Context: Although the majority of pituitary macroadenomas is clinically nonfunctioning, treatments as well as follow-up strategy for this condition lack evidence from randomized studies.

Evidence acquisition: We evaluated the evidence of treatment and follow-up strategies for clinically nonfunctioning adenomas. PubMed was searched for articles on nonfunctioning adenomas in November 2007 and references of selected articles were assessed for potentially relevant articles.

Evidence synthesis: All evidence for treatment and follow-up for nonfunctioning adenomas is based on observational studies. The most effective treatment is transsphenoidal surgery, indicated in patients with visual field defects. A wait-and-see approach may be considered in nonfunctioning macroadenomas not reaching to the optic chiasm. Some of these tumors (10%) will show spontaneous regression, whereas in 50% there will be progression within 5 years of observation. Postoperative radiotherapy should not be applied to all patients after surgery, but can be considered in patients with large postoperative remnants of the tumor. During follow-up careful assessment and replacement of pituitary insufficiencies should be performed. MRI is advised with intervals of 1–3 years and evaluation of visual fields when appropriate. Recurrence rates are reported to be 6–46% after transsphenoidal surgery, whereas after postoperative radiotherapy recurrence rates of 0–36% are reported. Long-term sequelae of nonfunctioning macroadenomas are hypopituitarism, persistent visual field defects and decreased quality of life. Whether nonfunctioning macroadenomas are associated with an increased mortality is still a matter of debate.

Conclusion: Clinically nonfunctioning pituitary macroadenomas, although benign in nature, need individualized treatment and life long radiological and endocrinological follow-up.