1
|
Hanalioglu S, Gurses ME, Gecici NN, Baylarov B, Isikay I, Gürlek A, Berker M. Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent cushing's disease: safety, feasibility, and success. Pituitary 2024; 27:259-268. [PMID: 38748309 PMCID: PMC11150181 DOI: 10.1007/s11102-024-01396-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE The success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing's disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients. METHODS A retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission. RESULTS Among the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission. CONCLUSION Repeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications.
Collapse
Affiliation(s)
- Sahin Hanalioglu
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Muhammet Enes Gurses
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Neslihan Nisa Gecici
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Baylar Baylarov
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ilkay Isikay
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Alper Gürlek
- Department of Endocrinology and Metabolism, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mustafa Berker
- Department of Neurosurgery, Hacettepe University School of Medicine, Sihhiye, Ankara, 06230, Turkey.
| |
Collapse
|
2
|
Webb KL, Hinkle ML, Walsh MT, Bancos I, Shinya Y, Van Gompel JJ. Inferior Petrosal Sinus Sampling Tumor Lateralization and the Surgical Treatment of Cushing Disease: A Meta-Analysis and Systematic Review. World Neurosurg 2024; 182:e712-e720. [PMID: 38081579 DOI: 10.1016/j.wneu.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVE To determine whether accurate inferior petrosal sinus sampling (IPSS) tumor lateralization is associated with improved clinical outcomes following the surgical treatment of Cushing disease. METHODS The presented study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data regarding patient demographics, IPSS tumor lateralization, and postoperative endocrinologic outcomes were abstracted and pooled with random effects meta-analysis models. Additional meta-regression models were used to examine the association between the accuracy of IPSS tumor lateralization and postoperative outcomes (recurrence/persistence or remission/cure). Statistical analyses were performed using the Comprehensive Meta-Analysis software (significance of P < 0.05). RESULTS Seventeen eligible articles were identified, yielding data on 461 patients. Within average follow-up duration (∼59 months), the rate of correct IPSS tumor lateralization was 69% [95% confidence interval: 61%, 76%], and the rate of postoperative remission/cure was 78% [67%, 86%]. Preoperative IPSS tumor lateralization was concordant with magnetic resonance imaging lateralization for 53% of patients [40%, 66%]. There was no significant association between the rate of correct IPSS tumor lateralization and postoperative remission/cure among study-level data (P = 0.735). Additionally, there was no association among subgroup analyses for studies using stimulatory agents during IPSS (corticotropin-releasing hormone or desmopressin, P = 0.635), nor among subgroup analyses for adult (P = 0.363) and pediatric (P = 0.931) patients. CONCLUSIONS Limited data suggest that the rate of correct IPSS tumor lateralization may not be positively associated with postoperative remission or cure in patients with Cushing disease. These findings bring into question the utility of IPSS tumor lateralization in the context of preoperative planning and surgical approach rather than confirming a pituitary source.
Collapse
Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Mickayla L Hinkle
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuki Shinya
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
3
|
Lian X, Xu Z, Sun S, Wang W, Zhu H, Lu L, Hou X, Zhang F. Intensity-modulated radiotherapy for cushing's disease: single-center experience in 70 patients. Front Endocrinol (Lausanne) 2023; 14:1241669. [PMID: 37822603 PMCID: PMC10562628 DOI: 10.3389/fendo.2023.1241669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/31/2023] [Indexed: 10/13/2023] Open
Abstract
Context Intensity-modulated radiotherapy (IMRT) is a modern precision radiotherapy technique for the treatment of the pituitary adenoma. Objective Aim to investigate the efficacy and toxicity of IMRT in treating Cushing's Disease (CD). Methods 70 of 115 patients with CD treated with IMRT at our institute from April 2012 to August 2021 were included in the study. The radiation doses were usually 45-50 Gy in 25 fractions. After IMRT, endocrine evaluations were performed every 6 months and magnetic resonance imaging (MRI) annually. Endocrine remission was defined as suppression of 1 mg dexamethasone test (DST) or normal 24-hour urinary free cortisol level (24hUFC). The outcome of endocrine remission, endocrine recurrence, tumor control and complications were retrieved from medical record. Results At a median follow-up time of 36.8 months, the endocrine remission rate at 1, 2, 3 and 5 years were 28.5%, 50.2%, 62.5% and 74.0%, respectively. The median time to remission was 24 months (95%CI: 14.0-34.0). Endocrine recurrence was found in 5 patients (13.5%) till the last follow-up. The recurrence-free rate at 1, 2, 3 and 5 years after endocrine remission was 98.2%, 93.9%, 88.7% and 88.7%, respectively. The tumor control rate was 98%. The overall incidence of new onset hypopituitarism was 22.9%, with hypothyroidism serving as the most common individual axis deficiency. Univariate analysis indicated that only higher Ki-67 index (P=0.044) was significant favorable factors for endocrine remission. Conclusion IMRT was a highly effective second-line therapy with low side effect profile for CD patients. Endocrine remission, tumor control and recurrence rates were comparable to previous reports on FRT and SRS.
Collapse
Affiliation(s)
- Xin Lian
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhuoran Xu
- Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shuai Sun
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Weiping Wang
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| |
Collapse
|
4
|
Kinaci-Tas B, Alderliesten T, Verbraak FD, Rasch CRN. Radiation-Induced Retinopathy and Optic Neuropathy after Radiation Therapy for Brain, Head, and Neck Tumors: A Systematic Review. Cancers (Basel) 2023; 15:cancers15071999. [PMID: 37046660 PMCID: PMC10093581 DOI: 10.3390/cancers15071999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/02/2023] [Accepted: 03/09/2023] [Indexed: 03/30/2023] Open
Abstract
Background: Patients with brain, head, and neck tumors experience a decline in their quality of life due to radiation retinopathy and optic neuropathy. Little is known about the dose–response relationship and patient characteristics. We aimed to systematically review the prevalence of radiation retinopathy and optic neuropathy. Method: The primary outcome was the pooled prevalence of radiation retinopathy and optic neuropathy. The secondary outcome included the effect of the total radiation dose prescribed for the tumor according to the patient’s characteristics. Furthermore, we aimed to evaluate the radiation dose parameters for organs at risk of radiation retinopathy and optic neuropathy. Results: The pooled prevalence was 3.8%. No retinopathy was reported for the tumor’s prescribed dose of <50 Gy. Optic neuropathy was more prevalent for a prescribed dose of >50 Gy than <50 Gy. We observed a higher prevalence rate for retinopathy (6.0%) than optic neuropathy (2.0%). Insufficient data on the dose for organs at risk were reported. Conclusion: The prevalence of radiation retinopathy was higher compared to optic neuropathy. This review emphasizes the need for future studies considering retinopathy and optic neuropathy as primary objective parameters.
Collapse
Affiliation(s)
- Buket Kinaci-Tas
- Department of Radiation Oncology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
- Correspondence:
| | - Tanja Alderliesten
- Department of Radiation Oncology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Frank D. Verbraak
- Department of Ophthalmology, Amsterdam University Medical Centers, Location VU Medical Center, 1081 HV Amsterdam, The Netherlands
| | - Coen R. N. Rasch
- Department of Radiation Oncology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| |
Collapse
|
5
|
Losa M, Albano L, Bailo M, Barzaghi LR, Mortini P. Role of radiosurgery in the treatment of Cushing's disease. J Neuroendocrinol 2022; 34:e13134. [PMID: 35980263 DOI: 10.1111/jne.13134] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/21/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
Abstract
Radiotherapy is a useful adjuvant treatment for patients with Cushing's disease that is not cured by surgery. In particular, Gamma Knife radiosurgery (GKRS) has been increasingly used worldwide as the preferred radiation technique in patients with persistent or recurrent Cushing's disease. The most widely accepted criterion for hormonal remission after GKRS is normalization of urinary free cortisol (UFC) levels. When a clear biological target is not identified, irradiation of the whole pituitary gland can be considered. The 5-year probability of remission is 65%-75%. Normalization of hypercortisolism usually occurs within 3 years from GKRS treatment and control of tumor growth is optimal, approaching more than 90%. No clear predictor of a favorable outcome has emerged up to now, except for the experience of the treating team. In the largest series, development of partial or complete hypopituitarism occurred between 15% and 36%. Severe side effects of GKRS, such as optic neuropathy and oculomotor palsy, are uncommon but have been documented in patients previously exposed to radiation. Recurrence of disease has been reported in as high as 16%-18% of the patients who achieved normalization of UFC levels in the two largest series, whereas smaller series did not describe late failure of GKRS. The reason for this discrepancy is unclear, as is the relationship between hormonal and tumoral recurrence. Another unresolved issue is whether treatment with adrenal blocking drugs can jeopardize the results of GKRS. GKRS is an effective second-line treatment in patients with Cushing's disease not cured by surgery. Hypopituitarism is the most frequent side effect of GKRS, whereas severe neurologic complications are uncommon in radiation-naïve patients.
