Pituitary Incidentalomas are Different in an Oncology Setting 

Pituitary Incidentalomas are Different in an Oncology Setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pituitary Incidentalomas are Different in an Oncology Setting Sara Gil-Santos, Raquel Calheiros, Joana Oliveira, Ana Paula Santos, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6522010/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Pituitary incidentalomas (PIs) are pituitary lesions identified on imaging performed for unrelated reasons. Although well described in the general population, data on PIs in cancer patients remain scarce. We aimed to describe the etiology, clinical presentation, and follow-up of PIs in an oncological setting. Methods: We conducted a retrospective observational study of all CT and MRI reports containing the terms “sella(r)”, “pituitary” or “hypophysis” between September 2008 and September 2021 in our cancer center. Data on imaging, pituitary function, and outcomes were collected and analyzed. Results: Forty-three patients (7.5%) had a PI on imaging exam. Complaints of headache (25.6%) and previously known non-pituitary lesions (25.6%) lead to most imaging requests. Adenomas were the most frequent diagnosis (55.8%), followed by pituitary metastases (18.6%), mostly found in patients with breast cancer. Patients with metastasis had larger lesions (p=0.017) and were more frequently diagnosed with hypopituitarism (p<0.001), when compared to adenomas. Malignant pituitary involvement was associated with a higher mortality at 3 months (OR 3.1; p=0.025). Conclusion: In our oncology center, we reported a higher prevalence of metastasis, with higher rates of hypopituitarism, when compared to benign lesions. Symptoms typically attributed to malignancy may conceal an underlying pituitary hormonal dysfunction, emphasizing the need for systematic endocrine evaluation. Awareness of these patterns may help in the development of tailored diagnostic and management strategies in this population. pituitary incidentaloma cancer pituitary metastasis Introduction A pituitary incidentaloma (PI) is a previously unsuspected pituitary lesion detected on an imaging exam performed for reasons other than its evaluation. This excludes patients submitted to imaging techniques for symptoms attributable to the lesion, whether it be from mass effect or hormone dysfunction [ 1 ]. Incidence of PIs discovered on imaging exams varies wildly among different series (0.073-38,5%) [ 2 ], with reports indicating an increase in recent years, as a result of technological advances [ 3 , 4 ]. A large meta-analysis of autopsy studies, which included 18.902 patients, described an incidence of PIs of 10.7% (1.5–31%) [ 4 ]. Furthermore, as most patients don´t undergo surgery, definitive histological diagnosis of most PIs remains unknown [ 1 ]. According to available data, up to 90% of PIs in adults are adenomas, followed by other less common solid tumors, mostly craniopharyngiomas, and cystic lesions [ 4 ]. The most frequent reason for their detection is, in most cases, unrelated headache [ 2 , 4 ]. According to Esteves et al., in a study of 68 patients with PIs in a general tertiary hospital, 25% presented with hypopituitarism and 8.8% with hormonal hypersecretion, mostly hyperprolactinemia. Of the 29.4% of patients submitted to surgery, the most frequent diagnosis was gonadotroph cell adenoma (45%). Studies on PIs in cancer patients are scarce [ 5 ] and, based in our clinical practice, we hypothesize that there may be differences in their etiological distribution when compared to the general population. Understanding those differences may lead to the creation of specific diagnostic and surveillance protocols in this setting. Our aim was to describe incidentally discovered pituitary lesions, the reasons that led to their detection, and their follow-up in an Oncology Center. Materials and Methods We present an observational, retrospective study. We searched the Neuroradiology department database for the terms “sela(r)”, “pituitary” and “hypophysis” in every CT and MRI reports written between September 2008 and September 2021. An incidentaloma was defined as a pituitary lesion detected in an imaging exam performed for unrelated reasons, as stated by the Endocrine Society guidelines [ 1 ]. We excluded imaging exams describing an empty sella turca , unclear lesions or lesions that were unconfirmed in subsequent exams, as well as patients whose reason for the exam wasn´t clear in their medical records. Data regarding demographics, clinical presentation, analytical and imaging evaluation, and follow-up of 574 patients were reviewed. Three of the patients were children and their data was excluded from the analysis. Hormonal dysfunction was determined based on laboratory results or medical record statements. Evaluation by the Endocrinology Department usually leads to hormonal basal measurements, which include ACTH, morning cortisol, IGF1, LH, FSH, estradiol/total testosterone, TSH and free T4 levels. When the lesions affected the neurohypophysis, serum sodium and serum/urinary osmolality were requested. Variation in size was defined by an increase or decrease in lesion size of at least 1mm in any axis. Incidence of death 3 months after incidentaloma diagnosis was recorded. Statistical analysis was made using IBM SPSS Statistics 27.0©. Categorical variables were expressed as frequencies and percentages and continuous variables as mean ± standard deviation or