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Cordeiro D, Xu Z, Mehta GU, Ding D, Lee Vance M, Kano H, Sisterson N, Yang HC, Kondziolka D, Lunsford LD, Mathieu D, Barnett GH, Chiang V, Lee J, Sneed P, Su YH, Lee CC, Krsek M, Liscak R, Nabeel AM, El-Shehaby A, Abdel Karim K, Reda WA, Martinez-Moreno N, Martinez-Alvarez R, Blas K, Grills I, Lee KC, Kosak M, Cifarelli CP, Katsevman GA, Sheehan JP. Hypopituitarism after Gamma Knife radiosurgery for pituitary adenomas: a multicenter, international study. J Neurosurg 2018; 131:1188-1196. [PMID: 31369225 PMCID: PMC9535685 DOI: 10.3171/2018.5.jns18509] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recurrent or residual adenomas are frequently treated with Gamma Knife radiosurgery (GKRS). The most common complication after GKRS for pituitary adenomas is hypopituitarism. In the current study, the authors detail the timing and types of hypopituitarism in a multicenter, international cohort of pituitary adenoma patients treated with GKRS. METHODS Seventeen institutions pooled clinical data obtained from pituitary adenoma patients who were treated with GKRS from 1988 to 2016. Patients who had undergone prior radiotherapy were excluded. A total of 1023 patients met the study inclusion criteria. The treated lesions included 410 nonfunctioning pituitary adenomas (NFPAs), 262 cases of Cushing's disease (CD), and 251 cases of acromegaly. The median follow-up was 51 months (range 6-246 months). Statistical analysis was performed using a Cox proportional hazards model to evaluate factors associated with the development of new-onset hypopituitarism. RESULTS At last follow-up, 248 patients had developed new pituitary hormone deficiency (86 with NFPA, 66 with CD, and 96 with acromegaly). Among these patients, 150 (60.5%) had single and 98 (39.5%) had multiple hormone deficiencies. New hormonal changes included 82 cortisol (21.6%), 135 thyrotropin (35.6%), 92 gonadotropin (24.3%), 59 growth hormone (15.6%), and 11 vasopressin (2.9%) deficiencies. The actuarial 1-year, 3-year, 5-year, 7-year, and 10-year rates of hypopituitarism were 7.8%, 16.2%, 22.4%, 27.5%, and 31.3%, respectively. The median time to hypopituitarism onset was 39 months.In univariate analyses, an increased rate of new-onset hypopituitarism was significantly associated with a lower isodose line (p = 0.006, HR = 8.695), whole sellar targeting (p = 0.033, HR = 1.452), and treatment of a functional pituitary adenoma as compared with an NFPA (p = 0.008, HR = 1.510). In multivariate analyses, only a lower isodose line was found to be an independent predictor of new-onset hypopituitarism (p = 0.001, HR = 1.38). CONCLUSIONS Hypopituitarism remains the most common unintended effect of GKRS for a pituitary adenoma. Treating the target volume at an isodose line of 50% or greater and avoiding whole-sellar radiosurgery, unless necessary, will likely mitigate the risk of post-GKRS hypopituitarism. Follow-up of these patients is required to detect and treat latent endocrinopathies.
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Affiliation(s)
- Diogo Cordeiro
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Gautam U. Mehta
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Mary Lee Vance
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathaniel Sisterson
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Huai-che Yang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Douglas Kondziolka
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurosurgery, New York University, New York, New York
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David Mathieu
- Department of Surgery, Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Gene H. Barnett
- Department of Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Veronica Chiang
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - John Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Penny Sneed
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Yan-Hua Su
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Cheng-chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Michal Krsek
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Ahmed M. Nabeel
- Department of Neurosurgery, Faculty of Medicine, Benha University, Qalubya, Egypt
| | - Amr El-Shehaby
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Gamma Knife Center Cairo-Nasser Institute, Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Khaled Abdel Karim
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Gamma Knife Center Cairo-Nasser Institute, Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Wael A. Reda
- Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Gamma Knife Center Cairo-Nasser Institute, Neurosurgery Department, Ain Shams University, Cairo, Egypt
| | - Nuria Martinez-Moreno
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Roberto Martinez-Alvarez
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Kevin Blas
- Radiation Oncology Department, Beaumont Health System, Royal Oak, Michigan
| | - Inga Grills
- Radiation Oncology Department, Beaumont Health System, Royal Oak, Michigan
| | - Kuei C. Lee
- Radiation Oncology Department, Beaumont Health System, Royal Oak, Michigan
| | - Mikulas Kosak
- Third Department of Medicine, Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | | | | | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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302
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Yoshida K, Toda M, Akiyama T, Takahashi S, Nishimoto M, Ozawa H, Ikari Y, Yoshida K. Combined Endoscopic Endonasal and Video-microscopic Transcranial Approach with Preoperative Embolization for a Posterior Pituitary Tumor. World Neurosurg 2018; 119:201-208. [DOI: 10.1016/j.wneu.2018.07.245] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
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303
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Abstract
Pituitary adenomas are unique in multiple ways. They are rarely malignant in terms of metastases; yet, they may be aggressive. Their cancerous potential is defined in a classic oncological way by the ability to metastasise, and therefore, it has been crucial to differentiate this process from aggressive behaviour, characterised as a particularly invasive and/or recurrent behaviour and resistance to common modalities of therapy. Recently, however, important changes have been introduced to the diagnosis and management of aggressive and malignant pituitary tumours including the 4th edition of the World Health Organization (WHO) classification for endocrine tumours (2017) as well as ESE Clinical Guidelines (2018), although an attempt to establish predictive and/or prognostic markers of clinical aggressiveness remains difficult. In this review, we focus on a group of pituitary tumours causing significant problems in clinical practice and requiring multidisciplinary input. We summarise updates in definitions of tumour invasiveness, aggressiveness and malignant transformation, as well as histological classification, and emphasise the new considerations regarding aggressive and malignant potential and its relationship to therapeutic strategies.