Collapse
Affiliation(s)
- Marco Losa
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| | - Luigi Albano
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| | - Michele Bailo
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| | | | - Pietro Mortini
- Department of Neurosurgery, IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| |
Collapse
|
6
|
Янар ЭА, Маказан НВ, Карева МА, Воронцов АВ, Владимирова ВП, Безлепкина ОБ, Петеркова ВА. Course of Cushing`s disease and treatment outcomes in correlation with pituitary MRI in children. PROBLEMY ENDOKRINOLOGII 2022; 68:93-104. [PMID: 35841173 PMCID: PMC9762535 DOI: 10.14341/probl12854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Cushing's disease (CD) is a rare disorder of a persistent cortisol excess caused by ACTH-secreting pituitary tumor (corticotropinoma). Transsphenoidal surgery (TSS) is a treatment of choice for СD, which effectiveness range is from 70 to 90%. Recurrence rate after successful treatment is about 25%. If surgical treatment is unsuccessful or recurrence appear, radiation treatment is the next therapeutic option, which effectiveness range is also 90%, but the hypopituitarism rate as side effect of treatment is higher. Preoperative predictors of remission and recurrence are still unexplored what leads to further investigations. AIM Analysis of remission and recurrence rates of pediatric CD after successful treatment according to preoperative MRI and therapeutic option. MATERIALS AND METHODS We conducted a retrospective analysis of 90 pediatric patients with CD who were observed between 1992 and 2020 at the Endocrinology Research Centre. RESULTS The most common clinical symptoms of CD were weight gain [94%] and growth retardation [72%]. Pituitary tumor was detected on radiological imaging in 53/90 patients [59%], there were no signs of visible adenoma in 37/90 of patients [41%]. 63 of 90 patients underwent TSS (70%), 27 patients underwent radiosurgery (30%). Remission rate after TSS was 71% [45/63], after radiosurgery - 85% [23/27]. There were no significant differences in remission rates after radical treatment according to preoperative MRI results (P=0.21 after TSS and P=0.87 after radiosurgery, х2 analysis). Recurrence after successful treatment was diagnosed in 10 patients. There were no significant differences in time to recurrence according to preoperative MRI results (P=0.055, х2 analysis). Time to recurrence was statistically different after TSS compared to radiosurgery (P=0.007, Kaplan-Meier analysis) and in the group with developed adrenal insufficiency in the early postoperative period (P=0.04, Kaplan-Meier analysis). Analysis of side effect of treatment showed that the frequency of growth hormone and gonadotrophin deficiency was statistically higher after radiosurgery (р<0.01, Kruskel-Wallis ANOVA test). Diabetes insipidus was diagnosed only after TSS. CONCLUSION Results of our study didn`t allow to use MRI-results as predictor of effectiveness treatment in pediatric CD. Therapeutic option has an impact on time to recurrence, not on recurrence rates. The frequency of growth hormone and gonadotrophin deficiency was statistically higher after radiosurgery compared to TSS. Further studies are needed to identify predictors of remission and recurrence in CD.>< 0.01, Kruskel-Wallis ANOVA test). Diabetes insipidus was diagnosed only after TSS. CONCLUSION Results of our study didn`t allow to use MRI-results as predictor of effectiveness treatment in pediatric CD. Therapeutic option has an impact on time to recurrence, not on recurrence rates. The frequency of growth hormone and gonadotrophin deficiency was statistically higher after radiosurgery compared to TSS. Further studies are needed to identify predictors of remission and recurrence in CD.
Collapse
Affiliation(s)
- Э. А. Янар
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. В. Маказан
- Национальный медицинский исследовательский центр эндокринологии
| | - М. А. Карева
- Национальный медицинский исследовательский центр эндокринологии
| | - А. В. Воронцов
- Национальный медицинский исследовательский центр эндокринологии
| | | | | | - В. А. Петеркова
- Национальный медицинский исследовательский центр эндокринологии
| |
Collapse
|
7
|
Lin S, Han C, Lou X, Wu ZB. Hydroxychloroquine overcomes cabergoline resistance in a patient with Lactotroph Pituitary neuroendocrine tumor: a case report. Front Endocrinol (Lausanne) 2022; 13:955100. [PMID: 35983516 PMCID: PMC9379538 DOI: 10.3389/fendo.2022.955100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE A 22-year-old man complaining erectile dysfunction underwent transsphenoidal surgery for a 2.7 cm sellar mass with total resection and was confirmed at pathology to have a lactotroph pituitary neuroendocrine tumor (PiNET). Postoperatively, the patient's PRL remained at high level and therefore accepted high-dose dopamine receptor agonist (DA) therapy. After over 3 months of bromocriptine (BRC) (15mg/day) and over 3 years of cabergoline (CAB) (3mg/week) therapy, the patient's prolactin (PRL) never achieved long-term normalization. He was diagnosed with DA-resistant lactotroph PitNET. METHOD In this study, the patient was given hydroxychloroquine (HCQ) (200 mg/d) and CAB (3 mg/w) in combination for four months. His PRL level was tested by blood test every month. RESULTS Taking the combination therapy of HCQ and CAB, the patient's uncontrolled PRL level was normalized within one month and was maintained at the normal level thereafter. Pituitary magnetic resonance imaging (MRI) images with enhancement showed no recurrence. The patient also regained normal sexual function. DISCUSSION This is the first report on the combination of HCQ with CAB for the effective treatment of DA-resistant lactotroph pituitary neuroendocrine tumor in a patient, which might provide a novel treatment strategy for clinical management.
Collapse
Affiliation(s)
- Shaojian Lin
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Changxi Han
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohui Lou
- Department of Neurosurgery, Ruian People’s Hospital, The Third Affiliated Hospital of Wenzhou Medical University, Ruian, China
| | - Zhe Bao Wu
- Department of Neurosurgery, Center of Pituitary Tumor, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Zhe Bao Wu,
| |
Collapse
|
8
|
Sud S, Botticello T, Niemierko A, Daly J, Bussiere M, Shih HA. Dosimetric Comparison of Proton Versus Photon Radiosurgery for Treatment of Pituitary Adenoma. Adv Radiat Oncol 2021; 6:100806. [PMID: 34934865 PMCID: PMC8655425 DOI: 10.1016/j.adro.2021.100806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose To compare the dosimetric differences in stereotactic radiosurgery between use of passively scattered protons (PSRS) versus photons (XSRS) for pituitary adenomas. Methods and Materials Nine patients with pituitary adenomas were selected among patients receiving single-fraction proton stereotactic radiosurgery (PSRS) between 2016 and 2017. These cases were replanned with XSRS using volumetric-modulated arc therapy with 2.5 mm and 5 mm multileaf collimators (2.5XSRS and 5XSRS, respectively). PSRS was planned with a dedicated single scattering stereotactic proton unit delivered via 3 equally or unequally weighted isocentric fields. XSRS plans were created with optimization to spare organs at risk. Plans were generated using the original total treatment dose delivered in 1 fraction. Results Plans were evaluated for target volume dosimetry and estimated clinical toxicity. There was no significant difference in clinical target volume V100%, V95%, V90% or homogeneity index between treatment modalities. PSRS offered lower maximum dose (Dmax) to organs at risk and equivalent uniform dose (EUD) compared with 5XSRS and 2.5XSRS, respectively, for critical structures including optic nerve (right, Dmax 4.18, 5.32, 5.41; EUD 3.35, 4.08, 4.20) and hypothalamus (Dmax 1.71, 3.94, 3.77; EUD 0.94, 2.47, 2.39; P < .05 for PSRS vs 5XSRS and 2.5XSRS). The projected risk of secondary tumors in excess of baseline was lowest for PSRS plans (PSRS 5.28, 5XSRS 12.93, 2.5XSRS 12.66 cases per 10,000 patient-years; P = .008 for PSRS vs 5XSRS, PSRS vs 2.5XSRS, and P = .77 for 5XSRS vs 2.5XSRS). Conclusions We demonstrate that neither modality has empirically superior dosimetry and identify potential clinical advantages as well as limitations of each technique. PSRS, 5XSRS and 2.5XSRS demonstrate comparable target volume dosimetry for pituitary adenoma. PSRS compared with XSRS modalities offers modestly decreased maximum dose and EUD to critical proximal structures and decreases risk of radiation-induced secondary tumors by more than half.
Collapse
Affiliation(s)
- Shivani Sud
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Thomas Botticello
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrzej Niemierko
- Division of Biostatistics, Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jillian Daly
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc Bussiere
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
- Corresponding author: Helen A. Shih MD, MS, MPH.
| |
Collapse
|
9
|
Chang AY, Mirfakhraee S, King EE, Mercado JU, Donegan DM, Yuen KC. Mifepristone as Bridge or Adjunct Therapy in the Management of Challenging Cushing Disease Cases. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2021; 14:1179551421994102. [PMID: 33746521 PMCID: PMC7940725 DOI: 10.1177/1179551421994102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/20/2021] [Indexed: 11/16/2022]
Abstract
Establishing a definitive diagnosis of Cushing disease (CD), given its clinical and biochemical heterogeneity, initiating effective treatment to control the effects of hypercortisolism, and managing recurrence are challenging disease aspects to address. Mifepristone is a competitive glucocorticoid receptor antagonist that is approved in the US by the Food and Drug Administration to control hyperglycemia secondary to endogenous hypercortisolism (Cushing syndrome) in patients who have glucose intolerance or type 2 diabetes mellitus and have failed surgery or are not candidates for surgery. Herein, we describe 6 patients with CD who received mifepristone as adjunct/bridge therapy in the following clinical settings: to assess clinical benefits of treatment for suspected recurrent disease, to control hypercortisolism preoperatively for severe disease, to control hypercortisolism during the COVID-19 pandemic, and to provide adjunctive treatment to radiation therapy. The patients were treated at multiple medical practice settings. Mifepristone treatment in each of the described cases was associated with clinical improvements, including improvements in overall glycemia, hypertension, and weight loss. In addition, in one case where biochemical and radiological evidence of disease recurrence was uncertain, clinical improvement with mifepristone pointed toward likely disease recurrence. Adverse events associated with mifepristone reported in the 6 cases were consistent with those previously reported in the pivotal trial and included cortisol withdrawal symptoms, antiprogesterone effects (vaginal bleeding), hypothyroidism (treated with levothyroxine), and hypokalemia (treated with spironolactone). These cases show how mifepristone can potentially be utilized as a therapeutic trial in equivocal cases of CD recurrence; as a presurgical treatment strategy, particularly during the COVID-19 pandemic; and as bridge therapy, while awaiting the effects of radiation.
Collapse
Affiliation(s)
| | | | | | | | - Diane M Donegan
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kevin Cj Yuen
- Swedish Neuroscience Institute, Seattle, WA, USA.,Barrow Neurological Institute, Phoenix, AZ, USA
| |
Collapse
|
10
|
Abstract
External radiation therapy (RT) directed to the pituitary gland is generally recommended in patients with Cushing's disease (CD) as adjuvant to transsphenoidal surgery, among other second-line therapies offered to patients with residual or recurrent hypercortisolism (i.e., medical treatment, repeat surgery or bilateral adrenalectomy). RT is effective for the control of tumor growth, even in invasive tumors and in Nelson's syndrome. Progress in radiation stereotactic techniques lead to improved tumor targeting and radiation delivery, thus sparing the adjacent brain structures. Stereotactic RT is associated with a 55-65% rate of cortisol normalization after several months to a few years and potentially with a lower risk of long-term complications, compared with conventional RT. Cortisol-lowering medical therapy is recommended while awaiting the radiation effects. Hypopituitarism is the most frequent side-effect, damage to optic or cranial nerves or second brain tumors are rarely reported. This review presents the updates in the efficacy and safety of the stereotactic radiation techniques in CD patients. Practical points which should be considered by the clinician before recommending RT are also presented.
