August 15, 2025 — The Congress of Neurological Surgeons (CNS) has issued its first comprehensive, evidence-based guidelines on the care of adults with functioning pituitary adenomas (FPA) , a prevalent and complex condition. Tailored for neurosurgeons, endocrinologists, and other specialists, the guidelines mark a pivotal step in standardizing care, optimizing patient outcomes, and promoting multidisciplinary coordination.
The new CNS Guideline about FPA treatment stems from the review of approximately 20,000 published abstracts and is presented as four papers (43 pages plus Supplemental data) in an online supplement to Neurosurgery , the official publication of the CNS, which is part of the Lippincott portfolio by Wolters Kluwer .
The CNS and the American Association of Neurological Surgeons have endorsed the guidelines. The initiative was led by Dr. Isabelle M. Germano, MD, MBA, Professor of Neurosurgery at the Icahn School of Medicine at Mount Sinai and Chair of the AANS/CNS Section on Tumors (2022–2024), along with Dr. D. Ryan Ormond, MD, PhD, Associate Professor of Neurosurgery at the University of Colorado School of Medicine. Together, they assembled and worked with a multidisciplinary team of 18 experts in neurosurgery, endocrinology, neuroradiology, and radiation oncology from across the country to develop these guidelines.
The pituitary gland, located at the base of the brain, makes hormones that control important body functions. More than 10,000 pituitary tumors are diagnosed each year in the U.S., and almost all of them are non-cancerous "pituitary adenomas." About 66%–75% of those growths are called "functioning" pituitary adenomas because they secrete excessive amounts of hormones. FPAs can cause symptoms, depending on what kind of hormones they make, and they can put pressure on the brain or nearby brain parts. For those patients, healthcare providers may suggest medical (drug) therapy, surgery, radiation, or stereotactic radiosurgery (SRS), a form of radiation so precise that it creates a result similar to surgery.
The authors evaluate the role of trans-sphenoidal surgery compared with medical management of FPAs, endoscopic techniques versus microsurgery, the benefit of the use of adjunct surgical techniques, and the role of second surgery. They advise:
- For patients with a functioning pituitary microadenoma secreting prolactin, medical management is suggested over surgery at primary diagnosis. (Level III evidence)
- Conversely, for those with a microadenoma secreting growth hormone, surgery is suggested over medical management. (Level III)
- When surgical resection is required for FPA, endoscopic techniques are not superior to microscopic techniques for extent of surgical resection (EOR), hormone remission, length of stay, or complication rates. For patients with pituitary macroadenomas without cavernous sinus invasion there is a suggestion, however, that the endoscopic techniques may be superior to the microscopic technique for a shorter operative time and for better EOR and hormone remission rates. (Level III)
The authors also address decision-making about SRS for adults with progressive or recurrent FPAs. They conclude:
- Clinicians should use SRS, hypofractionated SRS, and fractionated and conventional radiation therapy to provide improved radiographic control. (Level III)
- For patients with FPAs who require SRS, clinicians may continue to administer endocrine suppressive medical treatment before SRS as this may not affect radiographic control. (Level III)
- There is insufficient evidence to make a recommendation about how stopping endocrine suppressive medications before SRS affects biochemical normalization.