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Affiliation(s)
- Dorota Dworakowska
- Department of Hypertension and Diabetes, Medical University of Gdańsk, Gdańsk, Poland
- Guys Richard Dimbleby Department of Cancer Research, Kings College London, London, UK
- Endocard LTD, London, UK
| | - Ashley B Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Centre for Endocrinology, William Harvey Institute, Barts and the London School of Medicine, London, UK
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304
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Liu W, Zahr RS, McCartney S, Cetas JS, Dogan A, Fleseriu M. Clinical outcomes in male patients with lactotroph adenomas who required pituitary surgery: a retrospective single center study. Pituitary 2018; 21:454-462. [PMID: 29936681 DOI: 10.1007/s11102-018-0898-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Lactotroph adenomas (LA) are the most frequently encountered pituitary tumors. Although more frequently observed in women, LAs in men were recently included in a more aggressive category regardless of histological grading, by the WHO. We aimed to perform a rigorous retrospective review of a single center's pre-operative evaluation, patient characteristics and outcomes of male LAs patients requiring pituitary surgery. METHODS A retrospective review, over 11 years, of patients who underwent resection of a pituitary adenoma at a single center was conducted. Predictors of persistent disease in male LAs patients along with a comparison to predictors of silent corticotroph adenomas (SCAs) patients who also underwent surgery at the center was also conducted. RESULTS Thirty-one male patients with LAs were identified. When compared to SCAs patients, LAs male patients were younger (41 vs. 50 years of age, p = 0.01). Men with LAs had more invasive tumors (75% vs. 44.7% p = 0.02). More LAs in men had residual tumor after surgery than patients with SCA (92.6% vs. 42.1%, p < 0.001). Male patients with LAs and patients with SCA had similar rates of requiring additional surgery (28.9% vs. 24.1%, p = NS) and radiation therapy (18.4% vs. 19.4%, p = NS). CONCLUSIONS High rates of DA resistance, invasive tumors and postoperative residual disease in male patients with LA who required surgery are shown. Surgery improved optic chiasm compression, PRL level and central hypogonadism but, not surprisingly, failed to normalize other pituitary hormones and/or eliminate need for DA therapy.
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Affiliation(s)
- Winnie Liu
- Department of Medicine, Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Roula Shraiky Zahr
- Department of Medicine, Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Shirley McCartney
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Justin S Cetas
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Aclan Dogan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
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305
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Abstract
PURPOSE Pituicytomas and spindle cell oncocytomas (SCOs) are two rare neoplasms of the sellar and suprasellar region, known to be challenging as they are extremely vascular and almost always misdiagnosed, altering our surgical planning and the patients' outcomes. Also we argue that recent update concerning the pathology findings of these tumors should be more widely generalized to our practice. METHODS This is a retrospective multicenter study, reporting the clinical manifestations, radiological characteristics, histopathological features, treatment strategies and long-term outcomes of patients who have been treated for a Pituicytoma at various institutions in Paris, France over the past 10 years. In addition, we compared our results to the world literature in order to identify similarities concerning the radiographic diagnosis and the treatment strategies of these tumors. RESULTS Eight patients were operated on in four different hospitals. Misdiagnosis was constant before surgery, pituitary adenoma or craniopharyngioma being suspected. During surgery (transsphenoidal approach: six cases, transcranial approach: two cases) unusual tumors were noted, with important bleeding in most cases. Complete resection could be obtained in five patients. Pathological diagnosis was confirmed in all cases. During the follow up two recurrences occurred. One was subsequently treated with radiotherapy, the other underwent a second surgery. CONCLUSION Recent updates concerning the histological diagnosis of pituicytomas should be generalized to our practice in order to provide a better understanding of this rare pathology and its natural course.
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Affiliation(s)
- Etienne Lefevre
- Department of Neurosurgery, Bâtiment Babinski, Groupe Hospitalier Pitié-Salpêtrière, APHP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Schahrazed Bouazza
- Department of Neurosurgery, Hôpital Lariboisière, APHP, 2 rue Ambroise Paré, 75010, Paris, France
| | - Franck Bielle
- Department of Neuropathology, Groupe Hospitalier Pitié-Salpêtrière, APHP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Bâtiment Babinski, Groupe Hospitalier Pitié-Salpêtrière, APHP, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
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306
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Clinical and Pathologic Characteristics Predicted the Postoperative Recurrence and Progression of Pituitary Adenoma: A Retrospective Study with 10 Years Follow-Up. World Neurosurg 2018; 118:e428-e435. [DOI: 10.1016/j.wneu.2018.06.210] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/23/2018] [Accepted: 06/26/2018] [Indexed: 12/15/2022]
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307
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Uro-Coste E. [ENT benign lesions and pseudo-tumors: Case No. 5]. Ann Pathol 2018; 38:283-287. [PMID: 30201430 DOI: 10.1016/j.annpat.2018.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Emmanuelle Uro-Coste
- Institut universitaire du Cancer-Oncopole, CHU de Toulouse, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France.
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308
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Zahr R, Fleseriu M. Updates in Diagnosis and Treatment of Acromegaly. EUROPEAN ENDOCRINOLOGY 2018; 14:57-61. [PMID: 30349595 PMCID: PMC6182922 DOI: 10.17925/ee.2018.14.2.57] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/03/2018] [Indexed: 12/13/2022]
Abstract
Acromegaly is a rare disease, caused largely by a growth hormone (GH) pituitary adenoma. Incidence is higher than previously thought. Due to increased morbidity and mortality, if not appropriately treated, early diagnosis efforts are essential. Screening is recommended for all patients with clinical features of GH excess. There is increased knowledge that classical diagnostic criteria no longer apply to all, and some patients can have GH excess with normal GH response to glucose. Treatment is multifactorial and personalised therapy is advised.
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Affiliation(s)
- Roula Zahr
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition
- Department of Neurological Surgery
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, US
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309
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Steinberger J, David Y, Yuk F, Hefti M, Schaberg M, Hadjipanayis C. In the nose, not the sella: Case report of an ectopic pituitary adenoma. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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310
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Batista RL, Trarbach EB, Marques MD, Cescato VA, da Silva GO, Herkenhoff CGB, Cunha-Neto MB, Musolino NR. Nonfunctioning Pituitary Adenoma Recurrence and Its Relationship with Sex, Size, and Hormonal Immunohistochemical Profile. World Neurosurg 2018; 120:e241-e246. [PMID: 30138730 DOI: 10.1016/j.wneu.2018.08.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/06/2018] [Accepted: 08/08/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Tumor recurrence or incomplete resection in nonfunctioning pituitary adenomas (NFPAs) is relatively common. However, predictive factors of tumor recurrence in NFPAs are not well established. We evaluated possible factors related to tumor recurrence in a large cohort of NFPAs at a single pituitary neurosurgery center. METHODS A retrospective analysis was conducted of 410 medical records of patients with NFPAs treated by transsphenoidal surgery between 2000 and 2014. RESULTS Among the participants, 210 were female (51.0%). A total of 14.1% had giant adenomas. Null-cell pituitary adenomas (n = 239; 58.9%) were the most frequent, followed by silent gonadotroph adenomas (n = 112; 27.3%). Null-cell adenomas were more frequent in women (P = 0.008) and silent gonadotroph adenomas were more frequent in men (P = 0.004). Recurrence was not related to sex or age. Tumor recurrence occurred more often among silent corticotropic adenomas and giant adenomas (hazard ratio 2.45; P < 0.0001 and hazard ratio 2.35; P = 0.001, respectively). Silent thyrotrophic adenoma presented a comparable frequency of recurrence of silent corticotropic adenomas, despite having borderline significance (P = 0.07). CONCLUSIONS NFPA tumors have a high heterogeneous hormonal profile and may have prognostic importance. Silent corticotropic adenomas and giant adenomas present a high rate of recurrence.
