ectopic mediastinal thyroid (EMT) with respect to EMT-related cancer and non-malignant findings related to the pathological report, clinical presentation, imaging traits, endocrine profile, connective tissue to the cervical (eutopic) thyroid gland, biopsy or fine needle aspiration (FNA) results, surgical techniques and post-operatory outcome. This was a comprehensive review based on revising any type of freely PubMed-accessible English, full-length original papers including the keywords "ectopic thyroid" and "mediastinum" from inception until March 2024. We included 89 original articles that specified EMTs data. We classified them into four main groups: (I) studies/case series (n = 10; N = 36 EMT patients); (II) malignant EMTs (N = 22 subjects; except for one newborn with immature teratoma in the EMT, only adults were reported; mean age of 62.94 years; ranges: 34 to 90 years; female to male ratio of 0.9). Histological analysis in adults showed the following: papillary (N = 11/21); follicular variant of the papillary type (N = 2/21); Hürthle cell thyroid follicular malignancy (N = 1/21); poorly differentiated (N = 1/21); anaplastic (N = 2/21); medullary (N = 1/21); lymphoma (N = 2/21); and MALT (mucosa-associated lymphoid tissue) (N = 1/21); (III) benign EMTs with no thyroid anomalies (N = 37 subjects; mean age of 56.32 years; ranges: 30 to 80 years; female to male ratio of 1.8); (IV) benign EMTs with thyroid anomalies (N = 23; female to male ratio of 5.6; average age of 52.1 years). This panel involved clinical/subclinical hypothyroidism (iatrogenic, congenital, thyroiditis-induced, and transitory type upon EMT removal); thyrotoxicosis (including autonomous activity in EMTs that suppressed eutopic gland); autoimmune thyroiditis/Graves's disease; nodules/multinodular goiter and cancer in eutopic thyroid or prior thyroidectomy (before EMT detection). We propose a 10-item algorithm that might help navigate through the EMT domain. To conclude, across this focused-sample analysis (to our knowledge, the largest of its kind) of EMTs, the EMT clinical index of suspicion remains low; a higher rate of cancer is reported than prior data (18.8%), incident imagery-based detection was found in 10-14% of the EMTs; surgery offered an overall good outcome. A wide range of imagery, biopsy/FNA and surgical procedures is part of an otherwise complex personalized management.

Predicting the Consistency of Pituitary Macroadenomas: The Utility of Diffusion-Weighted Imaging and Apparent Diffusion Coefficient Measurements for Surgical Planning

Understanding the consistency of pituitary macroadenomas is crucial for neurosurgeons planning surgery. This retrospective study aimed to evaluate the utility of diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) as non-invasive imaging modalities for predicting the consistency of pituitary macroadenomas. This could contribute to appropriate surgical planning and therefore reduce the likelihood of incomplete resections. The study included 45 patients with pathologically confirmed pituitary macroadenomas. Conventional MRI sequences, DWIs, ADC maps, and pre- and post-contrast MRIs were performed. Two neuroradiologists assessed all of the images. Neurosurgeons assessed the consistency of the tumor macroscopically, and histopathologists examined it microscopically. The MRI findings were compared with postoperative data. According to the operative data, macroadenomas were divided into the two following categories based on their consistency: aspirable (n = 27) and non-aspirable tumors (n = 18). A statistically significant difference in DWI findings was found when comparing macroadenomas of different consistencies (p < 0.001). Most aspirable macroadenomas (66.7%) were hyperintense according to DWI and hypointense on ADC maps, whereas most non-aspirable macroadenomas (83.3%) were hypointense for DWI and hyperintense on ADC maps. At a cut-off value of 0.63 × 10-3 mm2/s, the ADC showed a sensitivity of 85.7% and a specificity of 75% for the detection of non-aspirable macroadenomas (AUC, 0.946). The study concluded that DWI should be routinely performed in conjunction with ADC measurements in the preoperative evaluation of pituitary macroadenomas. This approach may aid in surgical planning, ensure that appropriate techniques are utilized, and reduce the risk of incomplete resection.

Profiling of Unfolded Protein Response Markers and Effect of IRE1α-specific Inhibitor in Pituitary Neuroendocrine Tumor

CONTEXT

Inositol-requiring enzyme 1α (IRE1α) and PKR-like ER kinase (PERK), which are endoplasmic reticulum (ER) membrane proteins, regulate the unfolded protein response (UPR). These molecules have recently gained attention as a novel therapeutic target in secretory tumors. The roles of the UPR in pituitary neuroendocrine tumors (PitNETs) are unclear.

OBJECTIVE

To clarify UPR profiling of PitNETs and to investigate the effect of pharmacological modulation of UPR by KIRA8, a newly developed IRE1α-specific inhibitor.