Collapse
Affiliation(s)
- Monica Livia Gheorghiu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; National Institute of Endocrinology C.I. Parhon, Bucharest, Romania.
| |
Collapse
|
11
|
Braun LT, Rubinstein G, Zopp S, Vogel F, Schmid-Tannwald C, Escudero MP, Honegger J, Ladurner R, Reincke M. Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment. Endocrine 2020; 70:218-231. [PMID: 32743767 PMCID: PMC7396205 DOI: 10.1007/s12020-020-02432-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient.
Collapse
Affiliation(s)
- Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Montserrat Pazos Escudero
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Klinikum der Universität München, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
| |
Collapse
|
12
|
Clinical management of patients with Cushing syndrome treated with mifepristone: consensus recommendations. Clin Diabetes Endocrinol 2020; 6:18. [PMID: 33292727 PMCID: PMC7596972 DOI: 10.1186/s40842-020-00105-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/01/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND While surgery is the first-line treatment for patients with endogenous hypercortisolism (Cushing syndrome [CS]), mifepristone has been shown to be a beneficial medical treatment option, as demonstrated in the SEISMIC (Study of the Efficacy and Safety of Mifepristone in the Treatment of Endogenous Cushing Syndrome) trial. Mifepristone is a competitive glucocorticoid receptor antagonist and progesterone receptor antagonist that is associated with several treatment effects and adverse events that clinicians need to be aware of when considering its use. The objective of this review was to provide updated clinical management recommendations for patients with CS treated with mifepristone. METHODS A panel of endocrinologists from the US with extensive experience in treating patients with CS, including with mifepristone, convened as part of a clinical advisory board to develop a consensus on the practical, real-world clinical management of patients on mifepristone. RESULTS Comprehensive considerations and recommendations are provided for managing mifepristone-associated effects, including symptoms of cortisol withdrawal, hypokalemia, and change in thyroid function; effects related to its antiprogesterone activity; and rash. Additional management strategies to address concomitant medications and special clinical situations, such as surgery and use in specific populations, are also provided. CONCLUSION Safe and effective use of mifepristone requires clinical judgment and close patient monitoring to ensure optimal clinical outcomes. These consensus recommendations provide useful, practical guidance to clinicians using mifepristone.
Collapse
|
13
|
Capatina C, Hinojosa-Amaya JM, Poiana C, Fleseriu M. Management of patients with persistent or recurrent Cushing's disease after initial pituitary surgery. Expert Rev Endocrinol Metab 2020; 15:321-339. [PMID: 32813595 DOI: 10.1080/17446651.2020.1802243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/24/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Treatment options for persistent and recurrent Cushing's disease (CD) include an individualized approach for repeat surgery, medical treatment, radiation therapy (RT), and bilateral adrenalectomy (BLA). AREAS COVERED In this expert opinion perspective, the authors review the latest treatment(s) for persistent/recurrent CD. A PubMed search was undertaken (English articles through May 2020) and relevant articles discussed. Repeat pituitary surgery should be considered in most patients with proven hypercortisolism; there is potential for cure with low risk of major complications. Medical therapy is valuable either alone, while awaiting the effects of RT, or in preparation for BLA. Medical therapy includes steroidogenesis inhibitors, agents that act at the pituitary or glucocorticoid receptor level, and novel agents in development. Radiation therapy has been used successfully to treat CD, but hypopituitarism risk and delayed efficacy (improved with radiosurgery) are major drawbacks. Laparoscopic BLA is safe and effective in patients with severe, difficult-to-manage hypercortisolism, but long-term follow-up is required as corticotroph tumor progression can develop. EXPERT OPINION Treatment of persistent/recurrent CD is challenging. Most patients require >1 therapy to achieve long-lasting remission. There is currently no ideal single treatment option that provides high and rapid efficacy, low adverse effects, and preserves normal pituitary-adrenal axis function.
Collapse
Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology , Bucharest, Romania
| | - José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University , Portland, Oregon, USA
- Endocrinology Division, Department of Medicine, Hospital Universitario Dr. José E. González, Universidad Autónoma De Nuevo León , Monterrey, Nuevo León, Mexico
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology , Bucharest, Romania
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University , Portland, Oregon, USA
| |
Collapse
|
14
|
Khattab MH, Sherry AD, Xu MC, Kelly P, Anderson JL, Luo G, Chambless LB, Cmelak AJ, Attia A. Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma. J Neurol Surg B Skull Base 2020; 82:e51-e58. [PMID: 34306917 DOI: 10.1055/s-0040-1710518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/14/2020] [Indexed: 10/24/2022] Open
Abstract
Objectives Hypofractionated stereotactic radiotherapy (HSRT) in two to five fractions may offer patients with large nonfunctioning pituitary adenomas (NFPAs) with chiasm involvement a safe and effective treatment over a single week. However, little has been reported regarding this novel approach. Design We compared the feasibility, outcomes, and toxicity of single-fraction stereotactic radiosurgery and HSRT. Setting This study was conducted at a tertiary academic referral center. Participants After approval by the institutional review board, we performed a retrospective cohort study of patients treated at our institution with stereotactic radiosurgery (SRS) and HSRT for NFPA. Selection for SRS or HSRT was based on clinicopathologic factors including tumor size and cavernous sinus invasion at the discretion of the treating physician. Main Outcome Measures Local control, endocrinopathy, and radiation-associated toxicity were evaluated by binary logistic regression and Cox's proportional hazards regression. Results A total of 45 patients with mean follow-up of 5 years were enrolled including 26 patients treated by HSRT with mean follow-up of 3 years and 19 patients treated by SRS with median follow-up of 6 years. Clinicopathologic characteristics were balanced between cohorts. Local failure at last follow-up was 5% in the SRS cohort and 8% in the HSRT cohort, and rates of post-SRS endocrinopathy were similar between each cohort. Late complications including radionecrosis, visual deficit, and secondary malignancy were minimal in either cohort. Conclusions HSRT is an appropriate treatment strategy for patients with NFPAs, particularly for optic pathway preservation in the setting of large tumors with chiasm involvement. Further studies are needed to optimize fractionated approaches and patient selection.
Collapse
Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Joshua L Anderson
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| |
Collapse
|
15
|
Treutwein M, Steger F, Loeschel R, Koelbl O, Dobler B. The influence of radiotherapy techniques on the plan quality and on the risk of secondary tumors in patients with pituitary adenoma. BMC Cancer 2020; 20:88. [PMID: 32013920 PMCID: PMC6998093 DOI: 10.1186/s12885-020-6535-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/13/2020] [Indexed: 12/20/2022] Open
Abstract
Background This planning study compares different radiotherapy techniques for patients with pituitary adenoma, including flatness filter free mode (FFF), concerning plan quality and secondary malignancies for potentially young patients. The flatness filter has been described as main source of photon scatter. Material and methods Eleven patients with pituitary adenoma were included. An Elekta Synergy™ linac was used in the treatment planning system Oncentra® and for the measurements. 3D plans, IMRT, and VMAT plans and non-coplanar varieties were considered. The plan quality was evaluated regarding homogeneity, conformity, delivery time and dose to the organs at risk. The secondary malignancy risk was calculated from dose volume data and from measured dose to the periphery using different models for carcinoma and sarcoma risk. Results The homogeneity and conformity were nearly unchanged with and without flattening filter, neither was the delivery time found substantively different. VMAT plans were more homogenous, conformal and faster in delivery than IMRT plans. The secondary cancer risk was reduced with FFF both in the treated region and in the periphery. VMAT plans resulted in a higher secondary brain cancer risk than IMRT plans, but the risk for secondary peripheral cancer was reduced. Secondary sarcoma risk plays a minor role. No advantage was found for non-coplanar techniques. The FFF delivery times were not shortened due to additional monitor units needed and technical limitations. The risk for secondary brain cancer seems to depend on the irradiated volume. Secondary sarcoma risk is much smaller than carcinoma risk in accordance to the results of the atomic bomb survivors. The reduction of the peripheral dose and resulting secondary malignancy risk for FFF is statistically significant. However, it is negligible in comparison to the risk in the treated region. Conclusion Treatments with FFF can reduce secondary malignancy risk while retaining similar quality as with flattening filter and should be preferred. VMAT plans show the best plan quality combined with lowest peripheral secondary malignancy risk, but highest level of second brain cancer risk. Taking this into account VMAT FFF seems the most advantageous technique for the treatment of pituitary adenomas with the given equipment.
Collapse
Affiliation(s)
- Marius Treutwein
- Department for radiotherapy, Regensburg University Medical Center, Regensburg, Germany.
| | - Felix Steger
- Department for radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Rainer Loeschel
- Faculty of computer science and mathematics, Ostbayerische Technische Hochschule, Regensburg, Germany
| | - Oliver Koelbl
- Department for radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Barbara Dobler
- Department for radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| |
Collapse
|
16
|
Solari D, Pivonello R, Caggiano C, Guadagno E, Chiaramonte C, Miccoli G, Cavallo LM, Del Basso De Caro M, Colao A, Cappabianca P. Pituitary Adenomas: What Are the Key Features? What Are the Current Treatments? Where Is the Future Taking Us? World Neurosurg 2020; 127:695-709. [PMID: 31266132 DOI: 10.1016/j.wneu.2019.03.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/05/2019] [Indexed: 12/18/2022]
Abstract
Pituitary tumors are a heterogeneous group of lesions (usually benign) and proper understanding of the anatomy, physiology, and pathology of the hypothalamic/pituitary region is essential to make an accurate diagnosis and define the essential treatment options (i.e., surgery, medical therapies, and radiotherapy, alone or in combination). Surgery is the primary treatment for acromegaly, Cushing disease, thyroid-stimulating hormone-secreting adenomas, resistant prolactinomas, and nonfunctioning pituitary adenomas causing mass effect. Medical and radiation therapy are reserved in cases in which surgery is not possible or does not provide a complete cure. In the last decades, tremendous innovations (i.e., targeted drugs and refined surgical tools and techniques) have expanded the treatment strategies for pituitary adenomas. We herein report the current indications for and depiction of the surgical techniques in pituitary surgery, review current medical treatments, and provide a glimpse of future possibilities.