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Affiliation(s)
| | - Ericka Barbosa Trarbach
- Molecular and Cellular Laboratory - LIM/25, Endocrinology Discipline, Hospital das Clínicas da Universidade de São Paulo - HCFMUSP, São Paulo, Brazil
| | - Mateus Diniz Marques
- Clinical Medicine Departament, Health Sciences Centre, Universidade Federal de Santa Maria, Santa Maria/RS, Brazil
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312
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Pascual JM, Prieto R, Rosdolsky M, Strauss S, Castro-Dufourny I, Hofecker V, Winter E, Carrasco R, Ulrich W. Cystic tumors of the pituitary infundibulum: seminal autopsy specimens (1899 to 1904) that allowed clinical-pathological craniopharyngioma characterization. Pituitary 2018; 21:393-405. [PMID: 29680871 DOI: 10.1007/s11102-018-0889-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A heterogeneous group of epithelial cystic tumors developed at the infundibulum and the third ventricle disconcerted pathologists at the dawn of the twentieth century. Very little was known at that time about the physiological role played by the pituitary gland, and there was almost complete ignorance regarding the function of the hypothalamus. Acromegaly, or enlargement of acral body parts, described in 1886 by Pierre Marie, was the only disease linked to primary hypertrophies of the pituitary gland, known as "pituitary strumas". A growing number of young patients manifesting an unexplained combination of physical and mental symptoms, including absent or delayed sexual maturation, progressive obesity, abnormal somnolence, and dementia-like changes in behavior were reported to present large solid-cystic tumors which characteristically expanded within the infundibulum and third ventricle, above an anatomically intact pituitary gland. Between 1899 and 1904, five seminal autopsy studies from different countries thoroughly described the anatomical relationships and histological features of this newly recognized type of infundibular tumors. These cases were instrumental in fostering the systematic investigation of similar lesions by the Austrian pathologist Jakob Erdheim (1874-1937), who in 1904 was able to classify these infundibulo-tuberal cysts under the common category of hypophyseal duct tumors. The pioneering American neurosurgeon Harvey Cushing (1869-1939) unsuccessfully attempted to surgically remove one of these cysts, for the first time in history, in 1902. The term "craniopharyngioma", chosen by Cushing in 1929 to designate these lesions, would eventually prevail over Erdheim's more accurate denomination, which linked their origin to squamous cell remnants derived from the embryological structures that give rise to the pituitary gland. This paper presents a comprehensive, renewed account of the five clinical-pathological reports which laid the groundwork for the proper clinical diagnosis, topographic conceptualization and pathological categorization of craniopharyngiomas.
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Affiliation(s)
- José M Pascual
- Department of Neurosurgery, La Princesa University Hospital, C/Diego de León 62, 28006, Madrid, Spain.
| | - Ruth Prieto
- Department of Neurosurgery, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Sewan Strauss
- Department of Pediatrics, Hospital Dahme-Spreewald, Königs Wusterhausen, Germany
| | | | - Verena Hofecker
- Pathologisch-anatomische Sammlung im Narrenturm-NHM, Vienna, Austria
| | - Eduard Winter
- Pathologisch-anatomische Sammlung im Narrenturm-NHM, Vienna, Austria
| | - Rodrigo Carrasco
- Department of Neurosurgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - Walter Ulrich
- Department of Pathology and Clinical Bacteriology, Jakob Erdheim Institute, Vienna, Austria
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313
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Syro LV, Rotondo F, Ortiz LD, Kovacs K. 65 YEARS OF THE DOUBLE HELIX: Treatment of pituitary tumors with temozolomide: an update. Endocr Relat Cancer 2018. [PMID: 29535142 DOI: 10.1530/erc-18-0015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Temozolomide is an alkylating chemotherapeutic agent used in malignant neuroendocrine neoplasia, melanoma, brain metastases and an essential component of adjuvant therapy in the treatment of glioblastoma multiforme and anaplastic astrocytoma. Since 2006, it has been used for the treatment of pituitary carcinomas and aggressive pituitary adenomas. Here, we discuss the current indications and results of temozolomide therapy in pituitary tumors, as well as frequently asked questions regarding temozolomide treatment, duration of therapy, dosage, tumor recurrence and resistance.
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Affiliation(s)
- Luis V Syro
- Department of NeurosurgeryHospital Pablo Tobon Uribe and Clinica Medellin, Medellin, Colombia
| | - Fabio Rotondo
- Division of PathologyDepartment of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Leon D Ortiz
- Division of Neuro-OncologyInstituto de Cancerologia, Clinica Las Americas. Medellin, Colombia
| | - Kalman Kovacs
- Division of PathologyDepartment of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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314
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Is it time to consider the expression of specific-pituitary hormone genes when typifying pituitary tumours? PLoS One 2018; 13:e0198877. [PMID: 29979686 PMCID: PMC6034784 DOI: 10.1371/journal.pone.0198877] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/25/2018] [Indexed: 12/11/2022] Open
Abstract
The aim of the present study is to check whether we can replicate, in an independent series, previous results showing that the molecular study of pituitary-specific gene expression complements the inmunohistochemical identification of pituitary neuroendocrine tumours. We selected 112 patients (51 (46.4%) women; mean age 51.4±16 years; 102 macroadenomas (91.9%), 9 microadenomas (8.1%)) with complete clinical, radiological, immunohistochemical and molecular data from our data set of pituitary neuroendocrine tumours. Patients were different from those previously studied. We measured the expression of the pituitary-specific hormone genes and type 1 corticotrophin-releasing hormone and arginine vasopressin 1b receptors, by quantitative real-time polymerase chain reaction using TaqMan probes. Afterwards, we identified the different pituitary neuroendocrine tumour subtypes following the 2017 World Health Organization classification of pituitary tumours, calculating the concordance between their molecular and immuhistochemical identification. The concordance between molecular and immunohistochemical identification of functioning pituitary neuroendocrine tumours with the clinical diagnosis was globally similar to the previous series, where the SYBR Green technique was used instead of TaqMan probes. Our results also corroborated the poor correlation between molecular and immunohistochemical detection of the silent pituitary neuroendocrine tumour variants. This discrepancy was more remarkable in lactotroph, null-cell and plurihormonal pituitary neuroendocrine tumours. In conclusion, this study validates the results previously published by our group, highlighting a complementary role for the molecular study of the pituitary-specific hormone genes in the typification of pituitary neuroendocrine tumours subtypes.