median (interquartile range), depending on their distribution. Chi-square and parametric or non-parametric tests, depending on the variable’s distribution, were used for group comparison, when appropriate. We performed a logistic regression analysis to investigate the association between PI diagnosis and age, sex, size and death 3 months after diagnosis. Statistical significance was considered for a p value < 0.05. Results A total of 43 patients (7.5%) had a PI on imaging exam and their baseline characteristics are shown in table 1. The most frequent reasons for imaging exam requests were headache (11; 25.6%) and evaluation of a previously known non-pituitary lesion (11; 25.6%) (table 2.). Most lesions were detected by MRI (67.4%) and the remaining ones by CT scan. Table 3 sums up the imagological etiology of the included PIs. The most frequently found lesion were adenomas (24 patients; 55.8%), 17 (70.8%) of which were microadenomas. Eight patients (18.6%) presented with previously unknown pituitary metastatic disease, most of which had breast cancer (table 4). Headache was the most common reason for imaging exam request (37.5%) in this group. Metastatic lesions [22(28) mm] were significantly larger than adenomas [8 (7.6) mm] (p=0.017) (table 5). Nine patients had no record of pituitary function evaluation. Among the remaining 34, 7 (20.6%) had only their thyroid axis evaluated, and 1 (2.9%) only their gonadal axis, which were requested for other reasons during follow-up. Overall, anterior pituitary hypofunction was detected in 9/27 (33.3%) patients. Gonadotropin deficiency was present in 9/28 (32.4%), ACTH deficiency in 5/24 (20.8%) and TSH deficiency in 7/33 (21.2%). IGF1 levels were low in 3/26 (11.5%) patients. No patients presented with hormonal hypersecretion. The diagnosis of macroadenoma was associated with a higher prevalence of hypopituitarism, when compared to microadenoma (p=0.013). Hypopituitarism was even more frequent in patients diagnosed with metastases, when compared to adenomas (p<0.001) and this difference was still significant when compared to macroadenomas only (p=0.064). Among those with metastatic disease and pituitary function evaluation, 5/5 (100.0%) had gonadotropin deficiency, 4/5 (80.0%) had ACTH and TSH deficiency, 2/5 (40.0%) had low IGF1 levels and 2/8 (25.0%) had antidiuretic hormone (ADH) deficiency. Among the 9 patients that underwent formal visual field testing, only 1 patient, who was diagnosed with metastatic disease, presented with abnormalities. Regarding treatment, 1 patient with macroadenoma underwent surgery and another with suspected meningioma was submitted to fractionated stereotactic radiotherapy. Of the 8 patients with pituitary malignant involvement, 2 patients with breast cancer underwent chemotherapy, with lesion size reduction, and the remaining 6 underwent no further treatment and died shortly after diagnosis. Seven out of 8 (87.5%) passed away during follow up, after a median of 2 (9) months after the incidentaloma diagnosis. Overall, 22 patients managed conservatively had an imaging reevaluation. Among the macroincidentalomas (n=7), after a follow up of 26 (14) months, 2 had a size reduction (1 undetermined cystic lesion and 1 macroadenoma) and 5 had no size variation. In the microincidentalomas group (n=15) 2 microadenomas increased in size and 13 had no size variation after 39 (71) months or surveillance. Those with metastases presented a higher death incidence 3 months after diagnosis, when compared with all other incidentalomas (p=0.003). A logistic regression showed a higher likelihood of death in patients with metastases (OR 3.1, p=0.025), compared with other incidentalomas, regardless of sex, age and size. Discussion Our study shows that pituitary incidentalomas found in the oncological setting seem to be different when compared to data published regarding the general population. First of all, we found a slightly higher prevalence of pituitary lesions than other cohorts. We also report a greater proportion of incidentalomas found during the investigation of a previously known lesion of the central nervous system (CNS) when compared to the investigation of patient complaints, which is usually more common [ 4 , 6 – 8 ]. These two facts are probably related to the high number of imaging studies performed by patients with cancer. Data on pituitary metastases discovered incidentally is scarce [ 2 , 5 , 9 ]. Autopsy series have reported pituitary malignant involvement in 1-3.6% of patients with a known cancer diagnosis [ 9 ]. Famini et al. [ 9 ] described 1.8% of incidentalomas as secondary to malignant involvement (5/282 patients). In our study, we report a considerably higher prevalence of 18.6%, when compared to other series [ 6 , 7 , 9 , 10 ], which could be explained by the higher likelihood of pituitary malignant involvement in an oncology setting. Breast cancer is the most common malignancy to metastasize to the pituitary gland [ 11 , 12 ], and it was responsible for the majority of cases in our study too. Some authors have hypothesized that the prolactin rich environment of the pituitary gland may facilitate breast tumor cells proliferation [ 13 ]. In our series, there was a considerable number of patients with no pituitary function evaluation (20.9%) when compared to what is usually described: 6.8%-8.8% [ 6 , 10 ]. Nevertheless, we report a prevalence of hypopituitarism similar to previous case series (19.7%-37%), which underlines the importance of