METHODS

In 131 patients with PitNETs, we evaluated RNA expression of UPR markers in PitNETs and their clinical phenotypes. Using GH3 cells, we examined the effects of KIRA8 and its combination with octreotide on UPR profiling, cell growth, and apoptosis.

RESULTS

Cytoprotective adaptive-UPR (A-UPR) markers were more increased in functioning PitNETs (FPitNETs, n = 112) than in nonfunctioning PitNETs (NFPitNETs, n = 19), while there was no difference in proapoptotic terminal-UPR (T-UPR) markers. Similarly, overt somatotroph tumors (STs, acromegaly, n = 11) increased A-UPR compared with silent STs (n = 10). In STs, serum IGF-1 levels were inversely correlated with Txnip mRNA expression, a representative T-UPR marker. KIRA8 inhibited cell growth and facilitated apoptosis in GH3 cells with increased expressions of T-UPR markers, which was enhanced by the combination with octreotide. Octreotide increased mRNA expression of Txnip and Chop, but decreased spliced Xbp1 under ER stress. Octreotide is suggested to inhibit activation of IRE1α but to reciprocally induce T-UPR under PERK.

CONCLUSION

UPR markers in FPitNETs are implicated as dominant A-UPR but blunted T-UPR. KIRA8, enhanced with octreotide, unbalances the UPR, leading to antitumor effects. Targeting IRE1α may provide a novel strategy to treat PitNETs.

[Unification of pathomorphological examination of patients with neuroendocrine tumors of the pituitary gland. Controversial issues of the new classification]

The progressive improvement of the classification using modern analytical methods is an essential tool for the development of precise and personalized approaches to the treatment of pituitary adenomas. In recent years, endocrinologists have witnessed evolutionary changes that have occurred in the histopathological identification of pituitary neoplasms, revealing new possibilities for studying tumorigenesis and predicting biological behavior.The paper considers the historical aspects of the gradual improvement of the classification of pituitary adenomas, as well as the new international 2022 WHO classification, according to which pituitary adenomas are included in the list of neuroendocrine tumors (PitNETs) to reflect the biological aggressiveness of some non-metastatic pituitary adenomas. The characteristics of pituitary adenoma are presented, as well as a list of histological subtypes of aggressive neuroendocrine tumors of the pituitary gland, marked by the main potentials for invasive growth, an increased risk of recurrence and a negative clinical prognosis.The expediency of changing the definition of «pituitary adenoma» to «neuroendocrine tumor» is discussed. It is emphasized that the introduction of a unified clinical, laboratory and morphological protocol into national clinical practice will help provide comparable comparative studies on the prognosis of the disease and the effectiveness of secondary therapy and also contribute to adequate management of potentially aggressive PitNETs.

Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: Clinical recommendations on the perioperative management of pituitary tumors

Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7%-14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.

Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: clinical recommendations on the perioperative management of pituitary tumors

Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7-14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.

Aggressive pituitary tumors (PitNETs)

The majority of anterior pituitary tumors behave benignly, that is, they grow slowly and do not metastasize, and were therefore called adenomas. However, they would frequently invade adjacent structures, leading to recurrence. One of the misleading assumptions in their previous classification was the simplistic distinction made between adenoma and carcinoma. In the upcoming WHO 2022 classification, a new terminology will be introduced: pituitary neuroendocrine tumor (PitNET) which is consistent with that used for other neuroendocrine neoplasms. In general, aggressive PitNETs are invasive and proliferative tumors with frequent recurrences, resistant to conventional treatments, and yet virtually without metastases. At present, no single morphological or histological marker has been shown as yet to reliably predict their aggressive behavior. In terms of treatment, temozolomide (TMZ) had been considered promising and the sole therapeutic option for aggressive and malignant PitNETs following failure of standard therapies. However, recent reports have disclosed that TMZ does not provide long-term control of many aggressive PitNETs. A further multidisciplinary approach is necessary for both reliable prediction and successful management of aggressive PitNETs.

Single Cell Metabolic Landscape of Pituitary Neuroendocrine Tumor Subgroups and Lineages

Pituitary neuroendocrine tumors (PitNETs) are common intracranial tumors comprising numerous subtypes whose metabolic profiles have yet to be fully examined. The present <em>in silico</em> study analyzed single-cell expression profiles from 2311 PitNET cells from various lineages and subtypes to elucidate differences in metabolic activities. Gonadotroph tumors exhibited high activities with histidine metabolism, whose activity is low in lactotroph tumors. Somatotroph tumors enriched for sulfur and tyrosine metabolism, while lactotroph tumors were enriched metabolism of nitrogen, ascorbate, and aldarate. PIT-1 lineage tumors exhibited high sulfur and thiamine metabolism. These results set precedence for further translational studies for subgroup/lineage specific targeted therapies.