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315
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316
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Møller MW, Andersen MS, Pedersen CB, Kristensen BW, Poulsen FR. Intraoperative low field MRI in transsphenoidal pituitary surgery. Endocr Connect 2018; 7:897-906. [PMID: 29967186 PMCID: PMC6063879 DOI: 10.1530/ec-18-0140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 06/28/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraoperative low field MRI (iMRI, 0.15 T) during transsphenoidal surgery on pituitary adenomas (PAs) may significantly improve tumor removal. However, extensive surgery can lead to pituitary hormone deficiency. Furthermore, introduction of iMRI will prolong duration of surgery, which may elevate risk of postoperative infections. METHODS Overall, 180 transsphenoidal surgeries for PAs from 2007 to 2015 were included. IMRI was available from 2011 to 2015, during this period 67/78 (86%) surgeries were with iMRI (iMRI, n = 67). A total of 113 surgeries were performed without iMRI (controls). All surgical procedures were performed by microscopic technique. Tumor size, hormonal status and vision were assessed before surgery and 3-5 months postoperatively. RESULTS Gross total resection (GTR), mean tumor remnant volume and ∆-volumes were comparable between iMRI and controls: 15% (10/66) vs 23% (26/109) (P = 0.17), 2.97 cm3 (0.9-5) vs 2.1 cm3 (1.6-2.6) (P = 0.3) and 4.5 cm3 (3.6-5.5) vs 5.1 cm3 (4.2-6) (P = 0.4), respectively. Duration of surgery was significantly longer during iMRI vs controls: 126 min (117-135) vs 98 min (92-103) (P < 0.001). New pituitary-adrenal deficiency in iMRI vs controls was seen in 35% (17/48) and 35% (23/66) of surgeries, respectively (P = 0.95). New thyroid deficiency was found in 33% (13/29) and 41% (28/69) and visual field deficiencies improved in 44% (19/43) and 38% (23/60) in iMRI vs controls, respectively (P > 0.1). CONCLUSION Tumor remnant after pituitary surgery was not significantly reduced using intraoperative low field MRI. Duration of surgery was increased in iMRI, but was not associated with increased infection rate. Pituitary hormonal function and vision were comparable between iMRI and controls.
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Affiliation(s)
- Morten Winkler Møller
- Department of NeurosurgeryOdense University Hospital, Odense C, Denmark
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
| | - Marianne Skovsager Andersen
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
- Department of EndocrinologyOdense University Hospital, Odense C, Denmark
| | - Christian Bonde Pedersen
- Department of NeurosurgeryOdense University Hospital, Odense C, Denmark
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
| | - Bjarne Winther Kristensen
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
- Department of PathologyOdense University Hospital, Odense C, Denmark
| | - Frantz Rom Poulsen
- Department of NeurosurgeryOdense University Hospital, Odense C, Denmark
- Clinical InstituteUniversity of Southern Denmark, Odense C, Denmark
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317
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Role of EGFL7/EGFR-signaling pathway in migration and invasion of growth hormone-producing pituitary adenomas. SCIENCE CHINA-LIFE SCIENCES 2018; 61:893-901. [DOI: 10.1007/s11427-018-9320-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 05/17/2018] [Indexed: 12/14/2022]
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318
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Yoo F, Kuan EC, Heaney AP, Bergsneider M, Wang MB. Corticotrophic pituitary carcinoma with cervical metastases: case series and literature review. Pituitary 2018; 21:290-301. [PMID: 29404894 DOI: 10.1007/s11102-018-0872-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Pituitary tumors are the second most common intracranial tumors, however, pituitary carcinoma is a rare clinical entity which represents only 0.1-0.2% of all pituitary tumors. Diagnosis of pituitary carcinoma requires the presence of metastasis. Early identification of pituitary carcinoma is difficult, and only recently have guidelines been published for the treatment of aggressive pituitary tumors. We present two cases from our institution, with a review of other cases available in literature in order to better characterize this rare disease. METHODS A retrospective review of two patients with pituitary carcinoma treated at a tertiary medical center was performed. The MEDLINE database was searched for all cases of pituitary carcinoma. Information for age at diagnosis, sex, pituitary tumor type, latency period from pituitary tumor to presentation of carcinoma, sites of metastasis, number of surgical therapies, radiation and chemotherapy, and survival after diagnosis were collected. RESULTS A total of 69 studies were available for review for a total of 72 unique cases. The average age at diagnosis was 46.3 years. The most common tumors were ACTH-secreting (34.7%), Prolactin-secreting (23.6%), and Null Cell (15.3%). The average latency period from pituitary tumor diagnosis to metastasis was 9 years. All patients underwent surgical therapy during their treatment, with an average of 2.76 procedures. The mortality rate was 54.8% with average time to death after diagnosis of approximately 10 months. CONCLUSIONS Pituitary carcinoma is a rare disease with high mortality rate and is a diagnostic and treatment challenge. Further study is required but is difficult due to its low incidence.
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Affiliation(s)
- Frederick Yoo
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA.
| | - Edward C Kuan
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA
| | - Anthony P Heaney
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, USA
- Department of Medicine, Division of Endocrinology, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Marvin Bergsneider
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Marilene B Wang
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave. 62-132 CHS, Los Angeles, CA, 90095-1624, USA
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319
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Inoshita N, Nishioka H. The 2017 WHO classification of pituitary adenoma: overview and comments. Brain Tumor Pathol 2018; 35:51-56. [PMID: 29687298 DOI: 10.1007/s10014-018-0314-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 04/03/2018] [Indexed: 12/29/2022]
Abstract
The fourth edition of the World Health Organization classification of endocrine tumors has been recently published. There are two critical changes to the classification for pituitary adenomas in this edition. One is that the term "atypical adenoma," which was characterized based on highly proliferative properties to predict adenomas that carry a poor prognosis, was completely eliminated due to the lack of definitive evidence. The other change is the introduction of more precise cell lineage-based classification of pituitary adenoma that is defined based on lineage-specific transcription factors and hormones produced. Accordingly, null cell adenomas have been re-defined as those that show completely negative immunostaining either for hormones or for adenohypophyseal transcription factors. In this review, we summarized these changes in the WHO classification and discussed topics that are relevant to the diagnosis of actual cases: immunohistochemical study for pituitary endocrine tumors, predictive markers for malignant potential, the relationship between somatotroph adenomas and somatostatin analogs, and characteristics of plurihormonal adenomas.
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Affiliation(s)
- Naoko Inoshita
- Department of Pathology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan. .,Okinaka Memorial Institute for Medical Research, Tokyo, Japan.