a hormonal work-up in this setting [ 6 , 7 , 10 , 15 ]. Many of these PIs were discovered and overlooked by other specialties, and systemic complications of malignancy, including nonspecific symptoms, such as weakness and vomiting, may have masked an undiagnosed hypopituitarism [ 13 ]. Anterior pituitary hormone deficiency is more severe in patients with pituitary metastases than in those with adenomas, as we also demonstrated, which may be partially attributed to a their bigger size and the more pronounced process of pituitary ischemic necrosis secondary to obstruction of blood flow through portal vessels in these cases [ 14 ]. The lack of direct arterial blood supply to the anterior lobe of the pituitary explains the predilection for the posterior lobe in the metastatic process. This explains why diabete s insipidus (DI) is the most common symptom associated with pituitary metastases [ 13 ]. Although we reported DI in only 25% of patients, we also described ACTH deficiency in 80%, which can mask the presence of DI [ 13 ]. We have found a lower rate of surgically approached patients (only 1 patient prompted by visual disturbances), contrasting with previous reports [ 6 , 8 , 10 , 15 ]. The lower surgical rates in our series may be attributed to several factors, the most determinant ones being the prevalence of metastases treated with systemic treatment and the lack of surgical benefit in patients with a bad prognosis and short life expectancy. With this study, we aimed to respond to the lack of reports in literature of PIs in the oncology setting. In this specific group of patients, we have to be aware that symptoms frequently attributed to malignancy could mask the presence of hypopituitarism. Underdiagnosing these hormonal deficiencies can further negatively impact patients’ prognosis and quality of live. Considering the higher rates of hypopituitarism caused by metastases we have found herein, when compared to other series, evaluation by an endocrinologist is essential for appropriate management. Diagnosis of diabetes insipidus in cancer patients should always raise suspicion for pituitary metastases. Declarations Ethics approval This study protocol was reviewed and approved by the Department of Data Protection and the Ethics Committee for Health of the Portuguese Institute of Oncology of Porto. Conflict of Interest Statement The authors have no conflicts of interest to declare. Funding Sources This study was not supported by any sponsor or funder. Author Contributions Sara Gil Santos was responsible for the conception and design of the work, acquisition, analysis and interpretation of data, drafting the work and final approval. Raquel Calheiros aided in the analysis and interpretation of data, critical review of the manuscript and final approval. Joana Oliveira contributed to the conception, critical review and final approval of the manuscript. Ana Paula Santos contributed to the conception, critical review and final approval of the manuscript. Pedro Souteiro was responsible for the conception and design of the work, critical review of the manuscript and final approval. Data Availability Statement All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author. References Freda, P.U., et al., Pituitary incidentaloma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab, 2011. 96 (4): p. 894-904. Tahara, S., et al., An Overview of Pituitary Incidentalomas: Diagnosis, Clinical Features, and Management. Cancers (Basel), 2022. 14 (17). Giraldi, E., J.W. Allen, and A.G. Ioachimescu, Pituitary Incidentalomas: Best Practices and Looking Ahead. Endocr Pract, 2023. 29 (1): p. 60-68. Vasilev, V., et al., MANAGEMENT OF ENDOCRINE DISEASE: Pituitary 'incidentaloma': neuroradiological assessment and differential diagnosis. Eur J Endocrinol, 2016. 175 (4): p. R171-84. Jeong, S.Y., et al., Incidental pituitary uptake on whole-body 18F-FDG PET/CT: a multicentre study. Eur J Nucl Med Mol Imaging, 2010. 37 (12): p. 2334-43. Esteves, C., et al., Pituitary incidentalomas: analysis of a neuroradiological cohort. Pituitary, 2015. 18 (6): p. 777-81. Ishii, K., et al., Clinical investigation of pituitary incidentalomas: A two-center study. Intractable Rare Dis Res, 2019. 8 (4): p. 239-244. Anagnostis, P., et al., Pituitary incidentalomas: a single-centre experience. Int J Clin Pract, 2011. 65 (2): p. 172-7. Famini, P., M.M. Maya, and S. Melmed, Pituitary magnetic resonance imaging for sellar and parasellar masses: ten-year experience in 2598 patients. J Clin Endocrinol Metab, 2011. 96 (6): p. 1633-41. Vaninetti, N.M., et al., A comparative, population-based analysis of pituitary incidentalomas vs clinically manifesting sellar masses. Endocr Connect, 2018. 7 (5): p. 768-776. Javanbakht, A., et al., Pituitary metastasis: a rare condition. Endocr Connect, 2018. 7 (10): p. 1049-57. Schill, F., et al., Pituitary Metastases: A Nationwide Study on Current Characteristics With Special Reference to Breast Cancer. The Journal of Clinical Endocrinology & Metabolism, 2019. 104 (8): p. 3379-3388. Komninos, J., et al., Tumors metastatic to the pituitary gland: case report and literature review. J Clin Endocrinol Metab, 2004. 89 (2): p. 574-80. Al-Aridi, R., et al., Clinical and biochemical characteristic features of metastatic cancer to the sella turcica: an analytical review. Pituitary, 2014. 17 (6): p. 575-87. Damilano, R.A., et al., [Clinical and evolutionary characteristics of incidental pituitary adenomas: retrospective multicenter study]. Medicina (B Aires), 2023. 