Collapse
Affiliation(s)
- Domenico Solari
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | - Rosario Pivonello
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Chiara Caggiano
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Carmela Chiaramonte
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Miccoli
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Luigi M Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomedical Sciences, Section of Pathology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Annamaria Colao
- Division of Endocrinology, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
| |
Collapse
|
17
|
Thakkar K, Lila A, Sarathi V, Ramteke-Jadhav S, Goroshi M, Memon SS, Krishnatry R, Gupta T, Jalali R, Goel A, Shah A, Sankhe S, Patil V, Bandgar T, Shah NS. Cabergoline may act as a radioprotective agent in Cushing's disease. Clin Endocrinol (Oxf) 2020; 92:55-62. [PMID: 31698511 DOI: 10.1111/cen.14123] [Citation(s) in RCA: 10] [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] [Received: 06/29/2019] [Revised: 10/14/2019] [Accepted: 11/04/2019] [Indexed: 01/09/2023]
Abstract
CONTEXT Conventional fractionated radiotherapy (CRT) achieves control of pathological hypercortisolism in 75%-80% of patients with persistent or recurrent Cushing's disease (CD), over a mean period of 18-24 months. Medical therapy is recommended as bridge therapy while awaiting RT effect. OBJECTIVE To determine long-term outcome of CRT and its predictors in CD patients. DESIGN, SETTING AND PATIENTS This is a retrospective case record analysis of 42 patients with CD who received CRT as a treatment modality and had at least 12 months post-RT follow-up. The dose delivered was 45 Gy in 25 fractions over 5 weeks. Demographic details, hormonal evaluation and radiological data were extracted from case records. Dexamethasone suppressed cortisol at cut-off of 1.8 µg/dL was used to define remission or recurrence. Possible predictors for remission and recurrence were analysed. RESULTS The mean age at the time of CRT administration was 23.7 ± 10.7 (range: 12-48) years. A total of 29 (69%) patients achieved remission 26.5 ± 28.5 (median: 18, range: 3-120) months after RT, while 13 (31%) patients had persistent disease at last follow-up. There were no significant predictors of disease remission after CRT. Six (20.7%) patients had recurrence after a documented initial remission. Recurrence occurred 66.6 ± 25.9 (median: 74; range: 18 to 90) months after documented remission. Recurrence of the disease was exclusively seen in patients who received peri-RT cabergoline. Peri-CRT use of cabergoline was significantly associated with increased recurrence rates (P = .016). CONCLUSION Use of cabergoline in the peri-CRT period did not affect initial remission after CRT but was associated with increased recurrence after initial remission in CD.
Collapse
Affiliation(s)
- Kunal Thakkar
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Anurag Lila
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Narayana Medical College, Nellore, India
| | - Swati Ramteke-Jadhav
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Manjunath Goroshi
- Department of Endocrinology, JN Medical College and KLES Hospital, Belgaum, India
| | - Saba Samad Memon
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Tejpal Gupta
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Rakesh Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Apollo Hospitals, Chennai, India
| | - Atul Goel
- Department of Neurosurgery, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Abhidha Shah
- Department of Neurosurgery, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Shilpa Sankhe
- Department of Radiology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Virendra Patil
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| | - Nalini S Shah
- Department of Endocrinology, Seth G S Medical College & KEM Hospital, Mumbai, India
| |
Collapse
|
18
|
Sherry AD, Khattab MH, Xu MC, Kelly P, Anderson JL, Luo G, Utz AL, Chambless LB, Cmelak AJ, Attia A. Outcomes of stereotactic radiosurgery and hypofractionated stereotactic radiotherapy for refractory Cushing's disease. Pituitary 2019; 22:607-613. [PMID: 31552580 DOI: 10.1007/s11102-019-00992-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Hypofractionated stereotactic radiotherapy (HSRT) for refractory Cushing's disease may offer a condensed treatment schedule for patients with large tumors abutting the optic chiasm unsuitable for stereotactic radiosurgery (SRS). To-date only four patients have been treated by HSRT in the published literature. We investigated the feasibility, toxicity, and efficacy of HSRT compared to SRS. METHODS After approval, we retrospectively evaluated patients treated at our institution for refractory Cushing's disease with SRS or HSRT. Study outcomes included biochemical control, time to biochemical control, local control, and late complications. Binary logistic regression and Cox proportional hazards regression evaluated predictors of outcomes. RESULTS Patients treated with SRS (n = 9) and HSRT (n = 9) were enrolled with median follow-up of 3.4 years. Clinicopathologic details were balanced between the cohorts. Local control was 100% in both cohorts. Time to biochemical control was 6.6. and 9.5 months in the SRS and HSRT cohorts, respectively (p = 0.6258). Two patients in each cohort required salvage bilateral adrenalectomy. Late complications including secondary malignancy, radionecrosis, cranial nerve neuropathy, and optic pathway injury were minimal for either cohort. CONCLUSIONS HSRT is an appropriate treatment approach for refractory Cushing's disease, particularly for patients with large tumors abutting the optic apparatus. Prospective studies are needed to validate these findings and identify factors suggesting optimal fractionation approaches.
Collapse
Affiliation(s)
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA.
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
| | - Andrea L Utz
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Diabetes, Endocrinology & Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Pituitary Center, Nashville, TN, USA
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
19
|
Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
Collapse
Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
| |
Collapse
|
20
|
Abstract
Cushing's disease (CD) is caused by a pituitary tumour that secretes adrenocorticotropin (ACTH) autonomously, leading to excess cortisol secretion from the adrenal glands. The condition is associated with increased morbidity and mortality that can be mitigated by treatments that result in sustained endocrine remission. Transsphenoidal pituitary surgery (TSS) remains the mainstay of treatment for CD but requires considerable neurosurgical expertise and experience in order to optimize patient outcomes. Up to 90% of patients with microadenomas (tumour below 1 cm in largest diameter) and 65% of patients with macroadenomas (tumour at or above 1 cm in greatest diameter) achieve endocrine remission after TSS by an experienced surgeon. Patients who are not in remission postoperatively or those who relapse may benefit from undergoing a second pituitary operation. Alternatively, radiation therapy to the sella with interim medical therapy, or bilateral adrenalectomy, can be effective as definitive treatments of CD. Medical therapy is currently adjunctive in most patients with CD and is generally prescribed to patients who are about to receive radiation therapy and will be awaiting its salutary effects to occur. Available treatment options include steroidogenesis inhibitors, centrally acting agents and glucocorticoid receptor antagonists. Several novel agents are in clinical trials and may eventually constitute additional treatment options for this serious condition.
Collapse
Affiliation(s)
- N A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
21
|
Albano L, Losa M, Nadin F, Barzaghi LR, Parisi V, Del Vecchio A, Bolognesi A, Mortini P. Safety and efficacy of multisession gamma knife radiosurgery for residual or recurrent pituitary adenomas. Endocrine 2019; 64:639-647. [PMID: 30798432 DOI: 10.1007/s12020-019-01876-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To define the efficacy and complications of multisession Gamma Knife radiosurgery (MGKRS) delivered in three consecutive sessions for the treatment of residual or recurrent pituitary adenomas (PAs). METHODS This was a retrospective study of data from the Neurosurgery and Gamma Knife Radiosurgery Department at San Raffaele Hospital between May 2008 and September 2017. We recruited 47 consecutive patients undergoing MGKRS in three consecutive fractions for residual or recurrent PA with a distance from the anterior optic pathway inferior to 2-3 mm. RESULTS Thirty-eight (80.8%) patients had a nonfunctioning-PA (NFPA) while 9 (19.2%) had a hormone-secreting PA (HSPA). Tumor control was achieved in 100% of patients. Tumor shrinkage was seen in 33 out of 44 (75.0%) patients with a radiological follow-up. Mean tumor volume before MGKRS was 3.93 cm3. The mean tumor volume at last follow-up was 2.11 cm3, with a mean tumor shrinkage of 50.2%, as compared with baseline. One case of suspected radiation-induced optic neuropathy (RION) was documented while new-onset hypopituitarism for any axis occurred in 12 of the 31 (38.7%) patients at risk. The mean follow-up was 44.6 ± 4.0 months (range, 6-111 months). CONCLUSIONS MGKRS is a valid alternative to external fractionated radiotherapy and other types of stereotactic radiosurgery for the treatment of PAs, achieving a high tumor control rate with a low risk of visual deterioration. Moreover, the majority of patients showed a significant reduction of tumor size in the long term.
Collapse
Affiliation(s)
- Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Francesco Nadin
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Veronica Parisi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Angelo Bolognesi
- Department of Radiation therapy, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| |
Collapse
|
22
|
Hughes JD, Young WF, Chang AY, Link MJ, Garces YI, Laack NN, Thompson GB, Pollock BE. Radiosurgical Management of Patients With Persistent or Recurrent Cushing Disease After Prior Transsphenoidal Surgery: A Management Algorithm Based on a 25-Year Experience. Neurosurgery 2019; 86:557-564. [PMID: 31140563 DOI: 10.1093/neuros/nyz159] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 01/12/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joshua D Hughes
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - William F Young
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Alice Y Chang
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Department of Otorhinolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Yolanda I Garces
- Division of Endocrinology, Diabetes, and Metabolism, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Nadia N Laack
- Division of Endocrinology, Diabetes, and Metabolism, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Geoffrey B Thompson
- Division of Breast, Endocrine, Metabolic, and Gastrointestinal Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Division of Endocrinology, Diabetes, and Metabolism, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| |
Collapse
|
23
|
Castinetti F, Brue T, Ragnarsson O. Radiotherapy as a tool for the treatment of Cushing's disease. Eur J Endocrinol 2019; 180:D9-D18. [PMID: 30970325 DOI: 10.1530/eje-19-0092] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/03/2019] [Indexed: 11/08/2022]
Abstract
Treatment of Cushing's disease (CD) is one of the most challenging tasks in endocrinology. The first-line treatment, transsphenoidal pituitary surgery, is associated with a high failure rate and a high prevalence of recurrence. Re-operation is associated with an even higher rate of a failure and recurrence. There are three main second-line treatments for CD - pituitary radiation therapy (RT), bilateral adrenalectomy and chronic cortisol-lowering medical treatment. All these treatments have their limitations. While bilateral adrenalectomy provides permanent cure of the hypercortisolism in all patients, the unavoidable chronic adrenal insufficiency and the risk of development of Nelson syndrome are of concern. Chronic cortisol-lowering medical treatment is not efficient in all patients and side effects are often a limiting factor. RT is efficient for approximately two-thirds of all patients with CD. However, the high prevalence of pituitary insufficiency is of concern as well as potential optic nerve damage, development of cerebrovascular disease and secondary brain tumours. Thus, when it comes to decide appropriate treatment for patients with CD, who have either failed to achieve remission with pituitary surgery, or patients with recurrence, the pros and cons of all second-line treatment options must be considered.