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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320
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The expression profile of PD-L1 and CD8 + lymphocyte in pituitary adenomas indicating for immunotherapy. J Neurooncol 2018; 139:89-95. [PMID: 29680903 DOI: 10.1007/s11060-018-2844-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/21/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pituitary adenomas (PAs) are the second most common brain tumors, and mostly are benign tumors. However, there exists subtypes of PAs refractory to common treatments, and need novel therapy. Programmed death 1 (PD-1) blockade has shown durable objective response in a variety of malignancies, and the key predictive markers for this immunotherapy were PD-L1 and CD8+ tumor-infiltrating lymphocyte (TILs) expression. To evaluate the potential immunotherapy for PAs, we investigated the expression of these two immune markers in PAs. METHODS Immunohistochemistry (IHC) was performed to detect the expression of PD-L1 and CD8+ TILs in PAs. The ratio of positive expression of PD-L1 and CD8+ TILs was compared with chi-squared tests among different subtypes of PAs. The association between their expression profile and clinical parameters was analyzed using a chi-squared test, or Fisher's exact probability test when appropriate. RESULTS One hundred and ninety one patients with PAs were retrospectively involved in this study, consisting of 106 non-functioning PAs (NF-PAs, 55.5%), 40 PRL-secreting PAs (PRL-PAs, 20.9%), 31 GH-secreting PAs (GH-PAs, 16.2%), 9 ACTH-secreting PAs (ACTH-PAs, 4.7%) and 5 plurihormonal adenomas (2.6%) respectively. 36.6% of them were PD-L1 positive and 86.9% were CD8+ TILs positive. The positive PD-L1 immunostaining presented more frequently in functioning PAs (58.8%), compared with that (34.3%) in nonfunctioning group (p = 0.000). Moreover, the rates of PD-L1 expression were more associated with increased blood levels of PRL, GH, ACTH and cortisol. Contrastly, positive CD8+ TILs immunostaining was only correlated with elevated blood level of GH. For the analysis of immune markers with pathological results, PD-L1 expression was associated with PRL and GH immunostaining and higher Ki-67 index. But CD8+ TILs was only correlated with PRL immunostaining. CONCLUSION Our results showed that PD-L1 was frequently expressed in functioning PAs with association of aggressive behaviors in PAs. The immunotherapy could be a promising treatment option of PAs.
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321
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Feng Z, Mao Z, Wang Z, Liao B, Zhu Y, Wang H. Non-adenomatous pituitary tumours mimicking functioning pituitary adenomas. Br J Neurosurg 2018; 34:487-491. [PMID: 29667493 DOI: 10.1080/02688697.2018.1464121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objective: Pituicytomas and granular cell tumours (GCTs) of the neurohypophysis are considered non-adenomatous neoplasms in the sellar region. The association between hormone hypersecretion and the tumours is seldom discussed and unclear. Therefore, we attempt to investigate this association based on our experience and a review of the literature.Methods: We report three patients who presented with Cushing's syndrome- or acromegaly-like symptoms at our institution. They underwent transsphenoidal surgery for suspected pituitary adenomas, which were subsequently diagnosed as pituicytomas or hypophyseal GCTs following histological and immunohistochemical analysis. We also review previously reported relevant cases of pituitary non-adenomatous tumours in the literature.Results: Four cases of Cushing's syndrome with pituicytoma and one case of acromegaly with a GCT have recently been reported. In the three cases presented here, one patient with Cushing's syndrome and one patient with acromegaly also had a pituicytoma, while the second patient with acromegaly had a GCT.Conclusions: Rather than mere coexistence of non-adenomatous pituitary tumours with hypersecretory adenomas or hyperplasia, alternative causes for the observed symptoms maybe the presence of some unidentified substances produced by the tumours that stimulate the adenohypophysis to secrete pituitary hormones. The glial cells of the pituitary gland may play an important role in oncogenic differentiation and regulation of the release of hormones. Therefore, attention should be focused on investigating the origin and functions of glial cells.
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Affiliation(s)
- Zize Feng
- Department of Neurosurgery, Jiangmen Central Hospital, Jiangmen, China.,Key Laboratory of Pituitary Adenoma in Guangdong Province, Department of Neurosurgery, First Affiliated Hospital, SunYat-sen University, Guangzhou, China
| | - Zhigang Mao
- Key Laboratory of Pituitary Adenoma in Guangdong Province, Department of Neurosurgery, First Affiliated Hospital, SunYat-sen University, Guangzhou, China
| | - Zongming Wang
- Key Laboratory of Pituitary Adenoma in Guangdong Province, Department of Neurosurgery, First Affiliated Hospital, SunYat-sen University, Guangzhou, China
| | - Bing Liao
- Department of Pathology, the First Affiliated Hospital, SunYat-sen University, Guangzhou, China
| | - Yonghong Zhu
- Department of Histology and Embryology, Zhongshan School of Medicine, Zhongshan, China
| | - Haijun Wang
- Key Laboratory of Pituitary Adenoma in Guangdong Province, Department of Neurosurgery, First Affiliated Hospital, SunYat-sen University, Guangzhou, China
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322
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Delgado-López PD, Pi-Barrio J, Dueñas-Polo MT, Pascual-Llorente M, Gordón-Bolaños MC. Recurrent non-functioning pituitary adenomas: a review on the new pathological classification, management guidelines and treatment options. Clin Transl Oncol 2018; 20:1233-1245. [PMID: 29623588 DOI: 10.1007/s12094-018-1868-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 03/26/2018] [Indexed: 11/25/2022]
Abstract
At least 50% of surgically resected non-functioning pituitary adenomas (NFPA) recur. Either early or late adjuvant radiotherapy is highly efficacious in controlling recurrent NFPA but associates potentially burdensome complications like hypopituitarism, vascular complications or secondary neoplasm. Reoperation is indicated in bulky tumor rests compressing the optic pathway. To date, no standardized medical therapy is available for recurrent NFPA although cabergoline and temozolomide show promising results. Guidelines on the management of recurrent NFPAs are now available. The new 2017 WHO pituitary tumor classification, based on immunohistochemistry and transcription factor assessment, identifies a group of aggressive NFPA variants that may benefit from earlier adjuvant therapy. Nevertheless, NFPA patients exhibit a reduced overall life expectancy largely due to hypopituitarism and treatment-related morbidity. The management of recurrent NFPA benefits from a multidisciplinary teamwork of surgeons, endocrinologists, radiation oncologists, ophthalmologists, pathologists and neuro-radiologists in order to provide individualized therapy and anticipate deterioration.