83 (4): p. 514-521. Tables Table 1 Population characteristics. n=43 Age (years) - mean±SD 57.8±14.7 Sex Male - n (%) 17 (39.5) Female – n (%) 26 (60.5) Table 2 Reasons for MRI or CT request. n (%) Headache 11 (25.6) Evaluation of a previously known non-pituitary lesion 11 (25.6) Focal neurological signs 7 (16.3) Tumor staging 4 (9.3) Dementia/behavioral disturbance/altered mental state 4 (9.3) Vertigo/tinnitus 3 (7.0) Visual disturbances not related to the tumor 1 (2.3) Trauma 1 (2.3) Other 1 (2.3) Total 43 (100) Table 3 Imaging diagnosis of pituitary incidentaloma. n (%) Adenoma Microadenoma 17 (39.5) Macroadenoma 7 (16.3) Metastasis 8 (18.6) Hyperplasia 3 (7.0) Rathke’s cleft cyst 3 (7.0) Undetermined cystic lesion 3 (7.0) Meningioma 2 (4.6) Total 43 (100) Table 4 Cancer diagnosis of patients with pituitary metastases. n (%) Breast 5 (62.5) Lung 1 (12.5) Liver 1 (12.5) Pharynx 1 (12.5) Total 8 (100) Table 5 Characteristics of patients with adenomas and metastases. Adenomas Metastases p values Sex 0.519 Female – (%) 15 (62.5) 6 (75) Male – (%) 6 (37.5) 2 (25) Age (years) – mean±SD 53.71 ±16.3 63.5 ± 8.6 0.117 Lesion size (mm) – median (IQR) 8 (7.6) 22 (28.0) 0.017 Prevalence of hypopituitarism <0.001 Yes 16 (84.2) 0 (0) No 3 (15.8) 5 (100.0) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6522010","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451247229,"identity":"2c3c820a-85ab-4f36-b7c6-3e4765c90cf1","order_by":0,"name":"Sara Gil-Santos","email":"data:image/png;base64,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","orcid":"","institution":"Portuguese Institute of Oncology of Porto","correspondingAuthor":true,"prefix":"","firstName":"Sara","middleName":"","lastName":"Gil-Santos","suffix":""},{"id":451247230,"identity":"85b62bc0-28b9-41b4-b062-e6fb81fb18ee","order_by":1,"name":"Raquel Calheiros","email":"","orcid":"","institution":"Portuguese Institute of Oncology of Porto","correspondingAuthor":false,"prefix":"","firstName":"Raquel","middleName":"","lastName":"Calheiros","suffix":""},{"id":451247231,"identity":"edc5a6d3-fc35-4d42-abbc-712656da923b","order_by":2,"name":"Joana Oliveira","email":"","orcid":"","institution":"Portuguese Institute of Oncology of Porto","correspondingAuthor":false,"prefix":"","firstName":"Joana","middleName":"","lastName":"Oliveira","suffix":""},{"id":451247232,"identity":"f79502ac-c6a4-4f9f-88cb-de8cb2eda46d","order_by":3,"name":"Ana Paula Santos","email":"","orcid":"","institution":"Portuguese Institute of Oncology of Porto","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Paula","lastName":"Santos","suffix":""},{"id":451247233,"identity":"23ed23b2-2b92-49fd-980b-b8a2e750f9ea","order_by":4,"name":"Pedro Souteiro","email":"","orcid":"","institution":"Portuguese Institute of Oncology of Porto","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"","lastName":"Souteiro","suffix":""}],"badges":[],"createdAt":"2025-04-24 15:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6522010/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6522010/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82954201,"identity":"b9f1af1d-029f-48af-90fc-7488815c69af","added_by":"auto","created_at":"2025-05-17 13:16:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":422456,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6522010/v1/b620c8a2-145c-4fcf-8087-3e5800c61027.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pituitary Incidentalomas are Different in an Oncology Setting ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eA pituitary incidentaloma (PI) is a previously unsuspected pituitary lesion detected on an imaging exam performed for reasons other than its evaluation. This excludes patients submitted to imaging techniques for symptoms attributable to the lesion, whether it be from mass effect or hormone dysfunction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIncidence of PIs discovered on imaging exams varies wildly among different series (0.073-38,5%) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], with reports indicating an increase in recent years, as a result of technological advances [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A large meta-analysis of autopsy studies, which included 18.902 patients, described an incidence of PIs of 10.7% (1.5\u0026ndash;31%) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Furthermore, as most patients don\u0026acute;t undergo surgery, definitive histological diagnosis of most PIs remains unknown [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to available data, up to 90% of PIs in adults are adenomas, followed by other less common solid tumors, mostly craniopharyngiomas, and cystic lesions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The most frequent reason for their detection is, in most cases, unrelated headache [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. According to Esteves et al., in a study of 68 patients with PIs in a general tertiary hospital, 25% presented with hypopituitarism and 8.8% with hormonal hypersecretion, mostly hyperprolactinemia. Of the 29.4% of patients submitted to surgery, the most frequent diagnosis was gonadotroph cell adenoma (45%).\u003c/p\u003e \u003cp\u003eStudies on PIs in cancer patients are scarce [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and, based in our clinical practice, we hypothesize that there may be differences in their etiological distribution when compared to the general population. Understanding those differences may lead to the creation of specific diagnostic and surveillance protocols in this setting.