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Abstract Recurrent pituitary disease presents unique challenges, including in some cases difficulty localizing a tumor radiographically. Here, we present the case of a patient with recurrent Nelson syndrome whose radiographic work-up was complicated by a significant parasellar metallic artifact. Positron emission tomography ultimately localized the lesion, and coregistration with computed tomography allowed for accurate intraoperative navigation. Additionally, we review a range of imaging techniques available in the evaluation of pituitary disease.