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Affiliation(s)
- P D Delgado-López
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Avda Islas Baleares 3, 09006, Burgos, Spain.
| | - J Pi-Barrio
- Servicio de Endocrinología Y Nutrición, Hospital Universitario de Burgos, Burgos, Spain
| | - M T Dueñas-Polo
- Servicio de Oncología Radioterápica, Hospital Universitario de Burgos, Burgos, Spain
| | - M Pascual-Llorente
- Servicio de Anatomía Patológica, Hospital Universitario de Burgos, Burgos, Spain
| | - M C Gordón-Bolaños
- Servicio de Oftalmología, Hospital Universitario de Burgos, Burgos, Spain
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323
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Abstract
Non-functioning pituitary carcinomas (NFPC) are defined as tumours of adenophyseal origin with craniospinal or systemic dissemination, with the absence of a hormonal hypersecretion syndrome. These are a histologically heterogenous group of tumours, comprising gonadotroph, null cell, "silent" tumours of corticotroph, somatotroph or lactotroph cell lineages as well as plurihormonal Pit-1 tumours. NFPC are exceedingly rare, and hence few cases have been described. This review has identified 38 patients with NFPC reported in the literature. Recurrent invasive non-functioning pituitary adenomas (NFPA) were observed in a majority of patients. Various factors have been identified as markers of the potential for aggressive behaviour, including rapid tumour growth, growth after radiotherapy, gain or shift of hormone secretion and raised proliferative markers. Typically, there is a latency of several years from the original presentation with an NFPA to identification of metastases and only 5 cases reported with rapidly progressive malignant disease within 1 month of presentation. Therapeutic options include debulking surgery, radiation therapy and chemotherapy with temozolomide recommended as first line systemic treatment. Although long-term survivors are described, prognosis remains generally very poor (median survival 8 months). Improvements in molecular tumour profiling may assist in predicting tumour behaviour, guide therapeutic choices and identify novel therapies.
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Affiliation(s)
- Nèle Lenders
- Garvan Institute of Medical Research, Sydney, Australia
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Ann McCormack
- Garvan Institute of Medical Research, Sydney, Australia.
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia.
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324
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Abstract
Silent growth hormone adenomas (SGHA) are a rare entity of non-functioning pituitary neuroendocrine tumors. Diagnosis is invariably made post-operatively of a tumor immunopositive for GH (and Pit-1 in selected cases) but without clinical acromegaly. Mainly young females are affected, and tumors are often uncovered by investigation for headaches or oligoamenorrhea. Integration of clinical, pathological and biochemical data is required for proper diagnosis. Beside normal IGF-1 levels, a third of SGHAs displays elevated GH levels and some will eventually progress to acromegaly. Almost two-thirds will be mixed GH-prolactin tumors and sparsely-granulated monohormonal GH tumors seems the more aggressive subtype. Recurrence and need for radiation is higher than other non-functioning tumors so close follow-up is warranted.
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Affiliation(s)
- Fabienne Langlois
- Department of Endocrinology, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Randall Woltjer
- Department of Pathology, Oregon Health & Science University, Portland, OR, USA
| | - Justin S Cetas
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Maria Fleseriu
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
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325
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Abstract
Non-functioning pituitary neuroendocrine tumors do not cause endocrine symptoms related to hypersecretion of adenohypophyseal hormones and are clinically characterized by symptoms due to growing sellar tumor mass. Histopathological classification of this tumor group has always been challenging due to their heterogeneity, limited knowledge on their biology, and diverse methodological problems. We have searched PubMed database for data related to the histopathological classification of non-functioning pituitary tumors and methods for its application. Principles of the classification and grading presented in the recently released 4th edition of the World Health Organization classification of endocrine tumors have been summarized. Based on the expression of anterior pituitary hormones and pituitary specific transcription factors, gonadotroph tumors dominate within the group of clinically non-functioning tumors, followed by corticotroph type; however, other less common types of the non-functioning tumors can be identified. Assessment of tumor cell proliferation is important to identify "high-risk adenomas." A few subtypes of non-functioning tumors belong to the category of potentially aggressive tumors, independent of the cell proliferation rate. Here, we present up to date criteria for the classification of clinically non-functioning pituitary tumors, offer a diagnostic approach for the routine clinical use, and emphasize a need for inclusion of prognostic and predictive markers in the classification.
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Affiliation(s)
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Metabolism, Uppsala University Hospital, Uppsala, Sweden
| | - Olivera Casar-Borota
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
- Department of Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden.
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326
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Abstract
External beam radiotherapy (RT) is an essential part of the management of intracranial tumors and has been used in treating pituitary adenomas for more than five decades. It has been demonstrated that conventional RT for postoperative residual or progressive nonfunctioning pituitary adenomas (NFAs) present an excellent long-term local tumor control, although its use has been limited because of the potential late toxicity related to radiation treatments. Recent advances in radiation techniques have led to more accurate treatments, rendering obsolete many commonly held views of the "old" radiotherapy. New techniques include intensity modulated radiotherapy, volumetric-modulated arc therapy, and stereotactic techniques, either stereotactic radiosurgery or fractionated stereotactic radiotherapy. New techniques allow the delivering of higher radiation doses to the target with rapid dose fall-off in the surrounding normal tissues, and potentially limiting the long term toxicity of radiation. In this review, we present a critical analysis of the most recent available literature on the use of radiation in patients with NFAs, focusing particularly on the efficacy and safety of radiation stereotactic techniques.
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Affiliation(s)
- Giuseppe Minniti
- UPMC San Pietro FBF, Rome, Italy.
- IRCCS Neuromed, 86077, Pozzilli, IS, Italy.
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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327
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Abstract
PURPOSE Non-functioning pituitary adenomas (NFPAs) are benign pituitary neoplasms that do not cause a hormonal hypersecretory syndrome. An improved understanding of their epidemiology, clinical presentation and diagnosis is needed. METHOD A literature review was performed using Pubmed to identify research reports and clinical case series on NFPAs. RESULTS They account for 14-54% of pituitary adenomas and have a prevalence of 7-41.3/100,000 population. Their standardized incidence rate is 0.65-2.34/100,000 and the peak occurence is from the fourth to the eighth decade. The clinical spectrum of NFPAs varies from being completely asymptomatic to causing significant hypothalamic/pituitary dysfunction and visual field compromise due to their large size. Most patients present with symptoms of mass effect, such as headaches, visual field defects, ophthalmoplegias, and hypopituitarism but also hyperprolactinaemia due to pituitary stalk deviation and less frequently pituitary apoplexy. Non-functioning pituitary incidentalomas are found on brain imaging performed for an unrelated reason. Diagnostic approach includes magnetic resonance imaging of the sellar region, laboratory evaluations, screening for hormone hypersecretion and for hypopituitarism, and a visual field examination if the lesion abuts the optic nerves or chiasm. CONCLUSION This article reviews the epidemiology, clinical behaviour and diagnostic approach of non-functioning pituitary adenomas.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece.
| | - John A Wass
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
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328
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Abstract
INTRODUCTION Non-functioning pituitary adenomas (NFPAs) are in general large tumors that present with symptoms secondary to local pressure on adjacent structures. Transsphenoidal surgery is the first line of treatment but residual tumor mass is often detected post-operatively. Medical therapy, in any stage of tumor management, is not well established. METHODS A literature search was performed to review the available data on medical treatment of NFPAs. RESULTS Medications investigated for the treatment of NFPAs include dopamine receptor agonists (DA) and somatostatin receptor ligands. Randomized controlled trials are lacking, but available data suggest that DA have a positive effect on tumor remnant stabilization after surgery and could be considered in this setting. Temozolomide is reserved for aggressive tumors, although future studies are required. CONCLUSIONS NFPA are often not amenable to complete surgical resection. Conservative follow-up after surgery is associated with a high prevalence of tumor remnant progression. DA therapy may prevent residual tumor enlargement in over 85% of these patients, with a substantial consequent reduction in the need for repeat surgery or radiation therapy. It is our view that DA treatment should be routinely considered for the management of NFPA patients with incompletely resected tumors.