\u003c/p\u003e \u003cp\u003eOur aim was to describe incidentally discovered pituitary lesions, the reasons that led to their detection, and their follow-up in an Oncology Center.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eWe present an observational, retrospective study. We searched the Neuroradiology department database for the terms \u0026ldquo;sela(r)\u0026rdquo;, \u0026ldquo;pituitary\u0026rdquo; and \u0026ldquo;hypophysis\u0026rdquo; in every CT and MRI reports written between September 2008 and September 2021. An incidentaloma was defined as a pituitary lesion detected in an imaging exam performed for unrelated reasons, as stated by the Endocrine Society guidelines [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. We excluded imaging exams describing an empty \u003cem\u003esella turca\u003c/em\u003e, unclear lesions or lesions that were unconfirmed in subsequent exams, as well as patients whose reason for the exam wasn\u0026acute;t clear in their medical records. Data regarding demographics, clinical presentation, analytical and imaging evaluation, and follow-up of 574 patients were reviewed. Three of the patients were children and their data was excluded from the analysis. Hormonal dysfunction was determined based on laboratory results or medical record statements. Evaluation by the Endocrinology Department usually leads to hormonal basal measurements, which include ACTH, morning cortisol, IGF1, LH, FSH, estradiol/total testosterone, TSH and free T4 levels. When the lesions affected the neurohypophysis, serum sodium and serum/urinary osmolality were requested.\u003c/p\u003e \u003cp\u003eVariation in size was defined by an increase or decrease in lesion size of at least 1mm in any axis. Incidence of death 3 months after incidentaloma diagnosis was recorded.\u003c/p\u003e \u003cp\u003eStatistical analysis was made using IBM SPSS Statistics 27.0\u0026copy;. Categorical variables were expressed as frequencies and percentages and continuous variables as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (interquartile range), depending on their distribution. Chi-square and parametric or non-parametric tests, depending on the variable\u0026rsquo;s distribution, were used for group comparison, when appropriate. We performed a logistic regression analysis to investigate the association between PI diagnosis and age, sex, size and death 3 months after diagnosis. Statistical significance was considered for a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 43 patients (7.5%) had a PI on imaging exam and their baseline characteristics are shown in table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most frequent reasons for imaging exam requests were headache (11; 25.6%) and evaluation of a previously known non-pituitary lesion (11; 25.6%) (table 2.). Most lesions were detected by MRI (67.4%) and the remaining ones by CT scan. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 sums up the imagological etiology of the included PIs. The most frequently found lesion were adenomas (24 patients; 55.8%), 17 (70.8%) of which were microadenomas. Eight patients (18.6%) presented with previously unknown pituitary metastatic disease, most of which had breast cancer (table 4). Headache was the most common reason for imaging exam request (37.5%) in this group. Metastatic lesions [22(28) mm] were significantly larger than adenomas [8 (7.6) mm] (p=0.017) (table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNine patients had no record of pituitary function evaluation. Among the remaining 34, 7 (20.6%) had only their thyroid axis evaluated, and 1 (2.9%) only their gonadal axis, which were requested for other reasons during follow-up. Overall, anterior pituitary hypofunction was detected in 9/27 (33.3%) patients. Gonadotropin deficiency was present in 9/28 (32.4%), ACTH deficiency in 5/24 (20.8%) and TSH deficiency in 7/33 (21.2%). IGF1 levels were low in 3/26 (11.5%) patients. No patients presented with hormonal hypersecretion. The diagnosis of macroadenoma was associated with a higher prevalence of hypopituitarism, when compared to microadenoma (p=0.013). Hypopituitarism was even more frequent in patients diagnosed with metastases, when compared to adenomas (p\u0026lt;0.001) and this difference was still significant when compared to macroadenomas only (p=0.064). Among those with metastatic disease and pituitary function evaluation, 5/5 (100.0%) had gonadotropin deficiency, 4/5 (80.0%) had ACTH and TSH deficiency, 2/5 (40.0%) had low IGF1 levels and 2/8 (25.0%) had antidiuretic hormone (ADH) deficiency. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 9 patients that underwent formal visual field testing, only 1 patient, who was diagnosed with metastatic disease, presented with abnormalities.