Collapse
Affiliation(s)
- Frederic Castinetti
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Marseille Medical Genetics, Marseille, France
- Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille, Hôpital de la Conception, Centre de Référence des Maladies Rares de l'hypophyse, Marseille, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Marseille Medical Genetics, Marseille, France
- Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille, Hôpital de la Conception, Centre de Référence des Maladies Rares de l'hypophyse, Marseille, France
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| |
Collapse
|
24
|
Abstract
Radiation therapy (RT) is an effective treatment for patients with either nonfunctioning or secreting pituitary adenomas unsuccessfully treated by surgery and/or medical therapy, resulting in local control of 90-95% at 5-10 years and variable normalization of hormonal hypersecretion for patients with GH-, ACTH-, and prolactin-secreting adenomas in the range of 40-80% at 5 years; however, its use has been limited because of concerns regarding potential late toxicity of radiation and delayed efficacy in normalization of hormone hypersecretion. In the last decades, there have been advances in all aspects of radiation treatment, including more accurate immobilization, imaging, treatment planning and dose delivery. RT has evolved with the development of highly conformal stereotactic techniques and new planning and dose delivery techniques, including intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT). All these new techniques allow precise and sharply focused radiation delivery reducing the dose to surrounding critical neurovascular and brain structures, and potentially limiting the long-term consequences of radiation treatments. In this review, we present a critical analysis of the more recent available literature on the use of RT in patients with both nonfunctioning and secreting pituitary adenomas, focussing particularly on the risk/benefit ratio of modern radiation techniques.
Collapse
Affiliation(s)
- Giuseppe Minniti
- Radiation Unit, UPMC Hillman Cancer Center, San Pietro Hospital, Rome, Italy.
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
25
|
Shrivastava A, Mohammed N, Xu Z, Liščák R, Kosak M, Krsek M, Karim KA, Lee CC, Martínez-Moreno N, Lee Vance M, Lunsford LD, Sheehan JP. Outcomes After Gamma Knife Stereotactic Radiosurgery in Pediatric Patients with Cushing Disease or Acromegaly: A Multi-Institutional Study. World Neurosurg 2019; 125:e1104-e1113. [PMID: 30790739 DOI: 10.1016/j.wneu.2019.01.252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Pituitary adenomas comprise about 3% of all intracranial tumors in pediatric patients. This study examines the role of stereotactic radiosurgery in the management of pediatric acromegaly or patients with Cushing disease (CD). METHODS From an international consortium, we retrospectively collected treatment and outcome data on pediatric adrenocorticotrophic hormone and growth hormone-secreting pituitary adenomas treated with Gamma Knife radiosurgery (GKRS). There were a total of 36 patients including 24 with CD and 12 with acromegaly. The data were analyzed to assess outcomes including tumor control, endocrine remission, and adverse effects. Statistical analysis was performed to determine correlation between clinical/treatment parameters and outcomes. RESULTS At the last follow-up after GKRS, endocrine remission rates for CD and acromegaly were 80% and 42%, respectively. Tumor control was achieved in 87.5% of patients with CD and in 42% of patients with acromegaly. New pituitary hormone deficiency occurred in 7 of the 36 patients at a median time of 18 months after GKRS (range, 12-81 months). The predictive factors for endocrine remission were age <15 years (P = 0.015) and margin dose (P = 0.042). The median endocrine follow-up was 63.7 months (range, 7-246 months). CONCLUSIONS GKRS affords reasonable rates of endocrine remission and tumor control in most pediatric patients with functioning adenomas. The most common post-GKRS complication was hypopituitarism, although this occurred in only a few patients. Given the larger at-risk period for pediatric patients, further study is required to evaluate for delayed recurrences and hypopituitarism.
Collapse
Affiliation(s)
- Adesh Shrivastava
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Nasser Mohammed
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Zhiyuan Xu
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Roman Liščák
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, USA
| | - Mikulas Kosak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, USA
| | - Michal Krsek
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, USA
| | | | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veteran General Hospital, Taiwan, USA
| | - Nuria Martínez-Moreno
- Department of Neurological Surgery and Gamma Knife Radiosurgery, Ruber International Hospital, Madrid, USA
| | - Mary Lee Vance
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
| |
Collapse
|
26
|
Shepard MJ, Mehta GU, Xu Z, Kano H, Sisterson N, Su YH, Krsek M, Nabeel AM, El-Shehaby A, Kareem KA, Martinez-Moreno N, Mathieu D, McShane BJ, Blas K, Kondziolka D, Grills I, Lee JY, Martinez-Alvarez R, Reda WA, Liscak R, Lee CC, Lunsford LD, Lee Vance M, Sheehan JP. Technique of Whole-Sellar Stereotactic Radiosurgery for Cushing Disease: Results from a Multicenter, International Cohort Study. World Neurosurg 2018; 116:e670-e679. [DOI: 10.1016/j.wneu.2018.05.067] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 11/25/2022]
|
27
|
Maldaner N, Serra C, Tschopp O, Schmid C, Bozinov O, Regli L. [Modern Management of Pituitary Adenomas - Current State of Diagnosis, Treatment and Follow-Up]. PRAXIS 2018; 107:825-835. [PMID: 30043702 DOI: 10.1024/1661-8157/a003035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Modern Management of Pituitary Adenomas - Current State of Diagnosis, Treatment and Follow-Up Abstract. Pituitary adenomas (PA) are benign neoplasms originating from parenchymal cells of the anterior pituitary. Tumor mass effect can cause headaches, visual deficits by compression of the optic chiasm, and partial or complete hypopituitarism. Hormone secreting PA can cause several forms of specific syndromes such as Cushing's disease or acromegaly depending on the type of hormone. Endoscopic transsphenoidal resection is the preferred treatment option for most symptomatic or growing PA. Nowadays techniques like high definition intraoperative MRI can assist the surgeon in his goal of maximal safe resection. An exception are prolactinomas which can usually be treated medically with dopamine agonists. Therapy of PA is complex and should be managed in a high-volume center with an interdisciplinary team approach including neurosurgeons and endocrinologists.
Collapse
Affiliation(s)
- Nicolai Maldaner
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Carlo Serra
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Oliver Tschopp
- 2 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
| | - Christoph Schmid
- 2 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
| | - Oliver Bozinov
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| | - Luca Regli
- 1 Klinik für Neurochirurgie, Klinisches Neurozentrum, Universitätsspital Zürich
| |
Collapse
|
28
|
Hypopituitarism After Single-Fraction Pituitary Adenoma Radiosurgery: Dosimetric Analysis Based on Patients Treated Using Contemporary Techniques. Int J Radiat Oncol Biol Phys 2018; 101:618-623. [DOI: 10.1016/j.ijrobp.2018.02.169] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/19/2018] [Accepted: 02/28/2018] [Indexed: 11/18/2022]
|
29
|
Ironside N, Chen CJ, Lee CC, Trifiletti DM, Vance ML, Sheehan JP. Outcomes of Pituitary Radiation for Cushing's Disease. Endocrinol Metab Clin North Am 2018; 47:349-365. [PMID: 29754636 DOI: 10.1016/j.ecl.2018.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Achievement of biochemical remission with preservation of normal pituitary function is the goal of treatment for Cushing's disease. For patients with persistent or recurrent Cushing's disease after transsphenoidal resection, radiation therapy may be a safe and effective treatment. Stereotactic radiosurgery is favored over conventional fractionated external beam radiation. Hormonal recurrence rates range from 0% to 36% at 8 years after treatment. Tumor control rates are high. New pituitary hormone deficiency is the most common adverse effect after stereotactic radiosurgery and external beam radiation. The effects of radiation planning optimization and use of adjuvant medication on endocrine remission rates warrant investigation.
Collapse
Affiliation(s)
- Natasha Ironside
- Department of Neurosurgery, Auckland City Hospital, Private Bag 92 024, Auckland Mail Center, Auckland 1142, New Zealand
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, PO Box 800-212, Charlottesville, VA 22908, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, 17 Floor, No. 201, Sec. 2, Shipai Road, Beitou District, Taipei 11217, Taiwan
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Mary Lee Vance
- Division of Endocrinology and Metabolism, University of Virginia Health System, 2 Floor, Suite 2100, 415 Ray C Hunt Drive, Charlottesville, VA 22908, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, PO Box 800-212, Charlottesville, VA 22908, USA.
| |
Collapse
|
30
|
Radiation Therapy in Tumors of the Pituitary Gland. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_6-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
31
|
Barber SM, Teh BS, Baskin DS. Fractionated Stereotactic Radiotherapy for Pituitary Adenomas: Single-Center Experience in 75 Consecutive Patients. Neurosurgery 2017; 79:406-17. [PMID: 26657072 DOI: 10.1227/neu.0000000000001155] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Early results of postoperative fractionated stereotactic radiotherapy (FSRT) for functional and nonfunctional pituitary adenomas appear promising, but the majority of available evidence draws from small series with insufficient follow-up data to draw meaningful conclusions. OBJECTIVE To evaluate the long-term outcomes of a large series of patients undergoing FSRT for both functional and nonfunctional pituitary adenomas with the Novalis system (BrainLAB, Heimstetten, Germany). METHODS Chart data for 75 consecutive patients undergoing FSRT for a pituitary tumor (21 functional and 54 nonfunctional adenomas) at our institution between January 2004 and June 2013 were reviewed. RESULTS Radiographic progression-free survival was 100% over a mean of 47.8 months of radiographic follow-up (range, 12.0-131.2 months). Hormonal normalization was seen in 69.2% of patients with functional adenomas after FSRT, whereas 30.8% experienced partial hormonal control. Mild, grade I acute adverse effects were observed during radiotherapy treatment in 36 patients (48%), and objective, persistent worsening of vision occurred in a single patient (1.5%) after FSRT. New hormonal deficits were seen in 28.0% of patients after FSRT. Radiographic responses were inversely related to tumor volume. CONCLUSION FSRT delivers radiographic and functional outcomes similar to those seen with stereotactic radiosurgery and conventional radiotherapy with less resultant toxicity. FSRT is most beneficial for smaller tumors (those <3 cm in diameter). ABBREVIATIONS EBRT, external beam radiotherapyFSRT, fractionated stereotactic radiotherapyOR, odds ratioPTV, planning target volumeSRS, stereotactic radiosurgery.