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Affiliation(s)
- Naomi Even-Zohar
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Yona Greenman
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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329
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McCormack A, Dekkers OM, Petersenn S, Popovic V, Trouillas J, Raverot G, Burman P. Treatment of aggressive pituitary tumours and carcinomas: results of a European Society of Endocrinology (ESE) survey 2016. Eur J Endocrinol 2018; 178:265-276. [PMID: 29330228 DOI: 10.1530/eje-17-0933] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/08/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To collect outcome data in a large cohort of patients with aggressive pituitary tumours (APT)/carcinomas (PC) and specifically report effects of temozolomide (TMZ) treatment. DESIGN Electronic survey to ESE members Dec 2015-Nov 2016. RESULTS Reports on 166 patients (40 PC, 125 APT, 1 unclassified) were obtained. Median age at diagnosis was 43 (range 4-79) years. 69% of the tumours were clinically functioning, and the most frequent immunohistochemical subtype were corticotroph tumours (45%). Ki-67 index did not distinguish APT from PC, median 7% and 10% respectively. TMZ was first-line chemotherapy in 157 patients. At the end of the treatment (median 9 cycles), radiological evaluation showed complete response (CR) in 6%, partial response (PR) in 31%, stable disease (SD) in 33% and progressive disease in 30%. Response was more frequent in patients receiving concomitant radiotherapy and TMZ. CR was seen only in patients with low MGMT expression. Clinically functioning tumours were more likely to respond than non-functioning tumours, independent of MGMT status. Of patients with CR, PR and SD, 25, 40 and 48% respectively progressed after a median of 12-month follow-up. Other oncological drugs given as primary treatment and to TMZ failures resulted in PR in 20%. CONCLUSION This survey confirms that TMZ is established as first-line chemotherapeutic treatment of APT/PC. Clinically functioning tumours, low MGMT and concurrent radiotherapy were associated with a better response. The limited long-term effect of TMZ and the poor efficacy of other drugs highlight the need to identify additional effective therapies.
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Affiliation(s)
- Ann McCormack
- St Vincent's Hospital and Garvan Institute of Medical Research, Sydney, Australia
| | - Olaf M Dekkers
- Department of Internal Medicine (Section Endocrinology) & Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Jacqueline Trouillas
- Centre de Pathologie et de Biologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Gerald Raverot
- Fédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Université de Lyon, Bron, France
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital Malmö, University of Lund, Lund, Sweden
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330
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Bi WL, Larsen AG, Dunn IF. Genomic Alterations in Sporadic Pituitary Tumors. Curr Neurol Neurosci Rep 2018; 18:4. [DOI: 10.1007/s11910-018-0811-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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331
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New WHO classification of pituitary adenomas (4th edition): assessment of pituitary transcription factors and the prognostic histological factors. Brain Tumor Pathol 2018; 35:57-61. [PMID: 29318396 DOI: 10.1007/s10014-017-0307-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/26/2017] [Indexed: 12/20/2022]
Abstract
WHO classification of pituitary adenomas was revised in 2017. The two major and significant changes are discussed. (1) The new classification focuses on adenohypophysial-cell lineage for the designation of adenomas, and thus, assessment of pituitary transcription factors is recommended. Its appropriate use has a complementary role in obtaining an accurate diagnosis, particularly in hormone-negative adenomas. Subclassification of nonfunctioning adenomas was revised accordingly and, consequently, null cell adenomas became quite rare. (2) "Atypical adenoma", a previous category, was eliminated due to the poor reproducibility and predictive value. Assessment of tumor proliferation marker and other clinical parameters such as invasion are recommended to predict aggressiveness. "High-risk adenomas" are those with rapid growth, radiological invasion, and a high Ki-67 proliferation index, whereas some special adenoma subtypes commonly show aggressive behavior.
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332
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Bettencourt-Silva R, Pereira J, Belo S, Magalhães D, Queirós J, Carvalho D. Prolactin-Producing Pituitary Carcinoma, Hypopituitarism, and Graves' Disease-Report of a Challenging Case and Literature Review. Front Endocrinol (Lausanne) 2018; 9:312. [PMID: 29928263 PMCID: PMC5997786 DOI: 10.3389/fendo.2018.00312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/24/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The diagnosis of pituitary carcinoma is very rare, requires the evidence of metastatic disease, and has a poor overall survival. Malignant prolactinoma frequently requires dopamine agonist therapy, pituitary surgery, radiotherapy, and even chemotherapy. CASE DESCRIPTION A 19-year-old female presented with galactorrhea, primary amenorrhea, and left hemianopsia. Complementary study detected hyperprolactinemia and a pituitary macroadenoma with cavernous sinus invasion and suprasellar growth. She was treated with cabergoline and bromocriptine without clinical or analytical improvement. Resection of the pituitary lesion was programmed and a non-contiguous lesion of the nasal mucosa was detected during the approach. This metastasis led to the diagnosis of prolactin-producing pituitary carcinoma. After partial resection, the patient was submitted to radiotherapy for residual disease with persistent symptoms. She developed growth hormone deficiency, central hypothyroidism, hypogonadism, and permanent diabetes insipidus. Six years later she was admitted for the suspicion of secondary adrenal insufficiency and thyrotoxicosis. Physical findings, laboratory data, thyroid ultrasound, and scintigraphy achieved the diagnosis of Graves' disease and hypocortisolism. She was treated with hydrocortisone and methimazole, but central hypothyroidism recurred after antithyroid drug withdrawal. Nine years after the diagnosis of a pituitary carcinoma, she maintains treatment with bromocriptine, has a locally stable disease, with no metastases. CONCLUSION This report highlights an unusual presentation of a prolactin-producing pituitary carcinoma in a young female. The patient had multiple hormone deficiencies due to a pituitary lesion and treatments. The posterior development of hyperthyroidism and adrenal insufficiency brought an additional difficulty to the approach.