\u003c/p\u003e\n\u003cp\u003eRegarding treatment, 1 patient with macroadenoma underwent surgery and another with suspected meningioma was submitted to fractionated stereotactic radiotherapy. Of the 8 patients with pituitary malignant involvement, 2 patients with breast cancer underwent chemotherapy, with lesion size reduction, and the remaining 6 underwent no further treatment and died shortly after diagnosis. Seven out of 8 (87.5%) passed away during follow up, after a median of 2 (9) months after the incidentaloma diagnosis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, 22 patients managed conservatively had an imaging reevaluation. Among the macroincidentalomas (n=7), after a follow up of 26 (14) months, 2 had a size reduction (1 undetermined cystic lesion and 1 macroadenoma) and 5 had no size variation. In the microincidentalomas group (n=15) 2 microadenomas increased in size and 13 had no size variation after 39 (71) months or surveillance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThose with metastases presented a higher death incidence 3 months after diagnosis, when compared with all other incidentalomas (p=0.003). A logistic regression showed a higher likelihood of death in patients with metastases (OR 3.1, p=0.025), compared with other incidentalomas, regardless of sex, age and size.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study shows that pituitary incidentalomas found in the oncological setting seem to be different when compared to data published regarding the general population.\u003c/p\u003e \u003cp\u003eFirst of all, we found a slightly higher prevalence of pituitary lesions than other cohorts. We also report a greater proportion of incidentalomas found during the investigation of a previously known lesion of the central nervous system (CNS) when compared to the investigation of patient complaints, which is usually more common [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These two facts are probably related to the high number of imaging studies performed by patients with cancer.\u003c/p\u003e \u003cp\u003eData on pituitary metastases discovered incidentally is scarce [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Autopsy series have reported pituitary malignant involvement in 1-3.6% of patients with a known cancer diagnosis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Famini et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] described 1.8% of incidentalomas as secondary to malignant involvement (5/282 patients). In our study, we report a considerably higher prevalence of 18.6%, when compared to other series [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which could be explained by the higher likelihood of pituitary malignant involvement in an oncology setting. Breast cancer is the most common malignancy to metastasize to the pituitary gland [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and it was responsible for the majority of cases in our study too. Some authors have hypothesized that the prolactin rich environment of the pituitary gland may facilitate breast tumor cells proliferation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our series, there was a considerable number of patients with no pituitary function evaluation (20.9%) when compared to what is usually described: 6.8%-8.8% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Nevertheless, we report a prevalence of hypopituitarism similar to previous case series (19.7%-37%), which underlines the importance of a hormonal work-up in this setting [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Many of these PIs were discovered and overlooked by other specialties, and systemic complications of malignancy, including nonspecific symptoms, such as weakness and vomiting, may have masked an undiagnosed hypopituitarism [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Anterior pituitary hormone deficiency is more severe in patients with pituitary metastases than in those with adenomas, as we also demonstrated, which may be partially attributed to a their bigger size and the more pronounced process of pituitary ischemic necrosis secondary to obstruction of blood flow through portal vessels in these cases [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The lack of direct arterial blood supply to the anterior lobe of the pituitary explains the predilection for the posterior lobe in the metastatic process. This explains why diabete\u003cem\u003es insipidus\u003c/em\u003e (DI) is the most common symptom associated with pituitary metastases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Although we reported DI in only 25% of patients, we also described ACTH deficiency in 80%, which can mask the presence of DI [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe have found a lower rate of surgically approached patients (only 1 patient prompted by visual disturbances), contrasting with previous reports [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The lower surgical rates in our series may be attributed to several factors, the most determinant ones being the prevalence of metastases treated with systemic treatment and the lack of surgical benefit in patients with a bad prognosis and short life expectancy.\u003c/p\u003e \u003cp\u003eWith this study, we aimed to respond to the lack of reports in literature of PIs in the oncology setting. In this specific group of patients, we have to be aware that symptoms frequently attributed to malignancy could mask the presence of hypopituitarism. Underdiagnosing these hormonal deficiencies can further negatively impact patients\u0026rsquo; prognosis and quality of live. Considering the higher rates of hypopituitarism caused by metastases we have found herein, when compared to other series, evaluation by an endocrinologist is essential for appropriate management. Diagnosis of diabetes insipidus in cancer patients should always raise suspicion for pituitary metastases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study protocol was reviewed and approved by the Department of Data Protection and the Ethics Committee for Health of the Portuguese Institute of Oncology of Porto.