Collapse
Affiliation(s)
- Sean M Barber
- *Houston Methodist Neurological Institute, Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; ‡Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas; §Kenneth R. Peak Brain and Pituitary Tumor Treatment Center, Houston Methodist Hospital, Houston, Texas
| | | | | |
Collapse
|
32
|
Mehta GU, Ding D, Patibandla MR, Kano H, Sisterson N, Su YH, Krsek M, Nabeel AM, El-Shehaby A, Kareem KA, Martinez-Moreno N, Mathieu D, McShane B, Blas K, Kondziolka D, Grills I, Lee JY, Martinez-Alvarez R, Reda WA, Liscak R, Lee CC, Lunsford LD, Vance ML, Sheehan JP. Stereotactic Radiosurgery for Cushing Disease: Results of an International, Multicenter Study. J Clin Endocrinol Metab 2017; 102:4284-4291. [PMID: 28938462 DOI: 10.1210/jc.2017-01385] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 08/24/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Cushing disease (CD) due to adrenocorticotropic hormone-secreting pituitary tumors can be a management challenge. OBJECTIVE To better understand the outcomes of stereotactic radiosurgery (SRS) for CD and define its role in management. DESIGN International, multicenter, retrospective cohort analysis. SETTING Ten medical centers participating in the International Gamma Knife Research Foundation. PATIENTS Patients with CD with >6 months endocrine follow-up. INTERVENTION SRS using Gamma Knife radiosurgery. MAIN OUTCOME MEASURES The primary outcome was control of hypercortisolism (defined as normalization of free urinary cortisol). Radiologic response and adverse radiation effects (AREs) were recorded. RESULTS In total, 278 patients met inclusion criteria, with a mean follow-up of 5.6 years (0.5 to 20.5 years). Twenty-two patients received SRS as a primary treatment of CD. Mean margin dose was 23.7 Gy. Cumulative initial control of hypercortisolism was 80% at 10 years. Mean time to cortisol normalization was 14.5 months. Recurrences occurred in 18% with initial cortisol normalization. Overall, the rate of durable control of hypercortisolism was 64% at 10 years and 68% among patients who received SRS as a primary treatment. AREs included hypopituitarism (25%) and cranial neuropathy (3%). Visual deficits were related to treatment of tumor within the suprasellar cistern (P = 0.01), whereas both visual (P < 0.0001) and nonvisual cranial neuropathy (P = 0.02) were related to prior pituitary irradiation. CONCLUSIONS SRS for CD is well tolerated and frequently results in control of hypercortisolism. However, recurrences can occur. SRS should be considered for patients with persistent hypercortisolism after pituitary surgery and as a primary treatment in those unfit for surgery. Long-term endocrine follow-up is essential after SRS.
Collapse
Affiliation(s)
- Gautam U Mehta
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Dale Ding
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Mohana Rao Patibandla
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Hideyuki Kano
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Nathaniel Sisterson
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Yan-Hua Su
- Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan, Republic of China
| | - Michal Krsek
- Second Department of Medicine, Third Faculty of Medicine of the Charles University, Faculty Hospital Kralovske Vinohrady, 11636 Prague, Czech Republic
| | - Ahmed M Nabeel
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Benha University, Benha, Egypt 11566
| | - Amr El-Shehaby
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Khaled A Kareem
- Clinical Oncology Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Nuria Martinez-Moreno
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, 28034 Madrid, Spain
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec J1H 5N4, Canada
| | - Brendan McShane
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Kevin Blas
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan 48073
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Lagone, Medical Center, New York, New York 10016
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan 48073
| | - John Y Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Roberto Martinez-Alvarez
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, 28034 Madrid, Spain
| | - Wael A Reda
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, 11636 Prague, Czech Republic
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan, Republic of China
| | - L Dade Lunsford
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Mary Lee Vance
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Jason P Sheehan
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| |
Collapse
|
33
|
Zibar Tomšić K, Dušek T, Kraljević I, Heinrich Z, Solak M, Vučinović A, Ozretić D, Mihailović Marasanov S, Hršak H, Kaštelan D. Hypopituitarism after gamma knife radiosurgery for pituitary adenoma. Endocr Res 2017; 42:318-324. [PMID: 28537768 DOI: 10.1080/07435800.2017.1323913] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of the study was to investigate the incidence of and risk factors for hypopituitarism after gamma knife radiosurgery (GKRS) for pituitary adenoma. MATERIALS AND METHODS We conducted a retrospective analysis of the pituitary function of 90 patients who underwent GKRS for pituitary adenoma at the University Hospital Centre Zagreb between 2003 and 2014. Twenty seven of them met the inclusion criteria and the others were excluded from the study due to pituitary insufficiency which was present before GKRS. Eighteen patients had non-functioning and 9 patients had secretory adenomas. Median patients' age was 56 years (24-82). GKRS was performed using the Leksell gamma knife Model C. The median prescription radiation dose was 20 Gy (15-25) and the median tumor volume size was 3.4 cm3 (0.06-16.81). New onset hypopituitarism was defined as a new deficit of one of the three hormonal axes (corticotroph, thyreotroph, or gonadotroph) ≥3 months following GKRS. SPSS was used for statistical analysis, with the significance level at P<0.05. RESULTS During the median follow-up period of 72 months (range 6-144), 30% of patients developed new hypopituitarism after GKRS. This corresponds to incidence of one new case of hypopituitarism per 15 patient-years. Age, gender, tumor function, tumor volume, suprasellar extension, prescription dose of radiation, as well as dose-volume to the pituitary gland, stalk and hypothalamus were not predictive factors for the development of hypopituitarism. CONCLUSIONS In our cohort of patients with pituitary tumors who underwent GKRS, 30% developed new hypopituitarism during the follow-up period.
Collapse
Affiliation(s)
- Karin Zibar Tomšić
- a Vuk Vrhovac University Clinic for Diabetes , Endocrinology and Metabolic Diseases, Merkur University Hospital , Dugi Dol 4a, Zagreb , Croatia
| | - Tina Dušek
- b Department of Endocrinology , University Hospital Centre Zagreb , Zagreb , Croatia
- c School of Medicine , University of Zagreb , Zagreb , Croatia
| | - Ivana Kraljević
- b Department of Endocrinology , University Hospital Centre Zagreb , Zagreb , Croatia
| | - Zdravko Heinrich
- d Department of Neurosurgery , Gamma Knife Centre Zagreb, University Hospital Centre Zagreb , Zagreb , Croatia
| | - Mirsala Solak
- b Department of Endocrinology , University Hospital Centre Zagreb , Zagreb , Croatia
| | - Ana Vučinović
- e Department of Ophthalmology , University Hospital Centre Split , Spinciceva 1, 21000 , Split
| | - David Ozretić
- c School of Medicine , University of Zagreb , Zagreb , Croatia
- f Department of Diagnostic and Interventional Radiology , University Hospital Centre Zagreb , Kispaticeva 12, 10000 Zagreb , Croatia
| | - Sergej Mihailović Marasanov
- d Department of Neurosurgery , Gamma Knife Centre Zagreb, University Hospital Centre Zagreb , Zagreb , Croatia
| | - Hrvoje Hršak
- g Department of Medical Physics , Gamma Knife Centre Zagreb, University Hospital Centre Zagreb , Zagreb , Croatia
| | - Darko Kaštelan
- b Department of Endocrinology , University Hospital Centre Zagreb , Zagreb , Croatia
- c School of Medicine , University of Zagreb , Zagreb , Croatia
| |
Collapse
|
34
|
A Rapid Biochemical and Radiological Response to the Concomitant Therapy with Temozolomide and Radiotherapy in an Aggressive ACTH Pituitary Adenoma. Case Rep Endocrinol 2017; 2017:2419590. [PMID: 28357143 PMCID: PMC5357528 DOI: 10.1155/2017/2419590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/05/2017] [Accepted: 02/13/2017] [Indexed: 12/14/2022] Open
Abstract
Background and Importance. In the last eight years temozolomide (TMZ) has been used as the last-line treatment modality for aggressive pituitary tumors to be applied after the failure of surgery, medical therapy, and radiotherapy. The objective was to achieve a rapid control of tumor growth and hormone normalization with concurrent chemoradiotherapy in a patient with very aggressive ACTH pituitary adenoma. Clinical Presentation. We describe a patient with an aggressive ACTH-producing adenoma treated with concurrent temozolomide and radiotherapy. The patient suffered from an aggressive ACTH adenoma resistant to surgical and medical treatment. After two months of concurrent temozolomide and radiotherapy, cortisol normalization and significant tumor shrinkage were observed. After 22 months of follow-up, there is still no evidence of tumor recurrence. Conclusion. Concurrent treatment with temozolomide and irradiation appears to be highly effective in the achievement of the tumor volume control as well as in the control of ACTH secretion in aggressive ACTH adenoma.