Classifying Pituitary Adenoma Invasiveness Based on Radiological, Surgical and Histological Features: A Retrospective Assessment of 903 Cases

Invasiveness is a major predictor of surgical outcome and long-term prognosis in patients with pituitary adenomas (PAs). We assessed PA invasiveness via radiological, surgical and histological perspectives to establish a classification scheme for predicting invasive behavior and poor prognosis. We retrospectively analyzed 903 patients who underwent transnasal-transsphenoidal surgery between January 2013 and December 2019. Radiological (hazard ratio (HR) 5.11, 95% confidence interval (CI): 3.98−6.57, p < 0.001) and surgical (HR 6.40, 95% CI: 5.09−8.06, p < 0.001) invasiveness better predicted gross-total resection (GTR) and recurrence/progression-free survival (RPFS) rates than did histological invasiveness (HR 1.44, 95% CI: 1.14−1.81, p = 0.003). Knosp grades 2 (HR 4.63, 95% CI: 2.13−10.06, p < 0.001) and 3 (HR 2.23, 95% CI: 1.39−3.59, p = 0.011) with surgical invasiveness were better predictors of prognosis than corresponding Knosp grades without surgical invasiveness. Classifications 1 and 2 were established based on radiological, surgical and histological invasiveness, and Knosp classification and surgical invasiveness, respectively. Classification 2 predicted RPFS better than Knosp classification and Classification 1. Overall, radiological and surgical invasiveness were clinically valuable as prognostic predictors. The convenience and good accuracy of Invasiveness in Classification 2 is useful for identifying invasive PAs and facilitating the development of treatment plans.

The Application of Artificial Intelligence and Machine Learning in Pituitary Adenomas

Pituitary adenomas (PAs) are a group of tumors with complex and heterogeneous clinical manifestations. Early accurate diagnosis, individualized management, and precise prediction of the treatment response and prognosis of patients with PA are urgently needed. Artificial intelligence (AI) and machine learning (ML) have garnered increasing attention to quantitatively analyze complex medical data to improve individualized care for patients with PAs. Therefore, we critically examined the current use of AI and ML in the management of patients with PAs, and we propose improvements for future uses of AI and ML in patients with PAs. AI and ML can automatically extract many quantitative features based on massive medical data; moreover, related diagnosis and prediction models can be developed through quantitative analysis. Previous studies have suggested that AI and ML have wide applications in early accurate diagnosis; individualized treatment; predicting the response to treatments, including surgery, medications, and radiotherapy; and predicting the outcomes of patients with PAs. In addition, facial imaging-based AI and ML, pathological picture-based AI and ML, and surgical microscopic video-based AI and ML have also been reported to be useful in assisting the management of patients with PAs. In conclusion, the current use of AI and ML models has the potential to assist doctors and patients in making crucial surgical decisions by providing an accurate diagnosis, response to treatment, and prognosis of PAs. These AI and ML models can improve the quality and safety of medical services for patients with PAs and reduce the complication rates of neurosurgery. Further work is needed to obtain more reliable algorithms with high accuracy, sensitivity, and specificity for the management of PA patients.

Molecular Pathways in Prolactinomas: Translational and Therapeutic Implications

Prolactinoma has the highest incidence rate among patients with functional pituitary tumours. Although mostly benign, there is a subgroup that can be aggressive. Some clinical, radiological and pathology features have been associated with a poor prognostic. Therefore, it can be considered as a group of heterogeneous tumours. The aim of this paper is to give an overview of the molecular pathways involved in the behaviour of prolactinoma in order to improve our approach and gain deeper insight into the better understanding of tumour development and its management. This is essential for identifying patients harbouring aggressive prolactinoma and to establish personalised therapeutics options.

Dealing With Brain MRI Findings in Pediatric Patients With Endocrinological Conditions: Less Is More?

Neuroimaging is a key tool in the diagnostic process of various clinical conditions, especially in pediatric endocrinology. Thanks to continuous and remarkable technological developments, magnetic resonance imaging can precisely characterize numerous structural brain anomalies, including the pituitary gland and hypothalamus. Sometimes the use of radiological exams might become excessive and even disproportionate to the patients' medical needs, especially regarding the incidental findings, the so-called "incidentalomas". This unclarity is due to the absence of well-defined pediatric guidelines for managing and following these radiological findings. We review and summarize some indications on how to, and even if to, monitor these anomalies over time to avoid unnecessary, expensive, and time-consuming investigations and to encourage a more appropriate follow-up of brain MRI anomalies in the pediatric population with endocrinological conditions.