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any sponsor or funder.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSara Gil Santos was responsible for the conception and design of the work, acquisition, analysis and interpretation of data, drafting the work and final approval. Raquel Calheiros aided in the analysis and interpretation of data, critical review of the manuscript and final approval. Joana Oliveira contributed to the conception, critical review and final approval of the manuscript. Ana Paula Santos contributed to the conception, critical review and final approval of the manuscript. Pedro Souteiro was responsible for the conception and design of the work, critical review of the manuscript and final approval. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFreda, P.U., et al., \u003cem\u003ePituitary incidentaloma: an endocrine society clinical practice guideline.\u003c/em\u003e J Clin Endocrinol Metab, 2011. \u003cstrong\u003e96\u003c/strong\u003e(4): p. 894-904.\u003c/li\u003e\n\u003cli\u003eTahara, S., et al., \u003cem\u003eAn Overview of Pituitary Incidentalomas: Diagnosis, Clinical Features, and Management.\u003c/em\u003e Cancers (Basel), 2022. \u003cstrong\u003e14\u003c/strong\u003e(17).\u003c/li\u003e\n\u003cli\u003eGiraldi, E., J.W. Allen, and A.G. Ioachimescu, \u003cem\u003ePituitary Incidentalomas: Best Practices and Looking Ahead.\u003c/em\u003e Endocr Pract, 2023. \u003cstrong\u003e29\u003c/strong\u003e(1): p. 60-68.\u003c/li\u003e\n\u003cli\u003eVasilev, V., et al., \u003cem\u003eMANAGEMENT OF ENDOCRINE DISEASE: Pituitary \u0026apos;incidentaloma\u0026apos;: neuroradiological assessment and differential diagnosis.\u003c/em\u003e Eur J Endocrinol, 2016. \u003cstrong\u003e175\u003c/strong\u003e(4): p. R171-84.\u003c/li\u003e\n\u003cli\u003eJeong, S.Y., et al., \u003cem\u003eIncidental pituitary uptake on whole-body 18F-FDG PET/CT: a multicentre study.\u003c/em\u003e Eur J Nucl Med Mol Imaging, 2010. \u003cstrong\u003e37\u003c/strong\u003e(12): p. 2334-43.\u003c/li\u003e\n\u003cli\u003eEsteves, C., et al., \u003cem\u003ePituitary incidentalomas: analysis of a neuroradiological cohort.\u003c/em\u003e Pituitary, 2015. \u003cstrong\u003e18\u003c/strong\u003e(6): p. 777-81.\u003c/li\u003e\n\u003cli\u003eIshii, K., et al., \u003cem\u003eClinical investigation of pituitary incidentalomas: A two-center study.\u003c/em\u003e Intractable Rare Dis Res, 2019. \u003cstrong\u003e8\u003c/strong\u003e(4): p. 239-244.\u003c/li\u003e\n\u003cli\u003eAnagnostis, P., et al., \u003cem\u003ePituitary incidentalomas: a single-centre experience.\u003c/em\u003e Int J Clin Pract, 2011. \u003cstrong\u003e65\u003c/strong\u003e(2): p. 172-7.\u003c/li\u003e\n\u003cli\u003eFamini, P., M.M. Maya, and S. Melmed, \u003cem\u003ePituitary magnetic resonance imaging for sellar and parasellar masses: ten-year experience in 2598 patients.\u003c/em\u003e J Clin Endocrinol Metab, 2011. \u003cstrong\u003e96\u003c/strong\u003e(6): p. 1633-41.\u003c/li\u003e\n\u003cli\u003eVaninetti, N.M., et al., \u003cem\u003eA comparative, population-based analysis of pituitary incidentalomas vs clinically manifesting sellar masses.\u003c/em\u003e Endocr Connect, 2018. \u003cstrong\u003e7\u003c/strong\u003e(5): p. 768-776.\u003c/li\u003e\n\u003cli\u003eJavanbakht, A., et al., \u003cem\u003ePituitary metastasis: a rare condition.\u003c/em\u003e Endocr Connect, 2018. \u003cstrong\u003e7\u003c/strong\u003e(10): p. 1049-57.\u003c/li\u003e\n\u003cli\u003eSchill, F., et al., \u003cem\u003ePituitary Metastases: A Nationwide Study on Current Characteristics With Special Reference to Breast Cancer.\u003c/em\u003e The Journal of Clinical Endocrinology \u0026amp; Metabolism, 2019. \u003cstrong\u003e104\u003c/strong\u003e(8): p. 3379-3388.\u003c/li\u003e\n\u003cli\u003eKomninos, J., et al., \u003cem\u003eTumors metastatic to the pituitary gland: case report and literature review.\u003c/em\u003e J Clin Endocrinol Metab, 2004. \u003cstrong\u003e89\u003c/strong\u003e(2): p. 574-80.\u003c/li\u003e\n\u003cli\u003eAl-Aridi, R., et al., \u003cem\u003eClinical and biochemical characteristic features of metastatic cancer to the sella turcica: an analytical review.\u003c/em\u003e Pituitary, 2014. \u003cstrong\u003e17\u003c/strong\u003e(6): p. 575-87.\u003c/li\u003e\n\u003cli\u003eDamilano, R.A., et al., \u003cem\u003e[Clinical and evolutionary characteristics of incidental pituitary adenomas: retrospective multicenter study].\u003c/em\u003e Medicina (B Aires), 2023. \u003cstrong\u003e83\u003c/strong\u003e(4): p. 514-521.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Population characteristics.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003en=43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eAge (years) - mean\u0026plusmn;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e57.8\u0026plusmn;14.7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Male - n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e17 (39.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female \u0026ndash; n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e26 (60.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 Reasons for MRI or CT request.