Collapse
|
35
|
Gheorghiu ML, Fleseriu M. STEREOTACTIC RADIATION THERAPY IN PITUITARY ADENOMAS, IS IT BETTER THAN CONVENTIONAL RADIATION THERAPY? ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:476-490. [PMID: 31149219 DOI: 10.4183/aeb.2017.476] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Pituitary radiotherapy (RT) has undergone important progress in the last decades due to the development of new stereotactic techniques which provide more precise tumour targeting with less overall radiation received by the adjacent brain structures. Pituitary surgery is usually first-line therapy in most patients with nonfunctioning (NFPA) and functioning adenomas (except for prolactinomas and large growth hormone (GH) secreting adenomas), while RT is used as second or third-line therapy. The benefits of RT (tumour volume control and, in functional tumours, decreased hormonal secretion) are hampered by the long latency of the effect and the potential side effects. This review presents the updates in the efficacy and safety of the new stereotactic radiation techniques in patients with NFPA, GH-, ACTH- or PRL-secreting pituitary adenomas. Methods A systematic review was performed using PubMed and articles/abstracts and reviews detailing RT in pituitary adenomas from 2000 to 2017 were included. Results Stereotactic radiosurgery (SRS) and fractionated stereotactic RT (FSRT) provide high rates of tumour control i.e. stable or decrease in tumour size, in all types of pituitary adenomas (median 92 - 98%) at 5 years. Endocrinological remission is however significantly lower: 44-52% in acromegaly, 54-64% in Cushing's disease and around 30% in prolactinomas at 5 years. The rate of new hypopituitarism varies from 10% to 50% at 5 years in all tumour types and as expected increases with the duration of follow-up (FU). The risk for other radiation-induced complications is usually low (0-5% for new visual deficits, cranial nerves damage or brain radionecrosis and extremely low for secondary brain tumours), however longer FU is needed to determine rates of secondary tumours. Notably, in acromegaly, there may be a higher risk for stroke with FSRT. Conclusion Stereotactic radiotherapy can be an effective treatment option for patients with persistent or recurrent pituitary adenomas after unsuccessful surgery (especially if residual tumour is enlarging) and/or resistance or unavailability of medical therapy. Comparison with conventional radiation therapy (CRT) is rather difficult, due to the substantial heterogeneity of the studies. In order to evaluate the potential brain-sparing effect of the new stereotactic techniques, suggested by the current data, long-term studies evaluating secondary morbidity and mortality are needed.
Collapse
Affiliation(s)
- M L Gheorghiu
- "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - M Fleseriu
- Oregon Health & Science University, Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Portland, USA
| |
Collapse
|
36
|
Aggressive Pituitary Adenomas: The Dark Side of the Moon. World Neurosurg 2017; 97:140-155. [DOI: 10.1016/j.wneu.2016.09.092] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/18/2016] [Accepted: 09/23/2016] [Indexed: 01/14/2023]
|
37
|
Minniti G, Osti MF, Niyazi M. Target delineation and optimal radiosurgical dose for pituitary tumors. Radiat Oncol 2016; 11:135. [PMID: 27729088 PMCID: PMC5057503 DOI: 10.1186/s13014-016-0710-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/01/2016] [Indexed: 11/10/2022] Open
Abstract
Stereotactic radiosurgery (SRS) delivered as either single-fraction or multi-fraction SRS (2–5 fractions) is frequently employed in patients with residual or recurrent pituitary adenoma. The most common delivery systems used for SRS include the cobalt-60 system Gamma Knife, the CyberKnife (CK) robotic radiosurgery system, or a modified conventional radiotherapy machine (linear accelerator, LINAC). Tumor control and normalization of hormone hypersecretion have been reported in 75–100 % and 25–80 % of patients, respectively. Hypopituitarism is the most commonly reported late complication of radiation treatment, whereas other toxicities occur less frequently. We have provided an overview of the recent available literature on SRS in patients with a pituitary adenoma. Critical aspects of pituitary irradiation, including target delineation and doses to organs at risk, optimal radiation dose, as well as the long-term efficacy and toxicity of SRS for either nonfunctioning or secreting pituitary adenomas are discussed. Single-fraction SRS represents an effective treatment for patients with a pituitary adenoma; however, caution should be used for lesions > 2.5–3 cm in size and/or involving the anterior optic pathway. Future studies will be necessary to optimize target doses and critical organ dose constrains in order to reduce the long-term toxicity of treatments while maintaining high efficacy.
Collapse
Affiliation(s)
- Giuseppe Minniti
- Unit of Radiation Oncology, Sant' Andrea Hospital, University Sapienza, Rome, Italy. .,IRCCS Neuromed, Pozzilli (IS), Italy.
| | | | | |
Collapse
|
38
|
Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 288] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
Collapse
Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| |
Collapse
|
39
|
Marek J, Ježková J, Hána V, Kršek M, Liščák R, Vladyka V, Pecen L. Gamma knife radiosurgery for Cushing's disease and Nelson's syndrome. Pituitary 2015; 18:376-84. [PMID: 25008022 DOI: 10.1007/s11102-014-0584-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE This paper presents our 18 years of experience in treating ACTH secreting adenomas (Cushing's disease and Nelson's syndrome) using the Leksell gamma knife (LGK) irradiation. METHODS Twenty-six patients with Cushing's disease were followed-up after LGK irradiation for 48-216 months (median 78 months). Seventeen patients had undergone previous surgery, in nine patients LGK irradiation was the primary therapy. Furthermore, 14 patients with Nelson's syndrome were followed-up for 30-204 months (median 144 months). RESULTS LGK treatment resulted in hormonal normalization in 80.7 % of patients with Cushing's disease. Time to normalization was 6-54 months (median 30 months). The volume of the adenoma decreased in 92.3% (in 30.7% disappeared completely). There was no recurrence of the disease. In all 14 patients with Nelson's syndrome ACTH levels decreased (in two patients fully normalized) their ACTH levels. When checked up 5-10 years after irradiation regrowth of the adenoma was only detected in one patient (9.1%), in 27.3% adenoma volume remained unchanged, in 45.4% adenoma volume decreased and in 18.2% adenoma completely disappeared. Hypopituitarism did not develop in any patient where the critical dose to the pituitary and distal infundibulum was respected. CONCLUSION LGK radiation represents an effective and well-tolerated option for the treatment of patients with Cushing's disease after unsuccessful surgery and may be valuable even as a primary treatment in patients who are not suitable for, or refuse, surgery. In the case of Nelson's syndrome it is possible to impede tumorous growth and control the size of the adenoma in almost all patients.
Collapse
Affiliation(s)
- Josef Marek
- Third Department of Medicine, First Medical Faculty, Charles University, U nemocnice 1, 128 02, Prague 2, Czech Republic
| | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Radiation therapy is widely used in the management of intracranial (including sellar and parasellar) and systemic disorders. Although in many cases the irradiation aims to prevent the growth or regrowth and to control the hormonal hypersecretion of a pituitary tumor, in many others it adversely affects the hypothalamo-pituitary function simply because this area receives significant doses of radiation delivered for non-hypothalamo-pituitary disorders. The main long-term complications include hypopituitarism, optic neuropathy, cerebrovascular morbidity, and second brain tumors. Radiation technique and schedule are important determinants of these adverse effects.
Collapse
Affiliation(s)
- Georgia Ntali
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, UK
| | - Niki Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, UK.
| |
Collapse
|
41
|
Minniti G, Clarke E, Scaringi C, Enrici RM. Stereotactic radiotherapy and radiosurgery for non-functioning and secreting pituitary adenomas. Rep Pract Oncol Radiother 2014; 21:370-8. [PMID: 27330422 DOI: 10.1016/j.rpor.2014.09.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/28/2014] [Accepted: 09/16/2014] [Indexed: 11/18/2022] Open
Abstract
Radiotherapy (RT) is frequently employed in patients with residual or recurrent pituitary adenoma with excellent rates of tumor control and remission of hormonal hypersecretion. Advances in RT have improved with the use of stereotactic techniques either as fractionated stereotactic radiotherapy (FSRT) or stereotactic radiosurgery (SRS), all aiming to improve the dose distribution to the tumor while reducing the amount of normal brain receiving significant doses of radiation. We provide an overview of the recent published literature on the long-term efficacy and adverse effects of stereotactic irradiation in nonfunctioning and secreting pituitary adenomas. Both techniques are associated with excellent clinical outcomes; however, advantages and drawbacks of each of these techniques in terms of local control, hormonal excess normalization, and radiation-induced toxicity remain a matter of debate. In clinical practice, single-fraction SRS may represent a convenient approach to patients with small and medium-sized pituitary adenoma away at least 2 mm from the optic chiasm, whereas FSRT is preferred over SRS for lesions >2.5-3 cm in size and/or involving the anterior optic pathway.
Collapse
Affiliation(s)
- Giuseppe Minniti
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Enrico Clarke
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Claudia Scaringi
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Riccardo Maurizi Enrici
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| |
Collapse
|
42
|
Wattson DA, Tanguturi SK, Spiegel DY, Niemierko A, Biller BMK, Nachtigall LB, Bussière MR, Swearingen B, Chapman PH, Loeffler JS, Shih HA. Outcomes of proton therapy for patients with functional pituitary adenomas. Int J Radiat Oncol Biol Phys 2014; 90:532-9. [PMID: 25194666 DOI: 10.1016/j.ijrobp.2014.06.068] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/08/2014] [Accepted: 06/26/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE/OBJECTIVE(S) This study evaluated the efficacy and toxicity of proton therapy for functional pituitary adenomas (FPAs). METHODS AND MATERIALS We analyzed 165 patients with FPAs who were treated at a single institution with proton therapy between 1992 and 2012 and had at least 6 months of follow-up. All but 3 patients underwent prior resection, and 14 received prior photon irradiation. Proton stereotactic radiosurgery was used for 92% of patients, with a median dose of 20 Gy(RBE). The remainder received fractionated stereotactic proton therapy. Time to biochemical complete response (CR, defined as ≥ 3 months of normal laboratory values with no medical treatment), local control, and adverse effects are reported. RESULTS With a median follow-up time of 4.3 years (range, 0.5-20.6 years) for 144 evaluable patients, the actuarial 3-year CR rate and the median time to CR were 54% and 32 months among 74 patients with Cushing disease (CD), 63% and 27 months among 8 patients with Nelson syndrome (NS), 26% and 62 months among 50 patients with acromegaly, and 22% and 60 months among 9 patients with prolactinomas, respectively. One of 3 patients with thyroid stimulating hormone-secreting tumors achieved CR. Actuarial time to CR was significantly shorter for corticotroph FPAs (CD/NS) compared with other subtypes (P=.001). At a median imaging follow-up time of 43 months, tumor control was 98% among 140 patients. The actuarial 3-year and 5-year rates of development of new hypopituitarism were 45% and 62%, and the median time to deficiency was 40 months. Larger radiosurgery target volume as a continuous variable was a significant predictor of hypopituitarism (adjusted hazard ratio 1.3, P=.004). Four patients had new-onset postradiosurgery seizures suspected to be related to generously defined target volumes. There were no radiation-induced tumors. CONCLUSIONS Proton irradiation is an effective treatment for FPAs, and hypopituitarism remains the primary adverse effect.