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Affiliation(s)
- Rita Bettencourt-Silva
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal
| | - Josué Pereira
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Neurosurgery, Centro Hospitalar São João, Porto, Portugal
| | - Sandra Belo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal
| | - Daniela Magalhães
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal
| | - Joana Queirós
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal
| | - Davide Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal
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Behling F, Honegger J, Skardelly M, Gepfner-Tuma I, Tabatabai G, Tatagiba M, Schittenhelm J. High Expression of Somatostatin Receptors 2A, 3, and 5 in Corticotroph Pituitary Adenoma. Int J Endocrinol 2018; 2018:1763735. [PMID: 30627156 PMCID: PMC6304820 DOI: 10.1155/2018/1763735] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 01/27/2023] Open
Abstract
The development of somatostatin analogs for the treatment of pituitary Cushing's disease has been based on somatostatin receptor expression analyses of small cohorts of pituitary adenomas. Additionally, the classification of pituitary adenomas has recently changed. To enable progress with this treatment option, we assessed somatostatin receptors in a large cohort of corticotroph and other pituitary adenomas according to the new WHO classification of endocrine tumors. Paraffin-embedded tumor samples of 88 corticotroph pituitary adenomas and 30 nonadenomatous pituitary biopsies were analyzed after processing into tissue microarrays and immunohistochemical staining for SSTR 1, SSTR2A, SSTR3, SSTR4, and SSTR5. For comparison, 159 other noncorticotroph pituitary adenomas were analyzed. SSTR3 expression was higher in corticotroph adenomas compared to PIT-1-positive, gonadotroph, and nonfunctioning pituitary adenomas (p < 0.0001, p = 0.0280, and p < 0.0001, respectively). This was also the case for the expression of SSTR5 (p = 0.0003, p < 0.0001, and p < 0.0001, respectively). SSTR2A expression was higher compared to gonadotroph and nonfunctioning pituitary adenomas (p = 0.0217 and 0.0126, respectively) while PIT-1-positive adenomas showed even higher SSTR2A expression (p < 0.0001). SSTR2A and SSTR5 were both expressed higher in nonadenomatous pituitary biopsies than in pituitary adenomas (p = 0.0126 and p = 0.0008, respectively). There are marked expression differences of SSTR1-5 as well as changes in expression in recurrent disease that need to be addressed when looking for other possible substances for the treatment of Cushing's disease. SSTR2A, SSTR3, and SSTR5 seem to be most suitable biomarkers for a targeted therapy with somatostatin analogs.
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Affiliation(s)
- Felix Behling
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
| | - Jürgen Honegger
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
| | - Marco Skardelly
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
| | - Irina Gepfner-Tuma
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Department of Neurology, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Tuebingen, Germany
| | - Ghazaleh Tabatabai
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Department of Neurology, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Tuebingen, Germany
- Interdisciplinary Division of Neuro-Oncology, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- German Cancer Consortium (DKTK), DKFZ partner site Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
| | - Jens Schittenhelm
- Center for CNS Tumors, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
- Department of Neuropathology, University Hospital Tuebingen, Eberhard-Karls-University Tuebingen, Germany
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Syro LV, Rotondo F, Camargo M, Ortiz LD, Serna CA, Kovacs K. Temozolomide and Pituitary Tumors: Current Understanding, Unresolved Issues, and Future Directions. Front Endocrinol (Lausanne) 2018; 9:318. [PMID: 29963012 PMCID: PMC6013558 DOI: 10.3389/fendo.2018.00318] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 05/28/2018] [Indexed: 01/26/2023] Open
Abstract
Temozolomide, an alkylating agent, initially used in the treatment of gliomas was expanded to include pituitary tumors in 2006. After 12 years of use, temozolomide has shown a notable advancement in pituitary tumor treatment with a remarkable improvement rate in the 5-year overall survival and 5-year progression-free survival in both aggressive pituitary adenomas and pituitary carcinomas. In this paper, we review the mechanism of action of temozolomide as alkylating agent, its interaction with deoxyribonucleic acid repair systems, therapeutic effects in pituitary tumors, unresolved issues, and future directions relating to new possibilities of targeted therapy.
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Affiliation(s)
- Luis V. Syro
- Department of Neurosurgery, Hospital Pablo Tobon Uribe and Clinica Medellin, Medellin, Colombia
- *Correspondence: Luis V. Syro,
| | - Fabio Rotondo
- Department of Laboratory Medicine, Division of Pathology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Mauricio Camargo
- Genetics, Regeneration and Cancer Laboratory, Universidad de Antioquia, Medellin, Colombia
| | - Leon D. Ortiz
- Division of Neuro-oncology, Instituto de Cancerología, Clinica Las Americas, Pharmacogenomics, Universidad CES, Medellin, Colombia
| | - Carlos A. Serna
- Laboratorio de Patologia y Citologia Rodrigo Restrepo, Department of Pathology, Clinica Las Américas, Universidad CES, Medellin, Colombia
| | - Kalman Kovacs
- Department of Laboratory Medicine, Division of Pathology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
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Extent of surgical resection and tumor size predicts prognosis in granular cell tumor of the sellar region. Acta Neurochir (Wien) 2017; 159:2209-2216. [PMID: 28948361 DOI: 10.1007/s00701-017-3337-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/12/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Rarely, granular cell tumor (GCT) occurs in the sellar region. The natural history of this clinical entity is not well known. This study sought to determine the clinical features and long-term outcome of GCT of the sellar region. METHODS Institutional databases, the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and PubMed/EMBASE were searched for GCT of the sellar region. Patient-level data were extracted where available, including age, sex, symptoms, tumor size and location, presumed diagnosis, surgical approach and result, subtotal resection (STR) and gross-total resection (GTR), use of radiation, and outcome. The primary endpoints of recurrence and survival were determined. RESULTS A total of 141 cases were analyzed. The mean age at diagnosis was 48.9 (SD 15.3) with a female predominance (sex ratio 1.49:1). Almost all patients experienced either or both neurological and endocrine symptoms. The most common pre-operative diagnosis was pituitary adenoma. Approximately 60% of patients were treated with surgery, 57.7% with a craniotomy, and 39.7% with a transsphenoidal approach. The 5-year overall survival (OS) was 84.7% (standard error, SE 4.2). Patients with tumors less than 2.5 cm experienced a greater 5-year OS (100.0%) than patients with tumors 2.5 cm or larger (74.0%, SE: 11.7), (Mantel-Cox, p = 0.024). GTR resulted in a greater 5-year OS (95.7%, SE 4.3) than STR (88.8%, SE 5.5) and no surgery or biopsy alone (75.0%, SE 15.3) (Mantel-Cox, p = 0.016). The use of radiation therapy did not improve OS. The 5-year progression-free survival rate was 80.8% (SE 9.2). CONCLUSIONS Granular cell tumor of the sellar region is a relatively benign neoplasm with neurological and endocrine clinical manifestations. Surgical resection is appropriate for management. Tumor size and extent of resection influence overall survival.
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