title: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Residual or Recurrent Nonfunctioning Pituitary Adenomas.
abstract: Despite the advancement of microsurgical and endoscopic techniques, some nonfunctioning pituitary adenomas (NFPAs) can be difficult to cure. Tumor recurrence or incomplete resection may occur in some patients with NFPAs, and management strategies for these NFPAs remain unclear.
  
  
  
  To review the existing literature as it pertains to the management of postsurgical residual or recurrent NFPAs.
  
  
  
  A systematic review of the treatment options for residual or recurrent NFPAs was performed. In this review, the authors critically evaluated the evidence to support the options of repeat microsurgical resection, stereotactic radiosurgery (SRS), stereotactic radiotherapy (SRT), and fractionated radiation therapy (XRT).
  
  
  
  Forty-nine studies met the inclusion criteria for analysis: outcome of repeat surgical resection (n = 4), radiosurgery (ie, single-session or hypofractionated SRS; n = 24), or fractionated radiotherapy (ie, conventional XRT, proton beam radiotherapy, intensity-modulated radiotherapy, SRT; n = 21). No class I evidence was available; 6 studies met criteria for class II evidence; and other studies provided class III evidence. A meta-analysis of 5 class II studies with recurrence rates for both adjuvant radiation therapy and observation demonstrated that XRT for residual/recurrent NFPAs offered a lower rate of recurrence (odds ratio = 0.04; 95% confidence interval, 0.01-0.20; P < .001). The analysis also demonstrated significant heterogeneity between the included studies (χ = 20.70; P = .003; I = 81%).
  
  
  
  Repeat resection, SRS, SRT, and XRT play a role in the management of patients with recurrent or residual NFPAs. SRS or some type of radiation therapy is typically performed for patients with residual tumor or tumor recurrence after resection. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_7.
  
  
  
  NFPA, nonfunctioning pituitary adenomaSRS, stereotactic radiosurgerySRT, stereotactic radiotherapyXRT, fractionated radiation therapy.
authors.affiliation: *Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia; ‡Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; §Barrow Neurological Institute, Phoenix, Arizona; ¶Department of Neurosurgery, Emory University, Atlanta, Georgia; ‖Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California; #Department of Neurosurgery, George Washington University, Washington, DC; **Department of Neurological Surgery, University of Southern California, Los Angeles, Los Angeles, California; ‡‡Department of Neurosurgery, University of California, San Francisco, San Francisco, California.
authors.forename: Jason
authors.initials: J
authors.lastname: Sheehan
authors.forename: Cheng-Chia
authors.initials: CC
authors.lastname: Lee
authors.forename: Mary E
authors.initials: ME
authors.lastname: Bodach
authors.forename: Luis M
authors.initials: LM
authors.lastname: Tumialan
authors.forename: Nelson M
authors.initials: NM
authors.lastname: Oyesiku
authors.forename: Chirag G
authors.initials: CG
authors.lastname: Patil
authors.forename: Zachary
authors.initials: Z
authors.lastname: Litvack
authors.forename: Gabriel
authors.initials: G
authors.lastname: Zada
authors.forename: Manish K
authors.initials: MK
authors.lastname: Aghi
mesh_terms: D000236:Adenoma / Q000628:therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D009364:Neoplasm Recurrence, Local / Q000628:therapy*; D018365:Neoplasm, Residual / Q000628:therapy*; D010911:Pituitary Neoplasms / Q000628:therapy*; D050397:Radiotherapy, Intensity-Modulated; D016896:Treatment Outcome