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"415\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eHeadache\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eEvaluation of a previously known non-pituitary lesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e11 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eFocal neurological signs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eTumor staging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eDementia/behavioral disturbance/altered mental state\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e4 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eVertigo/tinnitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eVisual disturbances not related to the tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 330px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e43 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 Imaging diagnosis of pituitary incidentaloma.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAdenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Microadenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e17 (39.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Macroadenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e7 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMetastasis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHyperplasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eRathke\u0026rsquo;s cleft cyst\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eUndetermined cystic lesion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eMeningioma\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e43 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4 Cancer diagnosis of patients with pituitary metastases.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eLiver\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePharynx\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 5 Characteristics of patients with adenomas and metastases.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eAdenomas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMetastases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003ep values\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eSex\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.519\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eFemale \u0026ndash; (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e15 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eMale \u0026ndash; (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAge (years) \u0026ndash; mean\u0026plusmn;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e53.71 \u0026plusmn;16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e63.5 \u0026plusmn; 8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eLesion size (mm) \u0026ndash; median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e8 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e22 (28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePrevalence of hypopituitarism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e16 (84.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pituitary, incidentaloma, cancer, pituitary metastasis ","lastPublishedDoi":"10.21203/rs.3.rs-6522010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6522010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003ePituitary incidentalomas (PIs) are pituitary lesions identified on imaging performed for unrelated reasons. Although well described in the general population, data on PIs in cancer patients remain scarce. We aimed to describe the etiology, clinical presentation, and follow-up of PIs in an oncological setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted a retrospective observational study of all CT and MRI reports containing the terms “sella(r)”, “pituitary” or “hypophysis” between September 2008 and September 2021 in our cancer center. Data on imaging, pituitary function, and outcomes were collected and analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eForty-three patients (7.5%) had a PI on imaging exam. Complaints of headache (25.6%) and previously known non-pituitary lesions (25.6%) lead to most imaging requests. Adenomas were the most frequent diagnosis (55.8%), followed by pituitary metastases (18.6%), mostly found in patients with breast cancer. Patients with metastasis had larger lesions (p=0.017) and were more frequently diagnosed with hypopituitarism (p\u0026lt;0.001), when compared to adenomas. Malignant pituitary involvement was associated with a higher mortality at 3 months (OR 3.1; p=0.025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIn our oncology center, we reported a higher prevalence of metastasis, with higher rates of hypopituitarism, when compared to benign lesions. Symptoms typically attributed to malignancy may conceal an underlying pituitary hormonal dysfunction, emphasizing the need for systematic endocrine evaluation. Awareness of these patterns may help in the development of tailored diagnostic and management strategies in this population.\u003c/p\u003e","manuscriptTitle":"Pituitary Incidentalomas are Different in an Oncology Setting ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 13:16:19","doi":"10.21203/rs.3.rs-6522010/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"18a69b54-80be-4707-b51a-bff5094337ed","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-30T07:39:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-06 13:16:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6522010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6522010","identity":"rs-6522010","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}