Collapse
Affiliation(s)
| | | | | | - Andrzej Niemierko
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Lisa B Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc R Bussière
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul H Chapman
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
43
|
Abstract
A variety of histologic tumor types are present in the anterior skull base. Primary tumors of this area may be derived from the bone, paranasal sinuses, nasopharynx, dura, cranial nerves, pituitary gland and brain. Symptoms are caused mostly through mass effect but, if the tumor becomes aggressive, also through invasion. Selection of surgical approaches to the anterior skull base is based upon balancing risk reduction with maximizing extent of resection. Here we review a spectrum of neoplastic entities found in the anterior skull base in adults and discuss clinical and radiographic presentation, treatment options, and outcomes. Surgical resection remains the mainstay in treatment of these tumors, particularly in the hands of experienced surgeons exercising proper patient and case selection.
Collapse
Affiliation(s)
- Michael E Ivan
- Department of Neurological Surgery, University of California, San Francisco, CA, USAand
| | | | | |
Collapse
|
44
|
Budyal S, Lila AR, Jalali R, Gupta T, Kasliwal R, Jagtap VS, Bandgar T, Menon P, Shah NS. Encouraging efficacy of modern conformal fractionated radiotherapy in patients with uncured Cushing's disease. Pituitary 2014; 17:60-7. [PMID: 23381232 DOI: 10.1007/s11102-013-0466-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The objective of this study was to assess the efficacy of modern conformal fractionated radiotherapy (RT) in patients with uncured Cushing's disease (CD) after failed transsphenoidal surgery (TSS). In this retrospective analysis, we reviewed records of patients with CD who received modern conformal fractionated RT between 2001 and 2010. Records were evaluated for frequency and interval of remission post RT. The change in the tumour size, endocrine insufficiencies and complications developing post RT were noted. Remission was defined as 2 mg Low dose dexamethasone suppressed cortisol of <50 nmol/l. During the study period of 10 years, a total of 24 patients (mean age: 27.9, range: 21-48 years) underwent pituitary RT for CD. Out of these, long term follow up was available for 22 patients and 20 patients (15F/5M, 12 microadenomas/8 macroadenomas) were included for final analysis. All the patients received modern conformal fractionated external beam RT (45 Gy in 25 fractions) with the median follow up of 37.5 months (range 12-144). Fifteen patients (10 microadenomas/5 macroadenomas) underwent remission after a median follow up period of 20 months. None of the patients had recurrence. Post RT, new onset endocrine deficiencies were seen in 8 (40 %) patients. Modern conformal fractionated external beam radiotherapy is an effective modality for treatment of adult patients with CD after failed TSS.
Collapse
Affiliation(s)
- Sweta Budyal
- Department of Endocrinology, Seth G S Medical College, KEM Hospital, Parel, Mumbai, 400012, Maharashtra, India,
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Pashtan I, Oh KS, Loeffler JS. Radiation therapy in the management of pituitary adenomas. HANDBOOK OF CLINICAL NEUROLOGY 2014; 124:317-24. [PMID: 25248596 DOI: 10.1016/b978-0-444-59602-4.00021-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Radiation therapy in the form of fractionated treatment or radiosurgery has an important role in the management of pituitary adenomas. Radiation is a reliable way of gaining local control for radiographically progressing pituitary adenomas. For functioning adenomas that are biochemically recurrent or persistent, radiation therapy is less consistent in offering biochemical normalization and often requires a latency period of years or decades. The decision of when to use radiation therapy is a delicate balance between its benefits and late sequelae, especially in the context of benign disease. Recent technological advances in radiation oncology hold the potential to minimize dose to uninvolved normal tissue and therefore reduce the risk of toxicity.
Collapse
Affiliation(s)
- Itai Pashtan
- Harvard Radiation Oncology Program, Boston, MA, USA
| | - Kevin S Oh
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
46
|
Valderrábano P, Aller J, García-Valdecasas L, García-Uría J, Martín L, Palacios N, Estrada J. Results of repeated transsphenoidal surgery in Cushing's disease. Long-term follow-up. ACTA ACUST UNITED AC 2013; 61:176-83. [PMID: 24355549 DOI: 10.1016/j.endonu.2013.10.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 10/07/2013] [Accepted: 10/24/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) is the treatment of choice for Cushing's disease (CD). However, the best treatment option when hypercortisolism persists or recurs remains unknown. The aim of this study was to analyze the short and long-term outcome of repeat TSS in this situation and to search for response predictors. PATIENTS AND METHODS Data from 26 patients with persistent (n=11) or recurrent (n=15) hypercortisolism who underwent repeat surgery by a single neurosurgeon between 1982 and 2009 were retrospectively analyzed. Remission was defined as normalization of urinary free cortisol (UFC) levels, and recurrence as presence of elevated UFC levels after having achieved remission. The following potential outcome predictors were analyzed: adrenal status (persistence or recurrence) after initial TSS, tumor identification in imaging tests, degree of hypercortisolism before repeat TSS, same/different surgeon in both TSS, and time to repeat surgery. RESULTS Immediate postoperative remission was achieved in 12 patients (46.2%). Five of the 10 patients with available follow-up data relapsed after surgery (median time to recurrence, 13 months). New hormone deficiencies were seen in seven patients (37%), and two patients had cerebrospinal fluid leakage. No other major complications occurred. None of the preoperative factors analyzed was predictive of surgical outcome. CONCLUSIONS When compared to initial surgery, repeat TSS for CD is associated to a lower remission rate and a higher risk of recurrence and complications. Further studies are needed to define outcome predictors.
Collapse
Affiliation(s)
- Pablo Valderrábano
- Endocrinology Department, Hospital Universitario Puerta de Hierro Majadahonda, C/ Joaquín Rodrigo n° 2, 28222 Majadahonda, Madrid, Spain
| | - Javier Aller
- Endocrinology Department, Hospital Universitario Puerta de Hierro Majadahonda, C/ Joaquín Rodrigo n° 2, 28222 Majadahonda, Madrid, Spain
| | - Leopoldo García-Valdecasas
- Endocrinology Department, Hospital Universitario Puerta de Hierro Majadahonda, C/ Joaquín Rodrigo n° 2, 28222 Majadahonda, Madrid, Spain
| | - José García-Uría
- Neurosurgery Department, Hospital Universitario Puerta de Hierro Majadahonda, C/ Joaquín Rodrigo n° 2, 28222 Majadahonda, Madrid, Spain
| | - Laura Martín
- Endocrinology Department, Hospital Universitario Puerta de Hierro Majadahonda, C/ Joaquín Rodrigo n° 2, 28222 Majadahonda, Madrid, Spain
| | - Nuria Palacios
- Endocrinology Department, Hospital Universitario Puerta de Hierro Majadahonda, C/ Joaquín Rodrigo n° 2, 28222 Majadahonda, Madrid, Spain
| | - Javier Estrada
- Endocrinology Department, Hospital Universitario Puerta de Hierro Majadahonda, C/ Joaquín Rodrigo n° 2, 28222 Majadahonda, Madrid, Spain.
| |
Collapse
|
47
|
|
48
|
Incidence, causative mechanisms, and anatomic localization of stroke in pituitary adenoma patients treated with postoperative radiation therapy versus surgery alone. Int J Radiat Oncol Biol Phys 2013; 87:53-9. [PMID: 23920387 DOI: 10.1016/j.ijrobp.2013.05.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 04/28/2013] [Accepted: 05/01/2013] [Indexed: 11/21/2022]
Abstract
PURPOSE To assess and compare the incidence of stroke and stroke subtype in pituitary adenoma patients treated with postoperative radiation therapy (RT) and surgery alone. METHODS AND MATERIALS A cohort of 462 pituitary adenoma patients treated between 1959 and 2008 at the University Medical Center Groningen in The Netherlands was studied. Radiation therapy was administered in 236 patients. The TOAST (Trial of ORG 10172 in Acute Stroke Treatment) and the Oxfordshire Community Stroke Project classification methods were used to determine causative mechanism and anatomic localization of stroke. Stroke incidences in patients treated with RT were compared with that observed after surgery alone. Risk factors for stroke incidence were studied by log-rank test, without and with stratification for other significant risk factors. In addition, the stroke incidence was compared with the incidence rate in the general Dutch population. RESULTS Thirteen RT patients were diagnosed with stroke, compared with 12 surgery-alone patients. The relative risk (RR) for stroke in patients treated with postoperative RT was not significantly different compared with surgery-alone patients (univariate RR 0.62, 95% confidence interval [CI] 0.28-1.35, P=.23). Stroke risk factors were coronary or peripheral artery disease (univariate and multivariate RR 10.4, 95% CI 4.7-22.8, P<.001) and hypertension (univariate RR 3.9, 95% CI 1.6-9.8, P=.002). There was no difference in TOAST and Oxfordshire classification of stroke. In this pituitary adenoma cohort 25 strokes were observed, compared with 16.91 expected (standard incidence ratio 1.48, 95% CI 1.00-1.96, P=.049). CONCLUSIONS In pituitary adenoma patients, an increased incidence of stroke was observed compared with the general population. However, postoperative RT was not associated with an increased incidence of stroke or differences in causative mechanism or anatomic localization of stroke compared with surgery alone. The primary stroke risk factor was pre-existent coronary or peripheral artery disease.
Collapse
|
49
|
Ding D, Starke RM, Sheehan JP. Treatment paradigms for pituitary adenomas: defining the roles of radiosurgery and radiation therapy. J Neurooncol 2013; 117:445-57. [DOI: 10.1007/s11060-013-1262-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 09/22/2013] [Indexed: 12/25/2022]
|
50
|
McCutcheon IE. Pituitary adenomas: Surgery and radiotherapy in the age of molecular diagnostics and pathology. Curr Probl Cancer 2013; 37:6-37. [PMID: 23391140 DOI: 10.1016/j.currproblcancer.2012.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Ian E McCutcheon
- Department of Neurosurgery, The University of Texas M D Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA
| |
Collapse
|